Jennifer S. Hirsch

The measurement and meaning of unintended pregnancy.

Unintended pregnancy combines two aspects of fertility: unwanted and mistimed pregnancies. The personal partnership social and political realities of these two aspects are different and the use of separate categories may better reflect the way women think about a pregnancy. A better understanding of the multiple dimensions of unintended pregnancy also may lead to a better understanding of the consequences of these pregnancies. Likewise better knowledge of the extent of mistiming and perhaps the strength of intentions may be important in understanding health impact. Effective programs to prevent unintended pregnancy must use terms that are familiar to women and must build upon cultural understanding of the problem to be prevented. Research should focus on the meaning of pregnancy intentions to women and the processes women and their partners use in making fertility decisions. It should prospectively address the impact of pregnancy intentions on contraceptive use. Both qualitative and quantitative research have contributed to our understanding of fertility decisionmaking; both will be essential to the creation of more effective prevention programs. (excerpt)

Long-Term Health Correlates of Timing of Sexual Debut: Results From a National US Study

OBJECTIVES We explored long-term health consequences of age at sexual initiation and of abstinence until marriage to evaluate empirical support for the claim that postponing sexual initiation has beneficial health effects. METHODS We analyzed data from the 1996 National Sexual Health Survey, a cross-sectional study of the US adult population. We compared sexual health outcomes among individuals who had initiated sexual activity at an early or late age versus a normative age. We also compared individuals whose first sexual intercourse had occurred before versus after marriage. RESULTS Early initiation of sexual intercourse was associated with various sexual risk factors, including increased numbers of sexual partners and recent sexual intercourse under the influence of alcohol, whereas late initiation was associated with fewer risk factors. However, both early and late initiation were associated with sexual problems such as problems with arousal and orgasm, primarily among men. Relationship solidity and sexual relationship satisfaction were not associated with early or late initiation. CONCLUSIONS Early sexual debut is associated with certain long-term negative sexual health outcomes, including increased sexual risk behaviors and problems in sexual functioning. Late initiation was also associated with sexual problems, especially among men. Further research is needed to understand how sexual initiation patterns affect later health outcomes.

The Social Constructions of Sexuality: Marital Infidelity and Sexually Transmitted Disease–HIV Risk in a Mexican Migrant Community

OBJECTIVES This article explores the social context of the migration-related HIV epidemic in western Mexico. METHODS Data collection involved life histories and participant observation with migrant women in Atlanta and their sisters or sisters-in-law in Mexico. RESULTS Both younger and older women acknowledged that migrant mens sexual behavior may expose them to HIV and other sexually transmitted diseases.Younger Mexican women in both communities expressed a marital ideal characterized by mutual intimacy, communication, joint decisionmaking, and sexual pleasure, but not by willingness to use condoms as an HIV prevention strategy. CONCLUSIONS Migrant Mexican womens commitment to an illusion of fidelity will hinder HIV prevention initiatives targeted toward them. Furthermore, the changing meanings of marital sex may make it harder to convince young couples to use condoms as an HIV prevention strategy. If the chain of heterosexual marital HIV transmission is to be interrupted in this community, prevention programs must target men.

The inevitability of infidelity: sexual reputation, social geographies, and marital HIV risk in rural Mexico.

Marriage presents the single greatest risk for HIV infection among women in rural Mexico. We drew on 6 months of participant observation, 20 marital case studies, 37 key informant interviews, and archival research to explore the factors that shape HIV risk among married women in one of the countrys rural communities. We found that culturally constructed notions of reputation in this community lead to sexual behavior designed to minimize mens social risk (threats to ones social status or relationships), rather than viral risk and that mens desire for companionate intimacy may actually increase womens risk for HIV infection. We also describe the intertwining of reputation-based sexual identities with structurally patterned sexual geographies (i.e. the social spaces that shape sexual behavior). We propose that, because of the structural nature of mens extramarital sexual behavior, intervention development should concentrate on sexual geographies and risky spaces rather than risky behaviors or identities.

Pleasure, Power, and Inequality: Incorporating Sexuality Into Research on Contraceptive Use

We know surprisingly little about how contraception affects sexual enjoyment and functioning (and vice versa), particularly for women. What do people seek from sex, and how do sexual experiences shape contraceptive use? We draw on qualitative data to make 3 points. First, pleasure varies. Both women and men reported multiple aspects of enjoyment, of which physical pleasure was only one. Second, pleasure matters. Clear links exist between the forms of pleasure respondents seek and their contraceptive practices. Third, pleasure intersects with power and social inequality. Both gender and social class shape sexual preferences and contraceptive use patterns. These findings call for a reframing of behavioral models that explain why people use (or do not use) contraception.

Pleasure, Prophylaxis and Procreation: A Qualitative Analysis of Intermittent Contraceptive Use And Unintended Pregnancy

CONTEXT Although pregnancy ambivalence is consistently associated with poorer contraceptive use, little is known about the sexual, social and emotional dynamics at work in pregnancy ambivalence. METHODS During in-depth sexual and reproductive history interviews conducted in 2003, 36 women and men were asked about the relational and emotional circumstances surrounding each pregnancy, as well as their thoughts about conceiving a baby with both current and previous partners. An ethnographic, inductive approach was used to analyze the data. RESULTS Half of respondents had experienced at least one unintended pregnancy. Respondents described three categories of pleasure related to pregnancy ambivalence: active eroticization of risk, in which pregnancy fantasies heightened the charge of the sexual encounter; passive romanticization of pregnancy, in which people neither actively sought nor prevented conception; and an escapist pleasure in imagining that a pregnancy would sweep one away from hardship. All three categories were associated with misuse or nonuse of coitus-dependent methods. CONCLUSIONS For some individuals, the perceived emotional and sexual benefits of conception may outweigh the goal of averting conception, even when a child is not wholly intended. Future behavioral studies should collect more nuanced data on pregnancy-related pleasure. Clinicians and patients would benefit from clearer guidelines for assessing ambivalence and for linking ambivalent clients with longer-acting methods that are not coitus-dependent.

Gender, sexuality, and antiretroviral therapy : using social science to enhance outcomes and inform secondary prevention strategies

Objectives:To explore how, within the context of antiretroviral therapy (ART) uptake and adherence, social science research on gender and sexuality could complement existing epidemiological and behavioral research on uptake, adherence, disinhibition and reproduction. Methods:Bibliographical database searches on ART uptake and adherence, the sexual practices of HIV-positive individuals, and fertility management among HIV-positive men and women were conducted over a 6-month period using ISI Web of Science and Medline. Articles were sorted by main topic and then analysed to reveal the unarticulated assumptions that have framed research to date. Results:The adoption of more social scientific theoretical frameworks would move research on uptake, adherence, disinhibition, and reproduction among HIV-infected and affected individuals beyond the current overemphasis on how cognitive and ideological factors shape behavior and towards an understanding of how culture and inequality shapes the way people engage with ART and craft their sexual and reproductive lives. Research that pays greater attention to the social processes that create differentials in uptake and adherence, rather than just the quantification of those differentials, will open up new possibilities for community-based interventions. Similarly, social science research on gender and sexuality can provide insight into the social factors shaping reproductive and sexual behavior, and thus enhance our ability to manage the potentially competing priorities of limiting marital sexual risk and increasing access to reproductive choice among HIV-affected couples. Conclusion:The ability to produce good clinical outcomes and to develop effective policies for secondary prevention will be enhanced by a deeper understanding of how gender inequality and the social organization of sexuality shape the sexual and reproductive behavior of individuals using ART.

They "miss more than anything their normal life back home": masculinity and extramarital sex among Mexican migrants in Atlanta.

CONTEXT: Gender has been recognized as a significant influence on sexual health behaviors. Labor migration presents an important context of vulnerability for sexual health. To understand how the context of migration affects risk-related practices, both cultural and social aspects of gender need to be explored. METHODS: In the quantitative part of a mixed-methods study conducted in 1999 in Atlanta, 187 Mexican migrant men were asked about their demographic characteristics; sexual history; migration motivations; substance use; social support; leisure-time activities; and ideas about masculinity, sexuality and marriage. Multivariate regression analyses were conducted to test the association between these domains and mens number of partners since their arrival in Atlanta. RESULTS: Number of partners was positively associated with owning a home in Mexico; number of trips back to Mexico; social network size; having had a sex worker as a partner; and going out dancing and to strip clubs on weekends (coefficients, 0.3–4.1). It was negatively associated with age, education, contact with social network members and feeling that sex is tied to emotional intimacy (–0.4 to –1.0). CONCLUSIONS: Programs must acknowledge and target migrant mens social networks and the spaces in which they may encounter risky sexual situations. Multilevel strategies, such as the development of more health-enhancing community spaces and the promotion of safer sexual practices should form part of comprehensive efforts to reduce sexual risk among migrant men.

Psychosocial Implications of Homophobia and HIV Stigma in Social Support Networks Insights for High-Impact HIV Prevention Among Black Men Who Have Sex With Men

Black men who have sex with men (BMSM) bear an increasingly disproportionate burden of HIV in the United States. The Centers for Disease Control and Prevention recommends high-impact combination prevention for populations at high risk for HIV infection, such as BMSM. However, few scholars have considered the types of behavioral interventions that combined with biomedical prevention could prove effective for mitigating the epidemic among BMSM. Between June 2013 and May 2014, we conducted three in-depth interviews each with 31 BMSM, interviews with 17 community stakeholders, and participant observation in New York City to understand the sociocultural and structural factors that may affect the acceptance of and adherence to oral preexposure prophylaxis among BMSM and to inform an adherence clinical trial. BMSM and community leaders frequently described condomless sex as a consequence of psychosocial factors and economic circumstances stemming from internalized homophobia resulting from rejection by families and religious groups. BMSM revealed that internalized homophobia and HIV stigma resulted in perceived lack of self- and community efficacy in accepting and adhering to preexposure prophylaxis. Our results indicate that addressing internalized homophobia and fostering emotional social support in peer networks are key elements to improve the effectiveness of combination prevention among BMSM.

Patterns of geographic mobility predict barriers to engagement in HIV care and antiretroviral treatment adherence.

Migration and geographic mobility increase risk for HIV infection and may influence engagement in HIV care and adherence to antiretroviral therapy. Our goal is to use the migration-linked communities of Santo Domingo, Dominican Republic, and New York City, New York, to determine the impact of geographic mobility on HIV care engagement and adherence to treatment. In-depth interviews were conducted with HIV+Dominicans receiving antiretroviral therapy, reporting travel or migration in the past 6 months and key informants (n=45). Mobility maps, visual representations of individual migration histories, including lifetime residence(s) and all trips over the past 2 years, were generated for all HIV+ Dominicans. Data from interviews and field observation were iteratively reviewed for themes. Mobility mapping revealed five distinct mobility patterns: travel for care, work-related travel, transnational travel (nuclear family at both sites), frequent long-stay travel, and vacation. Mobility patterns, including distance, duration, and complexity, varied by motivation for travel. There were two dominant barriers to care. First, a fear of HIV-related stigma at the destination led to delays seeking care and poor adherence. Second, longer trips led to treatment interruptions due to limited medication supply (30-day maximum dictated by programs or insurers). There was a notable discordance between what patients and providers perceived as mobility-induced barriers to care and the most common barriers found in the analysis. Interventions to improve HIV care for mobile populations should consider motivation for travel and address structural barriers to engagement in care and adherence.