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Book Review   |    
High-Risk Sexual Behavior: Interventions With Vulnerable Populations
Francine Cournos, M.D.
Psychiatric Services 1999; doi:
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by Evvie Becker, Elizabeth Rankin, and Annette U. Rickel; New York City, Plenum Press, 1998, 168 pages, $39.50 hardcover, $22.50 softcover

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This book offers a detailed discussion of the adverse consequences of high-risk sexual behavior, the models of intervention designed to reduce these risky behaviors, and the results of research studies examining intervention effectiveness. The authors (whose disciplines are not stated) write from a broad and holistic public health perspective, focusing on the age of onset of sexual activity; teen pregnancy and the impact of socioeconomic factors on its occurrence; the sequelae of sexually transmitted infections; and individual, cultural, and gender issues that influence sexual behavior.

Chapter 3 is of particular interest. It offers lucid descriptions of the models that are most often used in designing prevention interventions. They include the five-stage model of behavioral change proposed by Prochaska and DiClemente, the theory of reasoned action offered by Azjen and Fishbein, the information-motivation-behavioral skills model developed by Fisher and Fisher, and the use of natural opinion leaders, proposed by Kelly and colleagues. Anyone interested in understanding the prevention literature will benefit from the concise explanations of each of these intervention models.

The authors review studies of interventions that have been conducted using these models. The studies assess how effective prevention programs have been with adolescents, women, gay and bisexual men, and members of specific ethnic minority groups. Considerable detail about the differences between groups is given. For example, the authors quote studies showing that compared with other ethnic groups, African-American women experience less disapproval of early sexual activity and pregnancy before marriage and are more effective in convincing partners to use condoms. It is this degree of specificity that allows the reader to come away with an understanding of how to design interventions for particular groups of people, and of the strength of the evidence for supporting one approach over another.

Although the authors address the links between use of alcohol and other drugs, sexual abuse and assault, and unsafe sexual practices, they do not focus on interventions tailored to specific psychiatric populations such as those with severe mental illness or substance use disorders. Mental health providers looking for models tailored to clinical settings will not find that kind of information here. The medical facts are occasionally incorrect; for example, maternal-fetal transmission of HIV itself is confused with the universal transmission of the mother's HIV antibodies to her unborn child. However, such inaccuracies are rarely important in this context, as the authors focus on changing behavior, and the medical points are mentioned only briefly to orient the reader. There is also some repetition, particularly of descriptions of prevention models, among the chapters.

In summary, this book will give the reader an excellent understanding of the importance of intervening at a public-health level to reduce high-risk sexual activity and of the models that have shown promise in doing so.

Dr. Cournos is professor of clinical psychiatry at the College of Physicians and Surgeons of Columbia University and director of the Washington Heights Community Service in New York City.

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