Condom use preferences among Latinos in Miami-Dade: emerging themes concerning men’s and women’s culturally-ascribed attitudes and behaviours

Abstract

Among Latinos, cultural values such as machismo and marianismo may promote inconsistent condom use representing a significant risk factor for HIV infection. Yet, there continues to be a need for additional research to explore the influence these cultural values have on Latino men and women’s condom use attitudes and behaviours given increasing HIV rates of HIV infection among Latinos. The purpose of this study was to explore further Latino traditional culturally-ascribed attitudes and behaviour for emerging themes toward condom use among a diverse group of adult Latino men and women living in Miami-Dade County, Florida (USA). The study used a qualitative study-design and collected data from sixteen focus groups with a total of 67 Latino men and women. Finding from the focus groups described attitudes and behaviours that counter traditional gender roles towards sex and expected sexual behaviours informed by machismo and marianismo. Common attitudes noted in the study include men’s classification of women as clean/dirty to determine condom use and women’s assertiveness during sexual encounters negotiating condom use-in favour and against it. As the findings of this study suggest, the process differ greatly between Latino men and women, having an impact on the risk behaviours in which each engage.

Introduction

The HIV epidemic continues to affect the Latino community disproportionately in the USA. In 2011, Hispanics/Latinos represented 16% of the population but accounted for 21% of new HIV infections, 20% of new AIDS diagnoses, and 19% of people living with HIV infection in the country (Centers for Disease Control 2013). Latinos have HIV incidence rates that are two times higher than those of non-Latino Whites. The impact of the HIV epidemic has been particularly felt in urban communities with a high concentration of Latinos. Miami-Dade County (Florida), where 64% of the population is of Latino descent, documented in 2011 the highest rate of new cases of HIV and the highest rate of people living with HIV in the nation (Centers for Disease Control 2013). The city of Miami, the largest city in the county, had the second highest rate of new AIDS diagnoses among all major US cities (Centers for Disease Control 2013). Eighty-seven percent of all new HIV cases in the county were among minorities, with Latinos (44%) and Blacks (41%) reporting the highest numbers respectively (MDCHD 2012a). Although the rate of new HIV cases has remained stable across the nation (Centers for Disease Control 2013), incidence rates have been increasing in Miami-Dade. In 2011, the county experienced a 21.5% increase in new HIV diagnoses and an 8.2% increase in reported new AIDS cases (MDCHD 2012a). While infection rates among Blacks decreased over the years in Miami-Dade County, the numbers of newly reported HIV infection cases among Latinos increased 15% between 2003 and 2012 (MDCHD 2012b).

As the extent of the HIV epidemic continues to evolve in Latino populations, research has shed light in understanding the importance of socio-cultural factors influencing the HIV risk behaviours of Latinos in the USA. Among Latinos, cultural values such as machismo and marianismo have been suggested as likely to promote unprotected sex and inconsistent condom use, representing a significant risk factor for HIV infection and the spread of HIV. Yet, there continues to be a need for additional studies that explore the influence that machismo and marianismo have on Latino men and women’s condom use attitudes and behaviours given the increasing HIV infection rates among Latinos, particularly living in large urban areas in which there exists much diversity among Latino sub-groups.

The purpose of this study is to explore further Latino traditional culturally-ascribed gender roles for emerging themes toward condom use influencing risk behaviours and attitudes among a diverse group of adult Latino men and women living in Miami-Dade County. Understanding risk factors and behaviours associated with HIV among Latinos is increasingly important as the size and diversity of the Latino populations continues to grow in large metropolitan areas in the USA. The arrival of new Latino groups in cities such as Miami, with long-standing Latinos populations is, in a way, reshaping the cultural environment and social fabric of these metropolitan areas (Portes and Stepick, 1993; Stepick 2003). By examining emerging perspectives on condom use among Latinos in Miami-Dade, this papers aims to contribute to the scarce literature on risk behaviours in urban areas with a high concentration of diverse Latino populations.

Review of Literature

Condom use in US Latino populations

Research has consistently reported low condom use among Latino populations in the USA (Knipper et al. 2007; Harvey and Henderson 2006; Fernandez-Esquer et al. 2004). Despite being aware of the benefit of condom use to prevent HIV and other sexually transmitted diseases (STDs), Latino men and women report widespread unprotected sex (Carballo-Dieguez and Dolezal 1996). Research notes that condom use is associated with the stability and nature of relationships; married Latino men and women report less condom use or when in a regular relationship (Pulerwitz et al. 2002). Both men and women report greater condom use with non-primarily sexual partners, perceiving fewer barriers to negotiate condom use as compared to primary relationships. The issue of trust is important factor for condom use. Accordingly, women may desist in their intent of condom negotiation due to the fear of being suspected of infidelity (San Doval et al. 1995).

Social and personal factors are important considerations in condom use as well. Aversion to condom use by Latino men has been cited as a significant barrier to consistent condom use (Hernandez et al. 2012). Gender inequality (Hernandez et al. 2012), lack of skills in negotiating condom use (Amaro and Raj 2000), low condom use self-efficacy (Fernandez-Esquer et al. 2004), adverse partner reaction to condoms (Cabral et al. 1998), and negative perceptions toward condoms (Ford et al. 2001) have all been cited as barriers.

Condom had also been found to vary with the level of acculturation among Latinos. Recent immigrant and less acculturated Latino men are more likely not to use condoms while engaging in high-risk sexual behaviours (e.g.. paying for sex, having sex under the influence of alcohol) (Sabogal et al. 1995). More acculturated Latino women report greater number of sexual partners with more consistent condom use (Marín et al. 1993). Although recent immigrant and less acculturated Latino women report fewer sexual partners, they also are less likely to have condoms available (Sabogal et al. 1995). Among Latino women in the USA, Mexican-American women have been found to have the lowest rates of condom use compare to other Latino women and other racial/ethnic minorities (He et al. 1998). Despite the heterogeneity of Latinos in the US, research on condom use patterns in relation to differences in country of origin, region, or ancestry remains limited.

Latino traditional gender roles and condom use

In Latino culture, machismo and marianismo are important cultural and social constructs influencing sexual risk behaviours and condom use (Ortiz-Torres et al. 2000). Machismo is a cultural value emphasising the man’s traditional role of protector and caretaker of the family. Valued by both men and women as a caring and strong characteristic, machismo also has disempowering and negative properties (Marín 2003; Sears 2008). As a risk factor for HIV, machismo may encourage Latino men to prove their manhood by having multiple sexual partners (Levy et al. 2005; Marín 2003), casual sexual relationships (Pleck, Sonenstein, and Ku 1993), and unprotected sex (Marín 2003). For Latino men, penetrative sex and procreation are strongly associated with virility and offer a reflection of manhood (Cianelli et al. 2008). In sexual relationships, machismo affirms men’s control over sexual encounters, including the use of condoms (Sears 2008; Fernandez-Esquer et al. 2004).

Complementing machismo’s sexual norms, marianismo promotes the image of a woman as sexually pure, submissive, and obedient, thus reflecting the characteristics of the Virgin Mary (Peragallo et al. 2012). Female chastity and asexuality are seen as important virtues of good women (Strait 1999). On the contrary, women who are sexually experienced and knowledgeable are seen as bad women and undesirable as spouses (Villegas et al. 2013). Under the influence of marianismo, the submission of women is a significant value taught to young girls, influencing their perceptions of sexuality and expected sexual behaviours. Women’s expectations are reflected in the suppression of opinions, ideas, emotions, and lack of assertiveness in sexual decision-making, even as older adults (Cianelli et al. 2008). Making sexual advances as well as initiating sex or conversation about sex remains largely a male prerogative (Galanti 2003; Bogart, Cecil, and Pinkerton 2000). Correspondingly, female desires and sexual pleasure is relegated to male desires and feelings (Cianelli et al. 2008). In this sense, traditionally, marianismo complements the cultural expectations of machismo dictating sexual attitudes and behaviours, making it difficult for Latino women to negotiate safe sexual practices even when known to be at risk for HIV or other sexually transmitted infections (STIs) (Cianelli et al. 2008).

Acculturation in the form of changes in the attitudes, values and behaviours of a group associated to the process of socialisation resulting from contact with a new culture (Phinney and Flores 2002), influences traditional sex role attitudes and expectations. Research has found that foreign-born Latino women that have spent more time in the USA, or Latino women born in the USA, tend to embrace wider, less-restrictive attitudes towards sexuality that challenge those informed by marianismo. Research has also found that second-generation Latino women are less traditional than their first-generation counterparts (Soto and Shaver 1982). On the other hand, even though recent Latino male immigrants may hold prominent views of male authority and dominance in sexual relationships, the influence of machismo has not been found to decline with time in the USA, or across generations, to the levels found among Latino women (Phinney and Flores 2002). Thus, it might be expected that acculturation will have more of an impact on risk behaviours, including condom use patterns, among Latino women than Latino men.

Methods

Participants

The findings presented in this paper derive from a larger study investigating risk behaviour among a group of Latino men and women participating in court-mandated community rehabilitation programmes. A total of 16 focus groups were conducted with a total of 67 Latino participants (39 men, 28 women). Forty-seven participants were recruited from a community agency that offers court-mandated rehabilitation classes and probation services at multiple locations in Miami-Dade County. Initial eligibility included individuals being (a) between 18–49 years of age, (b) self-identified as Hispanic/Latino, (c) heterosexual, and (c) residing in Miami-Dade. The remaining 20 participants were recruited from other community agencies or by word of mouth. In order to increase the recruitment of Latino women, recruitment criteria were opened to include women with involvement in the criminal justice system, having a history of substance use, or being related to someone with a drug abuse/criminal history. Despite the limitations of our recruitment approach, it was possible to capture some variation in the sample in terms of gender and place of birth in addition to other length of time in the USA (Table 1). Male and female participants racially identified mostly as white: 67% and 68% respectively. Seventy percent of the participants were foreign-born, the majority (51%) born in Cuba. Participants were then assigned to a focus group according to gender and preferred language (see Table 2).

Table 1.

Demographics of the focus group participants (n=67)

	Gender		Total
	Men	Women
Age*
18 – 24	8 (20.5%)	7 (25.9%)	15 (22.7%)
25 – 34	8 (20.5%)	11 (40.7%)	19 (28.8%)
35 – 44	18 (46.2%)	5 (18.5%)	23 (34.8%)
45 – 55	5 (12.8%)	4 (14.8%)	9 (13.6%)
Mean	35	32	33.8
Race
White	26 (66.7%)	19 (67.9%)	45 (67.2%)
Black	3 (7.7%)	1 (3.6%)	4 (6%)
Other	10 (25.6%)	8 (28.6%)	18 (26.9%)
Country of origin
US born	9 (23.1%)	11 (39.3%)	20** (29.9%)
Cuba	16 (41%)	8 (28.6%)	24 (35.8%)
Nicaragua	5 (12.8%)	1 (3.6%)	6 (9%)
Honduras	3 (7.7%)	3 (10.7%)	6 (9%)
Colombia	3 (7.7%)	1 (3.6%)	4 (6%)
Puerto Rico	1 (2.6%)	1 (3.6%)	2 (3%)
Mexico	0 (0%)	2 (7.1%)	2 (3%)
El Salvador	1 (2.6%)	0 (0%)	1 (1.5%)
Dominican Republic	1 (2.6%)	0 (0%)	1 (1.5%)
Venezuela	0 (0%)	1 (3.6%)	1 (1.5%)
Time in the USA***
native born	8 (21.1%)	11 (39.3%)	19** (28.8%)
1 – 5 years	4 (10.5%)	1 (3.6%)	5 (7.6%)
6 – 10 years	8 (21.1%)	4 (14.3%)	12 (18.2%)
11 – 15 years	6 (15.8%)	4 (14.3%)	10 (15.2%)
16 – 20 years	5 (13.2%)	4 (14.3%)	9 (13.6%)
20+ years	7 (18.4%)	4 (14.3%)	11 (16.7%)

^*One female participant did not disclosed age

^**One participant was born in the USA, but grew up in Colombia thus not as native born designated in this study as being ‘born and raised’ in the USA.

^***One male participant did not disclosed time in the USA.

Table 2.

Distribution of groups and participants per focus group (n=67)

	Language		Total
	Spanish	English
	No. of groups (No. of participants)
Gender
Women	4 (13)	4 (15)	8 (28)
Men	4 (22)	4 (17)	8 (39)
Total	8 (35)	8 (32)	16 (67)

Procedure

Recruitment involved research staff members being present at the targeted community agency’s offices throughout Miami-Dade. Recruitment was undertaken via presentations given to classes/groups of clients, or by approaching clients in the waiting room. Flyers were also posted explaining the study. Several individuals receiving information during the recruitment efforts provided contact information requesting more information about the study. The project director called each potential participant, described the study in detail, and, if the participant was interested, conducted a brief screening over the phone to determine eligibility. Once participants were determined as eligible to participate in the study, they were assigned to a focus group.

The number of focus group participants per group ranged from 2 to 7 participants and averaged 4 per group. The group sessions lasted between 60–90 minutes. Each group was audio-recorded. There was one moderator and a research assistant taking notes. Participants provided consent before the group began and some ground rules were provided such as the importance of maintaining the confidentiality of the group members. Each participant was given a number and was subsequently identified by that number during the group discussion. No names were used during the group discussion. The focus group guide consisted of several topic areas and questions including knowledge about HIV, motivations and attitudes toward risk reduction, barriers to risk reduction, HIV-related behavioural skill deficits and strengths, and real life decision-making scenarios.

Data Analysis

To maintain the integrity of the data, focus groups discussions were transcribed verbatim. Maintaining the original language of the focus groups in an accurate transcription is critical for the analysis of qualitative data (Oliver, Serovich, and Mason 2005). Coding of the transcripts was also completed in the original language of the interview. Segments of text from the focus groups were translated into English once they had been selected to be included in this paper by a native-speaking, bilingual research assistant. All transcriptions were reviewed for accuracy by the lead author.

Data management, coding, and analysis were done using Atlas.ti software v.7.1.7 (Atlas, 2014). Data were coded following a concurrent two-step metacoding approach (Ryan and Bernard 2000). First, the transcriptions were coded for thematic categories describing the participants’ risk behaviours and condom use from a list of predetermined categories related to the primary key research topics. The categories included: Latino culture, machismo, marianismo, and HIV risk behaviour. Second, the text was coded following a grounded theory approach, allowing categories, themes, and patterns to emerge (Strauss and Corbin 1998). Notes on patterns and themes observed during the coding were documented with memos using Atlas.ti’s Memo function. Memos were linked to the text as part of the analysis and coding of the data.

Results

In this paper, we focus on emerging themes on culturally-ascribed condom use attitudes and behaviours among a diverse group of Latino men and women in Miami-Dade. Results are interpreted from the perspective that men and women participate in the process of constructing notions of gender, power, and sexuality; that is, by exercising agency and redefining culturally ascribed gender roles and expectations in processes interacting with structural and sociocultural influences (Browner 2000). Among the multiplicity of factors influencing this process, acculturation is particularly relevant given the diverse background of the Latino population of the study. Although understanding acculturation involves an examination of complex processes and factors (Kulis et al 2012; Acevedo 2000), which is beyond the scope of this paper, critically, the concept provides a lens through which to interpret emergent themes on sexual risk behaviour participants express as they seek to reconcile traditional culture norms and sexuality with their everyday life experiences in a new and diverse socio-cultural environment.

Men’s construction of the “clean-dirty” woman classification for condom use

There was a general agreement among the Latino men participating in the study that condom use was disliked. Preference was given to having unprotected sex cited as being natural and more pleasurable even when men were aware of the risk for HIV infection and other STDs. Yet, men’s attitudes towards consistent condom use varied depending on the characteristic of the sexual partner.

If you see a girl that’s really easy, and she’s obviously a flirt and obviously got more than one boyfriend and stuff, you’re gonna consider using a condom. But if you meet some, plain Jane looking girl that seems okay and stuff, then you know, there’s a big difference. (Participant 6, Men’s English group 1)

Although many men offered similar examples of condoms use patterns, when asked specifically, many of the men described classifying potential sexual partners as either easy/dirty or good/clean when making the decision. The expected behaviour and demeanour of women (and by implication her adherence, or otherwise, to norms of marianismo) seemed to inform men’s construction of the “dirty women”

Dirty as in promiscuous or, they don’t get checked up regularly, or they’re willing to take anyone without a condom.’ (Participant 2, Men’s English group 1)

They’re loose, they’re sluts, they go out, their plan is to who can I sleep with tonight. (Participant 4, Men’s English group 4)

… like there’s no really like way to describe it, you just notice in like their personality. Like they are up front, they’re straight forward; they don’t care about what people think about them. (Participant 1, Men’s English group 4)

Men in the study also identified the social environment as a factor influencing the classification of women. According to many respondents meeting location informs their classification of women and their perceptions of risk,

If I go to a strip club and I’m there, and I’m sure there’s a red flag just popping…But if I’m in a supermarket or other places, in a different environment and, we happen to be – we’re in a family gathering – who knows! (Participant 2, Men’s English group 2)

It depends on where you met her, depends on how you meet. Because if you met at a club, at a bar, at a party. You always know that when the party ends, you go from there to the bed. (Participant 6, Men’s Spanish group 1)

A woman’s reputation is another important factor men took into account. For example, having sexual relations with a woman believed to have multiple sexual partners dictated condom use.

I always wanted to do it with this girl and then … my homeboy was telling me that she’ll be showing it around (sleeping around)…When I was with her and then we were gonna [have sex], I told her… she was like “oh you wanna use a condom.” I’m like “yeah, you know ‘cause I know you showing it…” (laughing). So I just strap up. (Participant 3, Men’s English group 4)

The differentiation men reported between dirty and clean women was reinforced further when men described safe sexual partners. For some men, once again, location and reputation were important factors influencing perceptions of a “clean” woman.

When I got out of prison, the first thing I did was I see girls out on street and I bought a handful of condoms and I put them in my wallet. But I never got to use them ‘cause I met some nice girl that lives next door…I ain’t got to worry about it. She’s fairly decent and clean. (Participant 6, Men’s English group 1)

I am more at ease, more comfortable, with a woman when I know I have to insist with her to have sex. Married women, for example; she is married and you have been insisting for one, two months. When the moment happens, I don’t feel I have the need to use a condom… (Participant 6, Men’s Spanish group 1)

Some men stressed the importance of sexual experience in the classification, equating youth with inexperience despite contradicting evidence.

I have a friend that he tends to seek younger females and he never uses a condom cause to him he says that, ‘they’re the cleanest,’ even though they’re the ones that do the most craziest things in the bedroom…(Participant 1, Men’s English group 1)

Although many men reporting trying to differentiate between dirty or clean women when deciding whether or not to use a condom, some participants acknowledged problems with the classification. After reflecting on his decision not to use condoms with his now long-term girlfriend, one man observed:

Participant: [when] I first met her, I didn’t know where she came from, and I – we didn’t talk about the sex thing before we had sex and unprotected sex and I…so she might have had something…

Facilitator: You didn’t talk about condoms or anything?

Participant: Nope. Not even used one, not even on the first time. Not even think about, ‘oh well, she look healthy’! Now that you bring it up to my attention (laughing), it’s not like we’re barhopping or whatever. But look, yeah, it’s too late…Now that I’m thinking about it, that’s pretty scary. (Participant 1, Men’s English group 2)

In addition to being problematic because of the risks some men may take, the classification informing condom use patterns is important because it was primarily discussed among the English-speaking Latino men in the study. As their narratives suggest, some of these men experienced changes in attitudes towards the use of condoms which are not often associated with traditional views of machismo, speaking to the potential impact of acculturation in the process.

Women’s empowerment - duality in condom preferences

Gender disparities and norms promote Latino men’s control over sexual encounters and decisions about condom use. In line with these same norms, Latino women tend to be submissive and less assertive with sexual partners. Although study participants discussed the influence of marianismo on women’s behaviours, many Latino women also reported being sexually assertive in sexual encounters, particularly in regards to negotiating condom use.

Whenever we (women) say “condom?” [men say] “No, I don’t have one.” “Then we’re not having sex.” “But I can’t just go get a condom.” “Ask a friend for a condom, I’m sure anybody has a condom, just go get a condom and comeback. If not we’re not having sex, as simple as that.” (Participant 2, women’s English group 4)

So, even sometimes, [men] beg you, please, to not use one. That’s difficult, but then you don’t want to have sex because they are so annoying. Is like a turn off. I am not going to change my mind regardless. I prefer…I have toys at home and I take care of myself. (Participant 2, women’s Spanish group 1)

Control over the sexual decision-making process was also evident among women in ongoing regular relationships. For example, one woman described how she forced her spouse to use condom after big arguments.

We used condoms after we got married because we had several fights and my husband left the house. So, when he returned I punished him with that. (Participant 1, Spanish group 1)

Many women displayed assertiveness in the way they actively participated in the decision-making concerning condom use as a way of staying healthy. For them, strict personal guidelines, including regular testing, were part of maintaining a healthy sexual life.

I am a person that I have been in relationships twice, over 4 years. But in order for me to not use condoms, I have to be with the person at least a year and tested regularly. (Participant 1, women’s Spanish group 3)

Us women, we tend to take more care. We can’t really much do anything, who we choose to be with, and who we choose to have relationship with, but at the same time, in a relationship nowadays, is not a 50/50 way. You go get checked and I go get checked. Because I think that women (are) more hesitant. I have my children to live for. I have a life to live for. (Participant 3, women’s English group 4)

Sexual assertiveness was also reported by some women in their preference for unprotected sex.

I know I look good, and the more men that we get… I used to think that we give it them, we give them without protection, they’re gonna like it more and it’s gonna have more feelings to it. And to me, personally, I like it without condoms too, because it gives me more pleasure as well. (Participant 3, women’s English group 1)

I personally do not like using condoms. I have been with a boyfriend 5 years, so I started to use the birth control pill, so I stopped using condoms with him. And luckily, sex is much better. It feels better without condoms. (Participant 2, men Spanish group 1)

Some of the men in the study shared women’s preference for unprotected sex, even against their own desire to use a condom.

I have been with women that I have told them “use a condom.” They say “No, no, no”; that they don’t like doing it with a condom. I am very clear and sincere. Without a condom I don’t do it because I have a family. (Participant 2, men Spanish group 2)

I got into fights because I wanna use it (condom) and she don’t wanna use it… Sometimes, the girls don’t want to use it. Even in my country (Nicaragua) they said that it’s ridiculous, that’s awkward. They want to experience it first…(Participant 3, men English group 3)

When asked, participants offered different opinions to explain women’s preference for not wanting to use condoms.

I’ve never had a man if I wanted to wear a condom say “no” to it. I just think that the women nowadays are becoming more loose. I guess promiscuous is the word and they’re just not caring about it. (Participant 1, women’s English group 1)

When I’ve been sitting with friends and I have spoken about using condoms and all my friends will be like “noo… it’s not the same, it doesn’t feel the same you know, you feel something in the way, it doesn’t feel natural, it doesn’t feel right…” (Participant 2, women’s English group 4)

For some of the women in the study, the idea of using condoms during sexual encounter was felt to be insulting. Participants commented how female preferences for unprotected sex is used was one way of affirming being “clean.”

I think girls they’re the ones that don’t wanna be using condoms anyway…it’s probably 50-50 percent but I’ve seen a lot of girls like that, ‘cause the one things that girl’s gonna say is… oh you don’t believe me…I’m clean…You could be like “oh I got a condom” and all of the sudden the girls would be like “why you wanna use that, you know me?” (Participant 3, men’s English group 4)

…things tense up when a lot of love, emotion, are involved so, that’s where the trust issue comes in. And I trust you, you trust me, so let’s just do it. And that’s the pressure because she doesn’t wanna make him feel offended, like she’s offending him. And he doesn’t wanna feel like he’s offending her, and say, hey wear a condom and I wear a condom. So what are you trying say “I’m dirty,” you know so…cause they love each other. (Participant 3, women’s English group 4)

While several women in the study explained their preference for unprotected sex in terms of a general aversion for condoms, others suggested that refusal may be indicative of something more than a personal preference.

Girls be like nowadays like ‘oh suck my dick you’ know… cause they act like they’re men. They wanna feel that power that guys do…that they get to do whatever they want. [Men] just come home and everything is done…and they could sleep around with whatever woman they want. So now girls, all of them, they’re sleeping with anybody. (Participant 1, women’s English group 3; emphasis added)

Similar to the trend noted among the men, women’s preference for condom use was primary reported by the English-speaking women in the study. Although this tendency was not aligned with the behaviours and attitudes expected of women through marianismo, it cannot be viewed as an outright rejection of marianismo by these women. Instead, the patterns highlights the influence of acculturation and the role this may play in informing sexuality and the construction of present-day Latino gender roles in the USA.

Discussion

Data from the study offer insights into perspectives on condom use among a group of diverse Latino men and women in Miami-Dade. Finding from the focus groups described attitudes and behaviours that run counter to traditional gender roles informed by machismo and marianismo. Common attitudes observed in this study include men’s classification of women into two types when making decisions about condom use, and women’s assertiveness during sexual encounters negotiating condom use, both in favour and against it. Under the influence of machismo and marianismo, the findings indicate attitudes towards condom use are informed by processes in which both men and women assess, control, and exercise decision making. The process differs greatly between men and women, having an impact on the risk behaviours in which each engage.

With regards to expected culturally ascribed behaviours, Latino men in the study report the least divergence from traditional patterns of machismo. This is not surprising given that machismo serves Latino men well. According to our findings, condom use is a preferred strategy when the perceived risk with sexual partners is determined to be high based on the ‘dirty-clean’ classification. Here, the classification of women takes place within the cultural fabric of machismo so as to maintain men’s control over the sexual encounter and gender power relations. Thus, engaging in protective behaviours when risky provides men with the ability to control sexual encounters and lower the risk of infection without having to put to one side other macho behaviours (e.g., sex with multiple sexual partners, Marín 2003).

The ‘clean/dirty distinction may have important implications for an understanding of risk behaviour patterns among Latinos for another reason. A post-hoc analysis of the codes used to identify themes of this distinction indicates that the classification was mostly reported by the English speaking Latino men, with 75% of the coding identifying the ‘dirty/clean’ classification being documented in the English focus groups transcripts. Although taking language as an sole indicator of acculturation level can be problematic, language use and preference, as an expression of cultural behaviour, is an important component of acculturation and thus may offer a useful proxy in this regard (Lee, Nguyen, and Tsui 2011; Marsiglia and Waller 2002). These findings suggest that acculturation may have an influence on risk behaviours which differs from the already known about behaviours associated with machismo.

Latino women on the other hand reported making the greatest adjustments in reference to expected traditional gender norms. As our findings suggest, many Latino women in the study act counter to expected traditional roles and demand condom use thereby subverting [women’s] culture (Ortiz-Torres et al. 2000). When exercising power over the decision-making about condom use, women report control over reducing the risk of infection. While in some cases women reported a sense of empowerment leading to safer sex (e.g., consistent condom use, ongoing testing), control over their sexuality was reported by other women via the adoption of behaviours that placed them at greater risk as well (e.g., through a preference for unprotected sex). One possible explanation to the conflicting pattern described in the study may reside in the nature of the study’s sample. Women participating in, or associated with someone in a court-mandated rehabilitation programme, may be less influenced by traditional Latino cultural norms. The scope of this study prevents is from drawing firm conclusions in this regard, which, added to the silence of the literature in this area, calls for additional research among members of this population.

A possible explanation for the contrasting patterns described among the Latino women in the study may also be linked to acculturation. Similar to the findings reported by men, the assertive patterns described by women in this study were primarily reported by English speaking Latino women. The analysis of the codes used to identify themes on women’s empowerment found that 61% of the codes were assigned to the transcripts from focus groups conducted in English. This is not surprising given that more acculturated Latino women may experience lesser influence of Latino gender role norms resulting in conduct that does not necessarily conform to traditional cultural expectations (Phinney and Flores 2002). Nevertheless, the contrast in condom use preference suggests the need to explore further risk behaviours among Latino women with the aid of more comprehensive assessments which include acculturation in the analysis. Undoubtedly, such a duality, much like in the case for men, presents an important challenge to practitioners seeking to develop prevention interventions that more accurately reflect women’s views on sex, sexual health, and risk.

There are several limitations to the study. First, this was an exploratory descriptive study that used a small sample size and therefore the findings have limited generalisability. However, a large number of focus groups were conducted in order to elicit different perspectives based on gender and language. Second, the focus group dynamic can present a participants with a barrier to sharing opinions and personal information on private topics such as sexual behaviours, preferences, and condom use in front of others. Social acceptance may be an issue with participants not wanting to be viewed negatively by others in the group. We addressed this issue in multiple ways. Need to of share information in a group format. Participants were made aware of this again as part of the informed consent procedures before the focus group. The importance of confidentiality and respect for other’s opinions inside the group was emphasised before and during each focus group discussion. Two highly experienced facilitators conducted each group to create a comfortable environment conducive to sharing experiences of a private nature. Third, the majority of the participants were recruited from an agency that provides court-mandated rehabilitation classes and probation services. The impact of the participants’ involvement in the criminal justice was not assessed in the analysis. Finally, concepts of machismo and marianismo offer an over-simplification of complex factors that vary among Latino sub-groups and situational contexts that are in need of deeper analysis.

Conclusions

Miami-Dade County currently leads the USA with the highest rates of new infections in the country, and the numbers of Latino men and women infected with HIV in the county continues to increase. Within the context in which this study took place, future research and more importantly future actions need to take into account the emerging themes pointed to here. Within this context, we suggest that the patterns of response seen here can best be interpreted from the perspective of a redefinition of gender roles and expectations for culturally diverse Latino men and women living in a multi-ethnic and racial environment. For example, study participants noted a shift in attitudes toward sex education with respect to educating their children. Many of them indicated that while they had never received a “sex talk” from their parents, they themselves had either already spoken to or intended to speak to their children about sex and condom use. Parental communication is an important socialising factor influencing not only attitudes toward the use of condoms, but also towards sex- and sexuality- related behaviours (Raffaelli and Green 2003). Although cultural values continue to play an important role in the everyday life of the Latino communities in the USA, the effects of acculturation resulting from time in the USA or by being US-born may affect the influence of traditional cultural values in gender roles and behaviours of Latino men and women (Lara et al. 2005; De la Rosa 2002). Thus, understanding risk behaviours and attitudes towards condom use can offer research insight into the construction of gender, power, and sexuality and what it means to be a Latino man and woman in the USA. Interventions that reflect such cultural redefinitions are needed to encourage and support safe sexual practices among individuals and their descendants.