A Cultural Perspective on Sexual Health: HIV Positive and Negative Monolingual Hispanic Women in South Florida.

Heterosexual transmission remains the principal source of HIV infection among women in the United States, accounting 80% of the newly diagnosed HIV/AIDS cases (Centers for Disease Control and Prevention [CDC], 2007). Seventy-six percent of HIV/AIDS infection cases reported in 2008 among Hispanic women in Miami-Dade County were through heterosexual contact (Florida Department of Health [FDOH], 2008). Minority women are disproportionately represented among HIV and AIDS cases, with 83% of all women who are HIV positive belonging to a minority group (CDC, 2007). Although minority women have shown the largest increase in rates of new AIDS cases in the United States, they remain relatively understudied. Among Hispanics in Florida and Miami-Dade County, diagnosed HIV cases increased by 76% and 14%, respectively, between 1999 and 2008 (FDOH, 2008). With a population of 2.4 million, Miami-Dade County is primarily Hispanic (1.5 million). In more than half of the Miami-Dade County households, Spanish is routinely spoken, contributing to a complex dynamic of bilingualism and biculturalism among Hispanics in South Florida (U.S. Census Bureau, 2006). Cultural values and beliefs influence the experiences of Hispanic women living with and at risk for HIV infection. Understanding both shared and diverging values and beliefs among Hispanics is critical, especially to the process of developing strategies for sexual risk-reduction interventions for monolingual Spanish-speaking Hispanic women. Sociocultural factors common to Hispanics may explain patterns of sexual behavior, which increase risk in this population. For instance, many women would risk having HIV infection rather than diminish their reproductive capacity and jeopardize their relationships (Panozzo, Battegay, Friedl, & Vernazza, 2003; Zorilla, 1999). Hispanic cultural norms prescribe submissive roles for women and domineering roles for men, which may explain why some women are aware of their risk of HIV infection, yet are unwilling to discuss or demand safer sex from their partner, fearing emotional and/or physical abuse or withdrawal of financial support (CDC, 2008). Thus, despite behavioral interventions, informational campaigns, and HIV-testing programs, infection rates among Hispanic women continue to increase (Amaro, 2000). This article seeks to explore the feelings and perceptions about HIV and sexual health among HIV-positive and HIV-negative at-risk Hispanic women who participated in NOW en Espanol, a cognitive behavioral sexual risk-reduction intervention. A Cultural Perspective Prevention studies emphasize tailoring interventions to address the needs, beliefs, and values of specific target populations (Amaro, 1995). For instance, cultural beliefs may affect communication and strategies for prevention, attitudes regarding childbearing, contraception (Bloom, Singh, & Suchindran, 2004; Ehrhardt & Exner, 2000), and fidelity (Hirsch, Higgins, Bentley, & Nathanson, 2002). HIV prevention strategies are often undermined by disempowering social (e.g., marginalization, poverty, racism) and cultural factors (e.g., machismo, sexual silence; Marin, 2003). Results from various studies across the United States with high-risk Hispanics highlight several mediating factors between high-risk behaviors and acculturation: low prevalence of sexual barrier use and HIV testing; low acceptability of sexual barriers (male and female condoms); the influence of poverty, violence, drug dealing, and an environment of illegality; perception of AIDS-related risk; and alcohol use (Deren et al., 1997; Marks, Cantero, & Simoni, 1998; Sabogal & Catania, 1996; Sorensen, Lopez, & Anderson, 2001). For instance, although perceived risk of HIV infection may be low because of misinformation (Kalichman & Cain, 2005), among Hispanic women, avoidance of HIV testing may occur because of fear of ostracism from traditional support systems for bringing “shame” on their family and their community by determining their HIV status (Pederson, 1996). Assimilating differences between traditional Hispanic culture and modern American lifestyle has become a source of personal and familial conflict for many Hispanics living in the United States. For example, first-generation Mexican immigrants generally maintained their traditional cultural values, whereas second- and third-generation Mexican immigrants tended to adopt the cultural values of their North American peers, often experiencing familial conflicts because of the cultural divide between them and their elders (Falicov, 2005). In this context, acculturation represented the degree to which an individual from one culture adapts to the ways of life, customs, values, mores, and languages of the host culture (Berry, 1980; Sullivan et al., 2007). For this study, most participants were considered to be at a relatively low level of acculturation based on their inability to communicate effectively in English as compared to their fluency in Spanish. The degree of participant acculturation could affect a woman’s perception of sexual health and communication on such topics. Hispanic values centered on family loyalty and unity and supported by cultural beliefs, such as machismo, are often contradicted by American ideals such as individuality, independence, gender equality, sexual freedom, and diversity (Bernal & Shapiro, 2005). These machismo beliefs also reinforce the male-dominated aspect of sexual behavior among the Hispanic community. Machismo and marianismo involve gender stereotypes, valued and sustained within Hispanic culture. Machismo embodies the masculine ideal where the man is proud, aggressive, and dominant. The masculinity of a machismo male is often expressed through sexuality. One study found that machismo men had multiple sexual partners, avoided expressing feelings, resulting in less intimate relationships with partners, took greater risks, and, more often, conceptualized male–female relationships as inherently problematic (Marin, 2003). In contrast, marianismo embodies the feminine ideal, the opposite and complement of male, in which the woman is expected to emulate traditional roles of being tender, devoted, passive, and submissive to the male (Durik et al., 2006; Espin, 1986). Traditionally, Hispanic men are viewed as the head of the household. Characteristics, such as strength, power, and dominance, make a man “macho” and is viewed as a desirable mate (Marin, 2003). Thus, less-acculturated Hispanic women may be the less assertive partner in a relationship, particularly in the context of sexuality. Other themes central to Hispanic culture include sexual silence, familismo, simpatia, and personalismo. The Hispanic community strongly ascribes to the cultural value of sexual silence, the complete suppression of openly discussing sex and sexuality (Amaro & Raj, 2000). Sexual silence stems from beliefs endorsed by both men and women such as women should be less experienced and should know less about sex than men. A woman’s knowledge about sex or high level of comfort discussing sexual topics could stigmatize her as promiscuous and “experienced” in sexual matters. This discomfort with talking about sex results in a decreased ability to negotiate sex and condom use (Marin, 2003), and can be a significant barrier to a Hispanic woman’s desire to improve her sexual health. Sexual silence perpetuates sexual coercion and inhibits women from discussing sexual issues with their partners such as condom use and extramarital relationships (Marin, 2003; Noland, 2006).