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Fam Viol Prev Health Pract. Author manuscript; available in PMC 2016 January 14. Published in final edited form as: Fam Viol Prev Health Pract. 2010 ; 1(10): .

Condom Coercion, Sexual Relationship Power, and Risk for HIV and Other Sexually Transmitted Infections Among Young Women Attending Urban Family Planning Clinics

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Anne M. Teitelman, PhD, CRNP, Assistant Professor, Center for Health Equities Research, School of Nursing, University of Pennsylvania, Fagin Hall, 2L (rm.244), 418 Curie Blvd., Philadelphia, PA 19104-4217 Phone: 215-898-1910, Fax: 215-573-9193 Julia M. Bohinski, BSN, and Doctoral Student, School of Nursing, University of Pennsylvania, Philadelphia, PA 19104, Phone: 570-809-0959 Adriane M. Tuttle, BA Research Assistant, School of Nursing, University of Pennsylvania, Philadelphia, PA 19104, Phone: 360-903-7823 Anne M. Teitelman: [email protected]; Julia M. Bohinski: [email protected]; Adriane M. Tuttle: [email protected]

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Introduction

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Relationship dynamics play an important role in young women's ability to protect themselves from HIV and other sexually transmitted infections (STIs) and can often impede their ability to negotiate for safe sex. In this paper we identify several forms of condom coercion that place young women at risk for acquiring HIV and STIs. Furthermore, we describe several common sexual gender norms that decrease young women's sexual relationships power (SRP) and foster a social climate supportive of condom coercion. This study drawns attention to the concern that conventional descriptions of physical, sexual, and psychological violence do not fully recognize the prevalence of coercion in the lives of young urban women. Furthermore, coerced unprotected sex is not widely recognized as an important factor in the spread of HIV/STIs. Policies and prevention programs are needed to address this issue, especially among the poor urban women most affected by these epidemics.

HIV/STIs In the United States, adolescents and young women, particularly those of racial and ethnic minority groups, are disproportionately affected by STIs, including gonorrhea, chlamydia, human papillomavirus (HPV), and herpes simplex virus (HSV, or genital herpes) (Centers for Disease Control and Prevention, 2009a). It is relevant to note that having an STI such as

Correspondence to: Anne M. Teitelman, [email protected].

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gonorrhea, chlamydia, or herpes is proven to increase a woman's susceptibility to contracting HIV if they are exposed to it (Galvin & Cohen, 2004). Compared to males of the same age, adolescent girls (13 to 19 years old) accounted for 40% of all HIV cases diagnosed among adolescents in 2007, the highest proportion in females among all age groups (Centers for Disease Control and Prevention, 2009b). As with other STIs, HIV disproportionately affects racial and ethnic minorities, with black women carrying the largest burden of HIV infection. The vast majority of HIV infections for women between 15 and 24 years of age were acquired through risky heterosexual encounters (Satcher & et al., 2007).

IPV and HIV/STI Risk

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Limiting one's number of sexual partners and the use of male condoms are both effective HIV/STI risk reduction strategies; however, effective implementation of these strategies involves young women negotiating with their male partners. Consequently, relationship dynamics including intimate partner violence (IPV) can influence young women's ability to enact safer sex practices. In addition to being at a high risk for HIV/STIs, young women under the age of 25 experience the highest rates of intimate partner violence compared to women of other age groups (Tjaden & Thoennes, 2000). IPV includes physical and sexual violence, threats, emotional/psychological abuse and controlling behaviors (Saltzman, 2002).

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Rates of physical IPV are higher among African American women and adolescent females (Centers for Disease Control and Prevention, 2009c). Nevertheless, IPV has also been found to be highest in neighborhoods of poverty and in households with economic distress. Thus, economic disadvantage accounts for most of the racial disparity in IPV rates, and reflects the overrepresentation of minorities, particularly African Americans, living in poor urban communities (Benson & Fox, 2004; Bent-Goodley, 2001).

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IPV has many physical and psychological consequences, including increased risk for HIV and other STIs for both adolescents and young women (Coker, 2007; Decker, Silverman, & Raj, 2005; Sareen, Pagura, & Grant, 2009; Wu, El-Bassel, Witte, Gilbert, & Chang, 2003). Multiple studies have demonstrated an association between IPV and sexual risk behaviors, which is especially prevalent among young urban women. Three primary mechanisms of risk have been identified: 1) forced or coercive sex with an infected partner (Maman, 2000); 2) non-monogamous male partners (Bauer et al., 2002; Raj, Silverman, & Amaro, 2004; Wingood, DiClemente, McCree, Harrington, & Davies, 2001); and 3) condom non-use. Condom non-use has been associated with physical and verbal abuse among adolescents and young women (Howard & Wang, 2003; Kreiter et al., 1999; Rickert, Wiemann, Harrykissoon, Berenson, & Kolb, 2002; Roberts, 2005; Silverman, Raj, & Clements, 2004; Silverman, Raj, Mucci, & Hathway, 2001; Teitelman, Ratcliffe, Dichter, & Sullivan, 2008; Teitelman, Ratcliffe, Morales-Aleman, & Sullivan, 2008; Wingood et al., 2001; Wu et al., 2003). More specifically, young women exposed to IPV often have difficulty negotiating condom use due to fear of violence or feeling less power to negotiate (Maman, 2000; Wingood et al., 2001). Multiple reviews on the intersection of IPV and HIV have indentified the need for further research on the mechanisms within these relationships that interfere with

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condom negotiation (Coker, 2007; Gielen et al., 2007; Maman, 2000; Teitelman, Dichter, Cederbaum, & Campbell, 2007).

IPV and Sexual Relationship Power

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Several studies have found an association between IPV, lower sexual relationship power (SRP), and sexual risk. SRP refers to one partner having greater influence over the other's sexual decision-making or behavior. Beadnell and colleagues (2000) found women with a history of physical IPV were more likely to indicate their partner had more say about safer sex. Pulerwitz (2000) reported that women who had greater SRP were found to have increased condom use and decreased physical IPV. Raj and colleagues (2004) found that women reporting physical or sexual IPV were not only more likely to fear partner response to condom negotiation but also experience greater male control over sexuality. Among adolescent females, those with a history of physical IPV perceived themselves as having less control over their sexuality (Wingood, et al., 2001). Teitelman and colleagues (2008) found evidence to suggest there may be a causal pathway between lower SRP, partner abuse, and inconsistent condom use among adolescent girls.

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Previous research by Jones (2006) with adult women indicates pressure to engage in unprotected sex is more likely to occur within a context where women adopt stereotypical gender expectations about sex and feel obligated to please their partner. Women experienced this type of systematic pressure more frequently than other various forms of overt coercion. Thus, young women are often “silenced” in their safer sex negotiations suggesting the importance of understanding the gendered context of women's STI/HIV risk (Amaro & Raj, 2000). Furthermore, inequitable gender norms favoring the male partner were more often adopted by women in abusive relationships in which these norms may be more rigidly enforced (Beadnell et al, 2000).

Gender Perspective on HIV/STI Risk

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Gendered social patterns are important in understanding interpersonal influences that increased women and adolescent girls' vulnerability to HIV and other STIs (Amaro & Raj, 2000; Wingood & DiClemente, 2000; Zierler, 1997). According to the Theory of Gender and Power (TGP) (Wingood & DiClemente, 2000) and other HIV prevention theories informed by a gender perspective (Amaro & Raj, 2000; Zierler, 1997), greater male authority and control in interpersonal relationships is one structural mechanism that can restrict women's ability to negotiate safer sex. This is manifest, for example, by a history of physical or sexual abuse or an imbalance in SRP. These inequitable power relations between men and women are influenced by two other structural mechanisms: economic inequalities (which can foster dependency and limit access to resources); and traditional gender norms (which support female passivity and male assertiveness in sexuality). For women and girls, the greater the exposure to any of these power differentials, the greater the disadvantage accrued and the more likely they are to experience HIV risks. Gender inequities also intersect in unique ways with inequalities pertaining to age, class, race, ethnicity, and sexuality, which also contribute to an increase risk for HIV (Zierler, 1997). Recognizing

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these intersecting inequalities can inform contextually-sensitive approaches to prevent HIV/STI for women, girls and the communities in which they live.

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A better understanding of the connections between HIV and other STIs, SRP, and partner violence can elucidate additional opportunities for intervention to help young women take control over their sexuality, recognize and manage their exposure to risky situations and identify needed community resources. Given the over-representativeness of African American young urban women in low income communities most affected by IPV and HIV, this study focuses on African-American young women who attended urban family planning clinics. This study aimed to: 1) understand how young women described their current (and teen) partner relationship dynamics including IPV and how it influenced their HIV/STI risk; and 2) identify the strategies that young women used to reduce unsafe sex in healthy and unhealthy relationships. In order to gain greater insight about their perspectives, we conducted individual qualitative in-depth interviews with participants. The study was approved by the appropriate Institutional Review Boards.

Methods Sample and Recruitment

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Women were recruited from an urban family planning clinic. Women learned about the study through a study team member in the waiting room who gave all women the flyer and asked if they would like to learn more about the study or be screened for eligibility. The flyer indicated that the study was being conducted in order to learn more about how women stay safe from HIV and STI in healthy and unhealthy relationships. There was a study phone number on the flyer that respondents could call as well. Flyers were also posted in the clinic and some women in the waiting rooms took flyers with them to either contact the study team at a later time or to give to others. Interested participants were screened for eligibility either in person in a confidential location in the clinic or over the phone. To be eligible for the study, participants needed to self-identify as African American, be between 18 and 25 years of age, and be able to speak and read English well enough to complete the requirements of the study and attend a family planning clinic. A purposive sampling strategy was used to ensure that approximately half of the sample had experienced either physical or verbal partner abuse. To assess for this exposure as part of the screening procedure the participant was asked: “Have you ever been yelled at, threatened, hit, kicked, or choked by a male partner?” Data Collection

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Informed consent was obtained prior to each interview. All interviews were conducted by a member of the research team in a private room in the nearby university building. Most interviews were completed within an hour to an hour and a half. Upon completion of the interview, participants were asked to fill out a brief health and demographic questionnaire. Participants received $25 as compensation for their time in addition to a list of community resources for young women.

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The interviews were semi-structured. In the first part of the interview, participants were asked to provide descriptions about their work and social activities, family life, and neighborhood environment. The next part of the interview focused on relationships. To understand their general relationship views, the participants were asked to do a pile sort activity in which they were given cards with various relationship qualities (i.e. takes care of me, sex, money, companionship, trust, jealousy, restricts my actions, protection, and violence). They were asked to separate the cards into good and bad piles. Many of the participants created a third pile for qualities that they thought could go in both the good and bad piles. They were also given blank cards to add additional relationship qualities that they believed should be included in the pile sort activity. After creating their piles, the young women were asked to talk about each quality and explain why they placed it in the chosen pile. This part of the interview informed our analysis of sexual expectations in a relationship and provided insight into gender roles and norms. After completing the pile sort activity, the participants were asked to describe their general views about relationships, including desirable and undesirable relationship qualities, strategies they used to keep a relationship and what made it hard to leave a relationship. We also asked the young women how they may have answered these questions differently during their teen years and what qualities were important to them as a teen.

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In the next part of the interview, the young women were asked to reflect on a significant meaningful relationship (self-defined by participant) during their teen years and answer a series of questions related to sex, sexual decision-making, relationship conflicts, and HIV and STI prevention in that relationship. Examples of interview questions included: How would you describe this relationship? How did you come to the decision to have sex in this relationship? Who was responsible for preventing STIs and pregnancy in this relationship? Describe a sex-related argument you had with a partner. What happened when you had a disagreement about sex? How did you resolve this conflict? What made you feel safe/unsafe in this relationship? These questions informed our analysis of the overt and subtle ways in which relationship dynamics can influence the HIV/STI risk of young women.

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In the brief health and demographic survey, the participants were asked to self-report their experiences with verbal abuse, threats, and physical abuse with response choices of yes/no (i.e. Has a partner ever called you names or put you down (with words)? Have you ever been threatened by a partner? Have you ever been hit, slapped, punched or kicked by a partner?). During the interview itself, many of the young women described situations in which they had been abused by a partner. In these instances, the interviewer probed the participant about the situation but was mindful to not label the incident or partner as “abusive” in an effort to maintain the participant's own interpretation of the experience. In the last part of the interview, participants were asked for their suggestions about what should be included in a teen-focused intervention to prevent violence and abuse in relationships. Data Analysis All interviews were audio-taped and professionally transcribed. Prior to being coded, the interview transcripts were checked for accuracy. All participants were assigned a pseudonym. The principal investigator and a research team member developed an initial

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code list which was based on the interview guide. All of the interviews were coded by two coders, one primary and one secondary. The primary coder met weekly with the principal investigator to discuss additions to the code list and emerging themes and patterns. Instances in which the young women were reflecting on their teen experiences were identified using the code “teen years” (Miles & Huberman, 1994). All of the interviews were coded and analyzed using Atlas.ti software© (Scientific Software Development, 1993-2010). Following each interview, the interviewer wrote a response summary to record initial observations and reactions to the interview. Prior to coding, the primary coder conducted an initial reading of each interview. From this initial read-through and with the help of the interview response summary, a narrative summary of the participant's story was constructed. Narrative summaries were useful in preserving the whole of the story and in connecting different pieces of the interview together (Riessman, 2008; Way, 1998). Data analysis was ongoing and occurred concurrently with data collection. To increase the validity of our findings, we presented our preliminary findings to our study's community advisory board members. We solicited their feedback regarding our interpretation of that data and topics that warranted further exploration. Through this process we were able to determine when data saturation was reached for the main objective of the study and concluded interviews.

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The coding scheme and narrative summaries were used to conduct cross-case analysis of the interviews in order to compare and contrast themes and patterns that emerged across interviews. We identified common themes across interviews and also examined patterns that were not consistent with the common themes, an approach consistent with the idea of trustworthiness (Lincoln & Guba, 1985). Within-case analysis was also used to link relationship qualities with sexual decision-making and also to capture self-reflection on earlier teen experiences when applicable. SPSS software© (2010) was used to analyze the data from the brief health and demographic questionnaire.

Results Sample Characteristics

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A total of 30 young African American women participated in the study. The majority of the sample (83%) was single and never married. Twenty percent had some high school education, 60% had graduated from high school or earned their GED, 13% had some college education and 7% had more than four years of college education. Forty percent reported having a romantic relationship by the age of 13. By 16 years old, 83% had been involved in a romantic relationship with a male partner. Intimate partner violence levels were as follows: 56.7% reported being verbally abused, 50% reported being threatened and 43.3% reported being physically abused. None of the participants were HIV positive; however, nearly half (47%) reported being treated for an STI. More than half (67%) of the participants reported being tested for HIV. Sexual Gender Norms In the following section, we discuss three common intertwining sexual gender norms that the young women described when talking about their relationships: expectations for sex; partner non-monogamy and condom non-use. All three common gender norms, to the extent

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they were adopted by participants and enforced by their partners, fostered sexual inequality that reduced young women's sexual relationship power and disadvantaged them in their safer sex negotiations (see Table 1 for quotes). Expectations for sex Many of the participants believed that sex was important in a relationship; however, the young women also frequently referenced pressure to have sex, suggesting that expectations for sex were the norm in relationships. The women valued their relationships and placed great emphasis on pleasing their partners. Given this normative expectation, some participants viewed sex as a way that they could make their partner happy and believed that they needed to meet their partner's sexual needs so that he would remain faithful.

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Many of the participants described getting into arguments with their partner about sex. These arguments were usually centered on the timing of sex with some feeling pressure to have sex more often than they desired. Some were able to talk with their partner and come to a mutually satisfying solution. Some of the young women refused their partner's requests for sex unless they wanted to have sex as well, while others had sex even when they did not want to, and, in some instances, were forced. Among the participants who said that they did not have sex with their partner every time he wanted to, the most common reaction to this refusal was anger. In some instances, the partner would become angry and frustrated but eventually accepted the woman's decision and the fight would end. Other participants described situations in which their partner's anger at their refusal escalated into controlling and abusive behaviors as ways to coerce them into having sex. Partner non-monogamy

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The pile sort activity revealed that partner infidelity and trust issues were common concerns among the young women in the study. Despite the fact that “cheating” was deemed inappropriate, more than half of the participants described being in relationships in which they knew or suspected their partner was having sex with someone else. However, many of the young women viewed non-monogamy as a normative male behavior. The participants reacted to their partner's infidelity in different ways. Some of the young women challenged this norm; upon finding out their partner was not being faithful to them, they too would have sex with other people, while others chose to end the relationship. It was more common, however, for the young women to stay with their partner and try to work through the infidelity issues. Among the participants who remained with their partner, they described lack of trust and infidelity as continuous sources of relationship conflict.

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Many of the participants acknowledged that their partner's infidelity placed them at an increased risk for contracting HIV and STIs. Some of the young women decided to leave the relationship if they perceived their HIV/STI risk to be too high to continue having sex with their partner, especially if they knew their partner was having unprotected sex with other partners. Others chose to stay in a non-monogamous relationship because they were emotionally attached to their partner and believed that most men were not monogamous. The women who chose or felt compelled to stay in the relationship tried to protect

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themselves by asking their partner to use a condom either with them or their other partners, but their partners often refused. Condom non-use

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The young women generally held positive beliefs about condoms. The participants cited pregnancy prevention and protection against HIV/STIs as the most salient reasons for using condoms. Condoms were sometimes used in the beginning of a relationship; however, after several months, condom use often ceased. Condom non-use combined with partner nonmonogamy was common practice, and placed young women at high risk for contracting HIV and STIs. Some participants described having a conversation with their partner in which they mutually decided to forgo using condoms on the premise of mutual monogamy. Others opted to get tested for HIV and STIs with their partner prior to having unprotected sex. Mutual testing was a risk reduction strategy that was employed by one-third of the participants in the study. The participants' discussions about condom use in their relationships revealed that regardless of whether condoms were used or not used, the male generally had more control over sexual decisions. The women described being pressured and in some instances coerced by their male partner to have unprotected sex. Thus, the young women's decisions to use condoms were largely influenced by the dynamics of their relationship.

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Condom coercion—Five participants challenged the norm of condom non-use and described a relationship in which they told their partners they wanted to use condoms. Their partners disagreed, and as a result, the partners ended up exerting various forms of condom coercion. In some cases participants were able to resist this coercion. Condom coercion strategies included: emotional manipulations, ignoring requests, insinuating promiscuity, leaving, minimizing risk, condom sabotage, forced unprotected sex, and having sex with someone else. Stories were volunteered when participants were asked if they had experienced any conflict about sex or safer sex; they were not asked specifically about conflict over condom use. While all had experience with non-physical partner abuse (verbal abuse and threatening behaviors), three also had a history of being in physically abusive relationships. Gena: Gena was 24 years old when interviewed, and she reflected back on a physically violent relationship she was in as a teen. Her partner used two types of condom coercion: emotional manipulation and ignoring requests. This young woman's experience also illustrates how the intertwined gender norms reduced her sexual relationship power which was further lowered by the partner age differential.

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Pursued by an older partner, she entered her first relationship at age 13 and fell in love. “…(We disagreed about) us using protection. He was saying if I was his girl and I'm his only girl and all this I shouldn't worry about using protection. So I took what he said…I did ask him (again) before I had got pregnant it was actually before the last time we did it before I got pregnant. I asked him ‘did we want to start using condoms?’ And he was like ‘yeah’ but he didn't.”

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Eventually, she became convinced that condom non-use was a sign of his commitment to her. A few years later after she was diagnosed with gonorrhea, it called into question many of her earlier assumptions, and she left the relationship. In so doing, she was also resisting the common gender norm of accepting partner non-monogamy. “But it was wrong now that I look at it, because like, all I know I was being used you know he is someone that always just wanted to have sex. (He) let me know what I wanted to hear.” Gena's story portrays a journey that, while difficult, led to a greater understanding about relationships and safety. She hoped that this same transformation could be made easier for girls like her by creating safe spaces in urban communities for girls to gather with each other and supportive adults. When asked what might have helped young teens like her, she responded:

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“Be around girls that (are) in the same situation I'm in and we can help each other. And you know we can better our life together so meaning that we won't have nobody cross the line with us. You know so we'd know early, we'd get respect from guys early.”

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Ayana: Ayana's story provides an example of emotional manipulation and insinuating promiscuity as forms of condom coercion in the context of known partner non-monogamy. She was 25 years old and had been with her partner on and off for 10 years in a physically non-abusive relationship. He was two years older than she was and they had their first child when she was 16 and another child a year prior to the interview. In addition to being emotionally invested in the relationship for many years, she mentioned how having children together was a binding tie with her partner that she wanted to maintain. She said that she had never been in an abusive relationship, but that her partner would threaten her and try to control her. Ayana had a job which she felt was important. It gave her control over the money she earned and how she spent her time, but her job was a point of disagreement in the relationship. She wanted to use condoms and her partner used the expectations of a committed relationship as a point of leverage for condom coercion. For example, he insinuated that she was breaking the rules of a committed relationship if she wanted to use condoms by not trusting him (emotional manipulation) and he accused her of sleeping with other people (insinuating promiscuity), thus shifting the focus away from his behavior. His position is consistent with the common norms of male non-monogamy and condom non-use.

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“Because I knew that he was gonna lie about cheatin', so I mean I knew he was doin' it, but he jus' didn't wanna tell me. His excuse was ‘well if I gotta use a condom with you, then there's no point in sleepin' wit'chu'…. It's like what do you mean? I think he told me that means I was sleepin' with other people….Because he would say cuz we livin’ together I'm his wife. Like he calls me his wife. So I'm his wife and he doesn't need to use condoms wit' me. Like I told him that, I bought ‘em and told him that he needed to start usin’ them.” Ayana's partner had other partners but refused to use condoms. As a result, she had recently moved out, which may have also given her more relationship power by allowing her to challenge his expectation that linked their living together and non-condom use. Although he

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tried to pressure her to move back in with him, she had so far resisted. Ayana felt she needed relationship counseling to provide her with support as she tried to manage her difficult situation, and also recommended the need to support younger teens with discussions about relationships.

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Wanda: The story provided by Wanda serves as an example of leaving as a form of condom coercion. Wanda was 21 and had one two-month-old child. Her partner had never been physically abusive with her but she described several occasions when he threatened her with physical violence which she described as “scary”, though she stated that she still loved him. During her pregnancy she refused to have sex without condoms since he openly acknowledged that he was having unprotected sex with other partners. She even suggested that he use condoms with his other partners. He refused to use condoms at all because he did not like to use them, demonstrating the common gender norm of condom non-use. She resisted this gendered sexual expectation by confronting him with the possible health consequences and he left for an extended period of time.

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“I remember one time we did have an argument about condoms. ‘Cause that's when I was pregnant, I asked him, I said, ‘So do you still… Do you still have other partners and stuff ‘cause I heard about you with some girl?’ And he said yeah. I said, ‘Do you use condoms when you with them?’ He said no. I said, ‘But you won't use condoms with me.’ And he said, ‘I know.’ He said he doesn't like condoms. I said, ‘Well what if, what if I get sick? Like what if I get sick? Like then the baby can catch it, whatever I get.’ I said, ‘I read about chlamydia and if I gave birth and had chlamydia like, my child could have that. That could affect my child. Or HIV.’ And he was like, he didn't wanna hear it. And I said, ‘well if we don't have sex, if you don't use condoms when you're havin' sex with them and you won't use condoms with me,’ I said, ‘like I'm not gonna have sex with you unless you stop havin' sex with the other girls.’ And he was mad. And I woke up… I went to sleep. I woke up and he was gone. Like one o'clock in the mornin', like he just left me. And so I didn't see him for like two, three weeks after that.” After he eventually returned, Wanda and her partner got back together but he subsequently went to jail. In their separation, she was able to view the relationship in a different light and decided to end the relationship.

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Angela: Angela, age 22, experienced her partner's attempt to minimize risk as a form of condom coercion. Angela described a recent non-abusive relationship of short duration in which she and her partner started out not using condoms. When she discovered he was bisexual and also had a male sexual partner, she told him she wanted to start using condoms, resisting the norm of condom non-use. He refused to use condoms, so she suggested they both get tested as a risk reduction strategy. “Like, right after I found out, I wanted to start usin' condoms and he said, ‘why start somethin' new?’ There was conflict with that. ‘It's the same guy (that he was having sex with all along). Like why start somethin' new?’ And then that's when we had (talked) about gettin' tested and stuff. I'd rather be safe than sorry.”

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Her partner indicated that because he had been with his other partner all along, there was no new risk to her and she had been willing to have sex without a condom previously. He was thus minimizing the risk of HIV/STI as a form of condom coercion. Although they both got tested, her partner continued to have another sexual partner and continued to refuse condoms. She eventually ended the relationship because she felt her health continued to be at risk. Unlike some of the other participants, Angela did not describe being deeply emotionally involved in her relationship and this was not an abusive relationship; hence, emotional commitment and the threat of violence were not barriers to ending the relationship.

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Erica: Erica's story is an example of condom coercion through condom sabotage, forced unprotected sex, and having sex with someone else. She was 22 years old and living with her young child. She reflected back on a relationship from her teen years that was controlling and verbally, physically, and sexually abusive. They were together for two years and she became pregnant by him at age 16. “I always tried to use condoms. I always brung ‘em there or whatever. It was one point that… ‘Cause the way I had got pregnant is, we had a condom but he had poked a hole in the condom and I didn't know that until after we finished havin' sex and he told me that he did it. But every time that I tried to make him use a condom, he would put it on and then end up takin' it off or somethin' like that, in the middle of us havin' sex.” Erica had long suspected he had other partners. However, after she found out he had given her an STI and thwarted condom use, she told him she did not want to continue to have sexual intercourse with him, challenging the gender norms of expectations for sex. Her refusal was met with forced sex.

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“It was one point that we argued about sex between the both of us because I didn't wanna have sex with him because he was havin' unprotected sex with other girls or whatever. And one day I had went to the doctors and I had found out that he had gave me a STD so at that point, I don't wanna talk to him or anything like that. I didn't want him to touch me and he got mad about that and forced me to have sex anyway when we was there. So, we used to argue a lot about that at one point because I didn't wanna have sex with him anymore…. That was the first time that happened that he forced me to have sex.” Toward the end of their relationship, they talked about her concerns about STIs/HIV and he got tested. She still insisted they use condoms and he left and had sex with someone else.

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“I told him still, if you still wanna have sex, we have to use protection. And he didn't agree to it so we ended up just not really havin' sex with each other. …He end up goin' out and gettin' it from somebody else…” Like some of the other participants, Erica thought teen girls could benefit from discussion groups with other women to talk about healthy relationships, learn about recognizing abuse, and how to get out of unhealthy relationships or how to avoid them altogether.

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In summary, these five young women resisted the common gender norm of non-condom use, some even in the face of threats of violence, and confronted various forms of condom coercion. In all of these relationships, the male partner had other partners which sometimes became evident when the young woman developed an STI. The combination of male nonmonogamy and refusal to wear condoms greatly increased the women's HIV/STI risk. Faced with few choices for sexual safety, the young women could opt for HIV/STI testing or to end the relationship. However, ending the relationship was a hard choice for some. The decision to leave was made even more difficult if they had children together, if the woman counted on her partner for emotional and material support, or if the male partner was controlling or abusive. Although some eventually ended the relationship, all of these women were at a high risk for HIV/STIs for a significant period of time. Several of the women believed that having a place to talk with others about relationships would have helped them. Moreover, some of the women believed that there was a need for a teen-focused abuse prevention program that would help girls recognize signs of abuse and controlling behaviors and give them a place where they could learn skills for avoiding or getting out of unhealthy relationships.

Discussion

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Results from this study provide important insights into the perspective of young women who attend urban family planning clinics about sexual gender norms and coercive condom practices that interfere with their safer sex practices. Common gendered norms about expecting sex, partner non-monogamy, and condom non-use were impediments to safer sex practices to the extent they are adopted within relationships and sexual encounters. Young women who wanted to use condoms may have internalized these norms that were common in their social environment, and were silenced in their desire to discuss condom use with partners. Condom coercion was used by males when they encountered their female partners' resistance to the common gender norms.

Sexual Gender Norms

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The combination of gendered expectations for sex, non-monogamy, and non- condom use was a dangerous mix of inequitable behavioral norms that lowered young women's sexual relationship power (SRP) and limited their safer sexual practices. Prior research findings with adult women indicate that having lower SRP is associated with decreased condom use (Pulerwitz, 2000). Thus, lower SRP, which represents a lack of control over sexual decisionmaking in general, may make it more difficult to negotiate condom use and places young women at higher risk for HIV/STIs. Studies have shown that women and girls who have experienced abuse have lower SRP are less likely to use condoms (Pulerwitz, 2000; Teitelman, Ratcliffe, Morales-Aleman, & Sullivan, 2008). This is especially concerning given that research has also shown that abusive partners are more likely to be nonmonogamous (Bauer et al., 2002; Raj et al., 2004; Wingood et al., 2001). Male partner non-monogamy was seen by many participants as normative and even natural. While several young women described ending these relationships (thereby reducing their sexual risk), others continued to be involved with partners who had other sexual partners.

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Although a few reacted by seeking other partners themselves, many young women felt powerless when confronted with partner non-monogamy. Recent research with urban adult and adolescent males also indicates partner concurrency is widely considered normative for men (Carey, Senn, Seward, & Vanable, 2010; Silverman et al., 2006). In adolescent heterosexual relationships, although jealously is common among both males and females, males are more likely to actually have concurrent partners than their adolescent female partners according to a study on urban youth (Miller, 2008). Adolescent male perpetrators of dating violence were found to embrace norms that males who could boast of their various sexual activities earned greater peer social status (Silverman et al., 2006).

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Non-monogamy increases both partners' HIV/STI risk, especially if condoms are not being used consistently by all partners. Our findings suggest that although condoms were more likely to be used when first getting to know someone, they were typically abandoned as the relationship progressed. This finding is supported by other studies, and occurs in relationships with and without IPV (Lescano et al., 2006; Raj et al., 2007; Watkins, Metzger, Woody, & McLellan, 1993).

Condom Coercion

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In this study, we identified several forms of coercive condom practices including: emotional manipulation, ignoring requests, insinuating promiscuity, leaving, minimizing risk, condom sabotage, forced unprotected sex, and having sex with someone else. We found a pattern that male partners employed some form of condom coercion when faced with female partners who challenged the inequitable sexual gender norms that placed them at increased risk for HIV/STIs. In most, but not all of these relationships, there was physical and /or non-physical abuse. Thus, condom coercion can occur in relationships not otherwise considered abusive. While some young women were able to resist condom coercion, some male partners engaged in heightened abuse to enforce the sexual norm. Thus, to more fully understand the dynamics of condom coercion it is important to identify the common gender norms regarding safer sex and assess for abuse as well as actual condom use. Inequitable sexual gender norms in a relationship may limit a woman's ability to overcome condom coercion and voice her concerns for her sexual safety. According to Jones (2006) internalized pressure to forgo condom use is more common than overt coercion. Prior research suggests there are gender differences in the interpretation of what constitutes the range of behaviors from sexual pressure to coercion (Hamby & Koss, 2003). In particular, some adolescent males treated for dating violence perpetration lacked accountability for sexual risk and minimized responsibility for coercive sexual acts (Silverman et al., 2006). Therefore, further research is needed on the gendered context of safer sex which includes both young women's and men's perspectives. Condom sabotage, with the intent of getting the partner pregnant, has been reported in the literature as a form of reproductive coercion (Miller et al., 2010; Miller et al., 2007). As reported here, condom sabotage had further implications beyond coercion to reproduce, to also include the additional risk of transmitting HIV/STIs especially in the context of nonmonogamy.

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HIV Testing as an Alternate Risk Reduction Strategy

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HIV/STI testing was used by some young women as a strategy for safer sex when they were unable to get a partner to use a condom or stop having concurrent partners. In most instances, their male partners were more likely to agree to get tested than to use condoms. Although HIV/STI testing is an important risk reduction strategy to enhance detection and treatment of those who become infected, it does not prevent disease in those who continue to be exposed. In addition, HIV/STI testing has some limitations in detecting disease and negative test results should not be interpreted as a guarantee against future exposure (Teitelman, 2009). Partner reaction to positive HIV/STI test results may also place young women at risk for abuse, especially if they are already in an abusive relationship (Maman, 2000). Further research is needed to better understand young people's understanding of HIV/STI testing as a safer sex strategy and as a response when thwarted from engaging in preventive safer sex practices.

Implications for Interventions

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Our findings indicate that future HIV/STI prevention interventions with young women and young men should address specific sexual norms in relation to safer sex practices and the impact on SRP. Particularly, young women could benefit from learning about specific forms of condom coercion and how to negotiate for sexual safety without increasing risk for greater levels of condom coercion or retaliatory abuse. In interventions with young men, it would be important to include discussions on identifying and mitigating the use of the various forms of condom coercion. Moreover, health care providers need to be educated about how relationship dynamics, specifically sexually coercive behaviors, place adolescent girls and women at increased risk for HIV and STIs. Screening for condom coercion and other abusive behaviors that limit girls' SRP should be incorporated into routine family planning visits.

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Findings from our study also indicate a need for advocacy programs to assist young women in recognizing abusive and controlling partner behaviors including condom coercion, as well as to help them with safety strategies related to condom coercion and to provide support to those who choose to leave their relationships. Programs are also needed for male partners to assist them to recognize and end their abusive, controlling, and coercive behaviors. There is also a need for a teen-focused abuse prevention program that would help adolescent girls and boys recognize signs of abuse and controlling behaviors and give them a place where they could seek relationship advice, health counseling, and referral for additional services. It may be beneficial for young adult women who have experienced condom coercion to share their stories, reflections, and wisdom with teens. Our findings also indicate that individual or group counseling and advocacy could be enhanced by interventions directed at the social environment to support gender norms that promote greater relationship equity between young women and their partners, especially regarding sexual decision-making and including safer sex practices. Thus, interventions are needed for both men and women that address stereotypical gender norms that limit girls' and women's ability to practice safe sex. Although not the focus of this analysis, the Theory of

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Gender and Power (Wingood & DiClemente, 2000) suggests economic inequality may further contribute to young women's vulnerability to relationships in which they have limited SRP. Thus, more structural interventions that offer job training, housing, and childcare may also be needed to enhance women's safety, especially among the poor urban teen population.

Limitations

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There were several limitations to this study. First, the young women in this study were recruited from an urban family planning clinic that served a low-income population of teens and women who were primarily African American. Therefore, the findings from this study may not be generalizable to all young women. Further research is needed with other groups to explore if sexual gender norms and condom coercion as identified in this study apply more broadly. Also, since we did not specifically ask about conflict over condom use, we may not have garnered all the experiences of condom coercion. Future studies should directly measure various forms of condom coercion. Another limitation was that we only captured young women's perspectives, not young men's. However, other research regarding condom use and non-monogamy conducted with males are consistent with our findings (Carey et al., 2010; Lescano et al., 2006; Raj et al., 2007; Silverman et al., 2006; Watkins et al., 1993).

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Also, we only interviewed participants at one point in time and asked them to reflect on prior experiences as they transitioned from adolescence to young adulthood. Although this yielded very rich and insightful comments from participants, especially about their teen experiences, future longitudinal research could strengthen this approach. Lastly, although it is beyond the scope of this paper, further research is needed to examine the social environment and structural issues that propel young urban men to practice unsafe sex, engage in condom coercion, and participate in violence in their relationships with young women. One such example is research by Jody Miller (2008) which describes how violent urban neighborhoods foster highly inequitable and rigid gender norms, and systemically and institutionally expose adolescent females to gendered violence.

Conclusion

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Condom coercion has been under-recognized as an important factor contributing to young women's HIV/STI risk. Although both males and females transmit and acquire HIV/STIs, a greater burden of untoward health consequences fall on young women as a result of unsafe sexual practices. Young women experience a limited ability to practice safer sex to the extent that inequitable sexual gender norms are adopted in the social environment and in their relationships. Normative expectations for sex, partner non-monogamy, and condom non-use often compromise young women's SRP. In relationships, condom coercion further undermines condom use. Therefore, HIV prevention interventions need to address and challenge inequitable sexual gender norms, coercive condom practices, and partner abuse and control that limit young women's ability to protect themselves from HIV/STIs. Broader community mobilization is needed to foster social environments that can sustain more equitable gender power in relationships. Also, adolescent girls and young women need safe

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spaces to gather to gain greater resilience when faced with challenges as they seek out loving and supportive relationships.

Acknowledgments This research was funded by grants from the Penn Institute for Urban Research and Center for AIDS Research at the University of Pennsylvania and from the National Institutes for Health, 1K01MH080649-01A1. This research was also supported by Award Number 5K01MH080649 (PI: Anne M. Teitelman) from the National Institute of Mental Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Mental Health or the National Institutes of Health. We also acknowledge the generosity of the participants who shared their stories with us.

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Table 1

Sexual Gender Norms

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Sex with expectations

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Relationships came with expectations about sex

“I did a lot of stuff for him… I was like really involved in his life and stuff like that. So I thought he would never, like, keep pressurin' me (to have sex) like that ‘cause we was getting' along so well. And so we started arguin’ about, you know, ‘When we gonna do it? When we gonna do it?’ and stuff like that…So he just kept on pressurin' like ‘When we gonna do this? I really care about you.’ ” (Nailah*)

Favors provided by partner heightened expectations for sex

“I was still fifteen at the time and my daughter needed diapers and stuff and I was just like I didn't wanna ask my grandma or my dad, so I asked him…I just started askin' him for stuff… and we ended up doing it (having sex)…I forgot how it happened but I'm gonna do this for you and I'm gonna do that and I probably felt like ‘cause he was doin' all this stuff for me and my daughter I needed to do something with him.” (Brenda*)

Sex was viewed as a way to keep a partner happy

“(I) probably turn to sex first as a way to, you know, a way as, you know, to be in a relationship or to try to keep a relationship.” (Tasha)

Women felt pressure to keep partner sexually satisfied so that he would not have sex with someone else

“Somebody will probably end up gettin' cheated on. You know? If there (isn't) too much, you know, spicy stuff goin' on in the bedroom… probably get cheated on.” (Cynthia)

Women felt pressured to have sex more often than desired

“If I wanna have sex then we can have it, but if you wanna have sex and I don't wanna have sex, I don't wanna have sex. I just, you know, we'd have disagreements about that. He'd say like ‘I haven't had any in like three days.’ I'd say “Okay, well that's it?’ That's like nothin' to me. So we'd disagree about it but it's not a big issue…He keeps tryin' and I keep sayin' no and I keep tellin' him ‘No, get off of me.’ ” (Katrina*)

Young women's refusal to have sex could result in verbal abuse as a coercive strateg

“But he would actually get mad because I wouldn't have sex with him and that would start a whole argument that would last from nine o'clock at night when it would start until three o'clock in the morning…I'd be all types of names and ‘Oh, you cheatin' on me.’ ” (Cynthia *)

Young women's refusal to have sex could result in controlling behaviors and abuse as a coercive strategy

“He wanted to have sex and I didn't want to have sex so he hid my clothes and stuff. He like, pushed me off his bed. ‘You can't sleep in my bed, you can't sleep on my couch, you gotta sleep on the floor can't have no covers.’ Just stuff, ‘You can't have nothing to eat’…” (Lelani*)

Partner non-monogamy

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Non-monogamy was considered normative male behavior

“You know, cause men like bein' with other females and stuff like that.” (Lisa)

Trust and infidelity issues were pervasive

“I just don't trust him as far as like he's, he's just a cheater…I didn't catch him doing' anything like lately or recently, but, I just can't let go of what, what happened in the past.” (Beverly)

Recognition of increased HIV/STI risk with non-monogamous partner

“You're with somebody else and you're sleeping with me, too; that's nasty, I can't do that because then you put me at risk right along with yourself…Like… anything, STDs, people got herpes, people got crabs…” (Lisa)

Condom non-use

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Condom non-use was a normative expectation within a relationship

“He was saying if I was his girl and I'm his only girl and all this I shouldn't worry about using protection.” (Gena*)

Sometimes condoms were used at the beginning of a relationships but were abandoned as a relationship progressed

“Actually like, in the beginning…we were using condoms but then like..I guess deep in the relationship or whatever you wanna call it… we weren't using condoms.” (Lelani*)

When condoms were used, male partner generally made that decision

“He just had ‘em. We didn't even have no conversation. He just had ‘em…except for oral sex…He didn't offer one then. Only when we was havin' sex he would put a condom on.” (Wanda*)

Mutual testing was seen as an HIV/STI risk reduction strategy

“We did start out usin' condoms, but we only stopped usin' them when we both went to the clinic and got checked for everything. If that didn't happen, then we would've never started havin' unprotected sex.” (Denise*)

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Sex with expectations

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HIV/STI testing: The male partners were more agreeable to getting tested than using condoms. Negative test results were used to negotiate for unprotected sex.

“It was one point that we argued about sex between the both of us because I didn't wanna have sex with him because he was havin' unprotected sex with other girls or whatever…Then we talked, sat down and talked about it and he was tellin' me that he was gonna go to the doctors and he went to the doctors and brung his test results back and stuff like that. But I told him still, if you still wanna have sex, we have to use protection. And he didn't agree to it so we ended up just not really havin' sex with each other.” (Erica*)

*

Quote is in reference to a relationship they had as adolescents

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