summarizes the characteristics, involvement in the criminal justice system, HIV and STI risk factors, history of IPV, and drug use of the 10 women who participated in the in-depth interviews. Per the eligibility requirements, all 10 participants reported having been arraigned for a misdemeanor, at least one HIV/STI risk factor, a history of IPV, and drug use. Arraignment charges for the participants included prostitution (n = 2), possession of illicit drugs (n = 1), open (alcohol) container violation (n = 2), petit larceny (n = 2), assault (n = 1), trespassing (n = 1), and reckless endangerment (n = 1). The demographic characteristics of the 10 participants did not vary greatly from those of the larger group of 91 women who were screened, although the screened women as a group were more likely to be married (12% vs. 0%) and less likely to be unemployed (49% vs. 80%). The total screened sample demonstrated similar criminal justice characteristics to the interview participants, with lower levels of previous arrests (53% vs. 70%) and incarceration (19% vs. 40%).
Characteristics of the Sample
Through constant comparative analysis of the interviews, we identified the following four themes: (a) fear of IPV prevents women from asking their sexual partners to use condoms; (b) demonstrating trust in the relationship prevents women from asking their sexual partners to use condoms; (c) substance abuse, engaging in prostitution, and a partner’s incarceration influence sexual risk behaviors with additional partners; and (d) women defendants are concerned about strategies to reduce the risks of HIV/AIDS and STI. These themes demonstrate the challenges of women involved in the criminal justice system in the contexts of their sexual relationships.
Fear of IPV
When the women were asked why they could not ask their partners to wear a condom, fear of IPV emerged as a barrier. This theme suggests that fear of violence prevents the participants from negotiating what they need to protect themselves from sexual HIV-related risks, as the following comments indicate:
Being safe, that’s hard to do …. I got raped and I had a boyfriend and I wanted him to use a condom. He was actually my boyfriend for three years—he didn’t have any [condom]. I didn’t have any [condom], and I got raped. (ID: 015)
If I was to say no when he wanted to have sex without a condom, I was scared that he would go and try to hurt somebody in my family or hurt me. They might be scared. I know that my ex-boyfriend would threaten me a whole bunch, and I was scared and I believed that he would do something. He would say, “Now I’ll do this, I’ll kill your family,” and I would be scared that he would do it. (ID: 053)
Domestic violence and intimacy … sometimes maybe women get it confused; he may be touching you, you know, relaxing you, but you might be thinking that he is gonna hit you. Some women go through that, and I have friends that been there—”I don’t know if he’s gonna hit me or he’s gonna hug me” type of stuff …. Yea, you don’t know if he’s trying to love you or he’s trying to hit you … After being beaten so much, going through that so much, they might be scared to use it [condom], or she might be scared she might say the wrong thing, and he might slap her. He might just force her to not use it, you know. And there would be a big argument and hence a whole bunch of nonsense after that. (ID: 079)
For women who engage in prostitution, conflicts with their managers (“pimps”) may lead to violent interactions and unprotected sex:
I correspond with the girls who work in the section that I used to work in. They tell me how they have been kidnapped by pimps. [The pimps] have sex with them and make them go back out on the street and work for them, beat them up …. Then my aunt that lives up here, she does good with her HIV/AIDS, but she got it doing the same thing that I was out there doing. Prostitution. And she got it from a pimp. (ID: 015)
Although this participant later reported that her manager supplied her with condoms as a way to make sure she was “working,” conflict with a pimp may lead to physical violence, coerced and/or unprotected sex, and the potential transmission of HIV.
A general fear of their sexual partners’ reaction to the use of condoms was a consistent theme for the women in the study. The participants indicated that they were scared to ask their sexual partners to use a condom:
I didn’t think about asking for a condom, but I’ve thought about it, I tried to pull the words out of my mouth, but I couldn’t because I was so scared …. I was so scared, and I felt so alone, what am I to do? (ID: 004)
I didn’t want to ask about condoms. Scared of how he might react. He might be like “whatcha mean” yelling “whatcha mean, I gotta wear a condom?” No. He might say “I am not wearing one” and expect me to listen. (ID: 088)
The participants described sexual relationships that were greatly influenced by power imbalances that were manifested in actual or feared IPV. Fear of a sexual partner’s reaction and the feeling of powerlessness have been well documented in the literature as obstacles to requests for safer sex and are consistent with this study’s findings (Sanders-Phillips, 2002
; Wingood & DiClemente, 1998
). For the women in this study, their lack of power in relationships and the fear of physical or emotional violence were key factors in engaging in unprotected sex.
Demonstrating Trust in the Relationship
Displaying trust by engaging in unprotected sex in their intimate relationships was a consistent theme for the participants. According to the women, suggesting that their partners, particularly their steady partners, should wear condoms, implied a lack of trust in the relationship. The women found it difficult to communicate about sex and condoms with their sexual partners without issues of trust emerging:
She wouldn’t be able to ask him to use condoms because he would also [say] …. “What, you don’t trust me? You don’t trust? What are you saying?” It’s like him always trying to have the upper hand. (ID: 008)
Personally for me, I’ve had this conversation before with my boyfriend, like “Why won’t you use condoms?” and his thing was “Oh, I feel like after three months, we don’t have to use condoms.” “Why is that?” “Oh, because I trust you.” They feel they can trust the person. (ID: 057)
It was easy to communicate at the beginning of the relationship; it becomes more difficult when trust is established. You build so much trust, if you did something, you’re scared to tell the other person because you may lose the person or you have to bring the trust back. (ID: 053)
In addition, 8 of the 10 women knew or suspected that their primary sexual partner was having sex with additional partners. The participants reported that engaging in multiple sexual partners was also common among women:
The females I know, they have multiple partners … it looks like the majority of them. Sometimes he makes me feel like he’s cheated on me because I know that we all play a lot. Just like, for example, one of his friends, his girlfriend, that’s pregnant, she is pregnant by his best friend. Yesterday, an incident happened: The father was messing with another female. She told him that was very disrespectful; you shouldn’t be doing that. She said, “You don’t even touch me that way,” so she told me that they broke up. (ID: 048)
Yea, he doesn’t want to be with her any more, trap him off. Yea, them one-night stands, those are the most dangerous, dangerous, because you don’t know the person, and the person doesn’t know you. You don’t know their background, and they don’t know your background. You can’t tell what’s going on with their insides right there at that time. And that one night of passion could lead you to so many years of pain. (ID: 057)
Although it appears that engaging in sex with multiple partners was not uncommon for the participants or their male partners, upholding an image of mutual trust in the relationship was an important theme. The participants said that this mutual trust was displayed by not using condoms. The maintenance of the appearance of trust remained, despite high levels of reported risky sexual behavior by each partner outside the primary relationship. In light of the previously stated findings on fear associated with power imbalances, this dynamic further illustrates low levels of relationship power, which has been described as the ability to negotiate and communicate appropriate sexual practices, including the use of condoms (Pulerwitz, Gortmaker, & DeJong, 2000
Substance Abuse, Engaging in Prostitution, and a Partner’s Incarceration
The third theme focused on situations that place participants at risk of HIV and STIs outside their primary sexual relationship. All the participants reported that drug and alcohol use influenced their risky sexual behavior. They said that drugs and alcohol allowed them to feel carefree, hindered their ability to use condoms, and contributed to their engagement in risky sexual behavior with multiple partners, as the following comments indicate:
When I smoke weed, it’s like you get more carefree, like you just let the moment take control of you. You get a little horny, I am not gonna lie. Some people say “Oh, when I drink or when I smoke, I don’t know what I am doing,” but I don’t believe that. Me per se, I know what I am doing; it’s just whatever feels better for me at the time. (ID: 004)
I know that where I live, most of the people are on drugs. Most of it is crack and heroin and stuff like that, and that leads to HIV. You don’t know who you’re sharing with. You don’t know who’s giving you what or what needle is clean. Where I live at, they don’t care; as long as they’re getting what they get, they don’t care. (ID: 053)
The women indicated that using drugs and alcohol allowed them to live in the moment. The also reported that substance use influenced their ability to use condoms and have sex with additional partners, as is evident in the following comments:
When somebody is high, they’re not using no condom because that’s the last thing on their mind. And they’re probably not in the right state of mind to think about a condom. Only thing they probably could think about is have another experience. (ID: 057)
Like I’ve been in a situation when my friend, he’s 20, he has his own apartment, and everybody is always up there, going up there to party and drink and smoke and dance and everything like that. And there’s been plenty of times when girls [have] gotten drunk and high and you know have sex with a few guys or have sex with somebody they just met, they don’t know them. Or had a train ran on them. A train is like you know, when one girl is there and there’s a whole bunch of guys having sex with her, back to back to back, that’s what that is. (ID: 004)
Drug and alcohol use appear to have contributed to the participants’ exposure to the risk of HIV by not using condoms and having sex with multiple partners concurrently. Moreover, drug use is a major route of exposure to HIV-related risk among African American women—a point that has been well documented in the literature (Lee & Fleming, 2001
; Sanders-Phillips, 2002
; Stevens, Estrada, & Estrada, 1998
Women who also engage in prostitution face unique challenges regarding the use of condoms with multiple sexual partners. Two participants who had recently been charged with prostitution described their difficulties using condoms within the context of sex trading:
Researcher: What about women who occasionally go out on the street to make money, what are some of the strategies they use to protect themselves?
Researcher: Are clients willing to use condoms?
Researcher: Are there times when they are not?
Respondent: For oral sex. A lot of people ask you, but you personally have enough contact; but, I am sure there are girls who’d do it if they needed the money. (ID: 088)
I have had dates that have tried to pay me 5, 6, 7 hundred dollars to go without a condom …. I don’t accept the money; it’s nothing I give away. But some of the girls out there, they don’t have condoms. I guess when they are out there, they’re used to doing it without them or have dates go get condoms. But 9 times out of 10, the dates don’t go get condoms. So I guess the ones that didn’t have condoms, I guess they dated without a condom. (ID: 015)
The negotiation of condom use while sex trading is influenced by financial compensation and presumably by the financial needs of the woman. Black women, who often experience unequal occupational and financial opportunities, may thus be subject to what has been termed an “economic exposure to HIV risk” on the basis of financial hardship or need (Wingood & DiClemente, 2000
The women described scenarios in which the likelihood of engaging in risky sex with additional partners increased when their partners were incarcerated and hence unavailable. One participant discussed her partner’s incarceration this way:
My baby’s father, he got arrested, and I was talking with somebody else and we had unprotected sex. That was risky because I could have got something from the other male and … my baby’s father [would not know] that I had it. See, in my community, the only time when somebody really messes with somebody else is when their boyfriends go to jail. (ID: 014)
Another participant also reported that she had multiple sexual encounters when her partner was incarcerated. The health effects of having a partner who is incarcerated and the association with HIV-related risk behaviors by girlfriends or wives of prisoners have not been well documented in the literature (Freudenberg, Daniels, Crum, Perkins, & Richie, 2005
; Lichtenstein, 2005
). Grinstead et al. (2005)
found that recently incarcerated men demonstrated high rates of postrelease unprotected sex with primary female partners. Having a partner with a history of incarceration was associated with increased STIs and forced sex for women (Kim et al., 2002
). However, research has focused primarily on the HIV-related risk behaviors of male offenders (Grinstead, Zack, & Faigeles, 1999
) and female offenders (Staton-Tindall et al., 2007
) but not on their sexual partners.
Strategies to Reduce the Risk of HIV/AIDS and STIs
The participants agreed that HIV is a serious issue in their neighborhoods, and each reported knowing at least one person who was living with HIV. When asked about the strategies that they used to reduce the risk of HIV and STIs, they reported the following: using condoms, reducing the number of sexual partners, abstinence, being tested regularly, improving verbal communication in relationships, and distributing condoms to friends and family members. This theme suggests that the participants were concerned about HIV and STIs and were looking for ways to reduce their risk. Most participants reported that using condoms is the best method to reduce risk:
Just use condoms, not try to sleep around and be a slut. But I mean you can sleep with just one person and get AIDS, so I would just say try to use a condom but not have sex at all, but who am I to tell somebody not to have sex? But the condom right now is the best way …. All these diseases, it’s crazy. I don’t even know, just try to wrap up; that’s what I would say. (ID: 004)
I use protection if I am having sex with other people, but I have a main person that I am having sex with, and I know he’s clean and he knows I am clean, and that’s how we keep it. Using protection it helps a lot; it does because I am pretty sure I could have ran into a lot of things that I didn’t run into, thank God. Protection is, that’s what’s up, and you gotta make sure you know how to use it right. (ID: 079)
Having one sex partner is how to stay clean. Using a condom with every guy, including your boyfriend, and carrying one. Or using a diaphragm. Make sure every guy that you have sex with, they have their condom, their own condom. And make sure that you and him both have enough. That’s really it. Females should have a bagful of condoms if they’re gonna have partners like that. (ID:088)
As the comments indicate, most women acknowledged that the use of condoms was a primary method of reducing the risk of HIV and STIs, although perceptions about the need to use condoms varied by the type of partner. In addition to their own use of condoms, some women reported distributing condoms and information on safer sex to their family members and friends:
When I go to health clinics and places like that, they give out condoms, and my cousin lives there, too; she is a female, I bring them back. I’ll give them condoms, anything I get back; [I say] “Hey, got condoms, hey, here you go.” I am the one who got condoms, got little pamphlets that I got from the hospital on diseases and infections and stuff like that. (ID: 008)
Even when I am on the street, and they handing out condoms with the packets about HIV, I take them, I take them. Girls be looking “that’s not ladylike, that’s not ladylike,” but I am safe. Like I am gonna be so safe. I don’t care what ya’ll think about me, ya’ll could think of me as a freak because I am walking around with a bunch of condoms, but I just may be the one. (ID: 057)
Although some women attempted to promote safer sex to family members and friends, they perceived that others view women who possess condoms negatively. Most participants believed that women who carry condoms are not perceived to be “ladylike,” and this perception may decrease the likelihood of women having condoms available or asking their sexual partners to use condoms. This is an important barrier to HIV/STI prevention for women, which was supported by previous research. These perceptions of femininity illustrate how women’s vulnerability to HIV should be considered within the broader context of social norms and gender roles (Connell, 1987
). In this instance, the issue of women’s sexuality (evidenced by carrying condoms) appears to be attached to social concerns, such as impurity and immorality—attributes that are commonly associated with more traditional or patriarchal gender norms.