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research-article2014

QHRXXX10.1177/1049732314529188Qualitative Health ResearchKassab et al.

Article

Views on Sex and Sex Education Among Gang-Involved Latino Youth in the United States

Qualitative Health Research 2014, Vol. 24(5) 654­–664 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049732314529188 qhr.sagepub.com

Veronica A. Kassab1, Ignacio D. Acevedo-Polakovich1, Megan M. Grzybowski1, Stacy Stout2, Allyn E. Richards3, Miya L. Barnett1, Aileen Guerra-Morales4, Katrina M. Bell5, Elizabeth A. Crider1, Kara L. Beck1, Jodi Brookins-Fisher1, Mario Alfaro6, and Suchita R. Saxena1

Abstract Although gang-involved Latino youth in the United States are uniquely at risk of adverse consequences from sexual behavior, little research is available that can guide those who wish to develop interventions to reduce sexual risk among these youth. To facilitate the development of effective interventions, we identified cultural and contextual factors that influence sexual behavior and sex education among gang-involved Latino youth in one U.S. community. By analyzing transcripts from interviews and focus groups with three different groups of key stakeholders—gangexperienced Latino youth, the parents of gang-experienced Latino youth, and the personnel of a program providing comprehensive human services for gang-involved Latino youth—we identified three domains to be considered in developing sexual risk-reduction interventions for gang-involved U.S. Latino youth. The focus of our discussion is on the implications of these findings for future development or adaptation of interventions. Keywords adolescents / youth, at risk; health promotion; intervention programs; Latino / Hispanic people; sexuality / sexual health Gang-involved Latino1 youth in the United States are uniquely at risk of engaging in sexual behaviors for three reasons: the conditions facing Latino youth, their participation in problem behaviors, and their involvement in gangs. Compared to national averages among all youth, youth who identify as Latino report higher rates of risky sexual behaviors, sexually transmitted infections (STIs), and lower rates of contraceptive use (Centers for Disease Control and Prevention [CDC], 2010). Compared to national averages, Latino youth also are more likely to have sex (49.1% vs. 46.0%), more likely to have sex before the age of 13 (6.7% vs. 5.9%), and more likely to have four or more sexual partners in their lives (14.2% vs. 13.8%; CDC). U.S. Latino youth who engage in multiple problem behaviors (e.g., substance use and delinquency) are even more likely to engage in risky sexual behavior (Schwartz et al., 2009). In quantitative data obtained from 227 highrisk Hispanic adolescents, Schwartz et al. found that conduct and behavioral problems (e.g., aggression and rule breaking) are directly related to youth sexual behavior. Low levels of functioning in multiple domains, such as

family and school functioning, additively affect adolescents’ engagement in problem behaviors. In turn, engagement in problem behaviors influences decisions to engage in sexual behaviors (Schwartz et al.). Among U.S. Latino youth who engage in multiple problem behaviors, those who are involved in gangs are exposed to unique situations that further promote risky sexual behaviors (Brooks, Lee, Stover, & Barkley, 2009). Gangs are collectives of youth who both identify and are recognized as belonging to a relatively permanent and organized group with an elevated level of criminal 1

Central Michigan University, Mount Pleasant, Michigan, USA Grand Rapids, Michigan, USA 3 University of Louisville, Louisville, Kentucky, USA 4 Community Mental Health for Central Michigan, Harrison, Michigan, USA 5 Hennepin County Medical Center, Minneapolis, Minnesota, USA 6 Hispanic Center of Western Michigan, Grand Rapids, Michigan, USA 2

Corresponding Author: Ignacio D. Acevedo-Polakovich, CMU Center for Children, Families, and Communities, 101 Sloan Hall, Mount Pleasant, MI 48859, USA. Email: [email protected]

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Kassab et al. activity (Esbensen, Winfree, He, & Taylor, 2001). In the United States, youth gangs tend to incorporate distinctive traditions, symbols, colors, numbers, and language (Esbensen et al., 2001). For example, the Latin Kings—a gang with origins in Chicago and prominence in the Midwestern and northeastern United States—uses brown and gold three- and five-point crowns among its symbols and follows traditions, principles, and practices outlined in the gang’s manifesto and constitution (Knox & McCurrie, 1996). In the United States, local youth gangs often align themselves with regional, national, or international gangs formed along ethnic or racial lines (Esbensen et al., 2001). For example, Tapia (2012) documented the affiliation of Latino youth gangs in Indianapolis with regional gangs originating in Chicago (i.e., Latin Kings), national gangs originating in California (i.e., Mexican Mafia), and international gangs (i.e., Mara Salvatrucha). There are complex rivalries and alliances among these gangs, usually driven at least in part by efforts to control resources that facilitate the conduct of income-earning criminal activities (Tapia). Youth gangs in the United States tend to espouse distorted views of masculinity that lead to behaviors, including sexual ones, that exemplify aggression and dominance (Belitz & Valdez, 1997). In fact, many U.S. Latino gangs normalize the sexual assault and rape of women. Women who want to join a gang are sometimes “sexed in,” a practice that requires them to have sexual intercourse with multiple male gang members (Valdez, 2007). In some cases these women are under the influence of drugs or alcohol (Sanders, Lankenau, & Jackson-Bloom, 2009). Latino gang members report multiple sexual partners and limited use of condoms, actions that increase the risks associated with these sexual behaviors (Brooks et al., 2009; Sanders et al., 2009; Valdez). The multiple layers of factors that raise the likelihood of involvement in risky sexual activity by gang-involved U.S. Latino youth underscore the need to develop and test interventions that reduce sexual risk among this group. Although to our knowledge there is no literature about such interventions, the literature about the development of sexual risk-reduction interventions for Latino youth who are not involved in gangs documents that the effectiveness of these interventions is increased when their developers incorporate relevant cultural and contextual variables (Herbst et al., 2007; Villarruel, Jemmott, & Jemmott, 2005). Cultural and contextual variables can be identified through deliberate inquiry about the perspectives and experiences of the group of interest, such as ethnographic formative interviews (Herbst et al.; Zayas & Rojas-Flores, 2002). In addition to documenting the need to account for cultural and contextual variables when developing or adapting interventions for U.S. Latinos (e.g., Herbst

et al., 2007; Zayas & Rojas-Flores, 2002), scholars have identified various factors that should be considered in such accounting (e.g., Bernal, Bonilla, & Bellido, 1995) and have described research processes by which to identify these variables and adapt existing interventions (e.g., Domenech-Rodriguez & Wieling, 2004; Herbst et al.). For example, Domenech-Rodriguez and Wieling proposed a three-phase approach that begins with qualitative inquiry that focuses on developing an understanding of a community’s needs and its perceptions of already existing interventions. In a second phase, researchers use the findings from this qualitative inquiry to guide their identification of interventions that are responsive to the community and to make adaptations that will make the intervention more effective. To refine a proposed intervention in this second phase, input regarding proposed interventions and adaptations is sought from community members and content experts. During the final phase, the intervention is piloted, its effectiveness and acceptability in the community are examined, and directions for future service and research are developed. Guided by the process that Domenech-Rodriguez and Wieling (2004) described, we documented cultural and contextual perspectives on the sexual behavior and sex education of gang-involved Latino youth in one mediumsized U.S. city. We held focus groups and conducted interviews with individuals from each of the following groups: gang-experienced Latino youth, caregivers of gang-experienced Latino youth, and human service providers working with gang-involved Latino youth. When reporting results, we focus on illustrating their implications for the development or adaptation of interventions to decrease sexual risk among gang-involved Latino youth.

Method Participants To gain a comprehensive understanding of views on sex and sex education, three groups of stakeholders participated in our study: (a) gang-experienced youth, (b) parents of gang-experienced youth, and (c) personnel of a community program working with gang-involved youth. Consistent with prior research (Bjerregaard, 2002), we assessed gang involvement by allowing participants to self-identify as gang members and then identifying which among a variety of options best described their amount of participation in illicit activity. These options ranged from “no involvement” to “involvement including partaking in serious crimes.” Gang-experienced youth. Five Latino men between the ages of 19 and 21 years (M = 20, SD = 1) who had been involved in a community program that provided

656 comprehensive human services for gang-involved youth participated in a focus group. All youth participants identified as Puerto Rican and were, or had recently been, active in a local youth gang. Their current self-report of gang involvement ranged between “no involvement” and “involvement including partaking in serious crimes.” Their highest level of self-reported retrospective gang involvement ranged between “strong association with other gang members” and “involvement including partaking in serious crimes.” Parents of gang-experienced youth.  Five parents of gangexperienced Latino youth participated in this study. Three were mothers between the ages of 33 and 41 years (M = 38, SD = 4.36) who identified their ethnic origin as either Puerto Rican (n = 2) or Mexican (n = 1). Their report of their son’s current gang involvement ranged between “no involvement” and “some association with other gang members,” and their highest level of reported prior gang involvement ranged between “some association with other gang members” and “involvement including partaking in serious crimes.” One father and 1 grandfather, both of whom held primary custody of a Latino gang-experienced youth, also participated. Their ages were 43 and 63 years, respectively. Their self-reported ethnicities were Mexican and Mexican American. Although only one of them reported his child’s current gang involvement as “no involvement,” both indicated the highest level of reported past gang involvement as “some association with other gang members.” Program personnel. Two adult men and 1 adult woman who worked with a community program providing comprehensive human services to Latino gang-involved youth participated in the study. Their ages were 31, 32, and 32 years, and their self-reported ethnic membership was Mexican American (n = 2) and Salvadoran (n = 1).

Procedure The personnel of a nonprofit organization that operated a program for gang-involved youth recruited the parents and gang-experienced youth, and the university-based coauthors of this article recruited the program personnel. We interviewed program personnel individually to reduce the risk of coercion because one of the program participants held supervisory responsibilities over the others. Because program personnel suggested that cultural mores regarding gender would present an obstacle for frank discussion of sex-related topics among the parents of gangexperienced youth, we ran separate focus groups for mothers and fathers. We also ran a separate focus group for gang-experienced youth. The Institutional Review

Qualitative Health Research 24(5) Board (IRB) of Central Michigan University approved all procedures, protocols, and consent forms. We followed the same informed consent procedure for interviews and group discussions. Potential participants read an IRB-approved consent form that included information about the purpose of the research, the tasks they would be involved in, the benefits and risks of the research project, and contact information for the second author. We then gave potential participants an opportunity to ask questions. Individuals who signed the consent form provided some background information before participating in either a group discussion or individual interview. The interviews and group discussions covered the following topics, in the order listed: the participants’ experiences with and opinions about sexual behaviors among gang-experienced youth, the factors influencing these behaviors, and the suggested format for sexual riskreduction programs for gang-experienced youth. We conducted the research procedures involving the program personnel and the gang-experienced youth in English because the participants indicated it was their preferred language. We conducted procedures with the parents in Spanish because all but one of these participants indicated they preferred it; the 1 parent who preferred English was able and willing to participate in Spanish. All of the interviews and focus groups were conducted by one or more authors. The two who led the youth focus group—a university-affiliated researcher and a leader from the program for gang-involved youth who is trained in focus group facilitation—identify as Mexican American. The same university-affiliated researcher led the fathers’ as well as the mothers’ focus group. The mothers’ group was co-led by a master’s-level mental health counselor who identifies as Puerto Rican and is trained in focus group facilitation. The interviews with staff members were conducted by a non-Latino university-­ affiliated researcher who identifies as Chaldean American. Although we conducted all of the focus groups at the facility hosting the program for gang-involved Latino youth, we conducted the staff interviews off site to maintain confidentiality and to reduce the risk of coercion. With the participants’ consent, we first audio recorded and then transcribed the interviews and focus groups. The second author, who is a native English–Spanish bilingual raised in Mexico with a history of publishing and presenting in both languages, verified the accuracy of all transcriptions.

Data Analysis We analyzed the transcripts using a process based on Marshall and Rossman’s (1995) method. Two authors independently reviewed each transcript to identify potential themes and develop definitions for the themes. They

Kassab et al. then compared themes and definitions to create a final list through dialogue and consensus. The same two authors then independently examined the transcripts for occurrences of the themes they had agreed on. They next compared their coding and resolved any disagreements through dialogue and consensus. Four additional authors then examined themes from all focus groups and interviews to identify and describe overarching categories.

Results We identified three higher-order categories—environmental influences on youth behavior, beliefs about sex and romantic relationships, and characteristics of effective sex education programs—each with several component subcategories. These higher-order categories are each described below.

Environmental Influences on Youth Behavior Community violence affects youths’ behaviors. Participants suggested that the social environment influences the behavior of gang-experienced youth both directly and through its effects on their family. According to participants, violence is a pervasive influence on local youth. Mothers described it as being ever-present in their community: Mother 1: I see it in the community, in the street where I used to live, where I live still. Mother 2: They also hit [a] friend of his that had nothing to do with gangs. They cut his entire eyebrow.

Parents suggested that children often joined gangs to procure safety. One mother relayed that her child told her, “They are forcing me. . . . Other kids push us and if you don’t belong or you do not do what they tell you, they beat you.” Program personnel and gang-experienced youth also said that violence and dominance were fundamental characteristics of gangs. A program staff member explained, “This is what it means to the gang; it mean you gotta kill ’em.” One youth summarized his attitude toward any act of aggression against him: “Don’t hit me or you’re gonna be dead.” One program staff member said that, within gangs, violence and dominance are so pervasive that they become entwined with fidelity, caring, and sex: The gangs’ whole perception of love and family is based on violence. You know? I love you if I can beat you. I love you if I can rape you. I love you if you tag [paint gang insignia onto public spaces]. I love you if you hold this gun. You know what I mean? And then, so it’s just very twisted. And so when you add sex into it, it twists lovemaking, right? Because love is violent. . . . In the gang it’s very twisty and dirty.

657 Community characteristics affect families.  In addition to the direct effects of violence, parents suggested that the social environment also influences youth through its effects on families. In general, parents believed that the type of reception that Latinos receive in a community influences parents’ well-being, which in turn affects parents’ interactions with their children. The participants’ claims that there is a relationship between the characteristics of the community and family functioning corroborates past studies that have suggested that family dysfunction is associated with gang involvement (Belitz & Valdez, 1997), sexual risk-taking (Schwartz et al., 2009), and deficits in parent–child communication about safe sex (Malcolm et al., 2012). When describing his arrival in the community, one father said, “I wanted to go back, and well, I really couldn’t stand it. Then I met some friends and everything changed.” The importance the father placed on having social support suggests that sexual risk-reduction interventions are more likely to be successful if they support the parents of the youth they target. Mothers and fathers believed that the existence of accessible services and supports for children helped families prevent children from becoming involved in gangs. Parents believed that keeping children involved in structured activities was beneficial. One mother said, “Learn about karate or boxing, this is discipline. This is not so you can fight in the streets or whatever. Anything that you can think of as long as you keep them busy.” Parents also found value in services and personnel that directly target youth involved in criminal activity, such as probation officers and the program that was partnered in this research. One mother explained that “this program has helped us [because] it set him on a good path.” Participants’ descriptions of the manner in which multiple interacting systems—the community, families, gangs, and youth services—influence risky sexual behavior among gang-experienced Latino youth suggests that interventions with a multisystemic focus will likely be the most appropriate for reducing sexual risk among these youth. For example, Structural Ecosystems Therapy (SET), an individualized, family-ecological intervention that targets interactional patterns between family members and outside systems (e.g., community agencies and health care providers), has helped improve the psychosocial functioning of African American women diagnosed with HIV (Szapocznik et al., 2004) and Latino adolescents who use drugs (Robbins et al., 2008). SET involves a family component (i.e., family therapy sessions) and an ecological component (i.e., ecosystemic therapy sessions). The family therapy sessions are based on the principles of Brief Strategic Family Therapy (BSFT; Szapocznik, Hervis, & Schwartz, 2003), which involves restructuring maladaptive family relationships and creating an appropriate context for behavior change.

658 The ecosystemic therapy sessions are based on the social ecological theory of Bronfrenbrenner (1986) and involve coordinating sessions with the youth’s family and social systems (e.g., peer group, school, juvenile justice system) to reframe and restructure these relationships. Given participants’ reports of the pervasive and deleterious effects of violence and aggression on local youth, an additional benefit of considering SET is the ability for interventionists to focus on helping adolescents improve a wide array of behaviors, including violence and aggression. The implementation of multisystemic interventions such as SET could address sexual risk taking among ganginvolved Latino youth.

Beliefs About Sex Gender roles.  Participants highlighted the importance of considering perceptions of gender within a culture, particularly as they relate to sexual relationships, when pursuing the reduction of sexual risk taking among gang-involved Latinos. Youth and—to a lesser extent— other participants, distinguished between the behavior and values that guide romantic relationships and the behavior and values that guide sexual encounters. Participants’ perceptions of desirable romantic relationships and of sexual behavior closely aligned with aspects of marianismo and machismo, constructs that reflect the cultural understanding of femininity and masculinity, respectively, among Latinos (Marín, 2003; Raffaelli & Iturbide, 2009). According to participants, a woman’s desirability as a romantic partner was related to her ability to represent some of the core features of marianismo, such as being self-sacrificing and sexually modest (Raffaelli & Iturbide, 2009). The youth described the positive attributes of a long-term partner as including willingness to cook, clean, be sexually monogamous, and take care of children. They articulated several traditional characteristics of an ideal romantic relationship, including love, trust, faithfulness, and having common interests: Participant (P) 1: Trust. Trust. P 2: Happiness, faithfulness, let me see—always there for you. P 3: You don’t always gotta be happy. You can be arguing all the time as long as you two love each other.

Consistent with the sexual passivity prominent in marianismo, women’s sexual promiscuity was viewed negatively. One mother explained, “[Women’s] promiscuity. . . . I think that is very bad.” The youth in this study shared this view. One youth stated, “Some girl that been with a lotta [lot of] guys, [is] a ho [promiscuous woman].”

Qualitative Health Research 24(5) A man’s desirability as a romantic partner was related to his ability to represent the positive features of machismo, such as being a responsible protector and provider for his family and community (Raffaelli & Iturbide, 2009). Fathers, youth, and program personnel stressed that men should treat romantic partners with respect, especially if she is the mother of their child. One father explained that he wanted to teach his son to “[r]espect [and] [b]e a gentleman.” Mothers included in their idea of respect that men should dote on their romantic partners. One mother stated, “If you were romantic, you’d invite me to have some coffee at night. You’d give me some flowers once in a while.” Although men’s behavior within romantic relationships seemed guided by the more positive features of machismo, their sexual behavior seemed to be guided by the more deleterious features of this construct, including dominance and sexual prowess. One program personnel member explained, “They’re very like, ‘The more [sex] you get, the better you are.’ You know, conquests kinda thing.” This attitude was confirmed by the youth: [W]hen I grew up it was more about who was doing [having sex with] the most girls. Like everybody saying . . . I did that. I don’t know why I did it, if I got it from my dad or something, but I always loved women, always been attracted to women, and always had to have a woman. Different woman every time. I mean, it’s just me.

These findings suggest that sexual risk-reduction interventions are more likely to be successful with ganginvolved Latino youth if the interventions are responsive to how cultural constructions of gender are connected to sexual behavior and relationship mores. This link was articulated directly by one staff member who said, “[It] is bigger than just sex; it’s values. We need to talk about like, their self-esteem, their self-worth, and really have them challenge what is it to be a man.” ¡Cuídate! (Villarruel et al., 2005), an empirically supported HIV sexual risk-reduction program for Latino youth, exemplifies how sexual risk reductions can be adapted to be responsive to these gender issues. ¡Cuídate! involves six, 1-hour modules designed to increase knowledge about HIV, identify attitudes and beliefs about safe sex practices, improve self-efficacy in practicing safer sex behaviors, and learn negotiation skills in practicing safer behaviors. Latino cultural constructs (e.g., familismo—importance of family, and respeto—respect) and gender-role expectations are incorporated into the program and reframed to support safer sex behaviors (e.g., reframing condom use among women as a way to care for their family and among men as a way to protect their partners; Villarruel & Eakin, 2008).

Kassab et al. Our results suggest that among gang-involved youth, discussions about gender roles must consider youths’ expectations of primarily romantic relationships separately from those of primarily sexual relationships. Although expectations of men within romantic relationships seem guided by the more positive features of machismo, their sexual behavior seems to be guided by the more deleterious features of this construct. Similarly, although a woman’s desirability as a romantic partner is related to her ability to represent some of the core features of marianismo, a woman’s interest in sex is viewed negatively. Parent–child communication. Parent–child discussions about sex were associated with reduced sexual risk among Latino youth (Malcolm et al., 2012). Participants believed that talking to teens about risky behavior and relationships is important, that these conversations should occur at an early age, and that they should cover multiple risky behaviors including sex, drugs, and violence. Mothers in particular believed that open conversations about difficult topics foster healthy relationships. One mother explained, “That there is good communication [between parents and children]. That they see that they can say things openly to us. That they feel that trust, something healthy.” This insight aligns with prior research suggesting that U.S. Latino adolescents who perceive their parents as open and comfortable discussing sex are more likely to speak with them about it and to engage in safer sex practices (Driscoll, Biggs, Brindis, & Yankah, 2001). Although participants concurred that having open parent–child conversations about sex and other risky behaviors is important, they also reported that parent– child conversations about the topic could be uncomfortable. Mothers noted that their husbands were often embarrassed to discuss sex: “[Even] their dad gets embarrassed and I tell him, ‘You are the man and you get embarrassed?’” Program personnel suggested that parents’ discomfort might partly arise from a lack of knowledge: “Talking about sex can be really difficult when you don’t know the facts [about safer sex].” These findings also align with research documenting that addressing the topic of safer sexual behaviors can be a challenge for many U.S. Latino parents, for whom even using the proper names of anatomical parts can be uncomfortable (Marín & Gomez, 1997). Although the youth reported discomfort talking with their parents about sex, they generally perceived that their fathers—but not mothers—accepted sexual behavior and encouraged safer sex practices. One youth relayed his experience of telling his father that he had lost his virginity: “I told my dad. He was cool with it. He said as long as you wear protection, that’s fine, but don’t come home with no babies.” Another youth shared a similar experience:

659 I didn’t want to tell nobody about it, but my dad, he knew I had a girlfriend so he would ask me if you had lost your virginity. But he’d be like, “It’s okay as long as you use protection.” But I was scared to tell my mom. She’s like the jealous type personality; she’ll get mad.

Our findings confirm and expand on those of prior researchers who have described the discomfort that U.S. Latino families can experience when attempting to address safer sex behaviors. In our research, mothers believed that youth and their parents should have open discussion about sex and risky behaviors, and youth reported that they were comfortable discussing sex with their fathers and relationships with their mothers. These findings point to strategic points that the development or adaptation of interventions might target (e.g., by focusing on enhancing father–son communications about safer sex). Previous research with U.S. Latino youth who were not involved in gangs found that focusing on parent–child communication as part of an intervention is associated with improvements in general communication, communication about sex, and reductions in sexual risk taking (Prado et al., 2006; Villarruel, Cherry, Cabriales, Ronis, & Zhou, 2008). Consistent with prior research, our findings also suggest that a focus on parent–child communication should be incorporated into efforts to decrease sexual risk among gang-involved Latino youth. Moreover, such a focus is more likely to be successful if it is responsive to cultural constructions of gender and their relation to sexual behavior and relationship mores. Beliefs about contraceptives, pregnancy, and sexually transmitted infections.  Researchers have documented a variety of obstacles for the use of contraceptives among ganginvolved Latino youth, including a lack of information, barriers to access, and negative beliefs about contraceptive use (Brooks et al., 2009). All participants were asked to discuss contraceptives, pregnancy, and sexually transmitted infections (STIs). Although the reports of program personnel aligned with the findings of prior research, the data provided by parents and youth did not always follow this same pattern. Program personnel reported that inaccuracies about safer sex are prevalent. One of them explained, “They’re getting the information. It’s just wrong information from the street.” Program personnel also believed that youth are not using protection and that youth do not use condoms because they are unaware of the risks, are focused on having sex rather than having sex safely, and believe that condoms diminish the pleasure associated with sex. In contrast to program personnel’s concerns, youth and their parents expressed a fair amount of accurate knowledge about condoms and contraceptives. Youth and their mothers clearly believed that condoms and

660 contraceptives are not always successful in preventing pregnancy or STIs, and understood HIV infection and transmission. Most of the youth in the study knew how to obtain contraception and condoms and could discuss the proper use of condoms, cost-effective ways of obtaining condoms, and alternative forms of contraceptives should they choose not to use condoms. These included intrauterine devices, diaphragms, dental dams, and contraceptives in pill and injectable forms. Youth also believed that using condoms and contraceptives is the responsibility of both partners and said they found it acceptable for women to carry condoms and request their use. One youth stated, “Yeah, that’s fine, they [women] always strapped [carrying contraception].”Consistent with prior research (e.g., Sanders et al., 2009), these youth believed that condoms reduce pleasure during sex, which decreased their desire to use them: P 1: Then you can’t feel the wetness. That’s the whole point. P 2: You can’t feel the whole pleasure with it. P 1: It don’t feel the same.

Our findings suggest that some practical barriers regarding the use of contraception among gangexperienced Latino youth (e.g., having accurate information, being able to procure contraception) were somehow overcome among participants in this research. One factor that might account for these findings is that the gangexperienced youth involved in this research had participated in a community program that promoted general health information as part of their curriculum and provided access to free condoms for program participants. Even so, the attitudinal barriers to contraceptive use documented by other researchers remained. Although future research is needed to identify the mechanisms by which practical barriers are overcome, we believe it is safe to recommend that interventions seeking to reduce sexual risk taking among gang-involved Latino youth address both practical and attitudinal barriers to contraceptive use. In research with Latino youth who were not involved in gangs, focusing on attitudes as well as behaviors led to improved outcomes (Gallegos, Villarruel, Loveland-Cherry, Ronis, & Zhou, 2008). The findings from our research suggest that this dual focus should also be a component of interventions that target gang-involved Latino youth. Factors influencing sexual experiences. Researchers have documented that the contexts in which gang-involved Latino youth engage in sex lead to elevated risk of STI transmission and/or unwanted pregnancy (Sanders et al., 2009). Specifically, gang-involved youth are more likely than other youth to engage in sex after substances have been used (either by themselves or a partner) or engage in

Qualitative Health Research 24(5) sex and substance use as a group activity (Sanders et al.). Youth participants confirmed that substance use often affected their sexual decision making. One youth shared the following: I’m the type of person that if I’m wasted [under the influence] . . . I’m not gonna think about wearing a rubber [a condom] or nothing. I’m just going to go and that’s it. I might think about it after I do it the first time. The second time I might wear it, but [then] there ain’t no point.

Youth also raised the issue that their sexual debut was unplanned and in many cases occurred because they felt pressure from experienced women to engage in sex. Youth participants shared experiences of losing their virginity: P 1: When I lost mine, I didn’t even think I was gonna lose mine. This girl was just supposed to come over to chill [spend time together aimlessly]. And she was like, “All right, come out with it’ [she expressed interest in having sex]. She was even younger than me. I wasn’t planning on it anytime soon. To her, I guess she was trying to plan it. P 2: Me neither. P 1: I wasn’t going down like no fool. I didn’t know what to do. I got nervous, like I froze for a quick second. P 2: Me too. The girl was older and more experienced than me.

Program personnel perceived that youth with certain difficult backgrounds are more likely to have sex than others. Consistent with the findings of prior research (e.g., Malcolm et al., 2012; Schwartz et al., 2009), they noted that youth with unstable family backgrounds are more likely to have sex. According to program personnel, boys with such backgrounds also are more likely to attempt to get their partner pregnant to create a stable relationship in their life. One staff member stated, “If they get her pregnant, then she can’t leave. Again, it’s from a place of insecurity.” Personnel discussed some cases in which youth with limited skills and abilities engaged in sex and relationships to meet basic needs. A program participant shared the story of one youth: “Really he’s kind of whoring himself out to live off of these women, because he doesn’t have the skills to do it on [his] own.” Participants’ reports suggest that sexual risk-reduction interventions for gang-involved Latino youth must address both the situational (e.g., substance use, pressure from more experienced partners) and more permanent (e.g., family dysfunction, limited skills) factors that influence decisions about sex and sexual health. Existing interventions specifically targeting sexual behavior in Latino youth who are not involved in gangs often address situational factors by attempting to strengthen their

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Kassab et al. ability to successfully refuse sex and negotiate safer sex behaviors (Villarruel & Eakin, 2008). Our findings suggest that such approaches should be incorporated into interventions for gang-involved youth but that they should be complemented by intervention components that address the more permanent factors influencing decisions about sex and sexual health. The more permanent factors influencing decisions about sex and sexual health might require more intensive interventions. For example, BSFT, the family therapy approach that we introduced earlier, might be deployed with gang-involved Latino youth to improve family functioning, which in turn would impact the sexual attitudes and behaviors of youth. Research on gang-affiliated Mexican American youth has documented that when families are involved in BSFT, the families’ functioning improved; in turn, the youths’ problem behaviors across a variety of domains reduced (Valdez, Cepeda, Parrish, Horowitz, & Kaplan, 2013).

Characteristics of Effective Sex Education Programs General characteristics. Program personnel and youth believed that sexual risk-reduction programs should be multimodal and interactive. One staff member explained, “They don’t want to be in school. They want it to be different, you know?” Program personnel also believed that a sexual risk-reduction intervention for gang-involved youth should provide the parents with accurate information and training in effective communication with their children about sex and other related topics. As one staff member explained, “Teach them [parents] how to talk to their kids about it. It is hard to talk to [gang-involved youth] about this.” These findings align well with research findings suggesting that the most effective sexual risk-reduction interventions for adolescents are multifaceted; they include skill- and knowledge-development components, environmental support for healthy behaviors, as well as services for parents (Kirby, 2007). Engaging gang-involved youth. Participants discussed the characteristics of an effective facilitator for an intervention directed at gang-involved Latino youth. One youth shared, “How comfortable they [facilitators] are. These kids . . . might be talking,” suggesting that effective facilitators should be comfortable with the fact that ganginvolved youth tend to question, challenge, and occasionally intimidate authority figures. Youth emphasized that the ideal facilitator would be someone who understands how to work with gang-involved youth first and is then trained in sex education. One staff member raised the possibility of training a peer facilitator, suggesting that it might be a

benefit, you know, to have somebody that, you know, their own age, kind of addressing the same issues that they, you know, face. And, maybe it can be a case for a youth that’s already a father [to be a facilitator].

Perhaps reflecting an implicit understanding of the gender issues discussed throughout the results, a different staff member suggested that interventions be facilitated by mixed-gender teams: “So they [youth] can see a male and female talking about sex. . . . I’m showing respect for the male counterpart and he’s reinforcing respect for women.” Participants’ reports suggest that working with ganginvolved youth should be approached by someone who understands how gang culture impacts behavior, including sexual decision making. These findings align with prior research documenting the complexity of working with gang-involved youth, particularly through social and behavioral interventions (e.g., Belitz & Valdez, 1994). In working with gang-involved youth, Belitz and Valdez stressed that the provider build a trusting relationship with the youth and recognize the role gang membership plays in the youth’s life (e.g., protection, support, identity, livelihood). The program personnel and youth who participated in our study suggested that gang-involved youth might benefit from learning from other gang-involved youth. Although research on Latino youth who are not involved in gangs suggests that sexual health programs are more effective when delivered by non-peer and expert facilitators (Herbst et al., 2007), gang-involved youth are involved in unique social environments that might benefit from group and peer influences (Belitz & Valdez, 1994). Examining whether peer facilitation is effective with gang-involved Latino youth is an important direction for future research.

Discussion Our goal in this study was to facilitate the future development or adaptation of interventions to decrease sexual risk among gang-involved Latino youth in one mid-sized U.S. city by documenting cultural and contextual perspectives on sexual behavior and sexual education among these youth. For this reason, while describing our results we have discussed their implications for intervention development or adaptation. Specifically, if interventions are to be responsive to the needs of the community, they must present information in a way that is relevant to gang-involved Latino youth, address cultural expectations regarding gender and sexuality, provide specific skills and knowledge related to sexual risk, and address the multiple systemic influences on sexual behavior. Our references to specific interventions are meant to provide

662 illustrative examples and not to be a comprehensive analysis of existing interventions. Beyond the very important issue of responsiveness to community needs, one of the key aspects to consider when deciding to implement an intervention in a community setting—particularly when working with historically underserved groups such as gang-involved youth—is the feasibility of implementing the intervention in the target setting with fidelity and sustainability (Isaacs et al., 2008). The implementation requirements of an intervention should be carefully considered. For example, although SET is a more comprehensive intervention than ¡Cuídate! and has the flexibility to incorporate ¡Cuídate! or its components, implementing SET with fidelity is remarkably more complex and resource intensive (e.g., Robbins et al, 2008; Szapocznik et al., 2004). For this reason, despite its greater comprehensiveness and ability to incorporate other interventions, SET might not be the appropriate intervention to implement in a community setting that does not have the resources and infrastructure required for its successful and sustainable implementation.

Limitations Our findings should be considered in the context of the study’s limitations. We designed the study to identify contextual factors for gang-involved Latino youth in one community. It should also be noted that youth were recruited from among those who were involved with a program that provided comprehensive human service to gang-involved Latino youth and that all of them were of Puerto Rican heritage. Although our approach renders a high degree of ecological validity to the current findings with regard to the context in which they were collected, the degree to which findings are transferable to other subsets of gang-involved youth is unknown and is an important topic for future research (LeCompte & Goetz, 1982). Because the study was exploratory in nature, our recommendations regarding interventions are best interpreted as hypotheses amenable to future testing. Future research might compare the effectiveness and/or acceptability of interventions that incorporate the recommendations of the current study and interventions that do not.

Conclusions Despite its limitations, our study highlights four key characteristics that are likely to be of importance in developing or adapting sexual-risk-reduction interventions for gang-involved Latino youth: (a) information must be presented in a manner that is relevant to gang-involved Latino youth, (b) cultural expectations regarding gender and sexuality must be addressed, (c) skills and knowledge related to sexual risk must be provided, and (d) multiple

Qualitative Health Research 24(5) systemic influences on sexual behavior must be addressed. Our findings provide a foundation for needed efforts to understand and address risky sexual behavior among gang-involved U.S. Latino youth, a group whose lives are enveloped within multiple contexts of risk. Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The authors received no financial support for the research, authorship, and/or publication of this article.

Note 1. We acknowledge that the discussion regarding the terminology used to refer to the pan-ethnic group of individuals who live in the United States and trace their ancestry to Latin America is an ongoing and complex one (e.g., Comaz-Diaz, 2001; Gloria & Segura-Herrera, 2004; Liang, Salcedo, Rivera, & Lopez, 2009; Santiago-Rivera, Arredondo, & Gallardo-Cooper, 2002). In this article, we use the terms Latino and Latinos when referring to either mixed-gender groups or men with this heritage and the term Latinas when referring to women of said heritage. We use other terms that are sometimes used in reference to this same group of people (e.g., Hispanic) or that distinguish subgroups of Latinos (e.g., Mexican American, Puerto Rican, Mexican) only when the text applies to that subgroup or when used exclusively or primarily by the source being cited.

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Qualitative Health Research 24(5) Megan M. Grzybowski, BAA, is a graduate of Central Michigan University in Mount Pleasant, Michigan, USA. Stacy Stout, MPA, is a program manager at the W. K. Kellogg Foundation in Battle Creek, Michigan, USA. Allyn E. Richards, BS, is a doctoral student in clinical psychology at the University of Louisville in Louisville, Kentucky, USA. Miya L. Barnett, MA, is a doctoral student in clinical psychology at Central Michigan University in Mount Pleasant, Michigan, USA. Aileen Guerra-Morales, MA, is a therapist at Community Mental Health for Central Michigan in Harrison, Michigan, USA Katrina M. Bell, PhD, is a postdoctoral fellow at Hennepin County Medical Center in Minneapolis, Minnesota, USA. Elizabeth A. Crider, PhD, is an organizational development intern at Advocate Healthcare in Chicago, Illinois, USA. Kara L. Beck, MA, is a doctoral student in clinical psychology at Central Michigan University in Mount Pleasant, Michigan, USA.

Author Biographies

Jodi Brookins-Fisher, PhD, is a professor in the School of Health Sciences at Central Michigan University in Mount Pleasant, Michigan, USA.

Veronica A. Kassab, MA, is a doctoral student in clinical psychology at Central Michigan University in Mount Pleasant, Michigan, USA.

Mario Alfaro is a youth advocate and gang specialist at the Hispanic Center of Western Michigan in Grand Rapids, Michigan, USA.

Ignacio D. Acevedo-Polakovich, PhD, is a codirector of the Center for Children, Families, and Communities at Central Michigan University in Mount Pleasant, Michigan, USA.

Suchita R. Saxena, BS, is a doctoral student in clinical psychology at Central Michigan University in Mount Pleasant, Michigan, USA.