Journal of Women & Aging, 27:290–308, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0895-2841 print/1540-7322 online DOI: 10.1080/08952841.2014.954499

Relationship Power, Sexual Decision Making, and HIV Risk Among Midlife and Older Women JOANNE ALTSCHULER and SIYON RHEE School of Social Work, California State University, Los Angeles, CA

The number of midlife and older women with HIV/AIDS is high and increasing, especially among women of color. This article addresses these demographic realities by reporting on findings about self-esteem, relationship power, and HIV risk from a pilot study of midlife and older women. A purposive sample ( N = 110) of ethnically, economically, and educationally diverse women 40 years and older from the Greater Los Angeles Area was surveyed to determine their levels of self-esteem, general relationship power, sexual decision-making power, safer sex behaviors, and HIV knowledge. Women with higher levels of self-esteem exercised greater power in their relationships with their partner. Women with higher levels of general relationship power and self-esteem tend to exercise greater power in sexual decision making, such as having sex and choosing sexual acts. Income and sexual decision-making power were statistically significant in predicting the use of condoms. Implications and recommendations for future HIV/AIDS research and intervention targeting midlife and older women are presented. KEYWORDS ageism, HIV risk, midlife and older women, relationship power, self-esteem, sexual decision making

INTRODUCTION Many people continue to view HIV/AIDS as an irrelevant issue in the lives of older adults in general and older women in particular. Yet the number of cases of HIV/AIDS in both midlife and women 50 and older (the definition of older women used in this article) is on the rise, with rates of infection having had a disproportionate impact on older women in large metropolitan Address correspondence to Joanne Altschuler, 5151 State University Drive, Los Angeles, CA 90032. E-mail: [email protected] 290

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areas. Among women over 50, new diagnoses have increased by 40% over the past 5 years (Cahill, Justice, & Palow, 2010), and although women between the ages of 25 and 34 accounted for the largest share of new HIV infections (29%), women aged 45–54 accounted for 17% of new HIV infections, and women 55 and over accounted for 6% of new HIV infections (CDC, 2012). While men having sex with men (MSM) remains the largest at-risk group among older adults, three of the fastest-growing subgroups of older adults becoming infected are heterosexuals, females, and ethnic minority members (National Association of HIV Over Fifty, 2004; National Institute on Aging, 2013). The pervasive impact of HIV/AIDS on ethnic minority women is well documented. Women of color, particularly African American women, have been and continue to be disproportionately affected by HIV and represent the majority of new HIV infections and women living with the disease (CDC, 2012), as well as the majority of HIV-related deaths among women in the United States (CDC, 2013). In 2010, of the total number of new HIV infections among women in the United States, 64% occurred in African Americans, 18% were in Caucasians, and 15% were in Hispanics/Latinas (CDC, 2013). Most of them were infected through heterosexual sex. While infections among African American women remain high, new HIV infections among African American women decreased by 21%, from 7,700 in 2008 to 6,100 in 2010 (CDC, 2013). In spite of this promising decrease, CDC cautions that additional annual estimates are needed to see if this decline is, in fact, the signal of a longer-term trend. While Asian Americans are at lower risk compared to African Americans, Hispanics, and Caucasians, the proportion of older Asian Americans with a diagnosis of HIV has been increasing (Eckholdt, Chen, Manzon-Santos, & Kim, 1997), with Asian American women emerging as a group vulnerable to HIV infection (Office of Minority Health, 2012). Women over the age of 50 from non-Caucasian racial and ethnic communities are similarly disproportionately affected by HIV/AIDS, with approximately 70% of women 50 and older living with HIV/AIDS being African American or Hispanic/Latino (CDC, 2013). The rise in the number of cases of HIV/AIDS in midlife and older women of color has been especially steep, with most getting the virus from sex with infected partners. However, compared to younger cohorts, midlife and older women are generally perceived as not being an at-risk population for HIV and may not perceive themselves as personally at risk for infection (Henderson et al., 2004; Jackson, Early, Schim, & Penprase, 2005), with low levels of HIV/AIDS knowledge (Altschuler, Katz, & Tynan, 2008). Nonetheless, older women identify sexual health as a lifelong need (Woloski-Wruble, Oliel, Leefsma, & Hochner-Celnikier, 2010) and many engage in sexual activity (DeLamater & Sill, 2005; Smith, Mulhall, Deveci, Monaghan, & Reid, 2007; Trompeter, Bettencourt, & Barrett-Connor, 2012). In addition, newly widowed, divorced,

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and separated women are dating, sometimes for the first time in many years, with most getting the virus from unprotected sex with infected partners. Sexually active older women may be at greater HIV transmission risk than older men and younger women. This is due, in part, to deficiency in estrogen that can cause vaginal wall and cervical tissue thinning that can result in cuts and tears in the vaginal area, and as well as the fact that women who no longer worry about getting pregnant because of menopause may be less likely to use a condom and practice safe sex (Lindau, Leitsch, Lundberg, & Jerome, 2006; Linsk, 2000). In addition to not using condoms because of menopause, it has been shown that women have difficulty negotiating sexual safety for such reasons as drug and alcohol abuse, mental health issues, and desire for relationships that provide male companionship (Neundorfer, Harris, Britton, & Lynch, 2005). It has also been reported that older women may not question a sexual partner about sex or drug history because of inaccurate assumptions or beliefs, as well as having overall difficulty communicating about sexual behavior (Zablotsky & Kennedy, 2003). Research conducted with older women indicates that despite reporting HIV risk behaviors, women report low perceived vulnerability to HIV (Winningham, Richter, Corwin, & Gore-Felton, 2004), are less likely to undergo HIV testing, less likely to use condoms compared to sexually active younger women (Corneille, Zyzniewski, & Belgrave, 2008), and believe that HIV/AIDS has limited personal relevance despite their possessing minimal knowledge of age and gender-specific risk factors (Hillman, 2007). While younger and older female cohorts share similar risk factors and means of transmission, unique to midlife and older women is the potential impact and interaction of generational, cohort, and cultural differences. For example, the combination of generational and traditional cultural values concerning gender roles and behavioral expectations of men and women and the significance of family may create undue pressure on older sexually active adults in general, and women in particular, to have sex without a condom. This may be additionally reinforced by level of acculturation. Knight (2004) describes the impact of cohort membership on beliefs, attitudes, and values that distinguish one birth cohort from another, stating that “membership in a birth-year-defined group . . . is socialized into certain beliefs, attitudes, and personality dimensions that will stay stable . . . that distinguishes that cohort from those born earlier and later” (p. 15). Given these contexts, it is not surprising that many older women do not consider the topic of HIV/AIDS to be personally relevant (Zablotsky & Kennedy, 2003) and are less likely to discuss sex with a physician (Lindau et al., 2007). Moreover, physicians may collude with that silence, often failing to question or screen midlife and older women for sexual concerns or risk behaviors and not test for possible infection (Burd, Nevadunsky, & Bachmann, 2006; Gott & Hinchliff, 2003; Swartz et al., 2011).

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In 1995 CDC officially documented heterosexual contact as women’s primary source of acquiring HIV (Hader, Smith, Moore, & Holmberg, 2001). Although the male condom is a longstanding tool in HIV prevention programs that has been found to be highly effective in reducing HIV infection when used correctly and consistently (Anderson, 2003; Marrazzo & Cates, 2011), research informs us that older women’s inability to negotiate condom use is a major obstacle to practicing safer sex behaviors (Patel, Gillespie, & Foxman, 2003). While early HIV/AIDS research and interventions for women focused on negotiating condom use with a male partner, later and more current research and interventions address relational, structural, and environmental contexts of risk behaviors, encompassing dynamics of gender and ethnicity in sexual encounters (Amaro, 1995; Gómez & VanOss Marín, 1996; Gupta, 2001; Harvey, Bird, Galavotti, Duncan, & Greenberg, 2002; Pulerwitz & Dworkin, 2006; Sherman, Gielen, & McDonnell, 2000; Wingood & DiClemente, 1998; Wyatt, 2009). This body of literature challenges the assumption that with knowledge, women can simply or freely enact condom use, emphasizing that condom use is embedded in gender relations and women’s relationships with male partners (Dworkin & Ehrhardt, 2007). There is growing evidence that gender power inequality plays a role in HIV risk. Relationship power imbalances (Pulerwitz, Amaro, De Jong, Gortmaker, & Rudd, 2002) have been associated with reduced sexual autonomy and greater vulnerability to HIV. If a woman perceives her partner to be in control of the relationship, she may not communicate her desire for her partner to use a condom (Bird, Harvey, Beckman, & Johnson, 2001). Sterk, Klein, and Elifson (2005) found that negative condom-related attitudes were associated with greater frequency of engaging in sexual activities known to be associated with HIV transmission. They also found that more self-esteem was associated with more favorable condom attitudes. The link between selfesteem and high-risk behaviors has rarely been examined in women aged 50 and older, with one study (Jacobs & Kane, 2011) reporting how selfesteem is related to variables that can influence high-risk sexual behaviors in women over 50. Research investigating HIV/AIDS among midlife and older women has increased in recent years, yet the current authors are unaware of any that explore the role of gender and power imbalances in the role of sexual decision-making in the context of HIV risk and prevention in midlife and older women. The purpose of this article is threefold. First, it reports on findings from a pilot study that investigates the degree to which self-esteem and power in sexual relationships influence safer-sex negotiations among older women, testing the hypothesis that low levels of relationship power and self-esteem inhibit older women from successfully negotiating safe sex practices. Second, it discusses the meaning of the findings in the context of aging, older women and HIV risk. Third, it provides recommendations for research, practice, and education regarding older women and HIV/AIDS.

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METHODOLOGY Data Collection A purposive sample (N = 110) was selected from seven organizations serving midlife and older adults from the Greater Los Angeles Area. They consisted of two social clubs, one congregate meal site, three recreation and activity groups, and one health and social service program/agency. Participants were made aware of the study through the use of flyers as well as announcements by the first author at the organization research sites. The criteria for inclusion were being female and currently in or wanting to be in a relationship with a man. Only participants who willingly gave their permission to be contacted were included. Study participants responded to the structured questionnaire at the designated organization sites from which they were selected, and questionnaires were available in English or Spanish. In order to maximize participants being as honest and forthright as possible, questionnaires were not read aloud, and participants completed them by themselves. All procedures were taken to protect human subjects, and the study received full California State University Institutional Review Board approval before the project was implemented.

Measures The questionnaire consisted of six distinct parts: demographic characteristics, self-esteem, general relationship power, sexual decision-making power, safer sex behaviors, and HIV transmission knowledge. Demographic characteristics were measured with the following variables—age, ethnicity, religion, marital status, education, household annual income, and partner relationship status. Questions concerning self-esteem were measured by the Rosenberg Self-Esteem Scale (RSE), a 10-item scale that measures global self-esteem using statements related to self-acceptance and self-worth (e.g., “I am able to do things as well as most other people”). Participants rate items on a 4point Likert-type scale ranging from strongly agree to strongly disagree with a Cronbach’s alpha for various samples ranging from .77 to .88 (Rosenberg, 1989). Questions concerning relationship power were derived from the Sexual Relationship Power Scale (SRPS). The SRPS is a 23-item theoretically based and validated measure of relationship power dynamics developed by Pulerwitz, Gortmaker, and DeJong (2000) to measure power in sexual relationships and to investigate the role of relationship power in sexual decision making and HIV risk. The SRPS contains two subscales that address two conceptual dimensions of relationship power: Relationship Control (e.g., “My partner tells me who I can spend time with”) and Decision-Making Dominance (e.g., “My partner usually has more say about whether we have sex”). Most items use a 4-point Likert scale, ranging from strongly agree

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to strongly disagree. The SRPS has good internal reliability (Cronbach’s alpha = .84 for English version, .88 for Spanish version) and predictive and construct validity. The two subscales are sufficiently reliable to use independently or together. Women who reported low levels of relationship power were more likely to report experiences of partner violence and less likely to report consistent condom use (Pulerwitz et al., 2000). An eight-item General Relationship Power Sub-scale (GRPS) was constructed from Pulerwitz’s SRPS using the original 4-point Likert-type format, ranging from 1 (strongly agree) to 4 (strongly disagree). GRPS assessed the pattern of general decision-making power between the respondents and their partners with Cronbach’s alpha = 0.824. A three-item Sexual Decisionmaking Power Subscale (SDPS) was also extracted from SRPS to measure the pattern of dominance in sexual decision making. SDPS contains the following three statements: (1) “Who usually has more say about whether you have sex?”; (2) “Who usually has more say about whether you use condom?”; and (3) “Who usually has more say about what type of sexual acts you do?” All three statements had the same three answer categories—(1) your partner, (2) both of you equally, and (3) you. Safer sexual behaviors were measured with the following three statements: “I use a condom with my partner when we have sex” with three answer categories (always, sometimes, and never); “If I asked my partner to use a condom, he would get violent,” and “If I asked my partner to use a condom, he would get angry” with four answer choices (strongly agree, agree, disagree, and strongly disagree). For a binary logistic regression analysis, the dependent variable of condom use that had three answer categories of condom use was collapsed into two answer categories—yes (always and sometimes) and no (never). Three true/false questions specific to measurement of the level of knowledge about HIV prevention, transmission, and infection were developed based on HIV/AIDS and midlife/older adults’ literature: (1) “When putting on condoms, a space should be left at the tip”; (2) “Men who get HIV always show or feel symptoms”; and (3) ”Vaseline is a good lubricant to use with condoms.”

RESULTS Overview of the Sample The study sample consisted of 110 females residing in the metropolitan Greater Los Angeles Area. Participants who reported their age ranged from 40 to 80 years, with an average age of 50.5 years (SD = 6.8). Specifically, a little over three-quarters of the respondents (77.9%) were between the ages of 45 and 60. With regard to ethnic background, 40.0% identified themselves as Latino, 35.5% as Non-Hispanic Caucasians, 20.0% as African American, and 4.5% as Asian, Native American, and Middle Eastern American. A little

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over one-third of the participants (39.8%) were currently married; 21.5% were single; and 37.7% were widowed, separated, or divorced. Among 47 respondents who reported dating behaviors, 12.8% reported living with a male partner, 51.1% were dating one man only, 6.4% were dating more than one man, 10.6% were looking for a new relationship, and 19.1% were thinking about ending their current relationship(s). There was notable variance in the educational level of the participants: 56% of the participants were high school graduates or had some college, and 26.6% of the participants were college graduates or had a graduate degree. In contrast, 9.1% of the participants had not completed high school, and 7.4% of the participants had less than an eighth-grade education. With respect to income, a little less than a quarter of the participants (22.3%) reported income under $10,000; 12.6% between $10,001 and $20,000; 19.4% between $20,001 and $30,000; 6.8% between $30,001 and $40,000; 7.8% between $40,001 and $50,000; and almost one-third (31.1%) reported an annual income over $50,000. Finally, the vast majority of participants (93.5%) reported identification with a specific religion: 42.6% Protestant, 37.0% Catholic, 7.4% Jewish, 6.5% other religions, and 6.5% reported being unidentified with a religion (Table 1). TABLE 1 Sociodemographic Characteristics Variable Age (Mean = 50.5, SD = 6.8) 40–44 45–60 61 and above Ethnicity African American Latino Non-Hispanic White Other (Asian, Native American, Middle Eastern) Marital Status Single Married Widowed Separated Divorced Other Relationship Status Living with Male Partner (not married) Dating One Man Only Dating More Than One Man Looking for a New Relationship Thinking about Ending Current Relationship Formal Education Less Than 8th Grade Some High School

N

n

%

15 81 8

14.4% 77.9% 7.7%

22 44 39 5

20.0% 40.0% 35.5% 4.5%

20 37 6 13 16 1

21.5% 39.8% 6.5% 14.0% 17.2% 1.1%

6 24 3 5 9

12.8% 51.1% 6.4% 10.6% 19.1%

8 10

7.4% 9.1%

104

110

93

47

109

(Continued)

297

HIV Risk Among Midlife and Older Women TABLE 1 (Continued) Variable High School Diploma & Some College College Graduate & Graduate School Other Religion Protestant Catholic Jewish Other Unidentified Annual Household Income Less than $10,000 $10,000–$20,000 $20,001–$30,000 $30,001–$40,000 $40,001–$50,000 Over $50,000

N

n

%

61 29 1

56.0% 26.6% 0.9%

46 40 8 7 7

42.6% 37.0% 7.4% 6.5% 6.5%

23 13 20 7 8 32

22.3% 12.6% 19.4% 6.8% 7.8% 31.1%

108

103

General Relationship Power General relationship power was measured with eight statements, including “Most of the time, we do what my partner wants to do,” and “When my partner and I disagree, he gets his way most of the time.” Over one-third of the participants (36.7%) answered that they generally do what their partners want to do most of the time (5.5% strongly agree; 31.2% agree). Over onefourth (25.9%) of the participants either strongly agreed or agreed with the statement “My partner has more say than I do about important decisions that affect us.” In response to the question, “My partner does what he wants, even if I do not want him to,” nearly half of the participants (42.2%) either strongly agreed (17.4%) or agreed (24.8%). In response to the question, “When my partner and I disagree, he gets his way most of the time,” over one-third (36.7%) either strongly agreed or agreed.

Sexual Decision-Making Power Decision-making power in sexual relationships was measured in the following three dimensions: (1) “decision to have sex” measured by the question “Who has more say about having sex; (2) “decision to use contraceptives” measured by the question “Who has more say about using condoms”; and (3) “decision to choose sexual acts” measured by the question “Who has more say about what type of sexual acts they do.” Three answer categories were provided for all three of the questions—partner, both equally, and respondent herself . A little over 50% of the participants answered that both the partner and the participant herself had an equal say in all these three dimensions. However, about one out of five participants stated that her partner

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had more power in making decisions to have sex (20.4%) and in the types of sexual acts engaged in (22.2%).

Safer Sex Behaviors In response to the question, “I use a condom with my partner when we have sex,” which is referred to as “condom use,” only 26.4% (n = 28) responded always, 23.6% (n = 25) stated sometimes, and as high as 50% said never. In response to the question, “If I asked my partner to use a condom, he would get violent,” 18.2% (n = 12) either strongly agreed or agreed. On the other hand, in response to the question, “If I asked my partner to use a condom, he would get angry,” almost one-third of the participants (29.6%) either strongly agreed (12.0%) or agreed (17.6%). The majority of the women who participated in this study are not engaged in protected sex, and many of the participants reported that their male partners would get angry or violent if asked to use a condom.

Bivariate Relationships Chi-square statistics results show that there is no statistically significant relationship between condom use and ethnicity (χ 2 = 6.270, df = 6, p = .394) and no significant relationship between condom use and age (χ 2 = 1.762, df = 4, p = .779). However, when the annual income variable was dichotomized into two categories (0–30,000 and 30,001+ ), a significant relationship between condom use and income was found (χ 2 = 8.474, df = 2, p = .014), revealing that those who belong to the income category over 30,000 are far less likely to use condoms. With regard to the relationship between selected demographic variables and level of knowledge about HIV prevention and transmission, to our surprise, ethnicity, marital status, educational level, and age were not significantly related to HIV knowledge. On the other hand, annual household income was significantly related. Particularly in response to the question “When putting on condoms, a space should be left at the tip,” the majority of those who answered false belonged to the highest income category, while those who answered true were evenly distributed throughout all income categories (χ 2 = 13.98, df = 5, p = .016). In response to the question “Men who get HIV always show or feel symptoms,” those who belong to higher income categories were more likely to choose false, while the participants in lower income ranges were more likely to choose true (χ 2 = 12.36, df = 5, p = .030). The results show that among five demographic variables (ethnicity, marital status, educational level, age, and income), income is the only variable that is significantly related to HIV knowledge, suggesting that the higher income is, the more accurate HIV knowledge the participants have.

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TABLE 2 Correlation Matrix: General Relationship Power, Self-Esteem, Education, Income, and Sexual Decision-Making Power GP1 r (p) General Power Self-Esteem Education Income Sexual Decision-Making Power

.502 .112 .217 .307

SE2 r (p)

Education r (p)

Income r (p)

— (.000)∗∗ — (.252) .210 (.033)∗ — (.029)∗ .319 (.001)∗∗ .560 (.000)∗∗ — (.001)∗∗ .198 (.049)∗ .023 (.812) .161 (.112)

SD3

—

1

General Relationship Power. Self-Esteem. 3 Sexual Decision-Making Power. ∗∗ Correlation is significant at the 0.01 level (2-tailed). ∗ Correlation is significant at the 0.05 level (2-tailed). 2

It was also found that the positive correlation between overall selfesteem and general relationship power was statistically significant (r = .502, p = .000) at the .01 level, suggesting that participants with higher levels of self-esteem exercised greater power in their relationships with their partner. Likewise, income and general relationship power were also significantly positively correlated (r = .217, p = .029) at the .05 level. However, education and general relationship power were not significantly correlated. Both income and education were significantly positively correlated with self-esteem among the respondents (r = .319, p = .001; r = .210, p = .033 respectively). As expected, education and income were highly positively correlated (r = .560, p = .000). It is interesting to note that both general relationship power and self-esteem are significantly positively correlated with sexual decision-making power (r = .307, p = .001; r = .198, p = .049 respectively). The results indicate that participants who generally possessed higher levels of general relationship power and self-esteem tend to exercise greater power in sexual decision making such as having sex and choosing sexual acts. On the other hand, income and education were not significantly related to sexual decision-making power (see Table 2).

Logistic Regression Analysis Binary logistic regression was calculated to determine which independent variables (age, income, education, self-esteem, general relationship power, and sexual decision-making power) were predictors of the selection of two types of sexual behavior (never use condom or always/sometimes use condom). As shown in Table 3, regression results revealed that the participant’s income and sexual decision-making power were statistically significant in predicting the use of condoms, while age, education, self-esteem, and general relationship power were not significantly contributing to the model. The participants who had greater sexual decision-making power, Exp(B) = 1.448;

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TABLE 3 Use of Condom Regressed on Independent Variables (Logistic Regression Results) Variable Age Education Less Than High School High School/Some College College/Graduate School Income Less Than $20,000 $20,001–$40,000 $40,001–$60,000+ Self-Esteem General Relationship Power Sexual Decision-Making Power

Logit Coefficient

SE

P

Odds Ratio Exp(B)

−.011

.037

.767

.989

.448 .943

.711 .876

.528 .282

1.566 2.567

−.440 −1.693 .019 −.017 .370

.624 .747 .058 .054 .186

.481 .023 .747 .754 .047

— 0.644 0.184 1.019 0.983 1.448

p = .047, were significantly more likely to use a condom than those who exercised less power in sexual decision making. Finally, those who had high levels of annual income over $40,000 were much less likely (or 0.184 times) to use a condom compared to those who reported to have less income, Exp(B) = 0.184; p = .023.

DISCUSSION Results indicated that participants who possessed higher levels of general relationship power and self-esteem tended to exercise greater power in sexual decision making such as having sex and choosing sexual acts. Given the fact that midlife and older women suffer from a combination of ageism and sexism, with additional potential interactions of classism and racism, it is not unreasonable to expect that self-esteem would play a significant role in sexual decision-making power. This is consistent with early feminist explanations (Chodorow, 1978/1999; Gilligan, 1993) that theorize close ties between identity, self-esteem, and relationship status for women. They posit that women’s self-esteem is derived from being connected to and caring for others, and decision making is made in the context of relationships. Thus, if a woman’s self-esteem depends on approval (e.g., cultural, economic, emotional) from a male partner, she may engage in self-injurious behaviors (e.g., unsafe sex, denial of HIV/AIDS risk) in order to maintain the relationship. This is consistent with a qualitative study on 24 HIV-positive midlife and older women who reported taking sexual risks for the sake of a relationship (Neundorfer et al., 2005). The majority of the women who participated in this study are not engaged in protected sex, and many reported that their male partners

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would get angry or violent if asked to use a condom. This is consistent with findings among younger women that indicate a significant relationship between general relationship power and condom use, with women who do not experience or command enough power in their relationships not insisting on condoms. In contrast, participants who had greater sexual decision-making power were more likely to use a condom regardless of age and ethnicity. This finding provides a possible answer to the question of why increased age is generally associated with lack of condom use among women. The comparative lack of condom use among midlife and older women has previously been explained as the result of lower condom self-efficacy and discomfort with sexual communication (Winningham et al., 2004; Zablotsky & Kennedy, 2003), lack of knowledge (Altschuler, Katz, & Tynan, 2004), lack of perceived relevance due to menopause (Lindau et al., 2007), reliance on monogamy for protection (Savasta, 2004; Stampley, Mallory, & Gabrielson, 2005). Gerontological feminist perspectives (Browne, 1998; Calasanti, 1999) focus on oppression of older women based on the intersection of multiple aspects of identity (e.g., ethnicity, race, class, age, gender, sexual orientation, health), asserting that the loss and lack of status and power among older women results from limited options open to them earlier in life, with women often being expected to be attractive to men and do work for them and their children. In her seminal essay, Sontag (1972) points out that women’s aging—which socially, begins earlier than for men—marks the end of their social usefulness and results in being widowed and being seen as unattractive. Calasanti (2005) and Haber (2001) build upon Sontag’s perspective, commenting respectively on bodies and anti-aging efforts that target age as an entity to be resisted or fought. Thus, it is no surprise that midlife and older women are rarely perceived as being sexual or sexually desirable and are comparatively less studied and targeted for HIV/AIDS prevention efforts. Similarly, Holstein (2002) asserts that older women judge themselves through men’s eyes as well as the eyes of younger people and are thereby “doubly objectified.” Anti-aging efforts that address appearance (e.g., creams, potions, cosmetic surgeries) primarily target women—women are not supposed to have wrinkles, gray hair, natural bodily curves—in short, normal aging is to be avoided or disavowed. By comparison, anti-aging interventions for men primarily focus on performance, not appearance. Compared to younger females, the devaluation and powerlessness of older women is more intense, and Nett (1982) proposes that the reason older people have low status is because so many of them are females. Nett (1982) argued for changes in structural factors (e.g., economic, social), as a focus for explanation and change, suggesting that the central issue of aging is the of control “over the social resources of wealth and knowledge, and . . . our bodies . . .” (p. 226). Considering women in this context, it is not unreasonable to view midlife and older women as a stigmatized group in need of

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prevention interventions that address empowerment and build self-esteem, with the intersection of gender, age, and ethnicity creating triple jeopardy for older ethnic minority women (Beaulaurier, Craig, & De La Rosa, 2008). HIV intervention research indicates that empowerment interventions increase preventive behavior among women and generally among disadvantaged and stigmatized groups (Amaro & Raj, 2000; Gómez, 2011; Ickovics et al., 2002; O’Leary & Martins, 2000; Parker, 2001; Parker, Easton, & Klein, 2000; Sumartojo, 2000). However, to the authors’ best awareness, there are no comparable interventions for older women in general nor older ethnic minority women in particular.

IMPLICATIONS FOR RESEARCH AND EDUCATION The authors acknowledge that women who were less willing or did not want to respond to a questionnaire distributed in an organizational/public setting, especially one that asks about intimate behaviours, were not included. Such “missing” participants may be different from those in the study. This limitation highlights the need for future research efforts that augment questionnaires with interviews and that enlist the help of organization or community leaders to recruit reluctant participants. Additional studies on midlife and older ethnic minority women are needed, as are empirically based prevention education efforts. Such studies should have numbers sufficiently large enough to examine within-group variations, as well as to draw conclusions about contextual variables that facilitate safer-sex decisions, with the ultimate goal of preventing HIV transmission among midlife and older ethnic minority women. Additional research is needed to examine factors associated with effective partner communication, especially negotiation strategies around condom use among women over 50, as well as their strategies for negotiating sexual decision making. The fact that midlife and older women may be uncomfortable exerting decision-making power in sexual relationships, especially when dialogue might lead to conflict or potentially threaten a relationship, are important factors to consider when developing HIV prevention programs for midlife and older women. This is especially important for midlife and older women of color from traditional backgrounds where stigma and taboo may conspire against open discussion of sexuality in general and sexually transmitted infections; in other words, strategies should match the social norms that are relevant to the women attending. The findings from this study lead to additional questions for future research. For example, would these findings be similar if conducted with other populations such as midlife and older men or other older women? The fact that rates of HIV infection for women over 50 have not been steadily declining leads to questions about gender and generational differences and

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similarities. For example, to what degree will future cohorts of women struggle with such issues as self-esteem, sexual relationship power, and sexual decision making? To what extent will future cohorts of women make sexual decisions out of desire, not default? If women begin making choices out of desire, i.e., considering their own needs as legitimate, before reaching older ages, will this affect levels of self-esteem and sexual decision making and levels of HIV/AIDS infection? How does this play out among midlife and older African American women who have a gender ratio shortage and among Latinas who are frequently tied to traditional cultural values that emphasize communal over individual decision making? In addition to gender and age, to what extent does the intersection of gender, age, and ethnicity play a role in determining self-esteem, sexual relationship power, and sexual decision making? Attention to gender and power imbalances, as well as cultural issues pertinent to risk and protective factors among older ethnic women are needed in prevention and intervention research. There may be value in longitudinal research that follows the same women through a number of life cycle stages as Erikson (1993) did with the children he studied for Childhood and Society. This may offer opportunity for theory that discovers, explores, and incorporates issues that are salient to older women, such as societal expectations regarding femininity, age, and aging, and complex gender and ethnic roles and their impact on sexual decision making. Findings from this study highlight the need for expanding understanding and development of gender- and age-specific HIV prevention interventions so that the needs of midlife and older women gain more attention. Research is needed that addresses the source(s) and impact of ageism and sexism on self-esteem, relationship power, and safer-sex negotiation. Women in general, and ethnic minority women in particular, frequently experience lifelong social and economic disadvantages that exacerbate with age or are newly experienced following divorce, death of a partner, or loss of employment. Such cumulative or newly experienced disadvantages may create risks for older women that are overlooked in most interventions. Thus, developing more-comprehensive HIV prevention programs for midlife and older women means not only addressing risk factors that have been considered in the present pilot study (e.g., self-esteem, relationship power, sexual decision making) but perhaps expanding that to include additional risk factors that are addressed in younger women’s prevention programs that remain relevant to women as they age: employment and job training opportunities, drug use, STDs, and domestic violence. Albarracín, Kumkale, and Johnson (2004) note that empowerment interventions are particularly effective for women who traditionally lack decisionmaking power in sexual and romantic relationships. Thus, incorporating content that explores ways to empower women to become active partners in revitalizing their lives and developing sources of healthy social and economic

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support should be considered when developing interventions. In that vein, peer-led groups may be especially useful interventions for older women because of their potential to focus on changing gender roles, communication with male partners, and HIV/AIDS stigma. This study indicates a potential for younger and older women to unite around issues of being female, age, aging, gender dynamics, and HIV/AIDS. The goal of preventing HIV/AIDS has the potential of helping women transcend chronological age as a social barrier in order to identify such common concerns as self-esteem; ethnic, cultural, and societal expectations/messages; and sexual decision making. Programs that foster ongoing discussions on being female, age, aging, and gender dynamics can be conducted within and even between generations of women and can address such issues as challenges to being or becoming more self-protective (Altschuler, 2001) as applied to sexual behaviors. A call for intergenerational unity has the potential to address the absence of old age in feminist thinking, a significant gap addressed by Calasanti and Slevin (2006), and the potential to build self-esteem among women as they age. Finally, it is vital to “start where the client is” and offer prevention programs in places and through mediums that expand upon the more usual settings (e.g., health fairs, doctors’ offices, health lectures at older adult social service settings) and reflect the varied lives of economically and ethnically diverse midlife and older women: for example, telenovelas, laundromats, markets, beauty parlors, popular magazines, and religious settings. The present authors concur with a call for proposed changes in structural factors—economic, social, and political—as a needed focus for intervention in the feminization of HIV/AIDS (Dworkin & Ehrhardt, 2007; Wingood, 2003). While it is important to study what and how midlife and older women need to change, successful prevention intervention strategies must also consider gender relations; limited opportunities for male companionship for older heterosexual females; and lifelong and age-related contexts of economic, cultural, and social inequality that contribute to the significant impact HIV/AIDS continues to have among midlife and older women.

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