In the USA, human immunodeficiency virus (HIV) risk is defined by social inequalities in gender and race.1
Women now account for one fourth of all new infections, resulting in almost 10,000 new cases annually. The majority of these new infections have been occurring among women ages 15–39, indicating higher risk in this population.2
Racial and ethnic disparities in HIV risk also exist among women. Non-Hispanic black women account for 66% of cases diagnosed among women and are diagnosed with acquired immunodeficiency syndrome (AIDS) at a rate 23 times that of white women and four times that of Hispanic women.3
HIV is the leading cause of death among black women ages 25–34.4
Sexual intercourse remains the leading route of HIV transmission among women in the USA, accounting for more than 80% of new diagnoses.3
Many women become infected through their main partner due to low rates of consistent condom use in primary relationships.5,6
Because male condom use is not directly under a woman's control, gender inequalities may be particularly important in shaping this sexual risk behavior.
The theory of gender and power provides a framework that may help explain condom use within romantic relationships. It asserts that power dynamics between men and women can be explained by three major structures: sexual division of power (i.e., male partner dominance within relationships), sexual division of labor (i.e., economic inequality), and structure of cathexis (i.e., gender norms). These structures are maintained through societal and institutional social mechanisms and are manifest in relationship control, women's economic potential, and expectations of women's role in society.7,8
The sexual division of power is particularly relevant for understanding risk among low-resource women in the context of interpersonal relationships. Several studies have identified this power imbalance and have described its impact on sexual risk behavior. For example, in a study of urban Black men ages 18–24, the overwhelming majority believed that condom use was the man's decision. Only a small percentage conceded that their female partner may play a “small role” in choosing to use a condom.9
Another study of Black teenage women reported that 26% felt little control over condom use. Sixty-six percent felt that a male sex partner would be hurt, insulted, angry, or suspicious if questioned about his HIV risk factors.10
Additionally, studies report that demanding condom use would show a lack of trust in the relationship.10–12
Furthermore, in one study, Black teenage women sometimes feared rejection or violence when considering asking a partner to wear a condom.10
Therefore, urging women to demand condom use and encouraging monogamous relationships may not be an effective prevention strategy for women that do not perceive control in sexual decision-making.
Economic inequalities derived from the sexual division of labor may further exacerbate the power imbalance in romantic relationships. Women who are economically dependent on their partners may yield less power in romantic relationships and therefore less control over sexual decision-making. Empirical studies have linked economic inequality and poverty with increased HIV risk.1,13,14
For example, populations with lower incomes have been found to use condoms less and have higher rates of HIV/AIDS than populations with higher incomes.1,14
In a recent qualitative study with African American women, lack of economic opportunities and economic dependency were cited as compelling reasons for remaining in risky sexual relationships.13
Reduced economic autonomy may lead to the inability to maintain monogamous relationships or assert their sexuality. Additional literature suggests that one of the components of relationship power may be an imbalance of valued resources (e.g., economic and emotional) between partners.7,15,16
While we did not propose to test the theory of gender and power, we aimed to use this broader theory to better understand a specific component of sexual risk. In this paper, our primary objective was to examine whether economic dependence on a male partner was associated with condom use in early motherhood among young, primarily minority women who had previously been receiving prenatal care at two publicly funded clinics in two cities in the USA. Additionally, in order to understand one possible mechanism through which economic dependence could be related to condom use, we examined whether this relationship was mediated by sexual assertiveness with a partner.