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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”

Why Are Latino Gay and Bisexual Men at Risk?
Culture and Sexual Behavior
Editorial:  Mirror, Mirror
Recent Reports
Next Month
Why Are Latino Gay and Bisexual Men at Risk?
Francisco J. Gonzalez, MD
     Almost a decade and a half into the HIV epidemic, Latino gay
and bisexual men in the United States have emerged as a risk
group.  Some 17 percent of all AIDS cases in the United States
are among Latinos, although Latinos constitute only about 9
percent of the population.  Of these cases, 40 percent are among
gay and bisexual men.1 Why?  It is only relatively recently that
studies have begun to look at this complex question.
     The very label "Latino gay and bisexual men" obscures an
astonishing heterogeneity of races, nationalities, religious
practices, customs and beliefs, and sexual self-identifications
and behaviors.  Untangling this intricate web requires careful
research to identify compelling predictors of risk behavior that
can be targeted successfully for prevention.
     Few quantitative studies of Latino men's sexual practices
exist, but a slowly growing literature is shedding light on the
underlying structure of the epidemic in the United States.  For
example, over time investigators have correlated Latino ethnicity
with higher rates of unprotected sex.  One study of 807 men
leaving bathhouses in Los Angeles County in July and August 1986
found that being Hispanic, along with younger age and lower
educational and economic status, was significantly associated
with unprotected anal sex.2 A more recent study of urban sexually
transmitted disease clinics looked at 601 men who had engaged in
unprotected anal or oral intercourse in the previous four
months.3 Hispanic ethnicity, along with drug use and sex in a
steady relationship, again emerged as a consistent predictor of
risk behavior across sites.
     These results prove the now old adage that knowledge is not
enough to bring about behavior change.  But it is possible to
pinpoint wider cultural issues -- particularly the meaning of
homosexuality in Latino culture and the relationship between
family, coming out, and acculturation -- that interfere with the
behavior change process for some Latino men.
Gender Roles and (Homo)sexuality
     According to some ethnographers and cultural critics, sexual
role rather than sexual object choice forms the basis of
homosexuality in Latin America.4 While the defining component of
Anglo-European homosexuality is same-sex partner choice,
traditional Latino homosexuality is concerned more with the role
played in the sexual encounter, a script largely defined by
societal expectations of masculinity and femininity.  In a
culture that maintains relatively rigid gender roles, machismo
holds men accountable for their virility:  men must prove their
mettle in sexual conquest, invulnerability, aggressiveness, and
honor.  Homosexual encounters, viewed in this paradigm, re-enact
heterosexual desire.  They focus on insertive anal sex, in which
the macho activo partner penetrates the feminine pasivo.  The
insertive partner preserves his masculinity and thus his
heterosexuality; the pasivo is stigmatized as effeminate, and it
is his loss of manhood -- more than sex with another man per se --
that marks him as homosexual.
     This is, of course, a simplified cartoon of Latino
homosexual dynamics, but it helps explain the prominence of
bisexual behavior in the Latino HIV epidemic.  A man may have
occasional same-sex contacts without fundamentally putting his
heterosexual identity in question.
     The epidemic in Mexico is illustrative, notably because it
has assumed a middle position between the two basic
epidemiological patterns of HIV transmission as defined by the
World Health Organization.  In the type I pattern, found in the
United States, Europe, and Australia, transmission is primarily
through injection drug use and homosexual sex; in pattern II
countries, as in most African and Caribbean nations, heterosexual
transmission predominates.  Some researchers have characterized
the epidemic in Mexico as type I/II, alluding to the increasing
transmission by heterosexual contacts, much of which seems to be
due to the "bisexual bridge" between homosexuals and

     In a study of more than 5,000 gay and bisexual men in 18
cities in Mexico conducted from 1985 to 1990, Maria Garcia Garcia
of the Mexican Health Ministry found that frequency of bisexual
practice varied by community size: 67 percent of homosexually
active men in small communities also reported having sex with
women compared to 56 percent in metropolitan centers like Mexico
City.4 Bisexual men tended to be less educated than homosexual
men, and bisexual men in small towns were more likely than their
urban counterparts to establish stable relationships with women
and to have children.
     Garcia Garcia concludes:  "Bisexual activity among
homosexual men is more frequent in groups where homosexuality per
se is ostracized and where `machismo' in its more flamboyant
expression is looked upon as desirable.  In this type of
environment, the confirmed homosexual must hide behind
heterosexual relationships."5 While this position may overlook
the possibility of a "confirmed bisexual," it underscores how
homosexual stigma may affect sexual practice.
Acculturation and Sexuality
     In the case of Latino men living in the United States,
matters are complicated by acculturation.  Acculturation refers
to the facility an individual has in managing a foreign "cultural
economy":  the values, roles, language, and social networks that
make a culture distinct.  Taking majority Anglo culture as a
point of departure, a stereotypic "less acculturated" Latino
would speak more Spanish than English, hold traditional
conceptions of gender and sexuality, and value the family as the
primary social system.  As with language, an individual may
"speak" more than one culture fluently, and indeed many Latinos
are bicultural.  But like members of other minority groups,
Latinos must struggle with their difference from the majority
     For gay Latinos, this difference is doubly constituted in
terms of sexual orientation as well as ethnicity.  But developing
gay identity may come at the cost of losing cultural identity.
Since the values of strong kinship ties, religion, and conformity
to gender roles may serve as a way of fending off assimilation,
some Latinos may view "gayness" as eroding traditional "Old
World" values and moving toward dominant culture.  In this way,
the process of developing a gay identity may involve temporarily
(or permanently) setting aside identification as Latino, or
conversely, deferring coming out and living in a Latino closet.
     These are largely issues of personal development whereby an
individual explores questions of difference, for example,
homosexual versus heterosexual, in the formation of identity, in
this case, sexual identity.  A similar process occurs when the
difference is constituted by ethnicity.  Stigma is the
unfortunate engine of change as individuals wrestle with self-
acceptance, disclosure, and community building.  Caught between
homophobia and racism, gay Latino men are often caught in a
developmental double indemnity.
     For bisexual men, this developmental bind may be more acute.
Figured as the cultural "outside" of both the gay and straight
worlds, bisexuality is truly the love that dare not speak its
name.  While Latino gay men may be positioned between ethnic and
sexual cultures, bisexual men seem caught in cultural
unintelligibility, with no clear bisexual "identity," community,
or norms.
Where Is Prevention Failing?
     This cultural background provides a good foundation for
revisiting the issue of prevention.  A handful of studies have
begun to elucidate the predictors of risky behavior beyond the
blanket descriptor of ethnicity.
     A Tucson study of 159 English-speaking Latino gay men found
high rates of unprotected anal sex:  51 percent of the sample had
at least one unprotected encounter in the past 12 months.6 Intent
to perform safe sex, perception of self-control, substance use,
and sex in public were the most important predictors of HIV-
related risk.  A study of 200 HIV-knowledgeable gay and bisexual
men in the border town of Juarez, Mexico found that high-risk
behavior was associated with being a factory worker, meeting
partners in the street (as opposed to in a bar or disco), and
older age.7 Finally, a Puerto Rican study of gay and bisexual men
conducted from 1992 to 1993 found a history of childhood sexual
abuse to be a significant predictor of high-risk sex.  The
researchers hypothesize that the abuse constitutes a loss of
manhood for the boy, leaving him in a woman's role that
"prescribes acquiescence with a man's desire."8
     Is there a way to relate these disparate variables
underlying the broader category of ethnicity?  In his study of
Latino gay men, Rafael Diaz describes the "psychocultural
barriers" to safe sex intentions, including machismo, racism,
homophobia, sexual silence, and familism.9 He postulates that for
Latino gay men, societal proscriptions of homosexuality collude
with reticence on sexual matters and a primary allegiance to the
biological family of origin.  Homosexual desire remains
unintegrated with identity, something that must remain hidden or
unacknowledged by the individual.  Ultimately, internalized
homophobia and pressures to conform to societal expectations
compete with the intention to practice safer sex and result in
risky behavior.  A heterosexually identified man, for example,
might feel condom use compromises his masculinity if it affects
erection.  When seen as correlates of a dissociated sexuality,
the variables of substance use, sex in public, and a history of
childhood sexual abuse noted in the studies above lend support to
Diaz's model.
Implications for Intervention and Treatment
     Clinical interventions must speak to complex cultural
issues.  Clinicians should educate themselves about the specific
cultural and socioeconomic background of clients or consider
consultation or referral.  They should investigate with clients
possible correlates of high-risk behavior, including substance
abuse and sexual abuse.  In terms of prevention, providing a
therapeutic environment for exploring conflicts about sexuality
is more important than simply disseminating information about HIV
disease and developing communication skills about safe sex.
     The relationship between risk behavior and acculturation is
not clear, but acculturation issues can be potent mediators of
sexual identity struggles.  Assumptions of "gayness" and related
norms about safe sex may not apply to some homosexually active
Latino men, many of whom do not see themselves as "homosexual,"
much less as "gay."  Rather than embarking on an exploration of
highly charged sexual matters, clinicians may be better served by
examining acculturation issues that may act as proxies for
conflicts about sexuality.  For example, in working with an
immigrant pasivo client who engages in unprotected sex,
understanding what the client gained and lost during immigration,
his and his family's conception of masculinity, and his current
social support network might be important doorways to underlying
sexual issues.  Because most Latino families are relatively
silent on sexual issues, it is wise not to be cavalier in
addressing sexual concerns, but to concentrate on first
establishing a solid trust.
     The family is also a potentially rich site for
interventions.  Clinicians can help clients by exploring
decisions about disclosure, both in terms of sexual orientation
and serostatus, and they can even facilitate disclosure in family
sessions.  This is particularly important because despite
homophobic pressures, the family is the basis of social support
for many Latino gay men.  Finding creative ways of strengthening
those supportive ties may ameliorate HIV-related demoralization.
     Finally, much prevention work remains to be done at the
community level.  While "gay" may define a relatively stable
sociopolitical category or an axis of identity development, it
does little to describe sexual behaviors that may transmit the
virus.  We must find ways of allowing more open discussions of
sexuality -- including bisexuality -- and of acknowledging sexual
fluidity.  Cultural and political barriers (for example, the
recent passage of Proposition 187 in California*) will no doubt
make some of these men harder to reach.  To counter this,
prevention interventions might target locations where high-risk
sex occurs like parks and other public cruise spots.  Campaigns
accessing the so-called "general population" in work places,
community gatherings, and churches might avoid grouping
individuals as homosexual, while still reaching at-risk men.
Part of this intervention strategy should aim at exploring
homophobia, sexual discomfort, and gender issues.

     The most significant interventions will be those that foster
community building among Latino men and provide a forum for
exploring these complex issues.  The growth of an organized
Latino gay and bisexual community will be critical not only in
sustaining individual development, but also in challenging
established Latino and Anglo norms that make these men outsiders.
1.  Centers for Disease Control and Prevention.  HIV/AIDS
Surveillance Report, Year End Edition.  1993; 5(1):  19.
2.  Richwald GA, Morisky DE, Kyle GR, et al.  Sexual activities
in bathhouses in Los Angeles County:  Implications for AIDS
prevention education.  Journal of Sex Research.  1988; 25(2):
3.  Doll LS, Byers RH, Bolan G, et al.  Homosexual men who engage
in high-risk sexual behavior:  A multicenter comparison.
Sexually Transmitted Diseases.  1991; 18(3):  170-175.
4.  Almaguer T.  Chicano men:  A cartography of homosexual
identity and behavior.  In Abelove H, Barale MA, Halperin DM.
Lesbian and Gay Studies Reader.  New York:  Rutledge, 1993.
5.  Garcia Garcia MDL, Valdespino J, Izazola J, et al.
Bisexuality in Mexico: Current perspectives.  In Tielman R,
Carballo M, Hendricks A, eds.  Bisexuality and HIV/AIDS:  A
Global Perspective.  Prometheus Books:  Buffalo, NY, 1991.
6.  Diaz RM, Stall RD, Hoff C, et al.  HIV risk among Latino gay
men in the southwestern United States.  AIDS Education and
Prevention.  In press.
7.  Ramirez J, Suarez E, de la Rosa G, et al.  AIDS knowledge and
sexual behavior among Mexican gay and bisexual men.  AIDS
Education and Prevention.  1994; 6(2):  163-174.
8.  Carballo-Dieguez A, Dolezal C.  Association between history
of childhood sexual abuse and adult HIV risk behavior in Puerto
Rican men who have sex with men.  Child Abuse and Neglect.  In
9.  Diaz RM.  Latino gay men and the psycho-cultural barriers to
AIDS prevention.  In Levin M, Gagnon J, Nardi P, eds.  A Plague
of Our Own:  The Impact of the AIDS Epidemic on the Gay and
Lesbian Communities.  Chicago: University of Chicago Press, in
*Proposition 187, passed in November 1994, restricts services
such as public health and education for undocumented immigrants.
Francisco J. Gonzalez, MD is a fourth-year resident in psychiatry
at the University of California San Francisco and a researcher
at the UCSF Center for AIDS Prevention Studies.  He is the co-
author of a chapter on Latinos and homosexuality to be published
in 1996 in an American Psychiatric Press book.
Culture and Sexual Behavior
Cynthia A. Gomez, PhD
     Ignorance of cultural and contextual realities of sexual
behaviors continues to hamper the effectiveness of many HIV
prevention efforts, particularly efforts targeted at women.
Researchers have responded by focusing their attention on the
ways in which women are able or willing to exercise sexual
decision-making power in heterosexual relationships.  This
question is especially relevant for Latina women, and its
resolution is crucial to their implementing fundamental safer sex
     Over the past few years, my colleagues and I have focused on
the sexual behavior patterns of Latinos as they relate to HIV
prevention.  In a recent study of unmarried Latino adults living
in the United States, we began to explore some of these important
cultural and contextual factors.  Preliminary findings highlight
important variables for assessing predictors of condom use in
this population:  socialization of sexuality, interpersonal power
within relationships, and gender norms.
     This study was a population-based telephone survey of 846
women and 754 men, ranging in age from 18 to 49 years old.
Respondents were drawn from the 10 U.S. states where 87 percent
of the Latinos living in this country.  The sample replicates the
proportion of Latinos in the United States by country of origin,
for example, 58 percent were of Mexican origin, 12 percent of
Central American origin, and 10 percent of Puerto Rican origin.
Among those interviewed were first, second, and third generation
Latino immigrants:  43 percent were born in the United States; 22
percent had lived in this country for fewer than six years.
Fifty-seven percent, including 21 percent of those born in the
United States, chose to be interviewed in Spanish
Sexual Socialization
     People rarely dispute the importance of preparing for fires,
earthquakes, or heart attacks.  Sexual preparedness, however,
while it is also crucial to saving lives, remains a source of
great controversy.  Despite several studies showing that accurate
and developmentally appropriate sex education may actually delay
the onset of sexual activity,3,4 many people still fear that such
information will lead to sexual precociousness rather than sexual

     Understanding and managing the complexity of a sexual
encounter cannot be achieved without some guidance.  Yet, the
telephone survey found a pervasive "sexual silence," particularly
among women.  More than half of all respondents in the survey

reported that their mothers had never spoken to them about sex
when they were younger, and 58 percent of men and 82 percent of
women said that their fathers had never spoken to them about sex.
Latino respondents who reported that a parent or relative had
spoken to them about using condoms were more likely to report
using condoms in the year prior to the interview.
     Growing up in families where sex was an accepted topic of
discussion may also lead to sexual comfort, another factor that
was associated with condom use.5,6
Interpersonal Power and Coercion
     Earlier research found Latina women were less likely to use
condoms if they feared male partners would become angry or
violent if asked to use condoms.8 The most recent telephone
survey attempted to go beyond fear, to identify actual
experiences that could be considered coercive within the context
of sex.
     We asked 551 women who were sexually active in the last 12
months, "Of the times you had sex with a man in the last twelve
months, how often did he insist on having sex when you did not
want to?"  In response, 73 percent reported some amount of this
experience; 23 percent reported sexual partners had yelled at
them; 3 percent reported being hit; and 14 percent reported being
harmed in some other way.  The 621 men who were sexually active
in the last 12 months corroborated these patterns:  65 percent
reported insisting on having sex when their partners did not want
to; 51 percent reported having sex with a woman who initially
resisted, but then changed her mind; and 30 percent reported
lying to convince a woman to have sex.
     It is important to note that sexual coercion was defined in
the broadest of terms; the questions, themselves, did not label
these behaviors as "coercion."  For some, insisting on sex may
not be perceived as coercion but as the right of a man.  On the
other hand, being hit can have little other interpretation.  Men
who reported being coercive and women who reported being coerced
were more likely to agree with statements reflecting more
traditional sexual gender norms such as:  it's harmful for a man
to get excited without ejaculating and it's dangerous for a woman
to know as much about sex as a man.  Finally, coercion itself may
not be predictive of unsafe sex:  there are men who are coercive
and insist on condom use.
Cultural Gender Norms
     When asked if "a woman has to pay the consequences of
flirting with a man," Latina women who disagreed were more
consistent condom users than the Latina women who agreed with
that statement.  Men who disagreed with the statement were less
likely to report never using condoms.  Both men and women who
disagreed with the statement, "Women like dominant men," were
much more likely than those who agreed to be consistent condom
     The major challenge not only for Latinos living in the
United States, but also for many other cultures, is the need to
reject traditional cultural norms.  It is about developing not
only culturally sensitive prevention messages, but also
sensitivity to the dangerous effects of sex and gender norms
within cultures.
     The implications of this research extend beyond Latino

culture and women.  Assisting individuals to decrease their own
"sexual silence" must start with providers.  Doctors, counselors,
teachers, clergy, and other important "message givers" can be
models for talking openly about sex and sexual preparedness.
     Parents must also be given the tools to speak to their
children about sex.  Again, "message givers" who interact with
families can serve as mentors for parents -- particularly parents
who oppose school-based sex education -- by providing them with
skills for discussing sex with their children. HIV counselors and
educators must be careful not to ignore the power dynamics
present in all personal relationships.  When possible, they
should encourage couples rather than individuals to come for
counseling together so that therapy can address sexual decision-

making roles and responsibilities.  Interventions targeting women
must include assistance in identifying potentially abusive
situations, as well as teaching how women can assert their needs
within a sexual context.  Interventions targeting men should
challenge traditional gender norms and help men identify their
risks for being coercive in sexual encounters.  Our success in
these areas will depend on our abilities to educate beyond
knowledge, counsel clients beyond risk assessment, and study

sexual behavior beyond mere prevalence.
Editorial:  Mirror, Mirror
Robert Marks, Editor
     I have to admit that sometimes responding to diversity is
exhausting.  It is difficult enough to understand behavior within
my own culture.  So when I think about another article on the
multicultural aspects of the epidemic, part of me cringes, all
the more so because the challenges raised by culturally specific
behaviors are so thorny.  The funny thing is that when I read an
article on these topics, I am fascinated, even exhilarated, by
these differences and by the insights of the observers who
describe them. A good example of this phenomenon is this month's
issue of FOCUS. Both articles include information that, while not
groundbreaking, provides a good foundation for understanding the
variables that affect prevention in Latino communities.  But both
also include nuggets of insight about the most problematic and
intransigent issues.
     Francisco Gonzalez talks about the acculturation bind faced
by Latino gay and bisexual men:  the conflict between expressing
sexuality or ethnicity, between setting aside Latino identity or
"living in a Latino closet."  If we agree that acknowledging both
ethnic identity and sexual identity is important for personality
development, gay and bisexual Latino men -- as well as many others
-- face a Sophie's choice of watching as one or the other self is
sacrificed.  Can there be any better reason for HIV-related
     Cynthia Gomez's focus on sexual coercion again, while not
new, clarifies the extent to which coercive behavior exists in
Latino couples.  Power dynamics have always been discussed in
terms of condoms:  while women want them, their male partners
don't, and since the men are the ones who must actually "use"
condoms, their resistance determines whether sex is protected.
But Gomez's research should help us think of prevention in larger
terms:  the sexual dynamics for many men and women, particularly
in Latino culture, may be so dysfunctional as to have little to
do with the caring, loving attitude that prevention messages take
for granted as the basis for sexual relations and as the
foundation for behavior change.
     Gonzalez and Gomez both mention "sexual silence," a concept

that fellow researcher Barbara Marin has raised.  Marin and Gomez
found that sexual silence in families of origin leads to less
effective behavior change.  Gonzalez suggests that sexual silence
complicates interventions that include clients and their families

of origin.  This is perhaps the greatest challenge for counselors
and educators, again for both Latino clients and those from any
of the range of U.S. subcultures-talking about sexuality in ways
that get beyond discomfort, shame, and guilt.
     By the time I finish reading articles like these, I am no
longer cringing in the face of a multicultural monster, each
tentacle a problem so culturally specific as to be
unintelligible; I am gazing into a mirror noticing that the warts
on my face are not so very different from the warts on my
neighbor's face.  Counselors and educators caring for Latino
clients and populations must arm themselves both with magnifying
glasses to understand the differences among us and mirrors to
understand the similarities.  Human empathy, coupled with a
strong dose of imagination about other people's realities, may be
the best medicine for providers.
AIDS Cases among Hispanic Americans
Diaz T, Buehler JW, Castro KG, et al.  AIDS trends among
Hispanics in the United States.  American Journal of Public
Health.  1993; 83(4):  504-509.  (Centers for Disease Control and
     The overall rate of Hispanic AIDS cases in the United States
is two-and-one-half times that of non-Hispanic Whites, according
to a review of epidemiological data.  Notably, however, incidence

and route of infection vary among Hispanic groups.
     The Center for Disease Control and Prevention (CDC) surveyed
107,140 AIDS cases between 1988 and 1991.  The survey classified
Hispanics by country or territory of birth, geographic residence
in the United States, and exposure category.  1990 census data
provided a basis for the calculation of annual AIDS incidence
     For Hispanics born in the United States, the primary
exposure categories were male-to-male sex for men (51 percent)
and injection drug use for women (56 percent).  There were
variations in these patterns for subpopulations.  Injection drug
use was the predominant exposure category for both Puerto Rican-
born men and women.  Injection drug use was a less significant
vector for other Hispanic women, although more than one-third of
the cases among women born in the Dominican Republic and South
America were traced to heterosexual sex with an injection drug
user.  Seropositive Hispanic children are frequently infected via
perinatal transmission.
     Male-to-male sex was the predominant exposure category for
men born in South America, Cuba, Mexico, and Central America.
This category may well be vastly underreported due to cultural
biases against homosexuality and bisexuality.
Condom Availability and Sexual Activity
Sellers DE, McGraw SA, McKinlay JB. Does the promotion and
distribution of condoms increase teen sexual activity?  Evidence
from an HIV prevention program for Latino youth.  American
Journal of Public Health.  1994; 84(12): 1952-1959.  (New England
Research Institute.)
     A condom program targeting Latino adolescents did not
increase sexual activity among 536 New England teenagers.
     The prevention program targeted a primarily Puerto Rican
neighborhood in Boston in 1990.  The campaign included workshops
and peer-led informational events, widespread canvassing and
promotional messages, and condom distribution.  Neighborhood
teenagers who were 14 to 20 years of age -- 94% of whom were
Puerto Rican and 6 percent of whom where of other Latino origin
-- responded to a subsequent survey.  Researchers also surveyed a
similar population in Hartford, Connecticut as a control.  Survey
subjects responded to a series of questions about condom use and
sexual activity; follow-up interviews took place six months
     The study found no evidence that increased condom
availability increased sexual activity or promoted sex with
multiple partners.  In fact, male respondents in the intervention
city were less likely to initiate sexual activity than those in
the comparison city, and female respondents in the intervention
city were less likely to engage in sex with multiple partners.
Developing Culture-Specific Videos
O'Donnell L, San Doval A, Vornfett R, et al.  Reducing AIDS and
other STDs among inner-city Hispanics:  The use of qualitative
research in the development of video-based patient education.
AIDS Education and Prevention.  1994; 6(2):  140-153.  (Education
Development Center, Newton, Massachusetts.)
     Educational materials are too often based on untested
assumptions.  A review of the development of a prevention video
for inner-city Hispanics models how empirical qualitative
research can be used to create effective materials. Researchers
recruited 192 Hispanic men and women from the waiting rooms of
sexually transmitted disease treatment clinics in New York City.
Among the respondents -- the majority of whom were Puerto Rican
-- 70% self-identified as English-speaking or bilingual, and 30
percent communicated only in Spanish.  Although about 25 percent
of male respondents reported engaging in some form of sexual
activity with other men, only a minute percentage identified
themselves as gay.  Researchers used a series of surveys, focus
groups, and personal interviews to gauge receptivity to condom

use in different situations, the importance of gender roles in
negotiating condom use, and the level of knowledge about HIV
disease and other sexually transmitted diseases (STDs).
     Most participants had had at least one negative experience

with condom use.  A majority said it would be impossible to
introduce condom use into existing sexual relationships without
incurring anger and mistrust.  Women expressed the desire to
avoid confrontations with male partners who they said would be
angered by the suggestion to use condoms.  Most participants,
male and female, agreed that in heterosexual encounters the male
partner decided whether or not to use a condom.  Respondents
demonstrated relatively high levels of knowledge concerning HIV

disease, STDs, and condom protection.
     Video-based patient education is a popular approach because
it enables culture-specific communication in settings that do not
have bilingual/bicultural health care workers on staff.  The
video developed from this research includes a series of
dramatizations of interactions between both casual and primary
partners modeling protective behavior.  In developing an
educational video based upon this population and its responses,
educators considered both linguistic and cultural communication
obstacles.  Because most survey respondents spoke both English
and Spanish, the video used a combination of both languages.
Since many, especially women, expressed discomfort with the idea
of verbally negotiating condom use, the video models nonverbal
communication in a series of scenarios.  Due to the prevalence of
heterosexual identity in the target audience, the video depicts
primarily male-female encounters.
     In response to female respondents' fears of their male
partners' anger, the video depicts a scenario in which such
conflict is resolved.  The scene is meant to demonstrate that
anger and frustration are natural reactions that occur during
negotiation.  The woman in the scene avoids escalating the
confrontation by simply presenting a condom to her partner rather
than arguing with him.
HIV and Alcohol Abuse among Latina Youth
Flores-Ortiz YG. The role of cultural and gender values in
alcohol use patterns among Chicana/Latina high school and
university students: Implications for AIDS prevention.  The
International Journal for Addictions.  1994; 29(9); 1149-1171.
(University of California, Davis.)
     Latinas and Chicanas comprise almost 21 percent of the total
HIV-infected female population in the United States and are eight
times more likely to contract AIDS than are non-Hispanic White
women.  Two small California studies conclude that family and
cultural values shape these young women's sense of self-efficacy
in such a way as to reinforce high-risk behaviors, including
alcohol abuse.
     Both studies -- one of university students, the other of high
school students -- used focus groups and individualized surveys to
define HIV-related knowledge, alcohol and drug use, and level of
acculturation.  The high school sample included 14 focus group
participants and 30 individual surveys; the college sample
included 35 focus group participants and 65 individual surveys.
     Although almost all the participants shared a common
perception that Latina youth are supposed to be virgins until
marriage, not drink, and not discuss sexual matters openly, at
least 80 percent of both samples reported some incidence of
sexual intercourse, and 83 percent of the college sample reported
consistent use of alcohol.
     In both samples, participants often used alcohol as part of
sexual behavior, but subjects did not generally consider drinking
to be a high-risk behavior.  Despite high levels of HIV-related
knowledge and perceived self-efficacy, participants engaged in
consistently high-risk sexual behavior.  Cultural and familial
expectations often inhibited their ability to communicate openly
about issues of sexuality, alcohol, and HIV disease.
     The author suggests that Latino parents need to assume a
more active role in the sex education of their children, families
need to instill and reinforce more responsible alcohol use
behaviors, and male and female partners need to share the burden
of negotiating safe sex and reducing drinking equally.
Clearinghouse:  Latino Americans