Risky sexual behavior in low-income African American women: the impact of sexual health variables

Journal of Sex Research, August, 2005 by Beatrice E. Robinson, Karen Scheltema, Tonya Cherry

Within the United States, African Americans are disproportionately infected with HIV and other sexually transmitted diseases (STDs) (Wohl et al., 1998). For example, in the year 2000, African Americans made up 76% of gonorrhea cases, 71% of syphilis cases, 52% of HIV infection cases, and 38% of individuals diagnosed with AIDS, despite constituting only 12% of the U.S. population (Centers for Disease Control and Prevention, 2001). These epidemiologic data highlight a clear, critical need for research aimed at improving the sexual health of this community.

Measures of Risky Sexual Behavior

Multiple concurrent sexual partnerships. Multiple concurrent relationships are a major heterosexual HIV risk indicator for both men and women. Mathematical models demonstrated that concurrent partnerships can amplify nascent HIV epidemics by as much as tenfold (Morris & Kretzschmar, 1995, 1997; Watts & May, 1992), especially in high-prevalence communities (Finer, Darroch, & Singh, 1999) such as Blacks (Adimora & Schoenbach, 2002). Similar to men who have sex with men, there is evidence that multiple partnerships in African American populations (among men and possibly women) are more common than in other racial/ethnic groups (Adimora & Schoenbach; Adimora, Schoenbach, Bonas, et al., 2002; Bakken & Winter, 2002; Catania et al., 1992; Dolcini, Coates, Catania, Kegeles, & Hauck, 1995; Finer, Darroch, & Singh; Ford, Sohn, & Lepkowski, 2002; Peterson et al., 1992; Smith, 1991; Staples & Johnson, 1993; Weinberg & Williams, 1988). Since studies have shown that multiple partnerships are more likely to occur in unmarried relationships (Catania et al.), the higher rates of multiple partnerships in African American samples may be an artifact of the lower marriage rates among African American than in Caucasian and Hispanic samples (Allen & Olson, 2001; Graves & Hines, 1997; Roempke, Graefe, & Lichter, 2002).

In spite of its importance in the HIV-prevention literature, there appears to be little consensus as to terminology for the concept of multiple concurrent sexual partnerships. We found 12 different terms used to describe this concept: non-monogamy, non-monogamous sexual behavior, relative monogamy, non-exclusive relationships, extramarital sex/coitus, concurrent sexual partnerships, multiple partners, multiple sexual partners, overlapping relationships, non-mutually monogamous unions, concurrency/non-exclusivity, and individual concurrency and partnership concurrency (Adimora & Schoenbach, 2002; Bakken & Winter, 2002; Finer et al., 1999; Hines, Snowden, & Graves, 1998; Klitsch, 2002; Manhart, Aral, Holmes, & Foxman, 2002; Norris & Ford, 1999; Santelli, Lowry, Brener, & Robin, 2000; Shain et al., 2002; Short et al., 2003; Smith, 1991).

Consistent condom use. Evidence from HIV-discordant couples shows consistent condom use to be a highly effective HIV/STD prevention strategy, while inconsistent condom use offers insufficient protection (DeVincenzi, 1994; Feldblum, 1991; Miner, Robinson, Hoffman, Albright, & Bockting, 2002; O'Leary & Wingood, 2000; Pulerwitz, Amaro, DeJong, Gortmaker, & Rudd, 2002). Thus, consistent condom use is regarded as the primary outcome measure for HIV risk reduction and is recommended as the primary outcome measure for evaluating HIV-prevention program efficacy (O'Leary & Wingood).

The Sexual Health Model

There is a recognized need to address the sexual context of HIV risk in prevention efforts (Abraham & Sheeran, 1994; Boldero, Moore, & Rosenthal, 1992; Ehrhardt, Yingling, Zawadzki, & Martinez-Ramirez, 1992; Kalichman, 1998). A variety of sexuality variables such as acceptance and comfort with sexuality, sex guilt, and sexual self-esteem have been found to be associated with safer sex behaviors (Abraham & Sheeran; Boldero et al). To provide a conceptual framework for future research in this important area of HIV prevention, we recently developed the Sexual Health Model (Robinson, Bockting, Rosser, Miner, & Coleman, 2002). The model is derived from a sexological approach to education, and as such, is rooted in the belief that if one is more sexually literate, comfortable, and competent, one is also more likely to develop successful, long-term strategies for reducing HIV risk in the context of one's sexual behavior and relationships. This central hypothesis has just begun to be explored empirically in the design and evaluation of several HIV-prevention programs (Robinson, Uhl, et al., 2002; Rosser, Bockting, et al., 2002; Rosser, Ross, et al., 2002).

This study aimed to extend our testing of the Sexual Health Model as it applies to low-income African American women. We specifically focused on understanding the behaviors (e.g., inconsistent condom use, multiple concurrent partner partners) that mediate risk for HIV and other STDs. We explored these behaviors through the following variables in the Sexual Health Model: challenges or barriers to healthy sexuality, sexual anatomy and functioning, positive sexuality, sexual health care and safer sex, and cultural and sexual identity.