Re-Search The Missing Pieces in Investigating African-American Relationship Dynamics and Implications for hiv Risk

Abstract

Rates of hiv/aids are disproportionately high among African-Americans. Most prevention messaging has been focused at the individuals, while many of the drivers of hiv risk for African-Americans exist systemically. In order to make significant strides in hiv prevention and intervention, programs must account for the unique context of life experiences for African-Americans. In this manuscript, we make a call for conducting studies that more comprehensively examine the historical, societal, structural, and community-level factors that affect African-American heterosexual relationships, perpetuating increased risk for hiv/aids.

Introduction

African-Americans account for roughly 14% of the population, yet comprise 44% of new hiv/aids infections in the United States (Centers for Disease Control, 2013). These numbers represent a grave health disparity where African-Americans bear a disproportionate brunt of the hiv/aids epidemic. While much of the funding for research in hiv prevention among African-Americans remains focused on the msm (men who have sex with men) population, heterosexual African-Americans have been left with little direction for effectively confronting this epidemic. Furthermore, most prevention messaging is focused at the individual-level, encouraging mutual monogamy and consistent condom use (Prado, Lightfoot, & Brown, 2013; Nydegger, Keeler, Hood, Siegel & Stacy, 2013). However, placing onus solely on the individual is problematic as there are structural and community-level factors that complicate an individual’s ability to substantially reduce their risk. Here, we make a call for conducting studies that more comprehensively examine the historical, societal, structural, and community-level factors that affect African-American heterosexual relationships, perpetuating increased risk for hiv/aids infection in this group.

African-Americans, Racism, and Sex

African-American heterosexual relationships have been influenced by the racism encountered by this group, particularly by way of the media and through institutional racism (Bell, Bouie, & Baldwin, 1990). These influences have affected how African-American males and females relate to one another. Transhistorically, the media portrays African-American females as matriarchal, domineering, and emasculating, and of African-American males passive and irresponsible (Kambon, 1998). These skewed captions are further compounded by the current state of African-Americans’ economic positioning with high rates of unemployment for males, and the emergence of the self-proclaimed “independent woman” as African-American women are experiencing higher rates of college graduation and employment than their male counterparts (U.S. Bureau of Labor Statistics, 2014). Some African-American children grow up internalizing conflicting definitions of what manhood and womanhood mean while also navigating difficulties in gaining economic independence amidst the reality of economic marginalization. Oftentimes, some African-American girls are taught that womanhood encompasses attaining the status of wife and mother, but are also warned that as African-American women it is likely that they will be left at some point by their African-American male counterparts, so they should be ready to assume responsibility and economic stability for themselves and their families (Franklin, 1984). Some African-American males are raised to regard manhood as a display of dominance and as provider. However, the position of the African-American man in society makes it more difficult to project the quality of “provider” (Whitehead, 1997). African-Americans males are simultaneously given the message that in order to gain acceptance and survive in Euro-American society, one must temper displays of dominance outside the home. While concepts of manhood and womanhood present contradictions for African-Americans, these contradictions can confuse and complicate gender roles in relations between the sexes causing strain in African-American heterosexual relationships and the community at large.

The constructed images of manliness and womanliness generated by the media also cause individuals to pattern their behavior after those images. As African-American men are exposed to images of machoism and physical dominance as symbols of manhood, African-American women are inundated with images of sexiness equated with womanhood whereby power and identity for individuals is associated with physicality and sexuality (Wallace, 2007). Media tends to hyper-sexualize African-Americans in particular, perpetuating long-standing racial tropes such as the Black male “Buck” and the Black female sexually insatiable “Jezebel” (Patton, 2001; Stephens & Phillips, 2003; Townsend, Neilands, Thomas, & Jackson, 2010). This presents a problem, particularly as it relates to African-Americans attempting to form and sustain intimate romantic partnerships. As African-Americans enter into relationships, they bring with them the images of Black sexuality garnered from media influence. These images promote sex for fulfillment of physical urges and attainment of dominance. Inasmuch, it is a far departure from the African worldview perspective of sex within the context of responsibility and African-American family and legacy building. It is important then to view heterosexual African-American relationships through a cultural lens. To truly understand the dynamics at play between couples and how they affect sexual risk behavior, it is important to consider the cultural and societal factors that influence these relationships.

African-American Masculinity

Masculinity ideology is the endorsement of cultural belief systems regarding what it means to be masculine and personify male gender and how this compares to femininity and female gender (Pleck, Sonenstein, & Ku 1993). American society characterizes manhood as having social and economic independence, the ability to provide for family, dominance in gender relations, and sexual prowess (Liburd, Namageyo-Funa, & Jack 2007). African-American males historically, have not been as easily able to identify with the economic characteristics of manhood within American culture. A history of disenfranchisement, economic and institutional racism, and imposition of negative stereotypes related to hyper-sexualization have impeded African-American males’ ability to confidently identify with American masculinity and manhood. Studies of the African-American male’s conceptions of manhood and masculinity have revealed themes including self-determinism and accountability, connection to family, pride, spirituality, and community (Hammond, 2005). When some of these concepts of manhood are unattainable due to systematic marginalization and internalized racism, African-American males may attempt to assert manhood, through aggression, affecting their partners directly or indirectly (Liburd, Namageyo-Funa, & Jack 2007). This may play out in violence against others in their community, or through increased display of what they consider to be sexual prowess. It has been argued that the difficulty in finding opportunity for acquiring power in American society results in some African-American men resorting to adoption of a “Black machismo identity that solicits primarily sexual encounters with women and violent encounters with other Black men” (West, 1993, p. 89).

Research in masculinity ideology shows a link between a traditional concept of manhood (e.g, competitiveness, physical prowess, restricted emotionality, physical and sexual violence, and restricted affectionate behavior between men) and multiple sex partners (O’Sullivan et al. 2006; Pleck, Sonenstein, & Ku 1993), less intimate relationships with sex partners (Pleck, Sonenstein, & Ku 1993) and negative attitudes towards condom use (Noar & Morokoff 2002; Pleck, Sonenstein, & Ku 1993). Black heterosexual men who endorse traditional masculine ideologies are more likely to report having multiple sexual partners (Bowleg et al. 2011; Carey et al. 2010; Corneille et al. 2008; Whitehead, 1997), greater sexual availability (Bowleg et al., 2011), aversion to condoms (Whitehead, 1997), beliefs that women are responsible for condom use (Bowleg et al., 2011), and unprotected vaginal sex with primary sexual partners (Santana et al., 2006). Examining how masculinity ideology refutes safer sex practices is crucial in hiv prevention among heterosexuals (Campbell, 1995). Conversely, Corneille, Fife, Belgrave, and Sims (2012) have demonstrated a relationship between African American heterosexual men’s rejection of masculine ideologies and protective behaviors. In their quantitative study of Black male college students ages 18 to 25, men who rejected traditional masculinity ideologies reported greater relationship mutuality (e.g, relationship was mutually supportive) and fewer sexual partners. Since men’s sexual behaviors and men’s gender norms directly and indirectly involve women, it is important to understand how African American heterosexual men perceive their relationships with women to identify how these perceptions and attitudes towards masculinity may be associated with their sexual risk behaviors. Studies have revealed a positive relationship between experiences of racial discrimination and sexual-risk taking (Roberts et al., 2012) and others have demonstrated an association between the two (Bowleg et al., 2013). In an effort to address this relationship, Bowleg et al. (2013) found that increased social support can serve as a buffer against the effects of racial discrimination on sexual risk. This demonstrates the relevance of comprehensive hiv prevention efforts that are inclusive of not only individual sexual behaviors but also external factors that impact these individual sexual behaviors. Overall, the association between masculinity ideologies and sexual risk behavior among Black heterosexual men is important because masculine ideologies may influence the men’s experiences in their intimate relationships and how they are associated with protective and sexual risk behavior.

African-American Femininity

In her article, “Gender Roles Revisited”, Norma Burgess (1994) asserts that “It is virtually impossible to understand what African-American women are today without having a historical perspective for what their ancestors were, especially as it relates to the roles, functions, and responsibilities that women have traditionally held within the family unit” (Burgess, 1994, p. 393). Miller (1986) proposed a theory of women’s development that focused on connection, suggesting that a woman’s sense of self is rooted in the ability to effectively establish and maintain relationships with others. As such, some women’s romantic relationship status holds great value for them. Therefore, the value placed on being in a relationship may outweigh other concerns, such as protecting one’s health. Miller posits, “for many women, the threat of disruption of connections is perceived not just as a loss of a relationship, but as something closer to a total loss of self” (Miller, 1986). Bearing this in mind with regard to health behavior, for some women, creating a change or disruption in a relationship in an effort to reduce health risks (such as demanding consistent condom use or regular hiv testing) may require that a woman take a great personal risk to their relationship status, their opportunities for marriage and family, and thus, their self-structure, concept, and esteem (Amaro, 1995).

The role of mother is highly regarded in the African-American community (Fouquier, 2011). However, there are aspects of the community that make this role increasingly difficult to achieve within the often preferred context of marriage. A shortage of available African-American men for potential partnerships exists due to poorer health, higher mortality rates (Geronimus et al. 1996), violence (Geronimus et al. 1996), and high rates of incarceration (Department of Justice, 2010; Mechoulan, 2011; Green et al., 2012). It is important to note that African-American men who have been institutionally marginalized and less successful in academic and economic arenas may be less appealing as potential life partners to African-American women (Banks, 2011), which may be further narrowing the pool of eligible partners for African-American heterosexual coupling. This small pool of eligible male partners has been linked to lower rates of marriage for African-Americans (Chambers & Kravitz, 2011), and may also be related to increased risk for hiv infection in the African-American community.

Gender-Ration Imbalance and Limited Partner Availability

Some have posited that gender-ratio imbalance may play a role in increased vulnerability of African-Americans to hiv/aids (Wingood et al., 2000; Newsome & Airhihenbuwa, 2013; Ferguson, Quinn, Eng, & Sandelowski, 2006). The ratio of African-American women to men is unbalanced, with 91 males per every 100 females (U.S. Census Bureau, 2000). The gender ratios for other racial groups are not as drastically imbalanced compared to African-Americans, with Hispanics at 103 males per 100 females, Native Americans at 100 per 100 females, and Whites at 97 males per 100 females (U.S. Census Bureau, 2000). The rates of hiv infection in other racial groups are also lower than African-Americans with Whites accounting for 31% of new infections, Hispanics 21%, Asians 2%, and Native Americans accounting for about < 1% (Centers for Disease Control, 2013). The gender ratio for Asian Americans (91 males per 100 females) is similar to that of African-Americans, yet they experience lower rates of hiv infection (Centers for Disease Control, 2013). This may be largely due to the fact that Asian Americans have not experienced the same history of disenfranchisement in the United States, and are not confronted with the same levels of institutional racism and mortality risks that affect the African-American community, all known to be drivers of high hiv rates (Raj et al., 2014; Bowleg & Raj 2012; Williams, 1999). As such, there is a need to look beyond individual behavior, and expand focus to include societal and structural factors such as high mortality, low employment, high incarceration rates, and other adverse outcomes for African-American men and examine how these disrupt intimacy and relationships in the African-American community driving increased risk for hiv.

It is important to remember that the figures used to generate the gender ratios in Census data also include people who are incarcerated. In US state or federal prisons in 2008, about 34% of all sentenced prisoners were White, 38% were African-American, and 20% were Hispanic (U.S. Department of Justice, 2010). African-American men were incarcerated at a rate of six and a half times higher than White men in 2008. As African-American men also experience disproportionate rates of incarceration, it could be inferred that the gender ratio for the African-American population is even more unbalanced than the aforementioned gender ratios suggest. Disproportionate rates of incarceration for African-American men create more heavily weighted gender imbalance, decrease economic mobility, and negatively impact heterosexual relationships and sexual networks in the African-American community (Adimora, Schoenbach, & Floris-Moore 2009). These social dynamics have been attributed to higher rates of concurrent sexual partnerships; multiple simultaneous sexual relationships, or sexual relationships that overlap in time (Morris et al., 2009) which likely result in higher rates of hiv infection (Adimora et al., 2002) as concurrent sexual partnerships facilitate an even more rapid transmission of infection through a sexual network than would be the case if the partnerships had occurred sequentially (Morris & Kretzschmar, 1995). African-Americans are more likely to choose sexual partners who are also African-American (Laumann & Youm, 1999). Thus, their sexual network is a smaller circle within which a transmittable disease can spread more rapidly. In contrast to Whites, African-Americans with few sex partners are more likely to be sexually involved with partners who are involved in concurrent partnerships (Laumann & Youm, 1999). These community-level factors actually present a greater likelihood that an African-American would be infected with hiv than a White person, regardless of the number of sexual partners or sexual experiences (Adimora, Schoenbach & Floris-Moore, 2009), particularly as research has suggested that African-Americans are no less likely to use condoms consistently than other racial groups (Essien, Ross, Fernandez-Esquer, & Williams, 2005).

In addition to sheer epidemiological data regarding sexual network effects on hiv vulnerability, gender ratio imbalance and limited partner availability can change relationship dynamics within the community, driving hiv risk. In general, women are often socialized to view their self-worth through their ability to make intimate connections with male partners (Amaro, 1995). When there are limited men with whom women can form partnerships, relationship power is shifted in favor of the men. These dynamics can create a situation in which partner concurrency and frequent partner change is more common (Adimora & Schoenbach, 2002). African-American men in high demand by African-American women may have more power to negotiate the type of relationships that they desire. Men who maintain concurrent partnerships may be less likely to concede to their partners’ demands regarding standards for treatment, fidelity, and consistent condom use. This concern can place women in a vulnerable position in efforts to negotiate relationships characterized by safer sex and mutual monogamy for fear of losing their potential male partners to another less demanding female (Adimora, Schoenbach, and Doherty, 2006). Men may feel less inclined to establish emotionally and sexually committed monogamous relationships and experience less demand for condom use by their female partners because the women feel that they may lose their desirability and positioning for main partner status if they insist upon monogamy and condom use (Bowleg, 2004). In fact, Stevens-Watkins et al. (2013) found that African-American women who perceived difficulty in finding suitable African-American male partners were less likely to practice consistent condom use. Additionally, “man sharing” (a phenomenon where a woman consents to having a sexual relationship with a man who is known to have other female partners) has been noted in the African-American community, and is likely tied to the context of limited partner availability (Airhihenbuwa et al., 1992). Even within the context of known man sharing, women are still unlikely to insist upon consistent condom use as this may imply that their relationship is less special, as there is a common ideal that condoms are to be used with side partners, while unprotected sex is reserved for the main (most revered) partner (Afifi, 1999).

Mays, Cochran, & Zamudio (2004) hypothesized that disparities in hiv among African Americans are directly related to men having multiple sexual partners due to the low male-to-female ratio among African Americans in low-income urban communities. However, a study by Senn and colleagues (2010), demonstrated no evidence that fewer African American men in a designated area was associated with having multiple sexual partners. In any case, the varied effects of gender-ratio imbalance and limited partner availability on African-American women have gained increased attention in the media as of late. Subsequently, these issues are being addressed more frequently in the research and academic discourse on African-American relationships and hiv/aids risk (Ferguson, Quinn, Eng, & Sandelowski, 2006; Alleyne & Gaston, 2010) and warrant further inquiry as researchers attempt to identify unique drivers of hiv risk for African-Americans.

Re-Searching

Many of the tools used to analyze hiv risk for African-Americans have focused on individual-level factors. However, African-Americans descend from a collectivist culture, and tend to make individual decisions within the context of communal and interpersonal concern (Kambon, 1998). Using individual-level analyses and interventions to address problems of a collectivist culture is a mismatch, and likely responsible, at least in part, for our failure to effectively curb the hiv/aids epidemic in the African-American community. Africentric models and methods of analysis differ from Euro-American methods in that they reflect and account for the differences between African-Americans and other groups. The manner in which a group of people view the world is fundamental to the activities and behaviors in which they engage (Nobles, 2006). Africentric and other models that account from racism and its effects on health, such as Critical Race Theory (Ford & Airhihenbuwa, 2010) provide us with clearer insight for examining the motivators of behavior within the African-American context. This is useful when attempting to unveil the underlying differences in disproportionate rates of behaviorally linked health outcomes such as hiv infection. Regarding racism, gender-identity, and gender ratio imbalance and their effects on relationship dynamics, African-centered analyses can help to clarify the cultural norms of African-American heterosexual relationships and provide better perspective in examining how some of these components of African-American life affect their hiv risk. Research similar to the aforementioned study by Bowleg et al. (2013) may aid in identifying variables that can buffer the negative effects of the historical, societal, and structural factors that complicate African-American heterosexual relationships and provide us with the missing pieces in more effectively addressing African-American relationship dynamics and their implications for increased hiv risk.

The social norms and values commonly associated with African-American culture should be included in the discourse on hiv prevention and education as culturally-based approaches may be more effective motivators for behavior change in this community (Airhihenbuwa et al., 1992). It is critical to prevention efforts that research focus on the dynamics at play within the heterosexual relationships of African-Americans in the United States in light of the structural issues that impact those relationships, and how they influence hiv risk behavior. Human well-being is a “relational event” that results from and is defined by “situational-bound units of relationships between people” and their environment (King & Nobles, 1997). Future studies that account for the unique structural, social, and relational aspects of African-Americans are likely to prove more effective than the individual-level approaches that have seen little utility in lowering hiv rates among African-Americans. Prevention of hiv/aids in the African-American community would benefit from a paradigm shift in the design and implementation of interventions whereby the significant role of culture as it influences behavior and behavior change is central (Nobles, Goddard, & Gilbert, 2009). Scholars such as Kambon (1992), Akbar (1984), and Nobles (1980) have developed definitions, theories, and measures that explore and account for traditional African ways of knowing and aspects of African worldview in the American context. These lend added insight in the deconstruction of the factors that contribute to disruption in African-American heterosexual relationships as well as the disparities in risk behavior and adverse health outcomes observed within this group. As the structural forces at play in African-American heterosexual relationship dynamics may be slower to change, the values, norms, and experiences of the African-American community may be more salient influences and predictors of behavior change as it relates to hiv prevention than the individual-level approaches more characteristic of American culture (e.g., increasing knowledge and condom availability for individuals).

Future efforts aimed at this group should seek to validate the strides that they have already made in lowering their risk while also providing additional tools that affirm their collectivist and inter-relational view. For instance, a prevention campaign that promotes routine hiv testing (e.g., every 6 months) for couples may be an effective strategy for increasing perceived susceptibility and addressing hiv risk for African-Americans who are less likely to use condoms as a result of being involved in a relationship. Additionally, as women’s feelings about condoms may be strongly influenced by their perceptions of male partners’ preference for non-condom use, developing interventions and prevention messages that attempt to associate condoms positively with ideas about masculinity and encourage male partner support for and communication about condom use may be effective in increasing positive views toward the use of condoms within the context of relationships for African-American women. Future research among this group should also seek to illuminate the relationship between perceptions of gender-ratio imbalance and male partner availability to address its implications for women’s agency in sexual communication and negotiating safer sex. Hearing directly from African-American men is also essential in discovering the hiv prevention skills that they say they need (e.g., how to talk to their partners about hiv testing and condoms) (Bowleg, Mingho, & Massie, 2013). In order to make significant strides in hiv prevention and intervention, programs must account for the unique context of life experiences for African-Americans. Some scholars suggest that African-American heterosexual men would benefit from programs that may be linked to other programs (e.g., workforce development, post incarceration release programs, programs linked to women’s prevention programs and faith-based programs; Bowleg & Raj, 2012). While research and funding priorities appear to have turned away from heterosexual African-Americans (Raj & Bowleg, 2012), there remains much needed work to be done in addressing their plight, particularly as of all heterosexual groups, African-Americans experience the highest rates of hiv/aids infection. Here we make a call for a “re-search” of the missing yet salient pieces to the puzzle in addressing hiv risk for this group.