Exploring the Masculine Identity in the Context of HIV Prevention in Chile

Abstract

Purpose:

This study aims to describe human immunodeficiency virus (HIV)-related knowledge and beliefs, as well as understanding attitudes towards masculinity in the context of HIV prevention, held among Chilean men.

Design:

This study reports the qualitative findings of a sequential qualitative-quantitative mixed methodology study: Bringing men into HIV Prevention in Chile, NIH R01 TW007674-03.

Methods:

Twenty in-depth interviews using a qualitative, descriptive approach to elicit information for the study were conducted among men residing in two communities of low socio-economic status in Santiago, Chile.

Findings:

Content analysis of interviews revealed three main themes regarding machismo and how it relates to HIV: sexuality and machismo, the changing nature of machismo, and violence against women.

Conclusions:

Addressing HIV and intimate partner violence through developing education programs tailored to meet the needs of Chilean men are needed to include men in HIV prevention efforts.

Clinical Relevance:

Specifically, incorporating ideas of what men consider healthy masculinity and working to destigmatize men who have sex with men are important steps in addressing the negative aspects of machismo.

The most recent report from the Joint United Nations Program on HIV/AIDS (2011) indicated that over 34 million people worldwide were living with the human immunodeficiency virus (HIV), with 2.7 million new infections, and 1.8 million HIV-related deaths, which reflects an increase in HIV prevalence worldwide. This situation is similar in Latin America, where the total number of people living with HIV (PLWHIV) continues to grow, with a significantly higher number of HIV cases experienced among men in comparison to women (United Nations AIDS [UNAIDS], 2011).This growth in new infections is heavily concentrated among populations of men who have sex with men (MSM), sex workers, and injection drug users (UNAIDS, 2012).

According to UNAIDS (2011), the prevalence of HIV among adults in Chile was approximately 0.4% up to 2011. From 1986 to 1990, the ratio of men to women living with HIV was 7:1, however as of 2011 the ratio had dropped to 3.6:1. Even with increased cases of HIV among women, men still represent the larger portion of total cases (Chilean Ministry of Health, 2007, 2010; Ministerio de Salud, 2011). The main form of transmission in the Chilean population occurs through sexual contact (87.6%) with the highest rates being among adult men (UNAIDS, 2012). These data are reflected in Santiago, the region where more than half of the Chilean population resides and has been identified as having the third highest prevalence of HIV (Ministerio de Salud, 2011).

The majority of the reported HIV cases in Chile were acquired through sexual contact with an infected partner, a pattern that may be explained by the presence of traditional gender roles and gender inequalities presented in the concepts of machismo and marianismo (Cianelli, Ferrer, & McElmurry, 2008). Machismo is the expression of a masculine identity that frames men as providers, independent, strong, willing to face danger, dominant, heterosexual, virile, knowledgeable, aggressive, and in control of women (Cianelli et al., 2008; Gonzalez, Molina, Montero, Martinez, & Leyton, 2007). Marianismo is the expression of a feminine identity considered the complement of machismo; it denotes the submission of women to men and an ideal of women as being pure, dependent, vulnerable, abstinent until marriage, innocent, silent, and self-sacrificing (Cianelli et al., 2008; Patz, Mazin, & Zacarias, 1999). Marianismo discourages women from confronting their sexual partners about their sexual behavior and supports the submission of women to men (Arciniega, Anderson, Tovar-Blank, & Tracey, 2008; Cianelli et al., 2008).

The concept of machismo encourages men to have multiple female sexual partners as a way to express their masculinity. Having multiple sexual partners puts men and their partners at higher risk for contracting HIV because of the increased possibility of having a sexual contact who has HIV. Sexual contact under the influence of drugs and alcohol or having coerced sexual contact can increase HIV risk (Caceres, 2002; Cianelli et al., 2008; Gonzalez et al., 2007). In addition, the threat of being stigmatized for being an MSM, due to homophobia associated with machismo, is often considered cause for an MSM to engage in sexual contact with women (Estrada, Rigali-Oiler, Arciniega, & Tracey, 2011; UNAIDS, 2010). MSM have been reported to conceal having male sexual partners and continue sexual relationships with female partners, who believe they are engaged in a monogamous relationship (Cianelli et al., 2008; UNAIDS, 2010).

Intimate partner violence (IPV) and coerced sexual relationships are reported to be related to the negative aspects of machismo, increasing the risk for HIV acquisition (Miner, Ferrer, Cianelli, Bernales, & Cabieses, 2011). IPV is an important issue many Chilean women experience in relationships, and its significance can often be interrelated with cultural norms learned during childhood, such as that women must be good wives and mothers; that women must be respectful of and dependent on men; that men make all the important decisions, including those that have to do with women′s aspirations and goals in life; and that women must subordinate their pleasure to the decisions and feelings of men (Arcos et al., 1999; Cianelli, 2003; Cianelli et al., 2008).

However, while domestic violence in Chile is extremely taboo and some people accept the aggressor′s actions because of machismo, the culture promotes the supremacy of men over women (Cianelli, 2003; Cianelli et al., 2008). The reason why this is taboo relates also to machismo, since men can act aggressively and will receive no punishment; most women will stay silent, because it is accepted and sometimes even seen as something they deserve.

Machismo has also been reported to promote protective factors against HIV acquisition, in which a man is expected to treat women with respect, work hard to provide for his loved ones, and be a good husband and father (Arciniega et al., 2008; Cianelli et al., 2012; Neff, 2001). These positive traits are sometimes referred to as caballerismo (Arciniega et al., 2008; Cianelli et al., 2008). The changes in Chilean society—such as women working outside the home, equal access to education for women and men, and the identification of more egalitarian relationships in which men develop activities that are traditionally related to the woman′s role in society—may indicate a change in cultural values (Contreras & Plaza, 2010; Salinas, 2007). Chilean women are reported to be less willing to accept behaviors associated with machismo, particularly if they work outside of the home (Contreras & Plaza, 2010). Similarly, those women with more education reportedly experience less presence of traditional gender roles and have more access to work outside the home (Contreras & Plaza, 2010). However, other studies conducted in Chile indicated that even when men are open to gender equity, in daily life women are still responsible for household chores and childcare (Salinas, 2007).

Gaining deeper understanding of how Chilean men relate to masculinity, and machismo in particular, may help to identify sexual risk factors for HIV acquisition and increase men′s ability to discuss health-related issues related to certain risk factors. That understanding can be achieved through men′s testimonies and discourses of the meanings they assign to male roles and their connection to HIV, something not previously reported for Chile or foreign countries.

This study aims to qualitatively describe HIV-related knowledge and beliefs, as well as understanding of masculinity and HIV prevention held among Chilean men residing in two socio-economically disadvantaged communities in the Chilean capital, Santiago. Information was obtained through the original study, which used a sequential qualitative–quantitative design to identify contextually specific needs of low-income Chilean men and then to test the effectiveness of a culturally tailored peer group, an HIV/AIDS prevention intervention based on models that have been utilized for low-income Latinas in Chicago (Peragallo et al., 2005) and for adults and adolescents in rural Malawi (Norr et al., 2006).

Methods

To report the qualitative findings of the sequential qualitative–quantitative study, Bringing Men into HIV Prevention in Chile, a qualitative, descriptive approach using in-depth interviews to elicit information was utilized. This method was selected because it provides an in-depth understanding of the phenomenon of interest by obtaining a detailed view from the participant′s perspective (Creswell, 2007). Researchers stay closer to the data and to the meaning participants give to the facts (Sandelowski, 2000). The researchers obtained information from in-depth interviews with participants to disclose aspects of the phenomena that were less accessible in other research methods.

Setting and Participants

The study was conducted in Santiago, Chile, specifically in two low-income communities located in the southeast area of Santiago′s metropolitan region. This region, together with Arica-Parinacota, Tarapacá, and Valparaíso, has a large concentration of people living with HIV in Chile (Department of Epidemiology, Chilean Ministry of Health, 2013). The southeast area is one of the most affected by HIV infection in the Region Metropolitana (Chilean Ministry of Health, 2009). Considering their similar socioeconomic statuses, their high-risk profiles, and the potential benefits for the community that their participation could offer, these communities were invited to participate in the study.

Twenty men participated in the study. To be eligible, participants met the following inclusion criteria: (a) being Chilean, (b) being at least 18 years old, (c) living in one of the two selected communities, and (d) being willing to participate. All the participants were between 18 and 60 years old, lived in low-income communities in the southeast area of Santiago, and had at least 7 years of formal education. Most of them were working in construction or low-paying jobs.

Saturation was used to determine the sample size of the qualitative data. At the point when no new data were emerging from the interviews, it was determined that the topic was saturated, indicating that the limits of the phenomena had been covered, and the interviews were terminated. To accurately describe the phenomena under study, saturation of data in the study was obtained with 20 participants.

Ethics and Recruitment

The original study was approved by the Institutional Review Board at the Escuela de Enfermería, Pontificia Universidad Católica de Chile.

Participants were recruited from healthcare centers, sports clubs, and other community-based organizations in two low-income communities in Santiago, Chile. In addition, the research team placed fliers at popular sports gatherings in the two communities (e.g., churches, community centers, grocery stores, service agencies, libraries). Men who read the fliers and were interested in the study called a toll free number directed to the study. The study staff members contacted the potential participants to further describe the study and determine eligibility. If a potential participant was interested and met inclusion criteria, an appointment to conduct consent was made. Once the study was explained and written informed consent was obtained, an assessment was completed and the interview was scheduled.

Data Collection

Twenty in-depth interviews were conducted by research staff who were trained and led by the principal investigator and co-investigators. After obtaining consent, the interviewers conducted the in-depth interviews using a semistructured interview. This type of interview is most effective in situations where the interviewer only has one chance to interview someone. In-depth interviews allowed the researchers to gather rich data about machismo in the context of HIV prevention (Bernard, 1995). In-depth interviews were conducted using a semistructured interview guide (Table 1). The interview guide is often substantially less structured than the type of questionnaire used in survey research or opinion polling (Lofland & Lofland, 1995). A semistructured interview guide was appropriate for the purposes of this research because it allowed the interviewer to follow the guide and cover the same areas with each study participant. The questions chosen to guide the discussion were based on literature review, input from a panel of experts, and opinions of community leaders. Probes were used to stimulate the participant during the interview. The interviews lasted 30 to 60 min, and all the interviews were audio recorded. Machismo and HIV are topics that are not typically discussed openly among Chilean men in the community; consequently, a face-to-face interview facilitated the disclosure of perceptions about these topics.

Table 1.

Interview Guide

Topic/themes	Interview questions
HIV/AIDS	What is the first thing that comes to mind when hearing HIV/AIDS?
	Do you know how HIV/AIDS is transmitted?
	Do you think that HIV/AIDS is affecting men in your community?
Machismo	How do Chilean men behave in relationships?
	Tell me five words that best describe Chilean men in relationships.
	What have you heard about Chilean men have more than one sexual partner?
	What have you heard about Chilean men sometimes having a man as a sexual partner?
	What have you heard about Chilean men who have a man and a woman as sexual partners?
	Do you think that Chilean men’s behavior in relationships is related to the possibility that women in your community can acquire HIV/AIDS?
Marianismo	How do Chilean women behave in relationships
	What do you think of the following sentence? “Chilean women and men have the same rights in the relationship.” Is this the same in the sexual context?
	What have you heard about Chilean women having more than one sexual partner?
	Tell me five words that best describe Chilean women in relationships.
	Do you think that Chilean women’s behavior is related to the possibility that women in your community can acquire HIV/AIDS?
Domestic violence	How would you describe domestic violence in relationships?
	Have you heard of the term ″sexual violence″?
	Do you think that Chilean culture somehow accepts domestic violence?
	Do you believe that domestic violence is related to the possibility that the women in your community can acquire HIV/AIDS?
Substance abuse	Tell me what is happening with drug use in your community, including alcohol.
	Do you think drug use is related to the possibility that the women in your community can acquire HIV/AIDS?
HIV/AIDS prevention	Do you think people in this community know how to prevent HIV? What are the forms of prevention?
	What are the factors that promote and/or impede HIV prevention in these men?
	What do you think should be done to prevent HIV/AIDS among men in your community?
	If there was an HIV prevention program for men, what do you think that content should include? Do you think there should be an HIV/AIDS prevention program in this community?

Active listening and sensitivity to the verbal and nonverbal responses of the study participants was an important aspect considered by the interviewers. Interviewers responded neutrally to the participants throughout the interviews, without influencing their answers (Patton, 2002).

Data Analysis

All the audio recordings were transcribed verbatim in Spanish and translated to English for content analysis by a transcription and translation service. We were careful not to include any identifying information in the transcriptions. The research staff meticulously reviewed the transcriptions to verify that there were no discrepancies in either the Spanish or English versions. Research files were stored in a locked area, and digital files were saved in password-protected computers.

The principal investigator and a co-investigators of the study listened and reviewed all the transcriptions for accuracy. Qualitative content analysis was used to identify and define the major themes that emerged from the interviews. Content analysis is a method used to recognize, code, and categorize patterns from text data (Patton, 2002; Sandelowski, 2000). To analyze the transcripts, directed content analysis was used, a type of analysis recommended when there is prior literature related to the phenomenon of interest that can be of benefit from further description (Hsieh & Shannon, 2005).

Based on prior literature reviews of experiences working with different Chilean communities (Cianelli et al., 2011, 2012), broad categories were defined for the purpose of coding. We applied predetermined themes based on previous research findings in this field to guide the analysis of the interviews (see the interview guide, Table 1). A codebook and a coding sheet were developed to facilitate the coding process. Four research team members independently coded line by line, without input from others. At the point of completion, the results were compared, and a 90% agreement of transcription was obtained. The coders together determined the final themes and subthemes from the predetermined codes and new findings in the coding process.

Results

Three main categories emerged from the interviews regarding machismo and how it relates to HIV: sexuality and machismo, the changing nature of machismo, and violence against women.

Sexuality and Machismo

The participants in these two communities described machismo as a constant concession between what it is to be a man on an individual level and what society expects a man to be. This definition was tied into the previously mentioned concepts of machismo and caballerismo, in that men described both negative and positive aspects of masculinity. The term machismo was interwoven throughout most of the interviews as something negative that some men exhibit and other men do not. One man said:

I have machismo attitudes inculcated [from my family] since I was a kid, attitudes also inculcated as a social habit … the society is like this [machista] in this country and one is raised machista … I see it [machismo] as normal sometimes, but suddenly I realize that this is not normal … but you have it recorded in your system and one is like this.

In addition, a machista man is described as ″apprehensive, jealous, reckless, unaffectionate, a man who treats women very badly″ (″aprensivo, celoso, poco cuidadoso, poco cariñoso, el hombre como que trata muy mal a la mujer″). A participant said:

The man in his relationship is careless … I think that, the man does not know how to take care of his partner … I mean as we say in the jargon ″does not care his land,″ it does not matter … is because of the machismo that he has … ″this is mine, this is my property,″ as a cabinet or something that he buys, he says ″this TV is mine, I have the bill for this and this is mine.″ It is a rooted term [for example, this man] married a woman or the woman lived with this guy and [the man thinks] ″I can make twenty thousand mistakes but this is mine [the woman], I am free to make several mistakes because this is mine [the woman].″

While most participants did associate machismo with negative aspects of masculinity, some men also described a different type of machismo that could be used as a facilitator of HIV prevention, as someone who is ″understanding, loving, serious, and patient″ (comprensivo, amoroso, serio, paciente). In this description, these men may have been describing the previously defined concept of caballerismo, without referencing the specific term. The men also talked about the constant pull they felt in trying to be loving, kind, and faithful while also trying to prove themselves as ″macho″ through sexual contact with women. In the following subthemes, we will discuss the roles of both female and male sexual partners and their relationship to machismo and HIV prevention.

The Role of Female Sexual Partners

As mentioned, the negative interpretation of machismo was a prevalent narrative throughout the interviews. The way in which men treat their female partners was described as a key component of maintaining a macho identity. Interviews also revealed that having multiple female sexual partners, or at least claiming to have them, was an essential part of being macho. The phrase ″the more women, the more manly″ (″entre más mujeres, más hombre″) was frequently heard in the interviews. One participant said:

I believe … for example that infidelity exemplifies the machismo because … it is normal or parents tend to instill male children that ″the more women, the best macho you are.″ Do you understand me? … and therefore is a way of predispose their sons to take that attitude with their partners….

The men talked of having a primary female sexual partner, as well as keeping other female sexual partners on the side. Men emphasized the superiority earned by a man who could maintain their primary partner, usually the mother of his children, and could also have sexual relationships with other women. A man said:

A man will not let go to the first partner, I mean one will look for an adventure, but after that will go back to the first partner … for example … a friend, he always says he is bored, he is bored of being always with the same person, then he tries new things, find new people and have fun.

When discussing relationships with women, men described a common double standard in which a man who has more sexual partners is not only accepted, but seen as ″more manly″ (″más hombre″) and a woman who has more than one sexual partner ″is not a proper young lady″ (″no es señorita″). In other words, men are pressured to have more sexual partners to demonstrate more masculine behavior, and women are discouraged from having sexual partners to demonstrate more feminine behavior. One participant said:

The presence of the macho culture requires do not compromise feelings, the emotional part; [for this reason, men] tend to compromise the behavioral part … several times if you have more relationships or more contacts with women, or the more ″winner″ or gallant you are … the culture or the group of men tend to see you better, you have a better value.

The concept of maintaining multiple sexual partners to feel more macho was identified as a widespread trait among men by the interviewees. The participants explained that men are just ″this way″ and that men have ″more open and crazy sexual minds″ (″una mente sexual mas abierta, mas loca″), using nature to explain and justify this double standard. Finally, participants reported condom use as extremely uncommon and that both cost and lack of knowledge were major obstacles for men in the community. One participant, while demonstrating clear risk perception of unsafe sex, explained that while he understood the importance of condom use, people do not use them:

Men do not take precautions. Not all men use condoms … they may buy it, but they do not use it or they may not know how to use it. I personally go looking for other partners and I do not use a condom, but I should use one.

Another man said:

[it makes difficult to use condoms] in men the [high] cost … a box of condoms is not enough for a week if you have an active sexual life. And you do not go to the clinic to ask for condoms, because I believe, everyone told me that those condoms are bad [quality] that I should not go to get them…. [There is also] fear of going to buy condoms from the pharmacy… fear of being stigmatized by the society and that sex is bad. Even when you are buying condoms in the pharmacy, the ladies next to you look at you…. The Chilean society does not realize that this is to prevent pregnancy and STDs, besides AIDS and syphilis.

Here the participants cite both access challenges and lack of knowledge on condom use as the primary reasons for not using condoms. Similarly, another participant explained that while it is common for both men and women to have multiple sexual partners, many do not use protection because they do not understand the risks involved. This explanation further highlights lack of HIV prevention knowledge and risk as a barrier to condom use.

The Role of Male Sexual Partners

Defining masculinity based on sexuality goes beyond sexual relationships with women. Men also described the weight of sexual relationships with men in the context of machismo. Being a maricón or marica, derogatory terms used to label homosexual men, was a consistent fear expressed by participants. One of the ways to avoid the maricón label is rooted in reporting sexual activity with women. Not only did men describe feeling pressure to have multiple female sexual partners, but a need to make their sexual histories public within their social circles. A participant explained the idea that ″there′s a double standard: one acts macho so that nobody calls him anything else … so that nobody calls you a faggot or something.″ Another participant said:

In a group of five people, [a group of] five men sit down to talk … the one who has fewer women is not so macho as it should … that is, if you talk about abstinence or if you say: look guys, for a personal choice I prefer abstinence, [the men will say] no way, this guy is a faggot without any doubt.

In this sense, being a mariquita was depicted as the antithesis of a macho identity, though not all men expressed negative views towards homosexual men. Participants acknowledged that men sometimes had experiences with other men when under the influence of alcohol or if they were bored with their female partner. Sexual experimentation with other men during adolescence was also acknowledged as something that occurred in the community. A man said:

[I have seen] gay men with [heterosexual] drunk men, with men who are drunk, then the drunk man always messes with the gay … to experiment, to satisfy their animal instinct … he gets involved with a gay, and they have relationships and whatever.

Although participants wanted to exhibit macho characteristics in the context of homosexuality, men also distanced themselves from machismo, again stressing the dynamic relationship many had with masculinity. Many of the men expressed that they did feel they had machismo beliefs. However, they explained that they also saw it among other men in the community.

The Changing Nature of Machismo

Many of the men reported that ideas of masculinity are being reorganized and redefined. Men also noted that the definition of machismo is changing and that it does not have the connotation it once did. For example, one man stated, ″A Chilean man is a coward″ (″Un hombre chileno es un cobarde″) and explained that often Chilean men have children with more than one partner, which stigmatizes the act of having more multiple sexual partners. Another man interviewed stated:

It [machismo] has changed, before the woman had to be totally dependent on the man for everything and if he arrived at 6 a.m. and wanted fried eggs and his friends did too then the woman would have to be there and do what he said. Today this has changed; women do not do this. They are working and the man cannot make these demands because a woman can support herself and does not need to rely on the man for support.

This statement is significant, as it recognizes the changing nature of the masculinity experienced in the sampled communities and explains that in typical machista relationships men have explicit power over women, particularly financially. However, with more and more women entering the workforce in Chile, this domination cannot function in the way it once did. Another participant said:

Well, my opinion … now the relationship has changed … before was the man who worked, however now … women are incorporating in the workplace, they are being more independent … the man in this case will not like to admit it, I mean there are still some families that this [a woman working outside home] is not right, the woman has to stay at home to take care of the children.

The participant′s negative reaction to machismo demonstrates the diverse way in which men in these communities experience masculinity. Contrary to the belief that all men are hypersexual and that having multiple partners is natural, men rejected this overarching definition of masculinity. Some men stated that they viewed themselves as equals with their female partner and that the sexual relationship was discussed between them in such a way so that both people were satisfied. One participant shared his belief that:

Men and women are equal in relationship, women are stronger these days, demanding their rights. If my wife does not want to have sex, then I do not force her—we have to enjoy it. Some people are not this way.

Men shared that they communicated with their female partners and actively defined roles and responsibilities within the relationship. In these instances, the power play between men and women was seen as more egalitarian—recognizing women′s desires and needs as valid—and that recognizing this is not contradictory to being masculine.

Furthermore, men recognized the changing nature of interpersonal relationships, marriage, and the family unit. One man shared:

Before, the term macho did not exist … it was Don Juan or mujeriego in the 1960s. My father had three women with whom he had children—I only met two of them. Me personally, I did a lot [sexually] when I was single, but when I was married there were very few times that I visited those apartments, the ones that there are so many of downtown, but I also matured in the sense of giving them up one at a time.

This statement traces the history and reorganization of masculinity and marriage within the Chilean context. This participant acknowledged that historically, machismo was not recognized as it is today. The machos or Don Juans used to have a positive connotation, but today the concept of multiple sexual partners is not as commonly accepted. However, this respondent did say he at one point of his life frequented brothels during marriage and had to slowly quit going. At the same time, this participant made it clear that he did not go to brothels as often as he believed men of previous generations tended to, acknowledging both the present and past conditions of machismo.

Violence Against Women

Many of the participants reported having witnessed domestic abuse, whether physical, sexual, or financial, in their communities among other men. However, none of the men disclosed any personal experiences of violence in their own relationships towards their female partners. Though participants recognized that the male identity is changing, they spoke of violence in their communities and explained how this violence tied into the machismo identity. One man mentioned that ″being macho is abusing power through verbal and psychological violence and infidelity.″ According to this participant′s description, machismo incorporates violence against women as a way to establish power among men over women, clearly defining roles within intimate relationships and society. Domestic violence against women was regarded by participants as something relatively normal within relationships and that very few individuals intervened when they were witness to acts of violence in the sampled communities. For example, one of the men said, ″So each person worries about himself, like if I see another guy hitting his wife it′s not my problem.″ Another participant said:

It′s a little sad, that it doesn′t have to be this way, but the people or society are used to it, the same way they′re used to keeping quiet for example, when things like crime happen, when people are assaulted, everyone keeps quiet.

According to interview data, there is a general acknowledgement that violence against women exists in communities and there is a culture of silence and fear of getting involved in someone else′s business. However, at the same time, the participants also described the changes that were happening in their communities. For example, one participant explained that children these days are capable of calling the police immediately if they experience violence in their homes, something that was not typical in the past:

Today if the kids are around, I would say my granddaughter, my granddaughter is 11 years old and knows perfectly well that we have their address or if she sees something physical or whatever, she can call the police.

In the statement above, the participant, while acknowledging the prevalence of domestic violence and general complacency and fear of responding, he notes that children today know exactly what to do if they see violence and are capable of calling the police. Other participants said that older women would not call the police or try to stop violence against them. However, many participants noted that women today do not tolerate violence and will call the police or file a police report.

The narratives depict a change in the response to violence, but even so, they confirm that violence against women is still present in the communities. Although positive changes in women and young people′s reactions when faced with violence are clear in participant interviews, it is also evident that violence against women in these communities is far from being eradicated. A man said:

Everyone knows [about domestic violence] but is hidden … everything hidden, but ultimately everyone knows that there is violence in every house, in one way or another. Violence occurs at any time, you walk down the street and you can hear a person yelling, or the same violence, for example if one day I argue with my dad, with [xxx], and I do not talk to them and I will not feel bad, I think that′s also violence, though not physical.

Discussion

These findings revealed that the men did not feel vulnerable to contracting HIV because of cultural characteristics related to machismo and its consequences, such as homophobia and acceptance of male social dominance that promotes risky behavior for HIV. The findings indicated that for Chilean men the main form of acquiring HIV is sexual contact and that the presence of traditional gender roles increases the transmission, which is congruent with the literature (UNAIDS, 2012; Cianelli et al., 2008). The results of this study are essential for HIV prevention because, as evidenced earlier, many aspects of machismo can put men and women at risk for HIV/AIDS (Caceres, 2002; Cianelli et al., 2008; Parker, 1996; Miner et al., 2011; Pérez-Jiménez, Seal, & Serrano-García, 2009).

The themes identified in these interviews demonstrate the importance of societal pressure incorporated in the definition of masculinity and machismo. In many instances, men talked about the difficulties they faced trying to prove their masculinity in order to avoid being called homosexual, confirming previously conducted research that has demonstrated the complexity of the male identity, particularly among Latinos (Estrada et al., 2011; UNAIDS, 2010). Participants made direct links between the fear of being labeled homosexual and feeling pressured into having multiple sexual partners to avoid it. This is congruent with the literature, which describes that homophobia associated with machismo is often considered cause for MSM to engage in sexual contact with women (Estrada et al., 2011; UNAIDS, 2010).

At the same time, the participants acknowledged that men in the community did have sexual contact with other men. The stigma attached to male–male sexual contact creates a dangerous situation because, as reported in the interviews, men may enter into multiple sexual relationships with men and women, without using condoms, increasing their own risk for HIV and that of their partners, particularly those who believe they are in a monogamous relationship (Cianelli et al., 2008; Pérez-Jiménez et al., 2009). The use of drugs and alcohol was linked with this type of behavior, and it should be addressed in future studies because it can increase HIV risk (Caceres, 2002; Cianelli et al., 2008; Gonzalez et al., 2007).

The interviews clearly illustrated the struggle between caballerismo and machismo as defined by Cianelli et al. (2008) and Arciniega et al. (2008). The men defended their role as traditional provider and protector of the family, but rejected the negative abusive definition of machismo. Men talked about how the meaning of masculinity is changing and that the roles of men and women are not defined as they used to be. Additionally, men explained that the contexts where roles of masculinity develop are also changing, as each generation considers these changes and implements them when raising their children. This claim is important in that it follows previously conducted research on both the positive and negative aspects of male identity—machismo and caballerismo (Arciniega et al., 2008). However, while positive change towards more equal gender roles was a clear theme in the interviews, the emphasis on multiple sex partners, infidelity, and ambivalence about condom use were reported as remaining solid aspects of machismo today. Furthermore, the recognition that these ways of life put both men and their sexual partners at much higher risk for HIV/AIDS was communicated.

This initiative is essential for HIV prevention because, as evidenced earlier, many aspects of machismo can put men and women at risk for HIV/AIDS (Caceres, 2002; Cianelli et al., 2008; Miner et al., 2011; Parker, 1996; Pérez-Jiménez et al., 2009). However, there are other aspects of the male identity which could be used as facilitators of HIV prevention (Cianelli et al., 2008; Pérez-Jiménez et al., 2009).

Although the role of women is changing, domestic violence is still prevalent and used as a method of maintaining control over women and expressing masculinity. According to the interviews, women in the sampled communities are still expected to forgive both infidelity and abuse (Cianelli et al., 2008; Miner et al., 2011). This trend coincides with previous research within the Chilean community conducted by Cianelli et al. (2008), who identified that women call this behavior marianismo. While progress towards extinguishing the community′s acceptance of IPV has been made, it is important to understand how domestic violence, as well as other negative aspects of the macho identity such as multiple female sexual partners, and aggressive and dominant behaviors, increase the risk for HIV. IPV has been labeled as a risk factor for contracting HIV and a barrier to HIV prevention (Miner et al., 2011; Pérez-Jiménez et al., 2009). This is an important aspect of machismo that should be targeted when developing HIV prevention education in Chile.

Conclusions

The information extracted from these narratives gives insight to the struggles fought among men to understand their own identity within the community. These results were used to adapt the Mano a Mano para Hombres intervention, specifically in how to incorporate the role of the culture in HIV prevention among men. Based on these results, the intervention included different activities to increase awareness about HIV transmission and the consequences of infection and reduced misconceptions about the topic. For example, role playing is an excellent technique that can be included in prevention programs with Chileans to improve communication between partners.

In addition, these results should be considered in public health initiatives targeting men in Chile. Creating a public health response that incorporates and addresses different aspects of machismo is essential if men are to be engaged in public health interventions. Education programs addressing HIV prevention and IPV that are tailored to meet the needs of Chilean men are needed to incorporate men in HIV prevention. Specifically, incorporating ideas of what men consider healthy masculinity and working to destigmatize MSM are important steps in addressing the negative aspects of machismo.

Clinical Resources.

• Chilean Ministry of Health: http://web.minsal.cl/vihsida-e-its/

• Flacso Chile: http://www.flacsochile.org/