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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptNIH Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
 
J Adolesc Health. Author manuscript; available in PMC Jun 14, 2013.
Published in final edited form as:
PMCID: PMC3682825
NIHMSID: NIHMS456115
What Girls Won’t Do for Love: Human Immunodeficiency Virus/Sexually Transmitted Infections Risk Among Young African-American Women Driven by a Relationship Imperative
Jerris L. Raiford, Ph.D.,a* Puja Seth, Ph.D.,bc and Ralph J. DiClemente, Ph.D.bc
aDivision of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
bRollins School of Public Health, Department of Behavioral Sciences & Health Education, Emory University, Atlanta, Georgia
cEmory Center for AIDS Research, Social and Behavioral Sciences Core, Atlanta, Georgia
*Address correspondence to: Jerris L. Raiford, Ph.D., Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention, 1600 Clifton Road NE, Mailstop E-37, Atlanta, GA 30333. jraiford/at/cdc.gov (J.L. Raiford)
Dr. Seth is now in the Division of Global HIV/AIDS at the Centers for Disease Control and Prevention.
Purpose
Rates of Human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs) continue to increase among African-American youth. Adolescents who have a stronger identity in relation to others (relational identity) rather than to themselves (self-identity) may view intimate relationships as imperative to a positive self-concept, which may lead to risky sexual behavior and abuse. Therefore, the present study assessed the associations among a relationship imperative and HIV/STI-related risk factors and behaviors.
Methods
Participants were 715 African-American adolescent females, aged 15 to 21 years. They completed measures that assessed how important a relationship was to them and HIV-related risk factors and behaviors. Participants also provided vaginal swab specimens for STI testing.
Results
Multivariate logistic regression analyses, controlling for covariates, were conducted. Females who endorsed a relationship imperative (29%), compared to those who did not, were more likely to report: unprotected sex, less power in their relationships, perceived inability to refuse sex, anal sex, sex while their partner was high on alcohol/drugs, and partner abuse. Furthermore, participants with less power, recent partner abuse, and a perceived ability to refuse sex were more likely to test STI positive.
Conclusion
These results indicate that if African-American adolescent females believe a relationship is imperative, they are more likely to engage in riskier sexual behaviors. Additionally, less perceived power and partner abuse increases their risk for STIs. HIV/STI prevention programs should target males and females and address healthy relationships, sense of self-worth, self-esteem and the gender power imbalance that may persist in the community along with HIV/STI risk.
Keywords: Relationships, Sexual behavior, STIs, African-American, Adolescents
“I haven’t had a boyfriend or gotten asked out. I feel so unwanted. For heaven’s sake I am 13!”
excerpt from 1990s Teen Magazine’s advice column [1]
Human immunodeficiency virus (HIV), other sexually transmitted infections (STIs), and teenage pregnancy contribute to morbidity and mortality rates among adolescent girls and young women in the U.S. [2,3]. While the effects of various prevention programs have shown promise in reducing sexual risk behaviors among youth [4], understanding social factors that have been largely ignored among this group and their relationship to sexual risk can serve to strengthen these efforts. Adolescent romantic relationships and sexuality, once considered transitory and/or the byproducts of social dysfunction [5], have garnered increased attention in the literature. Although the study of the nature and development of romantic relationships in adolescence has increased in the last decade, its course has been largely descriptive and qualitative or lacking a focus on quantifiable adverse sexual outcomes [6]. This study quantifies the heightened risk for HIV/STIs during adolescence by examining the association between the relative importance adolescent girls place on being in a relationship and their engagement in risky sexual practices and other adverse relationship dynamics.
Although young people aged 15–24 years represent only 25% of the sexually experienced population, they acquire approximately half of all new STIs, [3] and approximately half of all new HIV infections occur in those less than 25 years of age [7]. It is estimated that 24.1% of adolescent girls aged 14–19 years have one of the five commonly reported STIs: herpes simplex virus (HSV), trichomoniasis, chlamydia, gonorrhea, and human papillomavirus (HPV) [8]. African-American adolescents are particularly at risk for STIs and account for 65% of HIV diagnoses among individuals who are 13–24 years old [7]. A national study found that among African-American female adolescents, aged 14–19 years, 44% had at least one STI [8]. Additionally, adolescents living in the southern part of the U.S. are more likely to be at risk for HIV infection [9].
Therefore, it is important to turn attention to more expansive research questions that consider factors occurring within romantic relationships that help and hinder normative development from adolescence to adulthood [6]. Findings in the past 10 years suggest the development of romantic relationships during adolescence may facilitate the development of a positive self-concept, general self-competence, and a sense of self-worth [1013]. Conversely, given the literature [2,14], it is also likely that the initiation and maintenance of such relationships may function to increase the likelihood that youth, particularly young women, may compromise psychosocial and sexual health to meet the demands of present-day social expectations for romantic relationships. This study extends previous research by attempting to better understand how the intensity and drive for a relationship in adolescence may affect sexual decision-making and risk.
Adolescence is typically defined as 11 to 25 years old [5] and is marked by the developmental task of establishing a positive sense of self (self-identity) and self in relation to others (relational identity), including parents and same-sex and opposite-sex peers [15]. Adolescents may be most concerned with their identity within a romantic relationship, which differs from peer relationships, in that romantic relationships embody a “distinctive intensity, commonly marked by expressions of affection and current or anticipated sexual behavior” (p. 632) [5]. Furthermore, youth with a stronger relational identity than self-identity may view intimate romantic relationships as imperative to a positive self-concept [10,1618]. In a qualitative textual analysis of 875 letters written to the advice column of Teen Magazine by adolescent girls in the 1990s, Van Roosmalen [1] uncovered a formidable sense of despair and anxiety plaguing young women regarding the urgency to be “coupled.” Teens expressed conflict between wanting to remain true to themselves and avoid sexual situations, while also desiring the social benefits of being in a romantic relationship, namely, social inclusion and popularity, often by engaging in or experiencing pressure to engage in sexual activity. This conflict characterizes the struggle between developing a self-identity and relational identity inherent in adolescence.
During adolescence, teens are learning how to interact with the other sex, methods for initiating and engaging in sexual activity, and in which sexual activities to participate [19]. Research suggests that how girls engage and communicate with same sex peers compared to cross-sex peers often looks different. A qualitative study found that while most girls were outspoken with their female friends, parents, and others, they were not able to “speak their minds” in their cross-sex relationships [20]. Overwhelming societal and same-sex peer pressure to be in a romantic relationship, [2,14] as well as pressure by potential male partners to engage in sex in order to maintain relationships, [21] may heighten sexual risk behaviors among young women. Another study [14] found that social status and fear of relationship termination was related to girls placing their boyfriends’ sexual needs above their own needs and placing condom negotiation and other safer sex practices at risk.
For many, dating in adolescence teaches young women how to bargain for the perceived social and emotional benefits of being in a relationship by exchanging sex in order to attain or maintain the coveted “girlfriend status” [1]. In addition to increased rates of HIV/STI infection, relationship factors such as partner abuse disproportionately affect this group and increase their risk for HIV/STIs [22]. Other related relationship dynamics and psychosocial factors are perceived power in the relationship and self-efficacy to refuse a partner’s or potential partner’s request to have sex [23]. The principle of least interest [24] suggests that young women who endorse the need to always be in a relationship will have less relational power and will be more likely to risk their sexual health by engaging in risky sex practices. In an ethnographic study exploring health-related issues within romantic relationships among female adolescents [14], girls reported abuse in response to attempts at condom negotiation. The study found that young women’s attitudes towards dating and their desire to be coupled outweighed their desire to limit or avoid substance abuse and partner abuse present in their relationship. Furthermore, they described their use of sex as a viable means to negotiate control in their dating relationships—going as far as to state that sex is “part of what you do” in order to hold onto the relationship [14].
Placing significant importance on being in a relationship at all times may lead to psychological traits that can significantly impact the developmental trajectory from adolescence to adulthood. Whereas previous work has focused on the qualitative and descriptive aspects of the importance of romantic relationships in adolescence, this study sought to identify the independent associations between a relationship imperative and sexual risk behaviors (e.g., unprotected vaginal sex, anal sex) and psychosocial factors (e.g., sex refusal self-efficacy, relationship power, and partner abuse) among African-American adolescent girls in the southeastern part of the U.S. In addition, this study assessed the associations between these factors and biological testing for STIs. Due to their associations with sexual risk behavior and relationship dynamics, age [7,8], receipt of public assistance [25], perceived social support [26], and typical or current age of partner [22,27] served as covariates in this study.
Participants and procedures
Participants were part of a larger study evaluating a sexual risk reduction intervention tailored for African-American adolescents [28]. The current analyses are from baseline data. Participants were recruited from three local community health agencies that provided sexual health services to predominantly inner-city adolescents in Atlanta, Georgia from March 2002 to August 2004. Eligibility criteria included: African-American female, age 15–21 years, and vaginal intercourse during the past 60 days. Adolescents who were married, currently pregnant, or attempting to become pregnant were excluded. Informed consent was obtained from all adolescents, with parental consent waived for those younger than 18 due to the confidential nature of clinic services. Of the 847 eligible adolescents, 84.4% (n = 715) completed baseline assessments. Adolescents also provided self-collected vaginal swabs to assess for STIs. Participants who tested STI-positive received directly observable single-dose antimicrobial treatment, risk-reduction counseling per CDC recommendations, and were encouraged to refer sex partners for treatment. The county health department was notified of reportable STDs, which included chlamydia and gonorrhea. The Emory University Institutional Review Board approved all study protocols.
Measures
Data were collected through an audio computer-assisted self-interview (ACASI) Relationship imperative, was assessed by asking participants to rate the degree to which they agreed with the statement “Having a partner at all times is important to me.” Responses were collapsed into two categories, 1 =relationship imperative (agree or strongly agree) and 0 =no relationship imperative (disagree or strongly disagree).
Covariates
Public assistance was assessed by asking participants if, in the past 12 months, they or someone they lived with received any money or services from Welfare, including TANF (Temporary Assistance to Needy Families) or SSI (Supplemental Security Income), or any money or services from food stamps, WIC (Women, Infants and Children), or Section 8 housing (housing subsidies). An 11-item, Likert-type scale [29] (α= .90) was used to measure each participant’s perceived social support (e.g., “There is a special person who is around when I am in need”). Low and high perceived social support categories were derived using a median split of the scale scores (Median = 35).
To assess the typical age difference between participants and their male sex partners, participants were asked, “In general, how old are the people you have sex with?” and participants responded to a 5-point Likert-type scale ranging from 1 (much younger than you—5 or more years) to 5 (much older than you—5 or more years). Typical age difference was categorized as 0 (participant being between 0 and 2 years younger) and 1 (participant being three or more years younger). Participants were also asked the age of their current boyfriend (if applicable). The age difference was dichotomized as 0 (boyfriend is two years older or less) and 1 (boyfriend is three years older or more).
Psychosocial factors
Relationship power was assessed using an 11-item, Likert-type scale [30] (α= .70). Items included “Most of the time we do what my partner wants to do,” and “I am more committed to our relationship than my partner.” A median split of scores was used to create high and low perceived relationship power categories (Median = 22). To assess participants perceived self-efficacy to refuse sex in various situations, participants responded to a 7-item, Likert-type scale [31] (α = .87) that asked participants whether they could or could not say no in various situations, such as “How sure are you that you would be able to say NO to having sex with someone you (a) want to date again? or (b) who refuses to wear a condom?” Response options ranged from (1) I definitely can’t say no to (4) I definitely can say no. Low and high refusal self-efficacy categories were derived using a median split of the scale scores (Median = 25). To assess fear of abuse and other negative consequences due to condom negotiation [32] an 8-item scale (α = .89) was used to ask participants about the degree to which they were worried about discussing condom use with their boyfriend/sex partner because he would respond in negative ways including threatening to hit, push, or kick them; leave them; swear at them; or call them names. Participants responded on a 5-item Likert-type scale ranging from 1 (never worried) to 5 (always worried). All scores were summed and fear (indicating some degree of fear for one or more items) and no fear categories were created.
Lifetime partner abuse was assessed by asking participants if they had ever been emotionally abused and if anyone had ever made them have vaginal or anal sex when they did not want to. To assess recent main partner abuse, participants 18 years and older were asked if they had been emotionally, physically (hit, punched, kicked, slapped, etc.), or sexually abused (forced vaginal or anal sex) by their boyfriend or main partner in the past 60 days. Due to mandatory reporting of suspected child abuse, participants under the age of 18 (n = 325) were not asked to report recent partner abuse experiences.
Sexual risk behaviors
The outcome variable, risky sexual behavior, was assessed five ways: whether participants (1) used a condom during the last sexual intercourse with a main partner; (2) used a condom during the last sexual intercourse with casual partner; (3) engaged in unprotected sex while experiencing STI symptoms prior to treatment; (4) engaged in unprotected sex while their partner was high on alcohol or drugs; and (5) ever engaged in anal sex.
Sexually transmitted infections
Participants provided two self-collected vaginal swab specimens to test for Chlamydia, gonorrhea, and trichomonas. Specimens were delivered and tested at the Emory University Pathology Laboratory. Any STI was defined as testing positive for one or more of the three STIs.
Data analyses
Separate hierarchical logistic regression analyses assessed the association between endorsing a relationship imperative and multiple risky sexual behaviors and psychosocial factors while controlling for previously mentioned covariates. Additionally, a backward stepwise logistic regression analysis examined the association between multiple risky sexual behaviors and psychosocial factors and STIs, while controlling for age and public assistance. An alpha of .05 was used to retain factors in each model.
Participant characteristics
Among this sample of 715 young African-American women, the mean age was 17.8 (SD = 1.7). Approximately half (47.8%) reported living in a household that received public financial assistance. Additionally, half (50.6%) reported that their sexual partners usually were two to four years older than they and 13.7% (n = 98) reported having partners who usually were 5 or more years older. The majority (83.6%) reported having a boyfriend at baseline and 29% (n = 206) endorsed a relationship imperative.
Separate hierarchical logistic regression analyses indicated that young women who endorsed a relationship imperative, compared to those who did not, were more likely to report perceiving themselves to have less power in their relationship (AOR = 2.3), perceiving themselves to be unable to refuse sex in multiple high-risk situations (AOR = 2.0), fear of negotiating condom use with a partner (AOR = 1.5), lifetime (AOR = 1.5), recent (AOR = 1.6) partner abuse, unprotected sex prior to being treated for STI symptoms (AOR = 3.9), unprotected sex at last sex with a casual (AOR = 2.1) and main (AOR = 1.6) partner, anal sex (AOR = 1.8), and sex while their partner was high on alcohol/drugs (AOR = 1.5) (see Table 1). Based on these findings, post-hoc analyses were conducted among participants reporting a relationship imperative (n = 206). Relationship between boyfriend status (yes vs. no) and perceived sex refusal self-efficacy was examined among this subgroup. Findings indicated that the odds of perceiving oneself as able to refuse sex in multiple situations (e.g., someone who you want to fall in love with you, date again, you’ve known for a few days, refuses to wear a condom, is pressuring you to have sex, or have had sex with before) was 2.8 times as great for girls with boyfriends as for girls without boyfriends.
Table 1
Table 1
The association between endorsing a relationship imperative and HIV/STI-related psychosexual outcomes and high-risk sexual behaviors
Correlates of sexually transmitted infections
When examining laboratory-confirmed STIs, a three-factor model was significant (χ2(6) = 20.59, p= .002), and the H–L goodness-of-fit statistic (χ2(8) = 7.65, p= .47) indicated that model fit was satisfactory. This model was able to correctly classify 70.4% of young women according to whether they had an STI. The odds of testing STI-positive were 3.9 times as great for those who perceived themselves as having less power in their relationship than for those who perceived themselves as having more relationship power. Also, the odds of testing STI-positive were 3.4 times as great for participants reporting recent partner abuse as for those reporting no recent partner abuse (see Table 2). The odds for testing STI-positive were 3.8 times as great for youth who perceived themselves as more able to refuse sex under various circumstances as for youth with a lower perceived ability to refuse sex. Endorsing a relationship imperative, reporting fear of condom negotiation, lifetime partner abuse, any unprotected sex, anal sex, or sex while partner was high on alcohol/drugs was not retained in the model examining correlates of STIs.
The present study examined the association between the relative importance African-American female adolescents place on being in a relationship and their engagement in risky sexual practices and other adverse relationship dynamics as well as whether these risk factors and behaviors increase risk for STIs. The results indicated that if young girls believe a relationship is imperative, they may engage in higher sexual risk behaviors or be in relationships characterized by a power imbalance or abuse. Furthermore, young women in relationships characterized by a power imbalance or abuse are at increased risk for STIs.
Interestingly, among young women who endorsed a relationship imperative, those without boyfriends perceived themselves to be less likely to refuse sex under various circumstances than those with boyfriends. It is possible that young girls who view relationships as imperative but do not have boyfriends are more likely to engage in sex because they believe it may help them get a boyfriend. One surprising finding was that young women who perceived themselves as more able to refuse sex under various circumstances were more likely to test STI-positive than those with a lower perceived ability. However, it is important to note that perceived ability to refuse sex was assessed and not actual refusal. Future research is needed to determine whether young women with higher self-efficacy actually utilize these skills with their partners or if the importance of being in a relationship takes precedence [22].
Peer norms often emphasize the importance of being in a relationship and male adolescent partners may compound the issue by pressuring their female partners to engage in sex [2,14]. As a result, relationships may be perceived as imperative in order to conform to peer pressures and to maintain self-esteem, and young women may be more likely to engage in risky behaviors to maintain their romantic relationships. Risks may be further exacerbated if they are in relationships where a power imbalance exists or where they experience partner abuse. In this study, partner abuse was associated with testing STI-positive.
Theories, such as the Theory of Gender and Power [33] should be considered when developing culturally appropriate and gender-specific HIV prevention interventions that promote self-worth and identity among youth. The Theory of Gender and Power [33] is a social structural theory that examines how three overlapping but distinct societal structures characterize the roles between men and women: (1) the division of labor; (2) the division of power; and (3) the structure of cathexis. In particular, the structure of cathexis is often illustrated by the emotional attachments that young women have with their male partners, who are often older, which is associated with STI-related risk factors [34] as seen in the current study. However, it is worthwhile noting that in this study, despite controlling for typical age of partner, relationship imperative was still associated with several adverse psychosexual outcomes and sexual risk behaviors. Girls who reported that being in a relationship at all times is important to them were also more likely than those not endorsing a relationship imperative to fear negotiating condom use with a male partner because it might lead to abuse, relationship termination, or other adverse relationship consequences.
Potential limitations of this study include cross-sectional data analyses that prevent causal interpretations, the use of a crude 1-item measure for assessing relationship imperative, data on risky sexual behaviors relying on retrospective self-report data and data not being available to support attachment theory [35] as a potential explanation for the findings. Given the limited research on relationship imperative, future research should focus on developing a scale to better examine it. Finally, the sample was homogeneous, all African-American female adolescents from the southeastern part of the U.S. who were seeking community-based sexual health services. Therefore, findings may have limited generalizability and replication with diverse populations would be needed.
Many HIV/STI intervention programs for young women focus on increasing skills regarding communication and negotiation of condom use [36]. Although it is important for young women to learn and utilize these skills within their relationships, it also is important to consider the context in which these skills will be most beneficial. If young women perceive that utilizing these skills may place their relationship at risk or if they may experience abuse, then they will be less likely to request or use condoms [22,37]. Therefore, it is important to focus on improving sense of self-worth and self-esteem among young women and to increase their understanding of healthy relationships. Given that previous research has indicated that adult African-American women are also more likely to engage in risky behaviors in order to maintain their relationships [38], it is pertinent to intervene with African-American female adolescents so that they do not continue to engage in these behaviors into adulthood.
Interventions that target both males and females and are couples-based or peer-led may be beneficial so that peer norms regarding relationships also can be targeted. This would provide an opportunity for peers to have an open discussion regarding relationships and potentially change cultural norms. It is important for adolescents to be targeted early so that they have a better understanding of what it means to be in a relationship. By increasing self-worth and self-esteem of African-American female adolescents along with addressing peer norms that may place them at risk, healthy relationships and the reduction of risky behaviors and STI infection can be facilitated.
Table 2
Table 2
Psychosocial factors associated with testing positive for a sexually transmitted infection
IMPLICATIONS AND CONTRIBUTION
This study examined the association between the relative importance adolescent girls place on being in a relationship and their engagement in risky sexual practices and other adverse relationship dynamics. The findings demonstrate a heightened risk for HIV and other STIs during adolescence.
Acknowledgments
This study was supported by a grant from the National Institute of Mental Health (R01-MH061210) awarded to the third author.
Footnotes
CDC Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.
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