Gender Ratio Imbalance Effects on HIV Risk Behaviors in African American Women

Abstract

Although literature suggests that African American women are no more likely to engage in risky sex than their White counterparts, they are more likely to have sex partners with higher HIV risk. Thus, it is not solely an individual’s behavior that determines their risk, but also the behavior of their partner and their position within a sexual network. For this reason, it is important to consider the dynamics of heterosexual relationships in the African American community. An important area of concern regarding African American heterosexual relationships is that of partner availability. A shortage of available African American men for potential partnerships exists and is reportedly due to poorer health and higher mortality rates. Some have argued that gender-ratio imbalance may be responsible for increased HIV vulnerability for African American women. This article reviews the literature on gender ratio imbalance and HIV risk in the African American community, and presents implications and suggestions for future research and intervention.

Acquired Immunodeficiency Syndrome (AIDS) is currently the leading cause of death for African American women between the ages of 25 and 34 (Centers for Disease Control and Prevention, 2009a). African Americans account for only about 12.8% of the population (U.S. Census Bureau, 2008) but for 51% of the HIV/AIDS population in the United States. Heterosexual contact (83%) is the most common method of transmission.

Studies suggest that although African American women are no more likely to engage in unprotected sex or have multiple sexual partners than their White counterparts, African American women are more likely to have sex partners with higher HIV risk (Tillerson, 2008). Thus, it is not solely an individual’s behavior that determines their risk, it is also the behavior of their partner and their position within a sexual network. As African American men have some of the highest rates of HIV infection in the United States, (Centers for Disease Control and Prevention, 2009a), African American women may be at a greater risk of infection because of the high risk of their heterosexual male partners (Neblett, Davey-Rothwell, Chander, & Latkin, 2011; Nunn et al., 2011). This article aims to provide information on structural factors that increase risk in this group so that health educators in practice settings have a better appreciation for what this means for policy interventions. We also draw attention to the importance of “risk situation” rather than “risk factors” as we believe practitioners should focus on addressing risks associated with circumstances experienced by a group rather than focusing only on individual-level risk behaviors.

Gender ratio imbalance has been cited as one factor contributing to vulnerability of African American women given a shortage of eligible men. The ratio of African American women to men is unbalanced, with 90.1 males per every 100 females (U.S. Census Bureau, 2000). The gender ratios for other racial groups are not as drastically imbalanced compared with African Americans, with Hispanics at 105.1 males per 100 females, Native Americans at 98.7 males per 100 females, Whites at 96.3 males per 100 females, and Asians at 92.8 males per 100 females (U.S. Census Bureau, 2000). Comparatively, Asian Americans experience similar gender ratio imbalance but do not confront the same level of institutional racism and mortality risks that affect the African American community. The rates of HIV infection in other racial groups are also lower than African Americans, with Whites accounting for 29% of new infections, Hispanics 18%, Asians 1%, and Native Americans accounting for less than 1% (Centers for Disease Control and Prevention, 2009b). As such, there is a need to look beyond individual behavior and focus on structural factors such as low employment rates and high incarceration rates for African American males and how this has disrupted intimacy and relationships in this community (Fullilove, Fullilove, Haynes, & Gross, 1990). African American men who have been economically marginalized may be less appealing as potential life partners to women, which may be further narrowing the pool of ideal partners and further exacerbating the gender ratio imbalance as it relates to partner availability in the African American community. If African American men are at greater risk for HIV infection, it is important to consider structural factors that likely expose these men to HIV risk without blaming them for the impact on their partners’ increased risk.

Though individual-level factors of HIV risk are of great importance, they are limited in accounting for the disparities observed in transmission rates across racial groups. When it comes to a matter of relationships, an individual’s behavior alone is not a sole predictor of HIV risk. A woman’s partner’s behavior and her own position within a sexual network are believed to account for more of her risk for HIV infection (Morris, Kurth, Hamilton, Moody, & Wakefield, 2009). This is particularly true where African Americans have a smaller sexual network (Laumann & Youm, 1999), as they more commonly tend to choose only other African Americans as sexual partners (Laumann & Youm, 1999), yet they have the lowest ratio of men to women compared with other racial groups (Tillerson, 2008). These relational dynamics in the African American community have been attributed to higher rates of concurrent sexual partnerships, likely resulting in higher rates of sexually transmitted infections (STIs)/HIV infections (Adimora et al., 2002).

SEXUAL NETWORKS

A sexual network is a group of individuals that are connected either directly or indirectly through sexual contact (Adimora et al., 2003). For African Americans, studies suggest differing patterns of sexual networks compared with White networks (Adimora, Schoenbach, & Doherty, 2006). Within–racial group patterns of relationships tend to be the norm for African Americans; particularly women, compared with Whites (Morris et al., 2009). As African Americans are more likely to choose sexual partners who are also African American (Laumann & Youm, 1999), the sexual network becomes a smaller circle within which a transmittable disease can spread more rapidly.

Another important feature of African American sexual networks is that of concurrent sexual partnerships. A concurrent partnership can be defined as multiple simultaneous sexual relationships, or sexual relationships that overlap in time (Morris et al., 2009). These types of partnerships facilitate an even more rapid transmission of infection through a sexual network than would be the case in sequential sexual partnering (Morris & Kretzschmar, 1995). In contrast to Whites, African Americans with fewer sex partners are still more likely to be sexually involved with partners who are involved in concurrent partnerships (Laumann & Youm, 1999), resulting in sexual networks where the high risk behaviors of a few increases the level of risk for the entire group. This is because the network is more racially segregated, and thus smaller, resulting in more frequent interactions between high- and low-risk individuals (Laumann & Youm, 1999). Within-group mixing, particularly when there is higher risk within the group, would tend to increase infection rates for everyone in the group (Adimora, Schoenbach, & Floris-Moore, 2009). This was demonstrated in a study conducted in 2007 found that African American men and women with “low-risk” behaviors had 25 times higher incidence of HIV and other STIs than their White counterparts (Hallfors, Iritani, Miller, & Bauer, 2007).

A study conducted by Morris et al. (2009) examining concurrent partnerships and HIV prevalence disparities found that the rates of concurrency in African American male participants between the ages of 20 and 38 were 3.5 times higher than their White counterparts and 1.9 times higher than men of other racial backgrounds. In the same study, African American females had rates of concurrency at 2.1 times higher than their White counterparts and 4.1 times higher than women from other racial backgrounds.

Results from the 1995 National Survey of Family Growth, sponsored by the National Center for Health Statistics, revealed that the prevalence of concurrent sexual partnerships was higher in African American women at 21% in the preceding 5 years than in Caucasian women at 11% in the preceding 5 years (Adimora et al., 2002). These differences are likely due to lower rates of marriage for African Americans (Bowleg, 2004) and earlier age of onset of sexual activity for African American females, as the differences between African American and Caucasian women diminished when these variables were controlled (Adimora et al., 2002; Adimora et al., 2006). The context of limited partners and its role in the notion of concurrency have become a primary concern in assessing control HIV transmission among African Americans.

GENDER RATIO IMBALANCE AND LIMITED PARTNERS

The risk behavior of African American women and concurrent partnerships has been related to the shortage of eligible and available African American males for heterosexual relationships (Wyatt, 1997) and unbalanced gender ratios which can negatively affect the quality and stability of relationships (Cornwell & Cunningham, 2008). It is likely that most young heterosexual adult women are eager to secure a marriageable partner with whom they can start a family. The limited availability of heterosexual African American men in the community may make this goal difficult to achieve. African American men in high demand by African American women may have more power to negotiate the type of relationships that they desire because of their limited availability. This dynamic can privilege men’s decision-making power and authority in a relationship. The more power available to men in heterosexual relationships, the greater the likelihood that women will have poor health outcomes (Wingood & DiClemente, 2000). Men who maintain concurrent partnerships may be less likely to concede to the demands of their female partners as they may feel confident that the women will be hesitant to jeopardize the status of the relationship because they are aware that primary relationships are difficult to secure in the African American community (Thomas & Thomas, 1999).

African American women contending with the gender ratio imbalance that exists may relinquish negotiating power in their relationships, be more likely to settle for less desirable partners, accept infidelity, and agree to engage in unprotected sex (Bowleg, 2004). A limited pool of potential partners may create competition among women for those African American men who are economically stable and interested in making marital and family commitments (Wyatt, Forge, & Guthrie, 1998). Such competition could place women in a vulnerable position of acquiescing to concurrent sexual relationships. Thus, gender ratio imbalance may also promote concurrent sexual partnerships in the African American community. Man sharing is a term commonly found in the literature addressing concurrent partnerships in the African American community (Airhihenbuwa, DiClemente, Wingood, & Lowe, 1992). This term refers to African American women engaging in sexual relationships with men who have other concurrent partnerships either with or without the knowledge of the women involved. This reinforces the point that a woman’s risk level is a factor of systemic and social arrangements rather than her own individual choices.

Ferguson, Quinn, Eng, and Sandelowski (2006), in a study conducted at historically Black colleges and universities found that African American college-age females believed that the a disproportionate gender ratio imbalance resulted in men having multiple female sexual partners and women relinquishing their agency and complying with men’s preferences for condom or non-condom use to secure a sexual partner. The young women in this study also perceived that the females outnumbered males in greater numbers on campus than was actually the case. The investigators posited that African American women outside the setting of historically Black colleges and universities are likely to have similar experiences in their attempts to form intimate partnerships (Ferguson et al., 2006).

Men are usually more motivated by the erotic and physical aspects of sex, whereas women are more motivated by the romantic and relational attachment of sex (Houston, 1981). Jones (2006) suggests that women may anticipate that patterns of unprotected sex could result in increased connection through physical intimacy and in feelings of reassurance even from ambivalent male partners. Thus, women who are fearful about losing their male partners may gain a sense of stability (albeit fleeting) as a result of establishing unprotected sexual partnerships (Jones, 2006). Even within the context of known man sharing, women may still be unlikely to insist on safer sex through condom use as the use of condoms may imply that “this person or encounter is not so special or unique” (Afifi, 1999). As many studies have found that the use of condoms in primary relationships can carry a stigma of distrust or limited commitment (Hammer, Fisher, Fitzgerald, & Fisher, 1996), women involved in man sharing may prefer to forego using condoms in order to maintain their outward sense of monogamy (Jones, 2006).

A GENDER- AND CULTURE-BASED APPROACH FOR INTERVENTION

In researching ways in which practitioners can approach future interventions to address risk situations in the African American community, theories such as those presented by Amaro (1995) and Miller (1986) are very instructive. Amaro offers the following four major assumptions that should foreground investigating women’s risk:

(a) women’s social status as a central feature in women’s risk, (b) connection and the relational self in women’s development and the fear of disconnection due to conflict as critical features in women’s risk, (c) male partners as key role players in women’s risk, and (d) experience and fear of physical and sexual abuse as an important barriers to risk reduction among some women. (p. 442)

In 1986, Miller proposed a theory of women’s development that focused on connection. This theory postulated that the relational self is at the center of self-structure for women. A relational self refers to the ability to establish and enhance relationships with others. The value placed on being connected to others (in this case male partners) may outweigh other aspects of life, such as health protection. Miller believes that “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” (p. 83). With this in mind, it is not difficult to understand that for many women, maintaining a relationship is oftentimes privileged over personal health risk to themselves, particularly when traditional gender roles reinforce a premium on love and romantic relationships (Higgins, Hoffman, & Dworkin, 2010).

Amaro (1995) also advanced a model that centralizes women’s experiences in addressing sexual risk:

(a) the centrality of connection to others as a core aspect of self, (b) the degree to which conflict in relationships [especially conflict related to safer sex negotiation] and fear of disconnection is threatening to women, (c) the degree of mutuality in the relationship with the male partner, (d) skills and comfort in dealing with conflict, and (e) the degree to which pregnancy and childbearing are perceived as avenues for further connecting with male partners. (p. 443)

This is instructive as a study by Wyatt et al. (2000) found that African American women’s emotional need for a romantic partner may be more influential in their decisions about protective behaviors than personal risk prevention decisions alone.

CONCLUSIONS

African American women are influenced by their relationships with their men and their broader social and institutional contexts (Bell, Bouie, & Baldwin, 1990). Future prevention and intervention efforts focusing on this group of women must account for their HIV risks relative to the particular dynamics at play within their sexual networks and the psychosocial drivers influencing their risk for HIV infection (i.e., desire for romantic partnerships). For this reason, the unique experience of African American women deserves a more targeted approach. HIV prevention and education in the form of culturally based approaches may be the most effective motivators for behavior change in this community (Airhihenbuwa et al., 1992). Gender-based theories such as those outlined above can provide a strong foundation for addressing prevention in this group. Combining these theories with a community-based participatory research approach would provide researchers with more insight into the underlying phenomena driving situational risk factors that affect the risk behaviors of these women. Both qualitative and quantitative research methods would help us better understand the ways in which the gender ratio imbalance and low partner availability affect African American women’s sexual risk where marriage, family, and motherhood are culturally valued and the relatively segregated sexual network presents a higher risk for HIV acquisition. Strategies aimed at increasing women’s awareness of the greater risk for individuals by virtue of their belonging to a particular race and sexual network could also enhance current prevention strategies in the African American community, as African American women tend to underestimate their risk for HIV infection (Neblett et al., 2011). The unique experiences of African American women deserve a more targeted approach. An eye toward gender coupled with a cultural lens may magnify the often overlooked variables that can prove most salient in identifying how and why HIV persists as a leading cause of death for African American women.