Accepted Manuscript Sexual Communication and Sexual Behavior Among Young Adult Heterosexual Latinos Carmen Alvarez, PhD, RN, C-NP, CNM Jose A. Bauermeister, PhD, MPH Antonia M. Villarruel, PhD, RN, FAAN PII:

S1055-3290(14)00138-1

DOI:

10.1016/j.jana.2014.06.005

Reference:

JANA 661

To appear in:

Journal of the Association of Nurses in AIDS Care

Received Date: 9 January 2014 Accepted Date: 29 June 2014

Please cite this article as: AlvarezC., BauermeisterJ.A. & VillarruelA.M., Sexual Communication and Sexual Behavior Among Young Adult Heterosexual Latinos, Journal of the Association of Nurses in AIDS Care (2014), doi: 10.1016/j.jana.2014.06.005. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT

Sexual Communication and Sexual Behavior Among Young Adult Heterosexual Latinos

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Carmen Alvarez, PhD, RN, C-NP, CNM Jose A. Bauermeister, PhD, MPH Antonia M. Villarruel, PhD, RN, FAAN

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Carmen Alvarez, PhD, RN, C-NP, CNM, is a Julio Bellber Post-Doctoral Fellow, George Washington University, Department of Health Policy, Washington, DC, USA; Jose Bauermeister, PhD, MPH, is Assistant Professor, University of Michigan, School of Public Health, Department of Health Behavior and Health Education, Ann Arbor, Michigan, USA;. Antonia Villarruel, PhD, RN, FAAN, is Associate Dean for Research and Professor, University of Michigan, School of Nursing, Division of Health Promotion and Risk Reduction, Ann Arbor, Michigan, USA. Corresponding Author: Carmen Alvarez: [email protected]

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Disclosures: The authors report no real or perceived vested interests that relate to this article that could be construed as a conflict of interest.

Acknowledgements

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The authors would like to acknowledge all entities that provided financial and technical support for this study. These include the following from the University of Michigan: Rackham

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Graduate School, the Global Health Center, the Institute for Research on Women and Gender, the School of Public Health SexLab, the School of Nursing, and CHASS Clinic. The authors also acknowledge the financial support of the Julio Bellber Fellowship.

ACCEPTED MANUSCRIPT 1 Abstract We examined verbal sexual health communication, pleasure discussions, and physical sexual communication in relation to condom use by young adult, heterosexual Latinos (ages 18-

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30). Participants (N = 220, 51% female) were recruited in a Midwestern state. Verbal sexual health communication was positively associated with consistent condom use among men (OR = 2.66, p < .05) and women (OR = 3.12, p < .05). For men, pleasure discussions were negatively

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associated with consistent condom use (OR = 0.21, p < .05). For women, verbal sexual health communication was positively associated with condom use at last sex (OR = 2.75, p < .05),

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whereas physical sexual communication was negatively associated with condom use at last sex (OR = .29, p < .05). Various aspects of sexual communication may be important in HIVprevention programs with young Latinos. Physical sexual communication and pleasure discussions, in particular, warrant further exploration given negative relationships with condom

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use.

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Keywords: AIDS, HIV, Latinos, sexual behavior, sexual communication, young adults

ACCEPTED MANUSCRIPT 2 Sexual Communication and Sexual Behavior Among Young Adult Heterosexual Latinos Compared to non-Hispanic Whites, Latinos have higher rates of sexually transmitted infections (STIs; Centers for Disease Control and Prevention [CDC], 2013) including HIV

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infection (CDC, 2012). When compared to non-Hispanic Whites, rates of chlamydia and

gonorrhea among Latinos are almost double (CDC, 2012). Regarding HIV infection, rates are three times higher among Latinos compared to non-Hispanic Whites. Further, Latinos accounted

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for 16% of the population but comprised 22% of new HIV infections in 2011 (CDC, 2012). Among Latinos, gender disparities also exist regarding HIV infection. In 2011, heterosexual

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contact was the major mode of transmission for 86% of new infections in Latina women and 9% among Latino men (CDC, 2011). High rates of infection in this demographic underscore the importance of promoting safer sex behaviors among Latinos. One important component of efforts to prevent unintended consequences of sex is sexual communication between sexual

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partners (Noar, Carlyle, & Cole, 2006). Our cross-sectional study examines multiple aspects of sexual communication and their associations with sexual behavior in young adult Latinos. Sexual Communication and Sexual Behavior

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Although sexual communication has been promoted in efforts to address increasing rates of adverse sexual health outcomes among Latinos, the long-term benefits of these efforts remain

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unclear. Further understanding of sexual communication among Latinos may encourage more beneficial sexual health-promotion. Regarding sexual communication, few studies exclusively focus on Latinos, and the majority of these studies focus on Latino women (Castaneda, 2000; Deardorff, Tschann, & Flores, 2008; Gomez, Hernandez, & Faigeles, 1999; Harvey & Henderson, 2006; Marston, 2004; Moore, Harrison, Kay, Deren, & Doll, 1995; Noland, 2006; Peragallo et al., 2005; Saul et al., 2000). Among the few studies that have examined the

ACCEPTED MANUSCRIPT 3 influence of sexual communication on condom use across diverse samples of Latinos, the findings are equivocal. Some studies were able to demonstrate a positive relationship between sexual communication and condom use (Ibanez, Marin, Villareal, & Gomez, 2005; Rojas-

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Guyler, Ellis, & Sanders, 2005; Tschann, Flores, de Groat, Deardorff, & Wibbelsman, 2010) while other studies found no relationship (Harvey & Henderson, 2006; Moore et al., 1995). A commonality among the studies that have explored sexual communication among

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Latinos is the perspective of sexual communication being only a verbal activity that focuses on condom use and sexual history. However, other aspects of sexual communication warrant

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consideration. Research has revealed an array of verbal and nonverbal strategies used to advocate as well as discourage condom use with partners (Bird, Harvey, Beckman, & Johnson, 2001; Noar, Morokoff, & Harlow, 2004; Tschann et al., 2010). Therefore, both verbal and nonverbal sexual communication should be given equal consideration when exploring the

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relationship between sexual communication and sexual behavior. For the purposes of our study, sexual communication refers to the verbal and nonverbal ways one employs to communicate sexual health issues, sexual preferences, and sexual satisfaction.

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Barriers to Sexual Communication Among Latinos Sexual communication between sexual partners is an important component of safer sex

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behavior. Consistent findings across different racial/ethnic groups is that sexual communication with a sexual partner, particularly regarding sexual history and risk behaviors, is challenging and uncomfortable to broach (Faulkner & Lannutti, 2010; Noar et al., 2012; Teitelman, Tennille, Bohinski, Jemmott, & Jemmott, 2011; Umphrey & Sherblom, 2007). The desire to forego condoms (Foster et al., 2012) to maximize sexual pleasure (Faulkner & Lannutti, 2010; Noar et al., 2012; Teitelman et al., 2011) further challenges the practice of safer sex. Several researchers

ACCEPTED MANUSCRIPT 4 argue that traditional cultural beliefs and sexual gender roles are barriers to sexual communication among Latinos (Marston, 2004; Noland, 2006; Ortiz-Torres, Serrano-Garcia, & Torres-Burgos, 2000). For example, the gender roles of marianismo and machismo encourage

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women to appear sexually naïve and faithful, while men are encouraged to demonstrate their masculinity by behaviors that include greater sexual freedoms and the power to make decisions about sex for the couple (Davila, 2005; Ortiz-Torres et al., 2000). These beliefs promote the

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practice of sexual silence (the avoidance of verbal communication about sex), a practice often cultivated from childhood that perpetuates discomfort and shame about sexual communication

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(Carrillo, 2002). Accordingly, Latino men and women may be less likely to discuss sexual behaviors with each other or advocate for safer sex practices such as consistent condom use and monogamy, thereby potentially increasing the risk for STI and HIV infection. Aside from traditional cultural beliefs, researchers have found other reasons why Latinos

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may avoid verbal sexual communication with their partners. Carrillo’s (2002) ethnographic work among Mexicans revealed that one’s desire for trust, love, intimacy, spontaneity, and irrationality dissuaded safer sex discussions and rationalized unprotected sex. Similarly, more recent

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qualitative descriptive work among young adult Latinos (primarily of Mexican descent) revealed that young adults’ sexual communications with their sexual partners emphasized sexual pleasure,

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which was often nonverbally communicated (Alvarez & Villarruel, 2013). These qualitative studies about sexual communication among Latinos underscore the importance of relationship context and the multidimensionality of sexual communication. In the public health and HIV prevention literature, there are a number of gaps and limitations in the study of sexual communication among young adult Latinos. One limitation is that few studies focus exclusively on Latinos. And, of these studies, findings regarding the

ACCEPTED MANUSCRIPT 5 relationship between sexual communication and sexual behavior are mixed, and potential confounders of the relationship are largely unexplored. In addition, the literature has focused primarily on verbal sexual communication about HIV, STIs, and condom use.

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Our study attempts to address these gaps by expanding the evaluation of sexual

communication among Latinos to include both physical sexual communication and pleasure discussions. Including these aspects of sexual communication may provide a more complete

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picture of sexual communication and how it influences sexual behavior. In this study, we

examine how several aspects of sexual communication (i.e., health-related, pleasure-related, and

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physical) are associated with sexual behaviors (i.e., condom use and concurrent sexual partners), and assess whether these relationships vary by gender in a young adult (ages 18-30), heterosexual, Latino sample in current sexual relationships. Methods

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Study Design and Setting

We conducted a descriptive study with participants recruited from a community-based health clinic and its surrounding neighborhoods in the Southwest Detroit area. Latinos comprise

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69% of the population in this community (U.S. Census Bureau, 2010), and the predominant ancestry is Mexican. Institutional review boards from the University of Michigan and the clinic

Sample

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where part of the recruitment took place approved the study recruitment, instruments, and design.

Individuals were eligible to participate in the study if they self-identified as Latino, were in a sexually active heterosexual relationship (had sex with their partner in the last 3 months), had been in the relationship for at least 3 months, were between the ages of 18 and 30 years, and could speak and write Spanish or English. Given the age group, and our interest in sexual

ACCEPTED MANUSCRIPT 6 communication between sexual partners, we opted to include people who identified as being in a relationship; use of the 3-month time frame was based on other sexual risk behavior research (Greene & Faulkner, 2005) and with the intention of selecting more established relationships

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relative to new and casual relationships. Individuals were excluded if they reported trying or planning to become pregnant, were pregnant, or were less than 3 months postpartum. Participants were asked to invite their primary partners to participate in the study; however, participation as a

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couple was not required. Partners invited to participate also had to meet the inclusion criteria for the study.

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Procedures

Recruitment of a convenience sample took place from May 2011 through August 2011. Potential participants from the clinic and the surrounding community were invited to participate in a brief study to learn more about romantic relationships among Latinos, particularly the

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communication that occurs between couples. Several recruitment methods were employed. At the clinic, a list of incoming patients and their ages were examined daily to identify eligible patients. Patients who met the age criteria were approached in the exam room prior to being seen

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by a provider. Clinic staff were also asked to forward individuals (who met the ethnic and age criteria) to the on-site recruiter for more information about eligibility. Finally, flyers were

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handed to potential participants sitting in waiting areas. All potential participants were informed that participation was completely voluntary and would have no impact on services received at the clinic. If they agreed to participate in the study, participants completed questionnaires after receipt of services (if any) at the clinic. Recruitment outside of the clinic included both active and passive strategies. Active recruitment occurred in public venues such as parks, church gatherings, local businesses,

ACCEPTED MANUSCRIPT 7 restaurants, and nightclubs. Informational flyers were distributed in these areas, and potential participants were individually approached to inquire about their interest and eligibility. Presentations about the study were made in settings such as churches, adult-learning centers, and

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women’s group meetings. Recruitment flyers with study contact information were also posted in various establishments (small businesses, grocery stores, gyms, etc.) throughout the community. Also, a project website was developed and used to advertise the study.

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Data collection consisted of participants completing self-administered paper-pencil questionnaires in English or Spanish, depending on participant preference. Individuals who

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agreed to participate were required to read the consent form that explained the objectives of the study, what their participation entailed, and the benefits and risks of their participation. Because several items in the questionnaire asked sensitive questions, including residency/citizenship status, no identifying information such as name or address was collected—completion of the

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questionnaire was considered confirmation of informed consent to participate in the research. All participants were compensated $10 cash for their participation. Measures

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Questionnaire items that were not available in Spanish were translated using the cultural decentering process (Werner & Campbell, 1970). The survey questionnaires were translated into

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Spanish by the principal investigator. Several other bilingual persons who had not seen the original questionnaires in English were asked to translate the questionnaires back to English. The principal investigator and a native Spanish speaker reviewed the final questionnaires to verify that both Spanish and English versions of the questionnaires were functionally equivalent. The questionnaire was pilot tested by 3 men and 3 women prior to the study; the pilot test yielded only typographical changes.

ACCEPTED MANUSCRIPT 8 Demographic Characteristics Participants were asked to provide their age, their sexual partner’s age, relationship status (married, cohabitating, or living apart), length of time in the relationship, level of education, and

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employment status. Level of acculturation was assessed using the Short Acculturation Scale (SAS; Marin, Sabogal, Marin, Otero-Sabogal, & Perez-Stable, 1987). The scale contains six items with a 5-point Likert scale ranging from (1 = Spanish only to 5 = English only). The scores

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were categorized into low level of acculturation (scores 1 - 2.99) and high level of acculturation (scores 3 - 5).

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Perceived Risk for STIs

Participants’ perceived risks for STIs was evaluated with the Perceived Risk for HIV Index (Moore et al., 1995). The 3-item, 4-point Likert scale (1 = none to 4 = a lot) was modified for our study to focus on STIs. Higher scores indicated greater perceived risk for STIs. Mean

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scores could range from 1 – 4 with this instrument. Sexual Communication with Primary Partner

The measures for sexual communication were informed by preliminary qualitative work

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among young adult Latinos ( Alvarez & Villarruel, 2013) and pre-existing measures (Deardorff et al., 2008; Wheeless, Wheeless, & Baus, 1984). Exploratory factor analyses were used to

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simplify the pre-existing measures and to explore different aspects of sexual communication (i.e., sexual health, pleasure, and physical sexual communication) as suggested by the previous qualitative study.

The components of sexual communication are described next. Verbal sexual communication. Verbal sexual communication refers to discussions that occur between sexual partners about various aspects of sex (i.e., what makes sex pleasurable,

ACCEPTED MANUSCRIPT 9 condom use, and past sexual partners). The verbal sexual communication scale in this study was adapted from the Comfort with Sexual Communication Scale (Deardorff et al., 2008). The Comfort with Sexual Communication Scale consists of 8-items, rated with a 5-point Likert scale

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(1 = not at all to 5 = very much) that address level of comfort discussing various sexual issues such as condom use and sexual satisfaction (i.e., preferred sexual positions). The original

instrument was developed based on findings with a young Latino population (N = 694; average

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age = 18.4 years; α = .84females, .89males). We modified items from the scale to inquire about

frequency of talking to one’s partner about sexual topics rather than one’s comfort level about

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discussing the sexual topics. For example, the item How would you feel talking to your partner about the sexual positions you prefer? was changed to How often do you talk to your partner about the sexual positions you prefer? Higher scores indicated greater frequency of verbal sexual communication between the couple. The sexual health communication included four items that

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addressed talking to one’s partner about pregnancy, condom use, and STIs. Factor analysis of the verbal sexual communication scale also resulted in the extraction of items categorized as pleasure discussions. Pleasure discussions included four items that

positions.

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addressed sexual satisfaction preferences such as oral sex, sharing sexual fantasies, and sexual

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Physical sexual communication. Physical sexual communication addresses the actions individuals show their sexual partners to relay information about sexual pleasure, discontent, or desire. The Sexual Communication Satisfaction Scale (Wheeless et al., 1984) was used to measure physical sexual communication. The Sexual Communication Satisfaction Scale, tested on 312 White students, is a 22-item, 7-point Likert scale that evaluates both verbal and nonverbal communication about sexual satisfaction in a relationship (α = .94). Nine items from this scale

ACCEPTED MANUSCRIPT 10 were selected to address nonverbal components of sexual communication. The original response options (strongly agree to strongly disagree) were modified to evaluate whether the participant actually engaged in the behavior and, if so, with what frequency. For example, I show my partner

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what pleases me during sex (1 = rarely, 4 = always). Higher scores indicate greater physical sexual communication between the couple. After factor analysis, physical sexual communication

sexually satisfied or what was sexually pleasurable. Sexual Behaviors

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included six items that addressed how one demonstrated to his/her partner when s/he was

were the three behaviors assessed.

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Consistent condom use, condom use at last sex, and number of current sexual partners

Consistent condom use. Consistent condom use with primary and secondary sexual partners was defined as condom use at all sexual encounters (i.e., How often do you use condoms

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with your partner? How often do you use condoms with your other partner(s)?; 1 = always, 2 = sometimes, 3 = never). Consistent condom use was dichotomized as consistent or not consistent for the purpose of analysis. Condom use at last sex was evaluated with one item, Did you use a

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condom the last time you had sex?

Current number of sexual partners. Sexual concurrency refers to having sex with at

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least one other person while still in a relationship (dating, cohabitating, married) and sexually active with the primary partner. Participants were asked to report the number of concurrent sex partners. This outcome variable was categorized as more than one sexual partner (1 = yes, 0 = no).

Data Analysis Descriptive analyses were conducted for all variables. To evaluate differences by gender,

ACCEPTED MANUSCRIPT 11 we conducted t-tests for continuous variables and χ2 analyses for categorical variables. Multivariable logistic regression models were estimated to examine the independent effects of age difference between partners, level of education, employment status, level of acculturation,

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length of time in relationship, relationship status, perceived risk for STIs, and sexual communication on the sexual behavior outcomes. Results

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Participants

Table 1 presents frequencies and means for all variables. More than half of participants

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completed the questionnaire in English (n = 129, 58.6%). The age of all participants included in the analysis ranged from 18 to 30 years (M = 23.49, SD = 3.61). The average age of partners ranged from 16 to 43 years with a mean age of 24.5 years (SD = 5.32). Most participants had partners who were also Latino (84.1%). The age difference between partners ranged from 8 to 20

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years, and the length of time in the relationship ranged from 3 months to 14 years (M = 3.84, SD = 3.05). Slightly more than half of the participants were either married (27.3%) or cohabitating (24.5%). As seen in Table 1, there were several gender differences; more women were married

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(42.3%) or cohabitating (30.6%) and, compared to male participants, women had been with their partners for more years.

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Sexual Behavior

Overall, participants had one current sexual partner (M = 1.24, SD = 0.96; range 1 – 8). Twenty percent of the sample reported at least one concurrent partner. Also compared to men, fewer women (5.4%) reported having more than one sexual partner (p = .055). More than half of the sample (57.7%) reported use of a birth control method other than condoms. Only 20.5% of the sample reported consistent condom use, and condom use at last sex was reported by 36.8% (n

ACCEPTED MANUSCRIPT 12 = 81). Condom use at last sex was the only sexual behavior outcome with differences between men and women, with men reporting more condom use at last sex (45% vs. 28.8%, p < .01). Sexual risk perceptions. Regarding perceived risk for STIs or HIV, on average,

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participants did not consider themselves at risk (M = 1.55, SD = 0.67). Sexual risk perceptions also differed by gender. Compared to men, women considered themselves to be at greater risk for STI or HIV infection (M = 1.65 vs. M = 1.45, p < .01).

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Sexual Communication

Reliability of sexual communication measures was evaluated. All measures demonstrated

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respectable reliability: sexual health communication (α = .75females and .69males), pleasure discussions (α = .69females and .68males), and physical sexual communication (α = .81females and .85males). Mean scores for sexual health communication (M = 2.60, SD = 0.85), pleasure discussions (M = 2.68, SD = 0.79), and physical sexual communication (M = 3.16, SD = 0.69)

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indicated that participants rarely engaged in sexual health and pleasure discussions and almost always engaged in physical sexual communication. Men (M = 2.36, SD = 0.79) and women (M = 2.83, SD = 0.86, p < .05) had significantly different mean scores for sexual health

partners than men.

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communication, indicating that women engaged in more sexual health communication with their

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Sexual Communication and Sexual Behaviors Condom use. Table 2 presents the fully adjusted odds ratios (AORs) and 95% confidence intervals for the effects of age differences between partners, length of time in the relationship, relationship status, level of education, employment status, level of acculturation, perceived risk for STIs, and sexual communication on condom use behaviors. Among men, relationship status was the only significant predictor of condom use at last sex. Men who were

ACCEPTED MANUSCRIPT 13 married (AOR = 0.11, p < .05) and cohabitating (AOR = 0.17, p < .05) had lower odds of having used condoms at last sex. Consistent condom use, however, was not associated with any demographic variables, level of acculturation, or perceived risk for STIs. Consistent condom use

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was negatively associated with pleasure discussions (AOR = 0.24, p < .05) and positively

associated with sexual health communication (AOR = 2.89, p < .05; Table 2). Consistent condom use was not associated with physical sexual communication.

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Among women, after controlling for the covariates, the odds of condom use at last sex was negatively associated with physical sexual communication (AOR = 0.28, p < .05) and

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positively associated with sexual health communication (AOR = 2.71, p < .05; see Table 3). Consistent condom use was also positively associated with sexual health communication (AOR = 2.85, p < .05).

Concurrent Sexual Partners. The initial model was trimmed to include age difference

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between partners, length of time in relationship, level of acculturation, perceived risk for STIs, and the sexual communication variables. Among men, having concurrent sexual partners was positively associated with perceived risk for STIs (AOR = 5.52, p < .05). While the model was

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significant for women, none of the variables were significantly associated with having concurrent sexual partners. Sexual health communication was not associated with having

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multiple partners (AOR = 0.25, p = .05). Discussion

We sought to explore the relationship between sexual communication and sexual behavior among young adult Latinos in heterosexual relationships. Consistent with prior qualitative findings with Latinos, communication pertaining to sexual satisfaction played a key role in sexual risk-taking behaviors, distinct from that of sexual health communication. We also

ACCEPTED MANUSCRIPT 14 noted that the relationship between sexual communication and sexual behavior differed by gender. These findings underscored the importance of considering sexual communication and gender in the development of sexual health programs for Latinos.

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Overall, consistent condom use was low for men and women; however, both males and females who engaged in sexual health communication were more likely to report consistent condom use. Men who engaged in more pleasure discussions, however, were less likely to use

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condoms consistently. This negative relationship between consistent condom use and pleasure discussions is consistent with other findings (Deardorff, Tschann, Flores, & Ozer, 2010) and at-

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risk populations (Bauermeister, Giguere, Carballo-Diéguez, Ventuneac, & Eisenberg, 2010). Although women reported similar amounts of pleasure discussions in their relationships as men, there was no relationship between pleasure discussions and consistent condom use among women in the sample. Given that consistent condom use is associated with both sexual health

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and pleasure discussions, it remains important to understand the contexts and circumstances in which these conversations occur and create intervention opportunities for men to reconcile their sexual health and pleasure discussions when deciding to use condoms within a relationship.

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Men were more likely to report greater condom use at last sex than women; however, unlike previous findings (Ibanez et al., 2005), we found no relationship between condom use at

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last sex and sexual communication among men. Women, on the other hand, were more likely to report condom use at last sex if they reported more frequent sexual health communication and less likely to report condom use at last sex if they reported engaging in more physical sexual communication with a partner. These findings underscored the importance of both sexual health and physical sexual communication among women and were consistent with prior evidence suggesting that women’s sexual enjoyment may be lessened when their partners use condoms

ACCEPTED MANUSCRIPT 15 (Pulerwitz & Dworkin, 2006). Furthermore, sexual power imbalances in a relationship may dissuade women from requesting condom use in their relationships, making them more dependent on their partners’ desires for condom use (Harvey, Beckman, Browner, & Sherman,

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2002).

Another possible reason for the negative relationship between communication about sexual satisfaction and condom use, noted among both sexes, is the decreased rational thinking

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that may occur during sexual arousal (Carrillo, 2002). Amidst the spontaneity and focus on pleasure, the rational thinking that would advocate for safe sex may be subdued. On the other

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hand, consistent with prior literature encouraging the acknowledgment of women’s agency in their pleasure negotiations (Dworkin, Beckford, & Ehrhardt, 2007), it is also possible that women choose not to use condoms with their partners as a sign of intimacy or because their desire for sexual pleasure and satisfaction outweighs their concerns for risk protection. Taken

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together, these findings highlight the need to propose strategies that help women reconcile their sexual health needs with their sexual desire and needs. When we examined the likelihood of having concurrent sexual partners, we found that

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men with multiple partners were also more likely to perceive themselves to be at greater risk for STIs. These findings suggest that men are aware of the sexual health consequences of having

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multiple partners; however, it was surprising to find that perceived risk for STIs was not associated with condom use behaviors. We also found no relationship between having concurrent sexual partners and sexual communication, contrary to prior findings noting a relationship between multiple partners and HIV-specific sexual communication (Moore et al., 1995). The absence of these relationships may be due to the low proportion of participants who selfdisclosed having multiple partners. Future research with a larger sample of Latino youth

ACCEPTED MANUSCRIPT 16 participating in concurrent partnerships is warranted to examine these relationships further. This study has several limitations. These data were only representative of individuals in heterosexual relationships. In addition to expanding research with same-sex couples, future

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research with dyadic data will provide opportunities to explore sexual communication

concordance within couples, as well as how factors such as trust may influence sexual

communication and behavior. This was also a cross-sectional study; therefore, we could not

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explore how sexual communication and sexual behavior change over time in relationships. In addition, data were collected from a convenience sample of which the majority was of Mexican

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heritage; therefore, these results are not generalizable to other Latino populations. There was not enough variation in our sample to explore differences among Latinos with Mexican versus Puerto Rican heritage, for example. Further, these data came from a young adult sample of which the majority had more than a high school education. Although education and age were not

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associated with sexual communication in this sample, we caution against generalizing the findings to another age group or less educated Latinos sample. Finally, given the sensitive nature of the study, participant responses may have been influenced by social desirability.

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Notwithstanding the limitations, this study has several strengths and contributes to the literature on sexual communication among Latinos. This is one of the few studies that has

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considered sexual health communication, pleasure discussions, and physical sexual communication, and the relationship of these variables to condom use as well as concurrent sexual partners. The significant negative relationship between both sexual satisfaction and physical sexual communication and the outcome of condom use behaviors underscores the importance of sexual satisfaction in sexual behavior. In fact, the study not only validates the relevance of multiple aspects of sexual communication in relation to sexual behavior, but also

ACCEPTED MANUSCRIPT 17 confirms that Latinos do not necessarily succumb to traditional gender norms to avoid sexual communication. Further efforts to increase safer sex practices among young adult Latinos should address

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the less explored aspect of physical sexual communication. Given that physical sexual

communication focused on sexual satisfaction, exploring this aspect of sexual behavior may inform how to promote safe sex. A possible approach would be to learn from young adult Latino

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couples what sexually satisfying experiences entail and how (if at all) safe sex is implemented. Findings from such a study may inform how HIV prevention/health promotion researchers can

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use physical sexual communication to encourage both sexual satisfaction and safe sex. Future research is needed to examine how gender differences and contexts for sexual satisfaction and

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pleasure affect condom use or other sexual behaviors among young adult Latinos.

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ACCEPTED MANUSCRIPT 23 Table 1 Demographics of Participants Women (N = 111) M (SD) or N (%) 24.28 (3.6)

Age of partner**

24.55 (5.32)

27.59 (4.97)

Partner is Latino

185 (84.1%)

95 (85.6%)

Age difference between

-1.07 (4.11)

-3.31 (4.12)

3.84 (3.05)

4.84 (3.38)

Number of years with partner** Relationship status Married

60 (27.3%)

Living together

54 (24.5%)

(not married) Live apart

106 (48.2%)

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(not married) Education Some high school or

64 (29.2%)

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less*

High school graduate or 155 (70.8%) more

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Job status

21.46 (3.62) 90 (82.6%)

1.21 (2.53)

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partners**

Men (N = 109) M (SD) or N (%) 22.68 (3.4)

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Age**

Total sample (N = 220) M (SD) or N (%) 23.49 (3.61)

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Characteristics

2.82 (2.28)

47 (42.3%)

13 (11.9%)

34 (30.6%)

20 (18.3%)

30 (27%)

76 (69.7%)

42 (37.8%)

22 (20.4%)

69 (62.2%)

86 (79.6%)

Employed full-time

127 (57.7%)

58 (52.3%)

69 (63.3%)

Not employed and

93 (42.3%)

53 (47.7%)

40 (36.7%)

United States

106 (48.2%)

42 (37.8%)

64 (58.7%)

Mexico

94 (42.7%)

58 (52.3%)

36 (33%)

Central America

20 (9.1%)

11 (9.9%)

9 (8.3%)

temporary employment Place of birth

ACCEPTED MANUSCRIPT 24 & the Caribbean Number of years in

16.51 (7.5)

15.43 (8.02)

17.62 (6.78)

Low acculturation

57.3%

63.1%

54.1%

Perceived risk for STI*

1.55 (.67)

1.65 (.69)

1.45 (.64)

Birth control

118 (55.9%)

62 (57.9%)

Consistent condom use

45 (20.5%)

20 (18%)

Condom use last sex*

81 (36.8%)

32 (28.8%)

Number of concurrent

1.24 (0.96)

1.17 (0.90)

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United States**

Sexual behavior

Multiple concurrent sex

20 (9.1%)

partners Birth control

118 (55.9%)

Consistent condom use

45 (20.5%)

Condom use last sex*

81 (36.8%)

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** p < .01, * p < .05

25 (22.9%) 49 (45%)

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sex partners

56 (53.8%)

1.30 (1.02)

6 (5.4%)

14 (12.8%)

62 (57.9%)

56 (53.8%)

20 (18%)

25 (22.9%)

32 (28.8%)

49 (45%)

Note: Significance notations refer to gender differences evaluated by Chi-squared analyses; STI

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= sexually transmitted infection.

ACCEPTED MANUSCRIPT 25 Table 2 Logistic Regression Analysis of Sexual Behaviors Among Men on Demographic and Relationship

Variables Consistent Condom Use AOR 95% CI 0.96 0.75 - 1.22

Length of time in relationship

0.88

0.69 - 1.12

0.73

Married

0.11*

0.02 – 0.79

0.50

0.04 - 6.92

Cohabitating

0.17*

0.04 - 0.75

0.28

0.03 - 2.86

Employment status

1.43

0.57 - 3.63

0.87

0.28 - 2.68

Education Perceived risk for STI

0.40 1.38

0.10 - 1.55 0.63 - 3.04

1.26 0.73

Level of acculturation

1.16

0.46 - 3.02

Sexual health communication

1.02

Pleasure discussions

1.11

Physical sexual communication

0.65

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Full Model: χ2 Cox & Snell R2 Nagelkerke R2

0.84 - 1.45

0.23 - 6.91 0.27 - 1.96

5.52*

2.06-14.82

3.20

0.94 - 10.89

2.24

0.48-10.52

0.50 – 2.04

2.89*

1.18 – 7.05

0.53

0.19 - 1.47

0.43 - 2.37

0.24*

0.08 - 0.70

1.78

0.47 - 6.65

0.26 – 1.59

0.72

0.24 – 2.14

0.46

0.13 - 1.62

22.54* .19 .25

Note. STI = sexually transmitted infection. ** p < .01, *p < .05

0.50 - 1.05

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1.11

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Age difference between partners

Multiple Partners AOR 95% CI 0.93 0.70 - 1.23

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Condom Use at Last Sex AOR 95% CI 0.90 0.75 - 1.08

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Independent Variables

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Characteristics, Level of Acculturation, Perceived Risk for STIs, and Sexual Communication

28.37* .23 .35

18.26* .15 .29

ACCEPTED MANUSCRIPT 26 Table 3 Logistic Regression Analysis of Sexual Behaviors Among Women on Demographic and

Communication Variables Independent Variables

Condom Use at Last Sex

Consistent Condom Use

95% CI 0.87 - 1.13

AOR 1.01

95% CI 0.87 - 1.18

Length of time in relationship

0.86

0.71 - 1.05

0.87

0.69 - 1.10

Married

0.49

0.11 - 2.14

0.33

0.06 - 1.90

Cohabitating

0.25

0.06 - 1.04

0.21

0.04 - 1.23

Employment

1.76

0.57 - 5.45

1.98

0.52 - 7.53

Education

0.41

0.12 - 1.41

0.68

0.17 - 2.71

Perceived risk for STI

0.85

0.39 - 1.83

1.13

Level of acculturation

0.83

0.24 - 2.84

Sexual health communication

2.71*

1.31 – 5.60

Pleasure discussions

95% CI 0.75 - 1.32 0.46 - 1.36

0.46 - 2.82

4.83

0.79 - 29.60

0.33

0.07 - 1.47

4.92

0.27 - 90.3

2.85*

1.16 – 7.03

0.24

0.06 - 1.01

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0.79

0.37 - 1.76

0.54

0.22 - 1.33

0.51

0.13 - 1.98

0.28*

0.10 – 0.81

0.68

0.21 – 2.26

0.98

0.11 - 9.12

25.95* .21 .30

Note. STI = sexually transmitted infection. ** p < .01, *p < .05

AOR 0.99

0.80

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Physical sexual communication Full Model: χ2 Cox & Snell R2 Nagelkerke R2

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Age difference between partners

Multiple Partners

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AOR 0.99

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Relationship Characteristics, Level of Acculturation, Perceived Risk for STIs, and Sexual

20.33* .17 .27

20.71* .17 .49

ACCEPTED MANUSCRIPT 27 Key Considerations •

Sexual health communication – talking to one’s partner about pregnancy, condom use, and sexually transmitted infections – is positively associated with condom use among young

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adult Latinos. Therefore, in addition to promoting condom use, nurses should encourage young adults to engage in sexual health communication with their sexual partners. •

Sexual pleasure is a common motivator for sexual activity. Pleasure-focused sexual

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communication is negatively associated with condom use behaviors and, consequently, a potential risk factor for HIV and STI. Therefore, nurses and other health care workers should

Given that Latinos remain disproportionately affected by HIV and STIs, nurses should

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continue to explore innovative solutions to support safer sex behaviors in this population.

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•

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brainstorm with young adults on how to have safe and pleasurable sex.