Understanding why some recently with HIV diagnosed men who have sex with men (MSM) choose for safer sex and regular STI testing, whereas others do not, is important for the development of interventions that aim to improve the sexual health of those newly infected.To gain insight into motives and barriers to condom use and regular STI testing among MSM soon after HIV diagnosis, 30 HIV-positive MSM participated in semi-structured qualitative interviews on sexual health behaviours in the first year after HIV diagnosis.Typical barriers to condom use soon after diagnosis were emotions such as anger, relief, and feelings of vulnerability. Additional barriers were related to pre-diagnosis patterns of sexual-social behaviour that were difficult to change, communication difficulties, and substance use. Barriers to STI testing revolved around perceptions of low STI risk, faulty beliefs, and burdensome testing procedures.The great diversity of motives and barriers to condom use and STI testing creates a challenge to accommodate newly infected men with information, motivation, and communication skills to match their personal needs. An adaptive, tailored intervention can be a promising tool of support. In 2014, 898 persons were newly diagnosed with HIV in the Netherlands, and men having sex with men (MSM) accounted for 68% of these diagnoses . Even noThe aim of this study is to investigate the motives and barriers to safer sex, and the motives and barriers to regular STI testing, among MSM who have been recently diagnosed with HIV. Understanding why recently diagnosed men choose for condom use and regular STI testing, whereas others do not, will assist us in developing tailored interventions that are dedicated to support sexual health soon after diagnosis. Addressing the barriers to safe sex and STI screening as soon as possible after HIV diagnosis, and addressing the specific needs that are unique to that phase in time, should set the foundation for a healthier future sexual career. Such a tailored approach for addressing barriers for health behaviours has proven effective in the past , 19 inclFrom May 2008 to April 2009, MSM were recruited at the STI outpatient clinic of the Public Health Service of Amsterdam (PHSA), a large clinic performing annually about 9000 consultations for MSM. About 25% of its consultations are for HIV-positive men, and about 100 MSM are newly diagnosed with HIV each year . We alsoIn order to answer the research questions we chose to conduct interviews with two groups of men. The first group consisted of those who were diagnosed with HIV within 12 months prior to the interview; the second group consisted of men who were diagnosed longer than 12 months prior to the interview. The first group could provide present-life experiences, with less recall bias but with limited long-term perspective and experiences. On the other hand, men in the second group were interviewed retrospectively about their first year post-diagnosis and could therefore provide a more crystallized longer view of their past experiences. By recruiting men of different periods post diagnosis (<1 year<) we expected to enhance the in-depth rapport and understanding of possible perceptions and experiences behind perceived barriers and motives.For those recently diagnosed with HIV, participation began at least 1 month after diagnosis, allowing them time to reflect on joining the study and increasing their possibility of having post-diagnosis sexual contact. For men diagnosed more than 12 months ago, we selected only those diagnosed after 1998, when cART had been widely available in the Netherlands for 2 years. We assumed this period provided sufficient time for reactive social and individual change to occur as a result of the introduction of cART.During a consecutive period of 11 months, visitors of the STI clinic who were diagnosed at that visit for HIV and met the inclusion criteria were asked to participate in the study. These men received an information leaflet outlining the study purpose and the interview methods from an STI nurse. Men who were interested were asked to provide their contact details. After a month, a study researcher contacted the men, provided more detailed information, and made an appointment to interview men willing to participate. For anonymity, the interviews were not linked to clinical data of the PHSA. Recruitment continued until data saturation was reached and no new topics emerged from the interviews. The process resulted in a total of 30 interviews, 15 among recently diagnosed MSM and 15 among MSM more than 1 year post-diagnosis. The men received a 20-euro gift certificate as a reimbursement for participating.A descriptive qualitative design was used to explore participant views and motives and barriers with regard to condom use and STI testing. Semi-structured interviews were chosen as they allow flexibility to explore new topics, facilitate empathy and trust, and can produce richer data . ParticiInterviews were conducted by researchers and nurses who were experienced with interviewing on sexual themes. There were 26 face-to-face interviews, each taking 60–90 min, and four online chat interviews, each taking 60–180 min. The interviewers were guided by a standardized interview manual which included the structural questions and the main topics as well as suggestions for open investigative questions.The interviews themselves were guided by our goal to generate as much as phenomenological richness and experiences as possible, therefore we did not limit our interview schedule to a specific psycho-social theory. However, when interpreting our results we used two theoretical models to formulate and justify future recommendations how to address part of the barriers we describe. We interpreted our results for the discussion through two theories: the Information Motivation Behaviour skills model (IMB)  and the According to the IMB model, information, motivation, and behavioural skills are interrelated determinants of behaviour. Applied to the context of sexual risk behavior and STI testing this model would suggest that the likelihood of initiate and maintain healthier behaviours is greatest when individuals are well informed, highly motivated, well skilled or have a positive sense of self-efficacy regarding the performance of safe sex behaviours and STI testing. The conceptual model for integrating social context in health-behaviour interventions focusses on social-context barriers . This model essentially suggests that safer sex and STI testing would increase when men experience societal and organizational facilitation towards these target behaviours.Each interview started with a short explanation of the study. This was followed by a short list of questions regarding age, ethnicity, sexual orientation, cART use, STI diagnoses, and education. Ethnicity was operationalized as Dutch or non Dutch, sexual orientation as homosexual, bisexual or heterosexual, education as low, middle and high according to standard Dutch classification.From there, a variety of topics was addressed to explore the men’s thoughts and emotions following their HIV diagnosis. They were asked to reflect in detail on their first sexual activity after diagnosis and their first incident of sexual risk (within 1 year of diagnosis). The motives and barriers to condom use were explored by asking for reasons why they did or did not use condoms or seek regular STI testing.Follow-up questions were used to collect information on context and rationale. All face-to-face interviews were audio-taped and transcribed verbatim, and all online interviews were saved. Interviews were in Dutch. All quotes used in this paper were translated into English and a selection was made to represent the barrier or motive identified based on relevance and conciseness.For the analyses of the transcripts we used Qualitative Data Analysis Software (MaxQDA2007). Analysis involved a team of three researchers with different social study backgrounds .After conducting the first two interviews, two researchers inductively coded the interviews, independently from one another. The process of open coding in which an unrestricted number of facets were expressed in preliminary code names was used. A discussion meeting involving the data analysis team took place to ensure that all relevant content was incorporated in codes.The iterative process of interviewing alternated with open coding was repeated two times. In the second phase of the analysis, the researchers reduced and renamed the codes by focussing on the research questions. All 30 transcripts were then coded by the principal researcher, and grouped the relevant codes into categories.The study was reviewed by the secretary of the Medical Ethical Committee of the Academic Medical Centre of Amsterdam, the Netherlands and received an exemption. In all interviews, transcriptions were anonymized prior to analysis by removing potential identifiers of the participants and their partners (i.e. first names). Interviews could not be linked to the electronic patient file of the STI outpatient clinic. Informed consent to record the interview was obtained orally (face-to-face-interview) or in writing (online chat-interview) before the interview started. Participants could withdraw from the study at any time without explanation.n = 15) were recently diagnosed (<12 months) and were interviewed at a median time of 0.8 years (IQR 0.5–0.9 years) after HIV diagnosis. Those not recently diagnosed (n = 15) were interviewed at a median of 3.7 years (IQR 1.9–4.7 years) after diagnosis.Of the 50 men who were asked to participate, 32 agreed to be contacted for the study; one participant withdrew and one could not be reached, resulting in 30 interviews. Table Except for one participant, all men engaged in sexual contact in the first year after HIV diagnosis. At time of HIV diagnosis, 13 men were involved in a steady relationship, and they all reportedly disclosed their HIV status to their steady partner. Overall, the first occurrence of anal sexual contact (with or without condom use) after the HIV diagnosis varied from the day of diagnosis to over 1 year after diagnosis.Table Four motivational aspects for condom use that were intended to protect the sex partner from HIV infection are described below.Yes, I made a decision: you may not infect somebody. You are playing with lives although, yes, life expectancies are good nowadays—but it is a traumatic thing you will inflict upon somebody, and it also causes social suffering. No, I think you have to carry your responsibility and use a condom. (RDB013)What I noticed in the gay scene is that people act like, ‘well I’m throwing the condom away, I have HIV, so it doesn’t matter anymore, carpe diem.’ Not that I would do such a thing but I hear it around me. But this is not the world I want to enter, it offends me: so this is how far you would go for personal sexual satisfaction . It’s a kind of lovelessness and hardness what I do not understand and it makes me angry and upset. (RDB014)Some men reported a personal norm not to infect others as a reason for condom use.Condoms, yes, during fucking always. I take extra care now, so it doesn’t go wrong with friends. And so I won’t come in their mouth any more; this is also risky, I now think.Now? (interviewer)It [HIV infection] happened to me that way. (RDB010)Another motive to use a condom was based upon participants’ own experience—how they thought they had been infected with HIV. This raised their awareness of HIV transmission, and they translated this awareness into taking extra care with condoms and other preventive behaviours with sex partners.That is why actually I do not want to have sex with people who are, for example, younger than 30 years. I think that when you are 30, you can weigh out the risks of unsafe sex, but before that you are a little too thoughtless. (RDB003)A younger age of the sex partner sometimes evoked extra motivation for protective measures. Participants considered partners too young to fully comprehend the risk of not using a condom. The following quote came from a participant who was infected at 25–30 years of age, which made him draw the line at that age.If I fuck somebody, and it is somebody I have some feelings for, I could not bear the thought that I perhaps did not use all the options of protection.What is the difference? (interviewer)Because you bond with that person. Just, you’re more concerned for his wellbeing. (RDB009)Several men felt extra protective towards somebody they cared for.We identified four motivational aspects for condom use that were of personal added value.Personally, I protect myself against STI and, I do not know exactly, possibly also against herpes or another type of HIV, because it seems there are 2 or 3 types of HIV, details I don’t know. But anyway, I think having one [i.e. HIV] is already bad enough.. (RDB023)But yes, now I am afraid that when I contract an STI, that my CD4 cells..uh..well after those antibiotics I had to take, those CD4 cells were very bad. (RDB003)Men were motivated to use condoms because they feared contracting another STI and/or had the notion of being more vulnerable to STI due to the HIV diagnosis.I prefer not to tell, but I take care that I have sex as safe as possible. Then I don’t have to tell, right? I mean, if I have sex as safe as possible, then it isn’t necessary to tell? (RDB012)I didn’t tell him, I let him believe I always use a condom and have safe sex, well then I don’t have to tell him because I feared the confrontation and being rejected. (RDB002)Some men used condoms as a way to avoid disclosure of their HIV status. They preferred to keep their status private and feared gossip and rejection.From the moment of my first sexual encounter—I was like 18 years or so—using a condom was the norm. That’s imprinted. So although I am involved in a steady relationship, I…. Yes, always a condom. (RDB009)Some men stated that condom use was a customary behaviour before their HIV diagnosis, and their attitude towards condom use was positive. For some of these men, the HIV diagnosis did not change this behaviour.Condoms often make you feel like you’re dealing with STI the whole time, and that’s not the 100% free feeling. However it is also good; I mean, it has a feeling of hygiene to use condoms, and that’s what I do like. I am somebody who loves clean and fresh. Sex with poop I don’t like at all, it feels dirty. So the advantage is, if accidently there is some poop on it, on the condom, just remove the condom and really, that’s what makes me feel clean again. Even the smell of poop makes me lose my erection. (RDA002)Some men mentioned hygiene as a motive for condom use.We identified two main triggers for condom use: mutual decision between the sex partners and situational cues.And how did you come to that decision that condoms should still be used? (interviewer).Well, I do not know exactly how it went, but there was an issue with him using medication already and I did not, so we did not want to have problems with another infection or re-infection, something like that. I had a young infection and he already for some time. So we felt it was not wise to not use a condom.And you had it figured out before you had sex? (interviewer)Yes, actually it was a very natural logical step. (RDB023)Sometimes a decision to use condom was based on a discussion that took place prior to the sexual act. In the following specific case the disclosed HIV status, care status, and the fear of re-infection played a role in the subsequent decision making:Some participants mentioned they always disclosed their HIV status before sex and then decided whether or not to have condomless sex based on the reaction to this disclosure, the discussion that sometimes followed, or the related decision taken by the sex partner.Yes, I am honest, if someone asks me directly.How did he react? (interviewer)He said: then we will use a condom. I said, ‘That’s fine.’ (RDB0008)Some men used condoms only if requested by their sex partner.All sex parties I know have clear rules: safe sex only. You can even be expelled if you do not follow them. (RDA014)Some social situations dictate customary sexual protective behaviours, e.g. a sex party or sex venue where condom use is the explicit norm.Almost half of the participants reported condomless anal sex in the first year following HIV diagnosis. Interviews with these men indicated 10 barriers to condom use during anal intercourse in the first year, divided into three distinct groups: (1) barriers related to emotions, (2) barriers related to the transition from an HIV-negative to an HIV-positive serostatus, and finally, (3) situational barriers related to the characteristics of the sexual partnerships/contacts or place of sexual contact.I felt like a lame horse going into battle, a worthless being, so really I don’t think I could cope if somebody rejected me. In the beginning I couldn’t handle this at all. Actually I needed, I accepted, any kind of sex—whatever the other person wanted, with or without [protection]. (RDB0211)Some men felt vulnerable after their diagnosis, experiencing a loss of self-esteem. They feared rejection if their HIV status became known and could not bear the consequences of people knowing their HIV status.First I was stunned, then I grew furious. Why should I care for others if they didn’t care for me? It took me two weeks to calm down, but I am not proud of what I did in those weeks. (RDA017)Some men expressed anger towards the person from whom they believed they had acquired the HIV infection. One man explicitly mentioned that this caused him to be frustrated and disappointed and to therefore engage in condomless sex.I must admit that I also felt a relief, never to be afraid anymore, as I always have been for HIV. I became less strict in condom use.” (RDB009)Some men said that being diagnosed with HIV put an end to their sexually active life of watching out for HIV, being always careful during sexual acts. They felt they had gained freedom from the fear of contracting HIV.For some men, the HIV diagnosis came as a shock. They had to cope with a life-changing situation and needed time to adapt and integrate HIV into their sexual life.Soon after, I didn’t know how to change. He would wonder why I would want him to use a condom; I couldn’t change that, and continued [in condomless sex]. Now, I seldom have sex anymore: only anonymous partners and only safe. Not with people I know, because they would expect me to do it unsafe. I’d rather not have to explain that I contracted it. (RDA014)Some men were, prior to the HIV diagnosis, involved in condomless anal intercourse with a regular sex partner. Some of them experienced difficulties in changing the pattern of condomless sex out of fear they could be challenged to disclose their HIV status.Before, when somebody else stressed condom use, -even though I told them I was checked and was negative, I thought they must have something bad, and I certainly would not go through with the sex…So stressing on condoms for me now is like telling everybody I’m HIV-positive.” (RDA 011)One man remembered when, being HIV-negative, he rejected sexual contact with a man who insisted on using condoms. His opinion was that men who insist on condom use with HIV-negative men must be HIV-positive. On becoming HIV-positive himself, this opinion persisted.I’ve gotten more careless towards condoms. I think, ‘You already have HIV.’ Yes, this is the worst what could happen to me, it has become reality and I am still alive. It’s a funny feeling. You survived. Yes, you survived. (RDB0066)Some men did not see any added value in using condoms. For example, they did not feel the need to protect themselves against STIs. Although aware of STIs, they felt that it would not matter to have a minor other infection besides the ‘worst of them all.’Well I did think like this, ‘I can fuck unsafe, but not with everybody.’ I do watch out with whom. Yes, if I think people don’t have it, then I am not engaging in unsafe sex just like that.How do you find out? (interviewer)Actually, you do not really know. (RDA019)Well, he clearly wanted to have sex without a condom so he must have been HIV-positive, or else how stupid can you be? (RDB0008)Some barriers for condom use were based on the interaction between the sex partners, the HIV status of the partner, and the context of the sexual encounter. A perceived concordant HIV-positive status of the partner was often mentioned as a reason to engage in condomless sex.It’s more up to the other. If the other says, ‘I want to use a condom,’ that’s fine with me. If the other says, ‘I want without a condom,’ I say, ‘But I am sero-positive, think twice.’ Then sometimes you hear them say, ‘Yes, I am as well.’And if they don’t? (interviewer)Then I think, ‘You’re old and wise enough.’ You know, these are not twenty-year-olds. They are forty or maybe fifty. You know enough. (RDB003)To make it easier and more honest and to avoid problems, I tell beforehand, 9 out of 10 times, especially via internet. If I want to date someone, I want to know how he feels about HIV-positive men, because I am HIV-positive. (RDA014)Some men said that, having disclosed their HIV-positive status, it was up to the sex partner to decide on condom use.He sometimes wants to have sex without a condom. Well, we have discussions. He says that when he’s top the risk is very small, but I don’t believe this…But we sometimes engage in unprotected sex.How does this make you feel? (interviewer)Well, mixed feelings. On one hand I think it’s his own responsibility, especially if he consciously does not use them; but on the other hand, I would feel very bad if he turns out to be infected at one time. (RDA0016)In general, the wish to protect an HIV-negative steady partner was strong. However, during a long-term relationship men sometimes engaged in condomless sex. This was related to the desire of the HIV-negative partner to have condomless sex.It makes it [sex] easier, yes. Also in the future on the occasion that I use drugs and there is the opportunity to fuck unsafe, then it is a lot easier. (RDA019)Alcohol and drug use were not uncommon among participants, both before and after the HIV diagnosis. Some men reported the difficulty of maintaining condom use when intoxicated, but stated that having sex while intoxicated was less stressful and made them worry less about transmission risks.Most of the men had visited STI/HIV testing services more than once before their HIV diagnosis. All but one man reported having had an STI before the HIV diagnosis: mostly gonorrhoea, chlamydia and or syphilis. In the year after HIV diagnosis, only a few men reported regular STI testing. Most men who were recently diagnosed had not yet gone for STI testing, and those who did, went irregularly. A total of 37% (11/30) of all the men reported having had an STI after being diagnosed with HIV. We identified four motives for testing and five barriers to testing.It’s good to have it all under control and I go every 3 months, so it should be under control and stays within limits (RDB023).You go every 6 months? (interviewer to RDB002)Yes, certain things you don’t notice you have them. It’s nice that they…that it will be fixed. (RDB002)Most men were trying to manage their health when diagnosed with HIV. For some, one way to manage their health was to get regularly tested for STIs, trying to avoid having STI-related problems or an STI that goes unnoticed.I mean, if you have casual contacts, then it’s kind of a duty to go and do this, for yourself but also for others. (RDB035)Well, at a certain moment we had a more open relationship, so we thought we have to do it [testing] again. Because for me as well as for my partner, it’s yes: you don’t know what others do and you hear more and more about STI. And I thought, let’s do it at least once a year standard. Just to be sure—and I have a partner and things can go wrong. It’s better to know. For me it’s like this: we have more often sex with others, and to prevent that we give each other something and ping-pong infections, it’s good to do it, but I did not have any symptoms or anything. (RDB012)By getting checked regularly, men tried to protect their sex partner for STI.Every 6 months, yes. Like last time: I had a bit of a sore throat and, having a cold or something, it does triggers something and I get paranoia: O God this is the end. And because I do blowjobs without a condom, I thought, ‘Oh sore throat, I got something,’ and immediately went for check-up, but it was nothing—just a common cold. (RDB013)Some men said that they tended to be more alert to physical complaints soon after their diagnosis, compared to the period before. Increased notions of vulnerability led to regular and sometimes more frequent STI clinic visits.Some men had justified reasons for not testing for STI, considering they had no sexual contact. However, for the majority of sexually active men, barriers to regular testing were divided into perceptions regarding risks and situational factors.While we did not conduct a systematic inventory of correct or incorrect knowledge of STIs during the interviews, in some of the cases such specific knowledge or lack of it was indicated by participants as a barrier for proper STI testing.I did want to come [for testing] regularly, especially when I had more sexual contacts, because I heard you can have an STI without symptoms. But you know, I thought, well I am doing it safe. (RDA002).Some men felt protected against STIs when using condoms and therefore did not go for regular testing.Yes, I get checked regularly, at the HIV clinic. In the beginning I went often and at this moment 2 or 3 times a year. About 6 litres of blood they draw every time, and the whole story gets checked, so for lues, other STI and HIV blood values, but also sugar etc. etc. (RDB0211)Men receiving HIV care sometimes had the false belief that they were checked for all STIs as part of their routine health controls at the HIV care centres. Consequently they felt safe and free of STI. However, presently, HIV clinics do not screen for bacterial STIs like gonorrhea and chlamydia.Now that I have HIV, I did not go back to this place again. Not because they did a bad job here. I don’t know, it is so complex. Looking back, I think they did a very good job, human, kind, supportive. But I don’t want to see her anymore. I did not want to get the test result from anybody else but her, but I get nervous thinking about her. Why should I come back? For STI testing? I am doubtful, I don’t want to go but I am not trusting X either. I also think because I have HIV, all the rest is less important. (RDA 008)Yes, it is a confrontation; I did not have the urge or necessity to come here again. No, and it is, to be honest, a bad place. Yes, it has a negative association. (RDA002)Some men hesitated to return to the location where they received the HIV diagnosis and to face the health care personnel.That’s the main issue, I think: it takes such a long time, you will have to spend the whole morning or evening. (RDA006)It stops you from regular testing? (Interviewer to RDB023.)Yes, even if you have a privileged appointment, even then it is, yes it’s just a long wait. And that’s awkward, all those people. (RDB023)Waiting time, as well as the time it takes to complete STI testing procedures, were mentioned as barriers.The purpose of this study was to gain insight into motives and barriers to condom use and regular STI testing among MSM soon after HIV diagnosis.Motives for condom use were based on the wish to protect the sex partner, perceived personal benefits, and situational triggers. Motives relating to the wish to protect the sex partner included, for example, a feeling of responsibility for less-experienced sex partners and, in general, for preventing further transmission of HIV. Motives related to personal benefits included self-protection from STI  and percThe motives we found towards compliance with desirable sexual health behaviours are the key to motivational communication with our target group, as they represent readily accepted reasons to engage in these behaviours. Our findings still need to be corroborated by quantitative studies, but our list of reasons why men choose to use condoms or test for STI soon after diagnosis can form the backbone of any intervention rationale to persuade these men to adopt these behaviours. However, the barriers we found towards these behaviours represent the greatest challenge for developing such persuasive communication.We found that many emotions such as anger, relief, and vulnerability were expressed by our participants post-diagnosis. These emotions, each in its own unique way, have negatively influenced the intrinsic motivation towards condom use. Following IMB principles, interventions should anticipate these emotions and help men to process them and to understand that, while usually temporary, they can influence behaviour in negative ways.Well actually I did not have any sex at all, in the beginning. Also because I didn’t feel sexy at all. And that’s very important; you don’t feel desirable because you do not feel mentally good at all. The effect of giving it a place, the effect it has on your live, that it is do-able, you notice that it [HIV infection] is not completely all comprehensive, as it has been. That you still continue you’re your work, keep the same contacts, the same house. (RDB002).As for the choices we have made in the recruitment process, our assumption that recruiting men who were diagnosed longer than 1 year before the interview will help yield rapport that reflects deeper understanding of barriers and motives has been corroborated by our participants. To quote one men with diagnosis time 1> :Not only emotions played an important role in the decision-making of our participants. Our men realized that although their sexual reference context had changed enormously, their sexual patterns and habits had not. Habits which were not harmful to others when one was HIV-negative had suddenly become harmful post-diagnosis. Preventive interventions should invest in helping men to change prior patterns of sexual risk behaviour according to their new reality. According to the IMB model, intervention efforts will need to enhance negotiation and communication skills to cope with changing social-sexual challenges such as manoeuvring in groups, dealing with community pressures, and managing interpersonal relationships –28.The environmental and the situational facets of sexual encounters also play a role in the ability of men to protect others and themselves. In our sample, as in other populations, alcohol and drugs were linked in a special way to HIV diagnosis . SubstanAs for STIs, men had certain assumptions about whether or not they are at risk. For some, low perceptions of STI risk were the reason for not testing. For some, these perceptions could be valid, but for many they are unwarranted. For example, men who engaged in frequent sex with different partners, but always used a condom, often assumed they did not need to test for STI, although infections can be acquired even with condom use. Furthermore, some participants incorrectly thought that they were tested for all STIs during visits to the HIV clinic, and therefore had a false sense of security. Those perceptions could be counteracted by addressing and explaining the testing procedures for STI during visits at the HIV specialist.It is important for preventive interventions post-diagnosis to sort out and correct problematic risk perceptions regarding STIs among the newly diagnosed. That can be done by direct communication by health professionals who convey clear messages and/or provide motivational counseling when indicated.The facilities for STI testing also form a barrier for some men. Some found the testing procedures burdensome (e.g. inconvenient opening hours) or expressed a strong negative association with a facility because it was the place they were diagnosed with HIV. On the organizational level, following principles of the Sorensen model of incorporating social context in health behaviour interventions, facilities can do better to accommodate these patients , 30. In Regarding study limitations, homosexual men of Dutch origin dominated the study sample. We did not include bisexual men or more than a few men of non-Dutch origin. Bisexual men and men originating from other countries may face problems not typical of our sample, and future research should explore the additional motives and barriers to condom use and regular testing that may exist in these groups , 32.The field of HIV is rapidly changing. Men are increasingly diagnosed earlier and also treated earlier, and consequently the impact of transmissibility will change. However, the fact remains that HIV diagnoses are not always immediately followed by treatment, –35 and oThat interim period is crucial for preventing further transmission of HIV as well as co-infection with other STIs  that might facilitate HIV-transmission or complicate the HIV treatment and prognosis. In addition the recent developments in preventive biomedical interventions could also influence sexual behavior post diagnosis with HIV negative partners using pre exposure prophylaxis (Prep). Men recently diagnosed not yet on treatment might indeed feel more comfortable having sexual contact with other men using PrEP. This prospect of ‘PrEP-sorting’, should be a topic that merits research in the future. Furthermore the perspective of being virally suppressed and hence non infectious once cART is initiated could also play an alleviating role in the perceptions of men recently diagnosed. Especially as these perceptions are now glowingly being recognized and accepted by HIV negative men. This topic also merits further research attention.MSM recently diagnosed with HIV need to deal with their new health condition and its implications. It is in this period, directly following the HIV diagnosis, that new perspectives on sexuality and new sexual behavioural patterns may be formed. Timely support could strengthen the ability of recently diagnosed men to make better-informed decisions regarding their sexual health. Considering the great diversity of motives and barriers to condom use and STI testing, professionals involved in their care are challenged to accommodate men individually with the information, motivation, and skills that match their personal needs. We believe that an intervention that will be adaptable and carefully tailored to the personal situation of each newly infected individual can be a promising tool of support. Such interventions can be provided through personal counselling or through tailored computer-based interventions online or offline.


This qualitative study examined Former Soviet Union (FSU) mothers' explicit and implicit attitudes and parenting practices around adolescents' autonomy development. Interviews were conducted with 10 mothers who had immigrated from the FSU to the US between 10 and 25 years ago, and who had daughters between the ages of 13 and 17 years. Mothers predominantly defined autonomy in terms of adolescents' ability to carry out instrumental tasks, make correct decisions, and financially provide for themselves, but rarely mentioned psychological or emotional independence. Mothers reflected on the various aspects of autonomy emphasized in their country of origin and America, and balancing the two sets of cultural values in their parenting. Although mothers discussed attempts to adopt a less authoritarian approach to parenting than they themselves experienced as children, some mothers' controlling attitudes were revealed through a close analysis of their language. The findings provide important insights into the parenting experiences of FSU immigrant mothers, and the way in which autonomy-related processes may vary cross-culturally. Implications for parenting and clinical practice are also discussed. The development of autonomy is one of the major tasks of adolescence, the achievement of which is significantly shaped by adolescent-parent interactions. Although some theorists posit autonomy as a universal human need, essential for youth's wellbeing  as Russian. All participants identified themselves as middle class. All discussed children were born in the US, except for the daughter of P #3, who was born in Israel and arrived to the US when she was 3-years-old, and P #9, who was born in the Ukraine and arrived to the US when she was 1-year-old. All children were bilingual. See Table Participants were interviewed by the first author, at a place of their preference—home, public library, work, etc. All interview locations were quiet and private. Before they were interviewed, participants were asked to fill out a demographic questionnaire. Interviews were conducted in Russian, and lasted between 30 and 90 min. Interviews were semi-structured and adjusted from one interview to the next, based on the emergent discoveries and knowledge presented by each participant. Interview questions revolved around mothers' definitions of autonomy, domains of autonomy and autonomy-supportive practices emphasized in the FSU and American cultures, and mothers' own approaches to parenting of their daughters in the immigration context. Interviews were digitally audio-recorded, and transcribed verbatim  for analyses.Following each interview, both of us listened to the audio recordings and read through transcripts, adjusting the interview protocol as necessary. Data collection was continued until a saturation of data was achieved. The interviews were collected within a 5-month period.In the current study we adopted a reflexive approach, which involves critical consideration of researchers' backgrounds in the course of data collection and interpretation .We also took a reflexive stance during data interpretation and analysis. After we both listened to the interviews independently, we discussed our observations and interpretations, which at times diverged or focused on different issues. We used these occasions as an opportunity to discuss our existing beliefs, eventually arriving at more informed and contextualized interpretations. For example, whereas the first author had an impression that Participant #1 adopted quite an Americanized, child-centered approach to raising her children, the second author noticed the mothers' language regarding her children's decisions, which she “pretended” to respect and tried to influence “from the side.” It is likely that the example drew the author's attention because of similar behaviors displayed by her own mother. The second author's insight was helpful in illuminating how the language used by this and other mothers implicitly betrayed skepticism about their children's ability to make responsible decisions.Another example involved mothers' strong preoccupation with their daughters' body image. On the surface, most mothers discussed regulating their children's dieting choices and exercising behaviors as primarily grounded in health concerns. However, given our similar experiences with own mothers around body image issues, we picked up on a different set of underlying concerns. These mothers expressed a sense of shame in their daughters' public appearance, which they felt reflected on the mothers themselves. Having considered these types of examples as well as participants' self-presentation concerns during interviews, we decided to broaden our analytical focus to the meanings implicitly conveyed in mothers' particular linguistic choices (see more on this below).As we were making sense of our data, we became increasingly aware of some assumptions derived from our American education. The first author's dissertation was on the topic of adolescent autonomy, which was predominantly guided by the Western models of development. Given this type of training as well as history with our mothers, whose behaviors we at times experienced as controlling and hurtful, it was sometimes challenging for us to refrain from psychopathologizing our participants' attitudes. Although we do not view the insights informed by our backgrounds necessarily as a weakness, we took an extra effort to conceptualize FSU mothers' views on autonomy as culturally-specific rather than inferior or unhealthy.While we were interested in FSU mothers' lived-in experiences of parenting, we also became cognizant of the importance of mothers' both explicit and implicit attitudes toward autonomy development. Hence, we employed the interpretative phenomenological analysis (IPA) approach . Any differences in researchers' interpretations of the data were discussed and integrated in the final analysis. Active reflection on the role of our backgrounds in interpretation of the data served as another source of validation. Additionally, findings were validated by a comprehensive review of the literature on autonomy, FSU culture, and immigrant parenting.As there is no literal translation of the word “autonomy” in Russian, at least as it applies to human functioning, two related words were used throughout the interviews: “самостоятельность”  and “независимость” . The three major ways in which participants defined these terms were: (1) instrumental tasks and discipline; (2) decision-making; and (3) financial independence.Most commonly, participants defined autonomy—especially when using the word “самостоятельность” —as children's ability to carry out instrumental tasks on their own. Frequently mentioned tasks were domestic chores such as cleaning, cooking, washing dishes, or shopping, as well as self-care tasks such as ironing one's own clothes and grooming. Participants also spoke of the importance of learning independent navigation of the environment outside of the home. Additionally, participants stressed children's self-discipline and ability to organize their time without parental monitoring. Here is one participant's definition of “self-sufficiency”:When a child can fulfill her functions without reminders. For example, my older daughter, she is more self-sufficient…. She wakes up early, walks the dog, cooks breakfast for herself, does her hair, puts on her make-up, chooses her clothes, irons these clothes…. She gets everything done on time. When she comes back, she doesn't circle around the room—she eats, she goes to work (she has a job), then she has swimming, some errands…. And so she is very structured during the day. She plans everything, starts her alarm, and you don't need to remind her anything—“Go eat, wash yourself, or walk the dog.” She does everything by herself (P #2).Mothers believed that organizing one's time and personal space was not only conducive to children's efficient completion of domestic and academic duties, but was also likely to foster internal discipline. As one mother (P #7) phrased it, “if there is order around her, then there will be order in her head.” The issue of discipline also commonly emerged around daughters' maintenance of a healthy body weight, which mothers encouraged the daughters to achieve through exercise and dieting (see the example in the end of the Results section).right” decisions. Mothers anticipated daughters to make mistakes, but expected the daughters to correct them and eventually agree with parental perspectives:Participants additionally defined self-sufficiency in terms of one's ability to make decisions; discussed decisions often revolved around academic and career choices. Mothers often stressed that it was important that daughters made the “Interviewer: And what will happen if she makes a decision that you don't want her to make?Participant: Nothing will happen. I am just certain that she won't do it because we are working on it, calmly, nicely, as it should be.…That's why she won't let herself, this is not allowed, this is wrong, this is not good….[If she wants to go out with a boy], I will say, “go ahead, let's say from 3 to 8 pm, you need to come back by 8. If you are running late, call mom and say, ‘I will come at 9, ok?”’ Do you understand? If she changes her mind about anything else—no problem, this is her right, this is her decision, and I even want her to do this…. I want her to clearly know, clearly know what she wants from her life, how to make independent, correct decisions, to understand, so I don't need to control how she leads her life. [I want her] to see clearly that a certain path might lead to bad things. Even if she follows this path and decides to make some of her own mistakes—I can understand—[I want her] to realize that those are mistakes that she has to correct on her own, and change the wrong way and go further (P #3.1).Many participants also defined autonomy—especially when using the word “независимость” —in terms of children's eventual ability to support themselves financially. As one mother explained, only after achieving financial independence through hard work over many years, can one be considered truly independent:She wants her own apartment, she wants…I've heard, “I wanna travel,” or something else, like adult things already.… Independence is when you can achieve things in life with your own work or some talent—this is independence, it does not happen in 1 day. If parents pay for your apartment, it doesn't mean that you are independent. I think that the independence we are seeking when we are 17, people achieve it possibly by their 40 s, but not everyone. I even remember with my first husband…. We didn't stand on our feet straight, we were shaking. That's why I think that a person must be able stand on his feet better. Then he will feel independent. (P #9).Although the theme of social functioning emerged with less prominence, two mothers did mention that autonomy involved an ability to make friends and interact with others without adult supervision and mediation. Interestingly, even when talking about daughters' social interactions, mothers did not spontaneously mention daughters' emotional or psychological independence from others as an important aspect of their autonomous functioning. Only one mother (P #7) defined autonomy as her daughter's ability to formulate her own opinions without excessively worrying about others' approval. When the interviewer directly asked about emotional independence, participants asserted it was natural for their daughters to absorb and depend on mothers' moods, and did not find this tendency particularly problematic.All of the participants stated that they wanted their daughters to be self-sufficient and independent. In line with their definitions of autonomy, mothers stressed its survival or practical functions. They frequently emphasized that it was vital for children to learn how to complete instrumental tasks and make decisions because parents may not always be around to help them. When directly probed about psychological aspects of autonomy, participants did discuss implications of behavioral and financial self-sufficiency for the internal sense of freedom, as in the example below when a mother reflects on her own dependence on her husband:Interviewer: I would like to ask you about a sense of internal freedom.Participant: Of course, if you are self-sufficient, independent, you will have internal freedom. You will feel calmer.Interviewer: Could you explain what does internal freedom mean to you?Participant: Let's say financially, I depend on my husband—I make very little, and he has a good salary. So he provides for our whole family. And financially…if I wanted, let's say we have a conflict, I want to leave, I want to leave him. But I can't because I depend on him. But if I were independent from him, he would behave differently in many situations (P #4).When pondering the issue of children's autonomy in the FSU versus the US, mothers provided multi-faceted responses, suggesting that relative to children in the US, children in the FSU were more autonomous in some ways but less autonomous in others. All mothers agreed that children in the FSU were more self-sufficient in terms of their life adaptability, but children in the US had a strong sense of their individuality.Participants unanimously agreed that children in the FSU were more self-sufficient in their ability to navigate the city and spend leisure time without adult supervision. As per mothers' recollections, in the FSU, children used public transportation and traveled from one point of the city to another by themselves from a very young age. FSU children also spent a lot of time in “yards”  and other common outdoor areas without parental supervision. Mothers observed that in the US, by contrast, parents or guardians transported their children from one activity to the next, and consequently American children were often too intimidated to navigate the city on their own. Mothers attributed these cultural differences to several factors, including: (a) more difficult life circumstances in the FSU where most parents worked full time with no babysitters available; (b) the FSU communal lifestyle where adults naturally took responsibility for each other's children; (c) US child safety laws, which preclude leaving children unattended on the street; and (d) perceptions of American streets as more dangerous. In the excerpt below, a mother is reminiscing about FSU communal lifestyle and sharing an anecdote of how she learned American norms of not leaving children unattended:Interviewer: You mentioned the difference between cultures. Why do you think children are not growing up on the streets here?Participant: Well, because children younger than 13 [in the US] are not allowed to be on the streets on their own… they have to be with their mom…. [In the FSU] children didn't grow up like this—they walked, ran around the streets on their own…. In every neighborhood, there are benches, people, neighbors sitting around, parks nearby, children playing. And even if I don't sit there, there is a neighbor with his child playing nearby. So, you know, there was a different atmosphere there…. For example, when we just arrived [to the US], Alexandra [pseudonym] was 3 years old, and she went to play in the building…. and all of a sudden my neighbor rang my doorbell and said, “Oh, what are you doing, the neighbors are going to call the cops, and they will take your child away!” I grabbed my child and told my husband, “I am going home. I won't stay here another 5 min. What kind of country is this that your child can be taken away to another family because she ran around in the building?” But later I got used to it of course (P #3.2).According to the participants, the FSU lifestyle involved many everyday hardships, and thus facilitated the development of a sense of children's responsibility to their home and family from a young age. Mothers believed that American children, on the other hand, at least in a middle class context, did not take domestic duties seriously because they knew that their family's survival did not depend on them. Here is one example:Interviewer: Could you describe your relationship with both of your children? Perhaps you would like to change something? Or are you happy with everything?Participant: With my daughter, I would like to change—, I think that she must help more around the house. I think that they are in some ways spoiled…. So there, to again compare life here [the US] and there [the FSU], we helped there more, both my sister and I, we helped mom around the house 100% more. And there, we had to wash dishes and everything. So we are trying to make them [children] do chores, but it seems to me that it's, it's somehow more difficult here. First of all, there is a cleaning lady, which on one hand is very good but on another hand, I think this is bad for children's upbringing because they somehow—, they have an attitude that the cleaning lady will still come and clean (P #1.1).Mothers asserted that “growing up on the streets” not only allowed FSU children to better adapt to everyday life, but also enabled them to function independently in the social context: as children had less adult supervision, they had no choice but to figure out how to negotiate and solve conflicts with their peers. Also, as one mother explained, children in the FSU were discouraged from snitching and seeking out adult intervention:Interviewer: How do you support her self-sufficiency, or help her to develop this quality?Participant: ….I have never intervened in her relationships with other children—for example, if something happened in school and she would comes crying in the evening because someone has hurt her…. She must learn how to solve problems on her own because I think that this is very important in life. But here [in the US] I think that this is completely killed at a very early age.Interviewer: What is killed?Participant: You know, the ability to build relationships with your friends. So I don't really understand when you complain to a head teacher because let's say someone has hurt you. You know, they [in the FSU] taught us not to snitch. So in some ways I think they overdo it here because children get used to.…So they believe that they must go and tell someone, and this someone will come and solve the problem (P #10.1).Mothers concurred that some aspects of children's autonomy were better facilitated by the American context. Mothers believed that American children had a stronger sense of their individuality and entitlement, which were revealed in their ability to formulate and assert their unique ideas. They described American children as behaving in more relaxed and less modest ways, being less inhibited in their interactions with adults than children in the FSU. These differences were attributed to both broad socio-cultural factors  and more specific factors pertaining to child upbringing at school and home . Below is how one mother articulated these cultural differences:Participant: The Soviet school system demanded much conformity, so there was a need to say specific things in specific ways…. But here, they have whole classes where they just talk, they discuss thing, or from a young age they express their thoughts, that's a huge difference… they are much more sure of themselves.… They [children in America] are more relaxed, they are freer, they are not shy, they are independent, they have some sense of their own rights. My sense of my rights only emerged here [in America], there [in FSU], there was simply no such thing in principle.Interviewer: Do you think this is good?Participant: I think, I think this is good, I think that a person should have self-confidence, but in a good way, not, not in an obnoxious way… that a person has rights, that a person has the right to achieve something (P #5.1).Mothers discussed adopting their parenting to the American context, but also fostering aspects of autonomy that were stressed in the FSU, and that they viewed as beneficial. Mothers also attempted to find a balance between supporting their daughters' autonomy and controlling their behavior.Mothers tended to think positively of the American focus on children's individuality and self-expression, and talked about their resistance to the excessive control exercised by their own parents. Mothers also realized that in the American context, realistically speaking, they had limited control over their daughters' behaviors. Mothers talked about adopting a less authoritarian parenting approach, with the following strategies: (a) not imposing their own opinions on children; (b) praising children for their accomplishments; (c) providing reasons for their decisions and resolving conflicts through negotiation; and (d) maintaining intimate, friendship-like relationships with their children. Mothers, as in the example below, also avoided psychologically controlling their daughters through silent treatments:Interviewer: Are there differences in raising children? How children were brought up there (FSU) and here (US)?Participant: My mom had these methods. For example, she never, you know, praised us…. My mom also talked with me, but I still was not quite open with her. So I try to be more like girlfriends with her [daughter], you know…. Mom was more dominant, she had more of this control, but it was more like mental, you know…. We were like on different wavelengths with her. Mom-, she-, she had-, she started those-, “boycotts,” as they say. So she could stop talking to me for a few days, and I would apologize first because I couldn't bear it anymore, it was like a torture. I could not talk to her…. But I do it very differently, like I try…first of all, I try to resolve conflicts right away, at least I try to make sure that they don't accumulate…. And second, I don't even know, but I maybe somehow give her [daughter] more freedom, like I trust her more (P #8).However, mothers resisted accepting child-centered parenting approach whole-heartedly, and expressed some reservations regarding the American focus on children's individuality. One mother explained that a strong focus on children's internal world could lead to children's self-centeredness and result in children's difficulties with self-regulation and decision-making in the future:Participant: They are brought up from childhood to look inside themselves, but there are people around you…. I think that this fixation on yourself is very, very-very bad for you.Interviewer: I am trying to understand…I asked you about self-sufficiency—trying to understand the connection.Participant: ….You know this egoism, they like wait for someone to come…. that it will be solved somehow, that everything will be solved for them…. But self-sufficiency is somehow making decisions, and following these decisions. And here [in the US] they are waiting for someone to make decisions for them to feel good. Because everyone should make sure that they feel good, that nobody hurts them, so they, you know, can relax, and, you know, get some of their desires or needs satisfied (P #10.2).In line with this, mothers discussed the importance of not over-indulging their children, for example by actively attempting to limit their praise. As mothers were concerned with their daughters' easy access to too many material things, they tried to teach them the value of hard work—for example, by earning their own money, as well as by pushing them hard toward achieving their educational and career gorals. Here is how one mother articulated this:Participant: In terms of bringing up children, I think that I, I think that I am very similar to my parents. I, I am a strict mom.Interviewer: What do you mean?Participant:.…I never praise children, as they say, “just for participation.” You know, in America they think-, they give gold stars and prizes for participation. I praise them only when they have really done something well. I have high standards for them because, again, they are both (knock on wood) very capable girls. I just somehow insist that they, as much as possible within their capacities, within their real capacities, do everything…. I don't know, let's say she gets a 96% average, when I know it's not difficult for her and she can do better. And she tells me that 96 is good, and I tell her, “You know very well that it can be let's say 98, and you know very well why 98 is important, because when you apply to college and so on, there will be a lot of competition, and every percent will play a big role.” (P #5.2).Mothers also mentioned the need to nurture the aspects of their daughters' autonomy that they had experienced as beneficial in their own upbringing and perceived as missing in American culture. Mothers stressed the necessity of independent navigation in the city, by pushing children to find directions and take public transportation on their own; a couple of mothers even used an opportunity of living in a gated community to create an environment for their American-born children similar to the one that they had experienced in the FSU yards.Mothers thought it was not only important to support their daughters' autonomy, but also maintain control over some of their behaviors. Mothers believed that by continuously nagging their children about domestic and academic responsibilities, they helped their daughters to succeed in the future:Interviewer: And do you think it is possible for parents to teach a sense of self-sufficiency [in their children]?Participant: With conversations, from morning to night. We are nagging her…. Listen, I also understand her….She got into high school now, and it's a little stressful for her, stressful situation. And then she comes back home, and instead of getting relaxed, she is getting nagged, so…. I understand all of this, but I cannot stop nagging.Interviewer: I understand. You are doing this because you think that the nagging is necessary?Participant: I think it is necessary. Actually I already tried all kinds of approaches. I thought, “if I don't say anything for a week, maybe…” But then the child does not do anything at all. You can't let her relax at all, hoping that her conscience wakes up and she will.…Maybe when she becomes older…. I try to explain to her, “you must want something—if you want a good job, you must work for it. The same with getting into college—so it's not just a dream, but it becomes a reality.” (P #6).Mothers asserted that the American context made the control particularly pertinent, in part because they perceived America as a dangerous place, where children can easily get in trouble without parental monitoring. One mother also articulated another concern with the lack of firm parental control in the US:Interviewer: Why is it important to develop a sense of self-sufficiency?Participant: …In America, in a free society, there is much less external control… That's why this internal control is so necessary here. So I think that parents need to help their children develop this internal control, that you don't do something bad, not because you are afraid that you will be punished by the teacher, punished by the parent, but just because your inner voice dictates to you that it is wrong (P #1.2).Mothers often explicitly discussed difficulties in maintaining a balance between giving their daughters freedom and regulating their behavior, However, close analysis of mothers' lexical choices revealed that some mothers' controlling and enmeshed attitudes emerged implicitly, without mothers' conscious awareness that these expressions at times contradicted their explicitly made statements.must put things in their places,” P #7), or diet . Additionally, mothers' behavioral prescriptions often took the form of directives rather than suggestions .All mothers described their parenting as non-coercive, non-intrusive, and respectful of children's individual choices, and yet often used words like “must” or “necessary” when discussing disagreements with their daughters. These terms emerged not only in regards to potentially risky behaviors such as doing drugs or staying out late, but also more personal and less consequential matters, such as cleaning one's own room .Despite mothers' common assertions of “respecting their daughters as individuals,” they seemed to be skeptical about their daughters' ability to form their own valid opinions. Implicitly invalidating, derogatory, or dismissive attitudes were often mentioned in passing. One mother (P#5), for example, minimized the importance of her daughter's input by describing the daughters' participation in adult conversations as, “if we meet with our friends, she is sitting with us at the table, she is listening, she is putting in her 2 cents” . Because mothers did not always trust their children's decisions but at the same time did not want to stifle their individuality, they sometimes resorted to subtler, covert methods of influence, as illustrated in the example below:Interviewer: First, I would like to ask you what the word “self-sufficiency” means to you?Participant: I try to respect both children…as separate individuals…. I try to give them “space” as they call it in English, I don't even know how to say it in Russian. So like not to intrude too strongly, or at least show that I am not intruding, or do it somehow from the side… give them the opportunity to make some decisions for themselves, especially where those decisions aren't so important. So like to show that I am not making the decision for them, or at least if I am making the decision for them, to do it in such a way that they think they made the decision (P #1.3).We didn't finish the homework, so we didn't want to go see the friend anymore.” Although mothers avoided long-term silent treatments, at times they mentioned managing interpersonal closeness by occasionally withdrawing from their daughters. The lack of strong mother-daughter boundaries also became apparent when mothers discussed their daughters' decisions as affecting mothers' own wellbeing. These feelings frequently came up when mothers discussed their concerns with their daughters' body image. In the example below, although this mother primarily justifies her concerns with her daughters' weight in terms of health and internal discipline, it also becomes quite apparent that her daughters' looks upset the mother personally, and reflects her preoccupation with how these looks are perceived by others in the community:Disregard for a child's individuality was also occasionally revealed in language that pointed to psychological enmeshment—for example when a mother (P #3) used the term “we” to describe her daughters' motivations: “she said, ‘mom, we [students at school] have vacation, can I go to see my friend?’ I said, ‘yes, if you finish your homework.’ Interviewer: Can you describe a specific conflict [you had with your daughter]?Participant: ….We were meeting with our friends, friends of our age, friends of her age, you know there was a big group. And she dressed up in a way that was very, you know, non-flattering. And you know, my husband and I were trying to explain to her that in her present body shape, in her present shape, you cannot dress like that, that you need to dress somehow differently…. And she categorically refused to understand what we were explaining to her—she got offended, very offended. So every time when… I tell her directly, “you must look at yourself from the outside, you do not look the way you can look,” she is offended. So she always tells me, “It's not helping.”Interviewer: Has it resolved somehow?Participant: It is resolving little by little…. I don't even ask her, I am just happy. One of her friend decided to watch her weight…. and they both watch what, what they eat at school, they both are switching to salads…. She herself found an app, which will help her to watch what she is eating, hmmm, like how much she exercises, and will recommend some activities to her….Interviewer: Could you explain a little why this is important for you?Participant: ….Because I think it's unhealthy…. Even her pediatrician noticed and said, “Oksana (pseudonym), you need, you need, you need to look after yourself.” ….So first of all health. But in addition…. I naturally want my daughter to look the way she can look… Hmmm and also, this is internal discipline…. this is a part of being able to look after yourself, achieve something, and not let yourself go.Interviewer: And when you say that you would also want her to look the way she can, what do you mean?Participant: She is a beautiful girl hmmm, I don't know, but when her stomach is hanging out, it is not very pretty…. She likes to dress up, she likes to wear clothes that in her present body shape are you know, non-flattering, and she doesn't look, doesn't look good, at least from my point of view. So I am somehow upset, I want my child to look good (P# 5.3).The present study was the first substantial investigation that specifically focused on FSU parents' experiences with fostering adolescent autonomy in the immigration context. We discovered that FSU mothers' explicit and implicit beliefs about autonomy and control revealed considerable complexity that extends much beyond the collectivism-individualism framework.By posing an open-ended question regarding participants' definitions of “autonomy” (by using Russian terms for “self-sufficiency” and “independence”), we were able to access features of adolescent independent functioning that were most salient to the FSU immigrant mothers. Mothers predominantly defined autonomy as an ability to plan and carry out domestic and self-care tasks and as financial independence, thus stressing its behavioral and practical domains. Even when discussing independent decision-making, which potentially involves cognitive aspects of autonomy, mothers focused on the practical: ensuring good career options and financial success. Somewhat strikingly, interviewed mothers rarely defined autonomy in cognitive or emotional terms—as an awareness of one's uniqueness, and ability to assert one's needs and desires without excessive worry about others' approval. Thus, FSU mothers' conceptualizations provide a contrasting view of autonomy development than commonly presented in Western psychological literature, which underscores the importance of emotional and cognitive independence from parents (Collins et al., The domains of autonomy emphasized by mothers in the current study are likely reflective of values particular to the mothers' socio-cultural circumstances. The focus on instrumental functions of autonomy, described by some as “hard individualism” Kuserow, , is consIn FSU culture, with its strong emphasis on social interdependence and compliance to authority (Schwartz and Bardi, While absent in the definitions of autonomy, cognitive and emotional independence did emerge as salient themes in mothers' discussions of perceived cultural differences. Mothers believed that American children were more at ease than FSU children with formulating their own unique ideas and expressing themselves in relaxed and entitled ways, especially with adults, and appraised such tendencies in positive ways. Although the explicit content of mothers' prescriptions, in parallel to their definitions of autonomy, focused on completion of instrumental tasks, an overall form of their parenting strategies seemed to reflect the desire to foster their daughters' individuality. Thus, mothers tried to structure interactions with their daughters in less hierarchical ways than they had experienced with their own parents.Mothers also talked about avoiding silent treatments. Consistently with previous research on silent treatments as a common disciplinary method in FSU families (Knafo et al., Importantly, mothers did not perceive American culture simply as freer and more facilitative of children's self-sufficiency than the FSU. In fact, mothers viewed some aspects of the culture as constraining autonomy—albeit, once again, mainly pertaining to its behavioral domains. Mothers expressed concerns with the current culture as hindering their children's self-sufficiency in domestic, navigation, and to a less extent, social areas, and discussed efforts to compensate for these shortcomings in their parenting. It is important to note that the differences perceived by mothers as grounded in culture, may actually reflect intergenerational differences, given the shift toward coddling children and over-monitoring their leisure time and navigation in the last few decades in the United States Ungar, . NeverthNotwithstanding the type of autonomy mothers tended to emphasize, they unanimously agreed that it was important for their daughters to eventually learn how to function in self-sufficient ways. Importantly, mothers did not conceptualize fostering autonomy as merely allowing children to do whatever they desired. In fact, mothers believed that enforcing responsibilities and restricting some of their daughters' choices actually contributed to these girls' independence. These mothers' intuitions were reflective of the views commonly discussed in the Western psychology literature, which posits pushing against parental restrictions, as long as they occur in the atmosphere of warmth and open negotiations, as one of the important mechanisms of autonomy development Smetana, .Furthermore, a few mothers believed that the American context made the parental control in some ways more pertinent. In these mothers' view, American stress on freedom and excessive focus on children's internality hindered children's ability to self-regulate and make responsible decisions. Mothers believed that by pushing children to work hard to achieve their goals and limiting their praise or other forms of indulgence, they helped their daughters to learn how to evaluate their behavior in realistic ways, and thus become more mature and independent.FSU mothers' beliefs in enforcing domestic responsibilities as a way to foster children's self-reliance and other important qualities is shared by parents in other non-Western cultures. For example, in their ethnographic study of responsibility development across cultures, Ochs and Izquierdo  demonstrfrom the side… especially where those decisions aren't so important,” did not seem to realize that pretending to respect her children's opinions was not the same as actually respecting them.Whereas many mothers acknowledged that some authority over their daughters was necessary, some of their controlling attitudes surfaced indirectly, at times contradicting their own explicit statements. Mothers' skepticism toward their daughters' ability to form their own valid decisions and opinions was betrayed by somewhat derogatory and minimizing language used in response to their daughters' perspectives. For example, a mother who talked about influencing her children's decisions “Moreover, mothers' definitions of autonomy often stressed the importance of learning how to make “correct” decisions, which revealed their distrust in daughters' ability to formulate their own sound opinions, when those diverged from mothers' own understandings. It seemed hard for some mothers to view their daughter's decisions outside of the right-wrong dichotomy, and consider that their appropriateness may depend on the specific priorities and needs of an individual child. Mothers' implicit controlling attitudes also became apparent when they used such strong terms as “must,” even regarding daughters' personal matters, and insisted on imposing the importance of some tasks by completing them in their daughters' stead. It was not always clear how such parenting practices would facilitate daughters' “internal control” that the mothers hoped for them to develop.The focus on “right” and “wrong,” and the expectation that children would eventually come around to their parents' superior perspective, may reflect the deeply engrained beliefs remnant from mothers' own upbringing in the FSU. This approach is consistent with a larger pattern in FSU collectivism, where people commonly provide unsolicited advice that assumes access to “correct” information (Chentsova-Dutton and Vaughn, It is possible that some mothers' controlling attitudes came up implicitly because they contradicted their conscious efforts to foster children's individualism and independent decision-making. This underscores the challenges faced by immigrant parents, who need to discern the aspects of their existing beliefs that they want to preserve and pass along and those that need to be readjusted in the new cultural context (Sherry and Ornstein, Taken together, our findings suggest that FSU mothers' nuanced conceptualizations of their daughters' autonomy are significantly shaped by their experiences and circumstances both in their country of origin and the US. On the one hand, FSU mothers' beliefs are parallel to immigrants from other countries, where children's independence and self-sufficiency does not necessitate emotional and psychological separation from parental figures (Kagitcibasi, At the same time, our findings demonstrate that some attitudes and concerns around autonomy may be uniquely emphasized in the FSU immigrant community. Whereas some of these concerns—for example, enforcing domestic and academic responsibilities—may be beneficial, other concerns—for example, insistence on the right-wrong dichotomy or over-focusing on children's looks—may have negative repercussions. To establish the adaptability of FSU mothers' parenting attitudes and related practices, future studies should assess FSU children's own perspectives and directly measure outcomes for their mental health and wellbeing. Also, many of these mothers' attitudes and emphasized concerns appeared to be quite gendered, and the role of gender should be further examined in the future.MK interviewed all participants, analyzed data, and wrote most of the sections except Methods. JL participated in data analysis and validation; she also wrote Methods section and edited other sections.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The study of any biological features, including genomic sequences, typically revolves around the question: what is this for? However, population genetic theory, combined with the data of comparative genomics, clearly indicates that such a “pan-adaptationist” approach is a fallacy. The proper question is: how has this sequence evolved? And the proper null hypothesis posits that it is a result of neutral evolution: that is, it survives by sheer chance provided that it is not deleterious enough to be efficiently purged by purifying selection. To claim adaptation, the neutral null has to be falsified. The adaptationist fallacy can be costly, inducing biologists to relentlessly seek function where there is none. Darwin’s concept of evolution is centered on natural selection, or survival of the fittest . AlthougCandide ou L’Optimisme , 7675, 7These routes of exaptation that appear to be central to eukaryotic evolution notably deviate from Gould’s and Lewontin’s original spandrel concept , 5 Fig.. The spaThe extensive recruitment of “junk” sequences for various roles calls for a modification to the very concept of biological function . Are theThe pervasive exaptation in complex organisms evolving in the weak selection regime appears as a striking paradox: the overall non-adaptive character of evolution in these organisms enables numerous adaptations which ultimately lead to the dramatic rise in organismal complexity . In a hiThe population genetic perspective calls for a change of the null model of evolution, from an unqualified adaptive one to one informed by population genetic theory, as I have argued elsewhere , 83. WhedN/dS) and the total number of genes in a genome are significantly, positively correlated, as opposed to the negative correlation implied by streamlining [The time for naïve adaptationist “just so stories” has passed. Not only are such stories conceptually flawed but they can be damaging by directing intensive research toward intensive search for molecular functions where there is none. However, science cannot progress without narratives, and we will continue telling stories, whether we like it or not . The goaamlining . The resamlining . This gramlining . Thus, aThe above example may carry a general message: the population genetic theory replaces adaptationist just-so stories with testable predictions, and research aimed at falsification of these can improve our understanding of evolution. We cannot get away from stories but making them much less arbitrary is realistic. Furthermore, although most biologists do not pay much attention to population genetic theory, the time seems to have come for this to change because, with advances in functional genomics, such theory becomes directly relevant for many directions of experimental research.


It has been argued that the alcohol industry uses corporate social responsibility activities to influence policy and undermine public health, and that every opportunity should be taken to scrutinise such activities. This study analyses a controversial Diageo-funded ‘responsible drinking’ campaign  in Ireland. The study aims to identify how the campaign and its advisory board members frame and define (i) alcohol-related harms, and their causes, and (ii) possible solutions.Documentary analysis of SOOCD campaign material. This includes newspaper articles (n = 9), media interviews (n = 11), Facebook posts (n = 92), and Tweets (n = 340) produced by the campaign and by board members. All material was coded inductively, and a thematic analysis undertaken, with codes aggregated into sub-themes.The SOOCD campaign utilises vague or self-defined concepts of ‘out of control’ and ‘moderate’ drinking, tending to present alcohol problems as behavioural rather than health issues. These are also unquantified with respect to actual drinking levels. It emphasises alcohol-related antisocial behaviour among young people, particularly young women. In discussing solutions to alcohol-related problems, it focuses on public opinion rather than on scientific evidence, and on educational approaches and information provision, misrepresenting these as effective. “Moderate drinking” is presented as a behavioural issue (“negative drinking behaviours”), rather than as a health issue.The ‘Stop Out of Control Drinking’ campaign frames alcohol problems and solutions in ways unfavourable to public health, and closely reflects other Diageo Corporate Social Responsibility (CSR) activity, as well as alcohol and tobacco industry strategies more generally. This framing, and in particular the framing of alcohol harms as a behavioural issue, with the implication that consumption should be guided only by self-defined limits, may not have been recognised by all board members. It suggests a need for awareness-raising efforts among the public, third sector and policymakers about alcohol industry strategies. For me…David Smith: The World Cancer Research Fund says three alcoholic drinks a day could cause liver cancer—that’s their definition.Interviewer: For me, it’s different for different people and that’s why actually the term “out of control drinking” is when your drinking is either affecting you or affecting other people  as ‘beware of out of control drinking’, we don’t really …David Smith (Diageo board member until his resignation in February 2015):So anything other than out-of-control drinking is moderate, so if you’re not ….falling around, you’re moderate?Interviewer: Well, out-of-control means different things to…to…to different people, clearly…David Smith: Well, what’s it mean to the drinks industry?Interviewer: It’s all about the individual, at the time, so if you drink so much that you can’t get up in the morning and take your child to the sport that they wanted, even though you weren’t really drunk the night before, that’s too much….I would say, ah, that people, should, em, know…how much they can drink, they should…ah…not step beyond that, and, and, really you know, part of the issue that we’ve got in Ireland… It’s much more about the attitude and the behaviour rather than any specific definition.David Smith: Moderate drinking involves not letting others down”   There are also frequent references to ‘our culture of drinking’ in the SOOCD Facebook posts, and ‘culture’ was a key theme in the public workshops .Board members frequently highlight that it is individuals that are responsible for creating this “drinking culture”. This is done by repeating that ‘we need to take a look at ourselves’, and we need to “look in the mirror”  35] [34 [3435]  50]. Th. Th50]. “It is the great Irish trick to seek to change everything but our own habit. So blaming the brewer, the distiller, the distributor, the publican, the legislators and the sporting organisations is a great distraction”(Gavin Duffy ).“It is very easy to call for tighter regulation of the alcohol industry, more control over prices of alcohol or more stringent ID requirements to purchase alcohol, but for every one of these valid calls I can give you real life anecdotes for how they will not stop young people drinking”.“I believe there's more to it than big business manipulating us. We have a long-standing culture of excessive drinking…Peer pressure more than advertising pressure is at work amongst our teens”(Ciara Kelly ).Elsewhere David Smith (Diageo board member) rejects the influence of alcohol pricing on consumption, recommending instead a focus on individual attitudes and behaviours . Ciara K“Out- of-control advertising encourages out-of-control drinking. It's the job of Government to rein in the drinks industry through legislation and regulation”(Ciara Kelly ).As in some of these quotes, peers and parents are frequently described as a key influence on young people’s consumption of alcohol 51. Twen“We have this view that this is a particular cultural problem in Ireland… I’d have to say Ireland and UK, but we like to convince ourselves that there is some type of Celtic gene that’s into excess- look what we did with bank borrowing for example. We do everything to excess in this country.”Gavin Duffy When it comes to solutions to the problem of ‘out of control drinking, the need for evidence is often mentioned. However scientific evidence is frequently presented as just one element to be considered, alongside views, conversations, stories and experiences, for example:“Everyone’s opinions, experiences and attitudes towards alcohol, as well as the evidence put forward by professionals working in the field are included” (Fergus Finlay ..51].Funded by Diageo, nobody tells us what to think” . In. In66]. The legitimacy of the SOOCD campaign has been the subject of public debate in Ireland. The emphasis on public opinion, as well as some board members’ frequent references to their own children (data not presented) may be intended to establish the campaign’s legitimacy. Some SOOCD board members’ questioning of the legitimacy of critics, by associating them with prohibition or temperance, is another well-recognised alcohol industry tactic 69. HoweOnce finalised, the plan will be presented to the government and community stakeholders for adoption and implementation over the coming five years”. Favouring such partnerships with the industry over legislation is an explicit Diageo position,  Once finposition, and a coposition,.The legitimacy of the board is also emphasised through frequent statements about the independence of board members, and the voluntary nature of their involvement. However as noted above and in It is interesting to note that there are strong resonances, in both content and wording, between the SOOCD campaign materials, and Diageo Australia’s submission to the Government of Western Australia’s review of the Liquor Act in 2013 . The DiaThese tactics are not unique to the alcohol industry, many being used by tobacco companies over many decades. In partOur search may have missed some interviews, however the high degree of consistency between the board members’ statements see  suggestsThe key strength of the study is the timely, in-depth analysis of an ongoing campaign which we believe will be relevant to other countries. As well as the Australian connection (above), the SOOCD campaign share similarities with Diageo’s ‘Drink Right’ campaign in Jamaica, which also emphasises ‘negative drinking behaviour’ and self-defined limits on consumption. We also The SOOCD board has stated that: “The campaign is independent. It’s a people’s campaign” . Our anaFinally, although the framing and tactics we have identified are not unique to the alcohol industry, it is possible that they were not known to all the SOOCD board members. Our findings therefore suggest that there is a pressing need for wider awareness-raising, and a wider public debate, among the public, third sector organisations, and policymakers about such tactics. The absence of information about board members’ current and previous links to Diageo and Guinness is particularly concerning, and highlights the need for such debate to address issues around transparency, and conflicts of interest relating to relationships with the alcohol industry in Ireland.Looking to the future, this analysis raises the need for wider debate and understanding about what the evidence actually shows in relation to effective action on alcohol harms. Board members repeat inaccurate statements about the evidence, and the final SOOCD report emphasises that the causes of alcohol harms are individuals, families and culture, while downplaying or ignoring the role of industry in shaping that drinking culture. The report also states that it is ‘evidence-based’, though the non-systematic review of the evidence which is included in the report strongly recommends ineffective information and educational interventions  25]- wh- wh25]- Further analysis of future campaign materials and activities may be possible, as SOOCD is a five-year campaign . However social media activity appears to have ceased, and at time of writing the SOOCD website is inaccessible. A more detailed analysis of the final SOOCD report would also be of value; such an analysis could analyse the evidence which it presents, and how it is framed. Future analyses could also examine the similarities between this campaign and future campaigns linked to Diageo and the industry more generally, including their framing of evidence, and their relationship to current and planned public health policies in the countries in which they are implemented. The reframing of alcohol harms in purely behavioural terms, while downplaying the health consequences, is also a priority for further research.S1 Appendix(PDF)Click here for additional data file.S1 Table(PDF)Click here for additional data file.


For too long, size perception research has been guided by the size distance invariance hypothesis. Although research to validate this hypothesis has been largely inconclusive, the hypothesis has endured, perhaps in part because alternative information sources for size perception were lacking. Here, I propose a binocular information source for size perception. The model, drawing on the binocular geometry of viewing a physical extent, is expressed solely in terms of four angular measures and interocular distance, with the explicit exclusion of egocentric distance information. Thus, the proposed information source, if utilized by the binocular system, should be able to augment the few existing sources of information for size perception . For successful encounters with our surrounding surfaces it is essential that we perceive the sizes of various objects accurately. Consider, for example, picking up an object. Two fingers suffice to pick up a cherry but not an apple. However, the grip needed to handle an apple must be readjusted to handle a melon. Consider an even simpler case, shaking hands, a universally accepted ritual of greetings. Even in this case, the opening of the hand must be adjusted to conform to the counterpart’s hand size. Clearly, shaking hands with a 5-year-old child differs from shaking hands with a female adult; and the latter differs from shaking hands with a 250-pound male adult.Another, but equally important, aspect of size perception involves being able to perceive various sizes of gaps in the environment. To weave through a crowded mall, gaps that can be negotiated must be differentiated reliably from those that should be avoided. Consider an even more challenging case of driving in the narrow streets of any European city. Oftentimes, the cars are parked along the sides of an already tight street. The opposing drivers, however, somehow manage the situation, sometimes barely squeezing by each other while at other times letting the oncoming car go first. Actually, size perception is engrained in virtually every aspect of our daily activities in one way or another. Yet, we cope with these challenges with little effort and with precision. How do we accomplish these tasks so easily?Figure 1A). Note that the two sides of the triangle, S and D, are inversely related to the angle, 𝜃, through a trigonometric relation, tan 𝜃 = S/D. When extended to perception, this geometric relation between S and D for a given angle 𝜃 forms a universally accepted law of visual perception, the size-distance invariance hypothesis (SDIH). The hypothesis states that the visual angle (𝜃) subtended by an object determines a unique ratio of the perceived size of the object (S′) to its perceived distance (D’), that is, tan 𝜃 = S’/D’ , compared to distance . Indeed,S’ = D’ tan 𝜃. Conceived this way, objective size becomes a property that is not perceived directly, but is derived indirectly via visual angle augmented by perception or knowledge of the object’s distance. For Helmholtz, this derivation, namely, calibrating visual angle by taking perceived distance into consideration, was an inferential or judgmental process of which the perceiver was unconscious of and thus was referred to as unconscious inference. The view that visual perception is mediated by unconscious inferences, eventually became the overriding theme in perception . L and R refer to the left and right eye, respectively, and hence, ρ, the interocular distance; whereas A and B are the two end points of the line segment. α and β are visual angles subtended by AB with respect to each eye, whereas γ and δ are binocular parallaxes of each end point of the segment with respect to the two eyes. From this geometry, the frontal size S  can be expressed as follows:O be the point of intersection of lines AR and BL, 𝜀 and η angles ∠OBA and ∠OAB, respectively. By applying the Sine Formula to the triangles ΔAOB and ΔLOR, respectively, we obtainLet By rearranging (1) and (2), we obtainBy applying the Sine Formula to the triangles 1AOL and 1BOR, respectively, we obtainDividing (5) by (4) gives the equationFrom (3) and (6), we obtainBO to obtainWe also rearrange (5) in terms of AB can be obtained fromFrom two similar triangles ΔAOB and ΔLOR, BO and LO into (7) and with further simplification, we obtainBy substituting 1The model is expressed solely in terms of four angular measures and interocular distance, with the explicit exclusion of egocentric distance information. Nevertheless, any frontal size can, in principle, be perceived binocularly based on the model provided that the visual system can access its interocular distance, which strong evidence suggests it can e.g., . In fact2 A metric source of information makes the proposed model even more unique. 3Some additional features also stand out. Note that the model can provide a metric basis for an object’s size for the binocular system. Most sources of spatial information identified to date are relative, that is, they provide ordinal but not absolute metric information . The question can be raised as to whether the perceived size of a slanted object is veridical, perhaps with some type of compensation for its slanted angle, or is distorted in conformity with its projected view. Evidence suggests that human observers are poor at judging the lengths of slanted line segments and, by extension, the shapes of objects .In summary, mounting evidence suggests that the SDIH may not be a suitable scheme to describe the perception of size, let alone as a model for binocular size perception. The alternative model proposed here, by contrast, is a binocular source conveying absolute metric information. More importantly, the model assumes that the information for an object’s size is directly available in optical stimulation.Figure 1A). Surprisingly, however, almost 25 centuries of research into size perception have resulted in virtually no candidate information source for size perception for the binocular visual system. A similar sentiment was expressed by For too long, size perception research has been dictated by the doctrine of size-distance invariance. Despite mounting evidence to the contrary, the doctrine has endured. Perhaps, as there must be some others, and size perception theorists have to identify and demonstrate them. All we can say is that they did not do it in the same way as they did for the distance estimations. This ignorance reflects a general ignorance about the perceptual variables underlying size perception. Most of the theoretical discussions about size perception appeal to familiarity (as do we) and ignore any other variables. But I have proposed a potential source of information for size perception that can fill this void. The model draws on the binocular geometry of viewing a physical extent. Hence, this model qualifies as one of a few binocular sources of information that have been identified to date. Added significance is the fact that the model, unlike other sources of information for spatial vision that provide only relative information, can provide an absolute metric for size perception. More importantly, the information for an object’s size is directly available in optical stimulation, even in the absence of egocentric distance information. With perceptions of size and distance no longer tied together as in the SDIH, changes in one percept  bear little influence on its counterpart .As The author confirms being the sole contributor of this work and approved it for publication.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The reviewer JG and handling Editor declared their shared affiliation.