This article was downloaded by: [Florida State University] On: 04 October 2014, At: 22:04 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/caic20
Evidence of increased STI/HIV-related risk behavior among male perpetrators of intimate partner violence in Guatemala: results from a national survey a
John Hembling & Katherine Andrinopoulos
a
a
Department of Global Health Systems and Development, Tulane School of Public Health and Tropical Medicine, New Orleans, LA, USA Published online: 06 May 2014.
To cite this article: John Hembling & Katherine Andrinopoulos (2014) Evidence of increased STI/HIV-related risk behavior among male perpetrators of intimate partner violence in Guatemala: results from a national survey, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 26:11, 1411-1418, DOI: 10.1080/09540121.2014.913766 To link to this article: http://dx.doi.org/10.1080/09540121.2014.913766
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
AIDS Care, 2014 Vol. 26, No. 11, 1411–1418, http://dx.doi.org/10.1080/09540121.2014.913766
Evidence of increased STI/HIV-related risk behavior among male perpetrators of intimate partner violence in Guatemala: results from a national survey John Hembling* and Katherine Andrinopoulos Department of Global Health Systems and Development, Tulane School of Public Health and Tropical Medicine, New Orleans, LA, USA
Downloaded by [Florida State University] at 22:04 04 October 2014
(Received 27 October 2013; accepted 4 April 2014) Intimate partner violence (IPV) is a significant public health problem with a demonstrated link to increased sexually transmitted infection (STI)/HIV-related risk and vulnerability. While IPV is an important issue in Central America, the link to STI/HIV risk has not been explored in this region. In this study, the relationship between emotional and physical/ sexual IPV and the STI/HIV-related risk behaviors of sex worker patronage and infidelity is assessed among male IPV perpetrators using data from a national survey conducted in 2009 in Guatemala (n = 4773 married/partnered men). Bivariate associations between background characteristics and emotional and physical IPV perpetration were explored. Logistic regression models were run to test associations between IPV for each sexual risk behavior. Perpetration of emotional and physical/sexual IPV was more common among married/partnered men who were older than 24, had more education, lived in urban areas, or were in common law versus married unions. Reports of past-year emotional IPV perpetration increased as wealth quintile increased. After adjusting for demographics and other characteristics, physical/ sexual IPV perpetration was associated with past-year infidelity (AOR 1.9, 95% CI: 1.1–3.6). Lifetime emotional IPV (AOR 1.4, 95% CI: 1.1–1.7) and physical/sexual IPV 1.6 (95% CI 1.2–2.0) were positively associated with a history of sex worker patronage. Endorsement of traditional gender role norms showed a marginally positive association with pastyear infidelity in the adjusted model (AOR 1.3, 95% CI 1.0–1.8). The study findings from Guatemala reinforce the growing evidence globally that male IPV perpetrators are more likely to engage in risky sexual behavior, including sex worker patronage and main partner infidelity. The concurrency of violence and increased STI/HIV risk may compound the health risks for female victims of IPV who also face injury and psychological trauma. Integration of prevention and screening of IPV and STI/HIV prevention services should be adopted in Guatemala and other similar contexts.
Keywords: intimate partner violence (IPV); sexually transmitted infection (STI); HIV; male perpetration; sexual risk behavior; Guatemala
Introduction Violence against women by their male intimate partners is a global public health problem (Garcia-Moreno, Jansen, Ellsberg, Heise, & Watt, 2005; Heise, Ellsberg, & Gottmoeller, 2002; Silverman, 2010). The World Health Organization (WHO, 2010) defines intimate partner violence (IPV) as “behavior within an intimate relationship that causes physical, sexual, or psychological harm, including acts of physical aggression, sexual coercion, psychological abuse, and controlling behaviors.” Studies consistently demonstrate that physical and sexual IPV victimization is associated with multiple negative outcomes, including poorer mental, self-reported physical and reproductive health outcomes. (M. Ellsberg et al., 2008; Silverman, 2010). Increased sexually transmitted infection (STI)/HIV risk among female victims of IPV has also been documented in studies from sub-Saharan Africa (Campbell et al., 2008; Dunkle et al., 2006; R. K. Jewkes, Dunkle, Nduna, & Shai, 2010) and South Asia (Decker, Seage, Hemenway, Raj, et al., 2009; Silverman, *Corresponding author. Email: [email protected] © 2014 Taylor & Francis
Decker, Kapur, Gupta, & Raj, 2007). There is a high prevalence of IPV throughout Central and South America (Bott, Guedes, Goodwin, & Mendoza, 2012; M. C. Ellsberg, Winkvist, Pena, & Stenlund, 2001; Flake, 2005), yet limited research exists on its potential link to STI/HIV risk in the region. This gap presents a potentially significant missed opportunity for STI/HIV prevention among men and women. An increased likelihood of STI/HIV risk behavior among male IPV perpetrators versus non-perpetrators has been found in the USA (El-Bassel, Gilbert, Wu, Chang, & Fontdevila, 2007; Frye et al., 2011), South Asia (Decker, Seage, Hemenway, Gupta, et al., 2009; Silverman et al., 2007), and sub-Saharan Africa (Dude, 2011; Dunkle et al., 2007; Kayibanda, Bitera, & Alary, 2012; Townsend et al., 2011; Vu, Tun, Karlyn, Adebajo, & Ahonsi, 2011). In these contexts, male IPV perpetrators are more likely to report STI/HIV risk behaviors, such as multiple partnerships, sex worker patronage, and inconsistent condom use, than non-perpetrators.
Downloaded by [Florida State University] at 22:04 04 October 2014
1412
J. Hembling and K. Andrinopoulos
The increased risk among male IPV perpetrators may also extend to their female spouses or partners, playing a role in the feminization of concentrated epidemics. The likelihood of STI/HIV infection is even greater for victims of sexual violence that results in genital lacerations. Increased STI/HIV risk of female sexual partners and IPV victims may also stem from their limited control over sexual relationships, including condom negotiation (Decker, Seage, Hemenway, Gupta, et al., 2009; Raj et al., 2006). Raj et al. (2006) indicate that traditional masculine gender role norms, or the perceptions of how men should behave in relationships and society, may underlay the relationship between IPV perpetration and risky sexual behavior. These masculinity norms may prioritize “sexual entitlement and multiple partnering, and physical and sexual domination of female partners” (Decker, Seage, Hemenway, Gupta, et al., 2009), which may lead to both IPV perpetration (Moore & Stuart, 2005) and STI/HIVrelated sexual behaviors (Pleck & O’Donnell, 2001; Shearer, Hosterman, & Gillen, 2005). Endorsement of traditional gender role norms was positively associated with unprotected vaginal sex and IPV perpetration among a US-based male clinic sample (Santana, Raj, Decker, La Marche, & Silverman, 2006). The role of IPV as an STI/HIV risk factor in Latin America, and Guatemala in particular, has not been explored in the literature. IPV represents a major problem in Guatemala, with 30% of women reporting lifetime physical/sexual IPV victimization (MSPAS, 2009), and there is evidence of increased miscarriage among pregnant women who experienced IPV (Johri et al., 2011). Guatemala has a national HIV prevalence of less than 1%. The epidemic is characterized as being concentrated among key populations, including female sex workers, and as steadily feminizing, potentially due to partner risk behavior (MSPAS, 2011). Among a large sample of pregnant Guatemalan women, Johri et al. (2010) found HIV infection to be associated with partner characteristics, including perceived infidelity. Some models suggest that bridge populations, including male clients of female sex workers, play an important role in the feminization of HIV (Hor, Detels, Heng, & Mun, 2005). Among male clients of sex workers in Escuintla, Guatemala, HIV prevalence was nearly twice the national prevalence estimate (Sabido et al., 2011). In that sample, 60% of male clients also reported having sex with stable female partners. This study utilized data from a national sample of Guatemalan men to assess the link between IPV perpetration and STI/HIV risk behavior. The STI/HIV risk behaviors of infidelity and sex worker patronage are described in relation to the perpetration of emotional and sexual/physical IPV among men currently in union. This study addresses an important research gap and describes
the role of IPV perpetration as a potential STI/HIV risk marker of the perpetrators and their female victims. Methods This study used the men’s data of the 2009 Guatemala Encuesta Nacional de Salud Materno Infantil (ENSMI). This nationally representative survey utilized a multistage cluster sampling design. A household questionnaire was completed for 10,324 out of the 10,995 selected households. A male respondent was randomly selected from a household roster to complete an individual questionnaire. Out of 7893 eligible men, 7086 were interviewed, for an overall response rate of 84.3%. The study received ethical approval from Guatemala’s Ministry of Public Health and Social Assistance. Ethical procedures included informed consent, specialized interviewer training to ask sensitive IPV-related questions and to ensure privacy, and the termination of the IPV module if the interview was interrupted (MSPAS, 2009). The sample was restricted to currently married/ partnered men and excluded 21 cases not meeting the privacy criteria, reducing the sample size to 4773. The survey questionnaires were interviewer administered in Spanish or one of four Mayan languages. All measures were self-reported (MSPAS, 2009). Given Guatemala’s concentrated HIV epidemic, the dichotomous dependent variables were past-year infidelity and lifetime sex worker patronage. Past-year sex worker patronage was not asked in the survey. Infidelity was defined as a married/partnered man who reported more than one sex partner in the past 12 months. Respondents who ever paid money or in-kind for sex, were classified as having a history of sex worker patronage. IPV perpetration was measured with four variables – lifetime and past-year emotional IPV perpetration and lifetime and past-year physical/sexual IPV perpetration. The ENSMI’s IPV module was adapted from the WHO multi-country domestic violence study (Garcia-Moreno et al., 2005; MSPAS, 2009). It contained five questions on emotional IPV perpetration, including whether the respondent has threatened, insulted, humiliated, or intimidated his partner. Similarly, the module contains six questions on physical IPV perpetration, including whether the male respondent hit or threw things at his partner, pushed, cornered, or pulled her hair, hit her with his fist or another object, kicked, dragged, or beat her, tried to strangle or burn her, or threatened to use or used a knife or a gun against her. Respondents were asked whether their partners ever had sex with them out of fear or whether they had forced their partners to have sex. Committing any of the eight acts was classified as lifetime physical/sexual IPV perpetration. Respondents who reported ever committing these acts of violence and past-year perpetration and were categorized accordingly.
Downloaded by [Florida State University] at 22:04 04 October 2014
AIDS Care Important control variables considered for this analysis were based on the existing literature, including age at first sex (Dunkle et al., 2006), excessive alcohol use (Frye et al., 2011; Raj, Reed, Welles, Santana, & Silverman, 2008), holding traditional gender role attitudes (Decker, Seage, Hemenway, Gupta, et al., 2009; Raj et al., 2006; Santana et al., 2006), and childhood maltreatment (McKinney, Caetano, Ramisetty-Mikler, & Nelson, 2009; Renner & Slack, 2006; Walsh, Latzman, & Latzman, 2013). A binary variable was created from a series of six yes/no questions to gauge men’s attitudes toward traditional gender role norms (Cronbach’s alpha = 0.53). Measures included “a good wife should always obey her husband even if she does not agree with him” and “the man has to demonstrate that he is in charge of his home.” A median split of the aggregate number of accepting attitudes was used to create categories of high (3–6 attitudes) and low (0–2 attitudes) endorsement of traditional gender role norms. Although the internal reliability of the scale was low, the measure was included in analysis for theoretical purposes and based on the literature (R. Jewkes & Morrell, 2010; Raj et al., 2006). Early sexual debut was defined as having reported first sexual intercourse before the age of 15. Having returned home drunk at least once in the past 30 days served as a measure of excessive alcohol consumption. To measure childhood maltreatment, men were asked if they were ever hit or physically abused before the age of 15.
Statistical analysis To account for the complex sampling design the analysis was adjusted for differential selection probabilities, clustering, and the sampling stratification. Analyses were conducted using STATA SE 12.0 (Stata Corp., College Station, TX). Unadjusted associations were assessed with Pearson χ2 analyses; significance for all statistical tests was set at p < 0.05. Multivariate logistic regression was used to test for associations between the dichotomous outcomes and emotional and physical/sexual IPV perpetration, controlling for potential confounders. Lifetime IPV variables were included in the model for lifetime sex worker patronage. The model predicting past-year infidelity included past-year IPV variables. Predicted probabilities were calculated from the results of the logistic regressions to show the effect of IPV perpetration on the outcome variables. Results are presented as percentages for ease of interpretation. Bivariate probit models were run for each sexual risk behavior and respective IPV perpetration variables, and no endogeneity was found in the models.
1413
Results Background characteristics and emotional and physical/sexual IPV perpetration IPV perpetration was prevalent among men currently in union. Nearly half (47.6%) reported ever perpetrating emotional IPV and almost a fifth (19.7%) reported the behavior in the 12 months prior to the survey. Lifetime physical/sexual IPV was reported by 17.0% of men and 3.1% in the past 12 months. Statistically significant bivariate associations were found between several sociodemographic characteristics, and past-year emotional and physical/sexual IPV (see Table 1). Reports of both emotional and physical/sexual IPV perpetration were higher among older age men, and among men with a higher level of education. Similarly, wealth quintile was positively associated with emotional IPV perpetration but not associated with past-year physical/sexual IPV perpetration. Men living in urban versus rural areas were more likely to report past-year emotional IPV and past-year physical/sexual IPV perpetration. Fewer married men reported past-year emotional or physical/sexual IPV than men in common-law union. There was no association between ethnicity and either form of IPV. Excessive alcohol use, early sexual debut, and childhood maltreatment were positively associated with past-year emotional and physical/sexual IPV perpetration. No association was found between high endorsement of traditional gender role norms and either form of IPV.
HIV/STI-related risk behavior and IPV Table 2 shows the results of the unadjusted and adjusted associations between past-year infidelity and select independent variables. Past-year emotional IPV perpetration was positively associated with infidelity in bivariate analysis, but this association did not remain statistically significant after controlling for sociodemographic and other risk factors. However, in both the unadjusted and adjusted models, past-year physical/ sexual IPV perpetration was positively associated with infidelity (AOR 1.9, 95% CI 1.1–3.6). There was a 4.1% difference in past-year partner infidelity attributed to physical/sexual IPV perpetration in the adjusted model (9.4% vs. 5.3%; Figure 1). Endorsement of traditional gender role norms showed a marginally positive association with past-year infidelity in the adjusted model (AOR 1.3, 95% CI 1.0– 1.8). The odds of infidelity were 2.2 (95% CI 1.5–3.0) times higher for men reporting excessive alcohol use and 3.27 (95% CI 2.40–4.45) times higher for men reporting early sexual debut. There was no association between child maltreatment and infidelity.
1414
J. Hembling and K. Andrinopoulos
Table 1. Background characteristics of 4733 married/partnered Guatemalan men and associations with past-year emotional and physical/sexual IPV perpetration, 2008–2009.
Downloaded by [Florida State University] at 22:04 04 October 2014
Characteristics
Emotional Total sample IPV (past Physical/sexual distribution, 12 months), IPV (past %b %a 12 months), %b
Total N/A 19.7 Age 15–24 13.1 12.3*** 25–44 59.0 21.2 45–59 27.9 28.5 Education None 18.8 15.5*** Primary 53.2 17.7 Secondary/ 28.0 26.2 superior Wealth quintile 1 (lowest) 22.5 16.1* 2 21.5 19.1 3 19.5 18.8 4 20.3 22.9 5 (highest) 16.2 22.5 Ethnicity Indigenous 49.8 18.9 Non-indigenous 50.2 20.5 Residence Urban 42.3 23.0*** Rural 57.7 17.2 Marital status Married 64.0 17.9** Common law 36.0 22.9 High endorsement of traditional gender roles No 65.9 19.2 Yes 35.1 20.6 Excessive alcohol use (past 30 days) No 86.8 18.2*** Yes 13.2 29.9 Early sexual debut No 78.4 18.5** Yes 21.6 23.5 Childhood maltreatment No 47.5 14.9*** Yes 52.5 24.0
3.1 1.0*** 3.4 6.4 1.9*** 2.8 4.6
3.3 3.1 2.4 3.9 2.7 2.9 3.4 4.0* 2.5 2.5* 4.3 2.8 3.8 2.7*** 6.3 2.7* 4.6 2.1** 4.0
a
Column percent; brow percent. *p < 0.05; **p < 0.01; ***p < 0.001.
Results of the unadjusted and adjusted associations between lifetime sex worker patronage and lifetime IPV perpetration are shown in Table 3. In both unadjusted and adjusted models, emotional IPV was positively associated with a history of sex worker patronage (AOR 1.4, 95% CI: 1.1–1.7). In the multivariate analysis, the odds of sex worker patronage were 1.6 (95% CI 1.2–2.0) times higher for men who reported lifetime physical/sexual IPV perpetration compared to
Table 2. Unadjusted and adjusted associations between pastyear IPV perpetration and infidelity among 4733 married/ partnered Guatemalan men, 2008–2009. %
OR (95% CI) AOR (95% CI)a
Infidelity 5.5 – – (total sample) Past 12 months physical/sexual IPV No 5.2 Ref. Ref. Yes 14.1 3.0 (1.7–5.3) 1.9 (1.1–3.6) p Value 0.000 0.000 0.043 Past 12 months emotional IPV No 4.7 Ref. Ref. Yes 8.6 1.9 (1.4–2.6) 1.3 (0.9–1.8) p Value 0.000 0.000 0.131 High endorsement of traditional gender roles No 5.9 Ref. Ref. Yes 4.8 0.8 (0.6–1.1) 1.3 (1.0–1.8) p Value 0.188 0.970 0.08 Drunkenness (past 30 days) No 4.7 Ref. Ref. Yes 10.8 2.4 (1.7–3.4) 2.2 (1.5–3.0) p Value 0.000 0.000 0.000 Early sexual debut No 3.3 Ref. Ref. Yes 13.3 4.5 (3.3–6.0) 3.3 (2.4–4.5) p Value 0.000 0.000 0.000 Childhood maltreatment No 6.0 Ref. Ref. Yes 5.0 0.8 (0.6–1.1) 0.8 (0.6–1.1) p Value 0.191 0.191 0.165 Note: aMultivariate logistic regression controls for age, education, urban/rural residence, wealth quintile, early sexual debut, experienced child maltreatment, ethnicity, and partner type.
non-perpetrators. Based on the adjusted model, there was a 5.6% difference in sex worker patronage associated with emotional IPV perpetration (29.1% vs. 23.5%) and an 8.7% difference related to physical/sexual IPV perpetration (34.8% vs. 26.1%; Figure 2). Endorsement of traditional gender role norms was not associated with sex worker patronage in either model. Excessive alcohol use and early sexual debut were positively associated with sex worker patronage. Childhood maltreatment was marginally associated with the sex worker patronage in the adjusted model.
Discussion Using a nationally representative sample of men, the study’s findings demonstrate that IPV perpetration is high in Guatemala, with nearly half of men currently in union reporting any emotional IPV perpetration and nearly 20% reporting any physical/sexual IPV perpetration. Relative to their non-abusive counterparts, men who reported perpetration of emotional or physical/sexual
Downloaded by [Florida State University] at 22:04 04 October 2014
AIDS Care
1415
Figure 1. Change in past-year infidelity associated with pastyear IPV perpetration. Adjusted model controls for age, education, urban/rural residence, wealth quintile, early sexual debut, experienced child maltreatment, ethnicity, partner type. *p < 0.05.
Figure 2. Change in lifetime sex worker patronage associated with lifetime IPV perpetration. Adjusted model controls for age, education, urban/rural residence, wealth quintile, early sexual debut, experienced child maltreatment, ethnicity, partner type. **p < 0.01; ***p < 0.001.
IPV were more likely to have paid for sex, which is consistent with studies in other regions (Decker, Seage, Hemenway, Gupta, et al., 2009; Gilbert, El-Bassel, Wu, & Chang, 2007; Vu et al., 2011). Physical/sexual IPV
perpetrators were more likely to engage in infidelity affirming results of other studies (Silverman, 2010; Townsend et al., 2011). This study is the first to assess the relationship between male IPV perpetration and STI/ HIV risk behavior in Central America. The results of this study may inform efforts to target STI/HIV and IPV prevention programming in Guatemala. Although female sex workers have been targeted for HIV prevention interventions, in general, women have been considered a low-risk and thus low-priority population in STI/HIV programming. However, Guatemala has seen a steady feminization of the epidemic (MSPAS, 2011). Female victims of IPV should be targeted for HIV programming given their potential increased risk of infection from their violent partners (Decker, Seage, Hemenway, Raj, et al., 2009). In terms of targeting for men, the results of this study indicate that male perpetrators of IPV in Guatemala practice higher STI/HIV-related risk and are more often older (25 years +), have a higher level of education, are wealthier, live in urban areas, and are in common-law versus formal unions. In addition to examining characteristics of male IPV perpetrators and direct links with STI/HIV risk behavior, this study also explored attitudes toward traditional gender role norms. Such accepting attitudes may underlay the clustering of HIV risk behavior and IPV perpetration as suggested in other studies (R. Jewkes & Morrell, 2010; Raj et al., 2006; Santana et al., 2006). However, this relationship was not found in the present analysis. Only the adjusted model for past-year infidelity included a marginally significant positive association between the endorsement of traditional gender norms and risky sexual behavior. The lack of association may be due to measurement issues. Gender role norms are highly context specific. The scale used to measure the
Table 3. Unadjusted and adjusted associations between lifetime IPV perpetration and lifetime sex worker patronage among 4733 married/partnered Guatemalan men, 2008–2009. %
OR (95% CI)
Total 26.3 – Lifetime physical/sexual IPV No 23.9 Ref. Yes 37.9 1.9 (1.6–2.4) p Value 0.000 0.000 Lifetime emotional IPV No 20.9 Ref. Yes 32.3 1.8 (1.5–2.1) p Value 0.000 0.000 High endorsement of traditional gender roles No 27.2 Ref. Yes 24.6 0.87 (0.72–1.1) p Value 0.159 0.159 Drunkenness (past 30 days) No 24.6 Ref. Yes 37.3 1.8 (1.5–2.3) p Value 0.000 0.000 Early sexual debut No 21.0 Ref. Yes 45.5 3.1 (2.5–3.9) p Value 0.000 0.000 Childhood maltreatment No 25.1 Ref. Yes 27.4 1.1 (0.9–1.3) p Value 0.205 0.226
AOR (95% CI)a – Ref. 1.6 (1.2–2.0) 0.000 Ref. 1.4 (1.1–1.7) 0.001 Ref. 1.1 (0.92–1.4) 0.167 Ref. 1.5 (1.2–3.0) 0.001 Ref. 2.4 (1.9–3.1) 0.000 Ref. 1.2 (0.9–1.4) 0.096
Note: aMultivariate logistic regression controls for age, education, urban/rural residence, wealth quintile, ethnicity, partner type and the other variables in the table.
Downloaded by [Florida State University] at 22:04 04 October 2014
1416
J. Hembling and K. Andrinopoulos
construct had not been validated in Guatemala and had low internal reliability. Further qualitative and quantitative research is needed to understand how gender role norms may be associated with men’s perpetration of IPV and sexual risk behaviors and the magnitude of this association (Decker et al., 2012; Raj et al., 2006). This study bolsters calls to address the dual problems of IPV and STI/HIV through integrated services (Anderson, Campbell, & Farley, 2013) and interventions targeted at root causes of both IPV and STI/HIV risk, such as adherence to traditional male gender norms (Dworkin, Treves-Kagan, & Lippman, 2013; Pronyk et al., 2006). In terms of integration, it is important to incorporate screening for STI/HIV risk in IPV interventions and vice versa, as well as referral processes for prevention across services. Several structural interventions have been implemented to modify male gender norms and promote more equitable relationships to reduce violence and STI/HIV risk behavior (Anderson et al., 2013; Gupta, 2000). For example, an impact evaluation of the Stepping Stones Program in South Africa, demonstrated the effectiveness of integrated programs at reducing STIs, IPV perpetration, transactional sex, and problem drinking (R. Jewkes et al., 2008). An impact evaluation of the Somos Diferentes, Somos Iguales Program in Nicaragua found that greater exposure to the program’s gender and HIV messages resulted in increased gender equitable attitudes among men, increased knowledge and use of HIV-related services and improved interpersonal communication between partners about HIV prevention and sexual behavior (Dworkin et al., 2013). More program evaluations of interventions that address IPV and related STI/ HIV risk behavior in the Latin America region are needed to assess their impact and identify appropriate program models and formats. Limitations The current findings should be considered in light of limitations. The wording of survey measures prohibits the ability to determine if the IPV and sexual behavior reported occurred in the context of the respondents’ current primary partnership. The study’s cross-sectional design prohibits conclusions about the temporality of the relationships uncovered. Longitudinal work is needed to understand the sequencing of IPV and high-risk behaviors on STI/HIV infection and transmission to female partners. The data are based on self-report and subject to social desirability and recall biases. Social desirability bias likely resulted in underreporting of IPV perpetration (11% of married/partnered women reported past-year physical/sexually IPV victimization in the ENSMI, while only 3% of men reported IPV perpetration). Additionally, the influence of sexual IPV perpetration could not
be assessed separately from physical IPV due to the low number of cases reported in the survey. Conclusion Despite these challenges, the study findings from Guatemala reinforce the growing evidence from Africa and South Asia that male IPV perpetrators are more likely to engage in risky sexual behavior, including sex worker patronage and infidelity. The concurrency of violence and increased STI/HIV risk may compound the health risks for female victims of IPV who face greater risk of HIV infection in addition to injury and psychological trauma compared to non-victims. These data suggest the importance of further exploring associations between masculinity norms and IPV perpetration, male sexual risk behavior, and HIV infection among female partners. Additionally, this study strengthens the claim for integrating prevention and screening of IPV and STI/HIV prevention programming. Acknowledgments We would like to thank Dr Paul Hutchinson for his review of initial drafts of the manuscript.
References Anderson, J. C., Campbell, J. C., & Farley, J. E. (2013). Interventions to address HIV and intimate partner violence in sub-Saharan Africa: A review of the literature. Journal of the Association of Nurses in AIDS Care, 24, 383–390. doi:10.1016/j.jana.2013.03.003S1055-3290(13)00080-0[pii] Bott, S., Guedes, A., Goodwin, M., & Mendoza, J. (2012). Violence against women in Latin America and the Caribbean: A comparative analysis of population-based data from 12 countries. Washington, DC: Pan American Health Organization. Campbell, J. C., Baty, M. L., Ghandour, R. M., Stockman, J. K., Francisco, L., & Wagman, J. (2008). The intersection of intimate partner violence against women and HIV/ AIDS: A review. International Journal of Injury Control and Safety Promotion, 15, 221–231. doi:10.1080/174573 00802423224 Decker, M. R., Seage, G. R., 3rd, Hemenway, D., Gupta, J., Raj, A., & Silverman, J. G. (2009). Intimate partner violence perpetration, standard and gendered STI/HIV risk behaviour, and STI/HIV diagnosis among a clinic-based sample of men. Sexually Transmitted Infections, 85, 555–560. doi:10.1136/sti.2009.036368 Decker, M. R., Seage, G. R., 3rd, Hemenway, D., Raj, A., Saggurti, N., Balaiah, D., & Silverman, J. G. (2009). Intimate partner violence functions as both a risk marker and risk factor for women’s HIV infection: Findings from Indian husband-wife dyads. Journal of Acquired Immune Deficiency Syndromes, 51, 593–600. doi:10.1097/ QAI.0b013e3181a255d6 Decker, M. R., Wirtz, A. L., Baral, S. D., Peryshkina, A., Mogilnyi, V., Weber, R. A., … Beyrer, C. (2012).
Downloaded by [Florida State University] at 22:04 04 October 2014
AIDS Care Injection drug use, sexual risk, violence and STI/HIVamong Moscow female sex workers. Sexually Transmitted Infections, 88, 278–283. doi:10.1136/sextrans-2011-050171 Dude, A. M. (2011). Spousal intimate partner violence is associated with HIV and other STIs among married Rwandan women. AIDS and Behavior, 15(1), 142–152. doi:10.1007/s10461-009-9526-1 Dunkle, K. L., Jewkes, R., Nduna, M., Jama, N., Levin, J., Sikweyiya, Y., & Koss, M. P. (2007). Transactional sex with casual and main partners among young South African men in the rural Eastern Cape: Prevalence, predictors, and associations with gender-based violence. Social Science & Medicine, 65, 1235–1248. doi:10.1016/j. socscimed.2007.04.029 Dunkle, K. L., Jewkes, R. K., Nduna, M., Levin, J., Jama, N., Khuzwayo, N., … Duvvury, N. (2006). Perpetration of partner violence and HIV risk behaviour among young men in the rural Eastern Cape, South Africa. AIDS, 20, 2107–2114. doi:10.1097/01.aids.0000247582.00826.52 Dworkin, S. L., Treves-Kagan, S., & Lippman, S. A. (2013). Gender-transformative interventions to reduce HIV risks and violence with heterosexually-active men: A review of the global evidence. AIDS and Behavior, 16, 181–202. doi:10.1007/s10461-013-0565-2 El-Bassel, N., Gilbert, L., Wu, E., Chang, M., & Fontdevila, J. (2007). Perpetration of intimate partner violence among men in methadone treatment programs in New York City. American Journal of Public Health, 97, 1230–1232. doi:10.2105/ajph.2006.090712 Ellsberg, M., Jansen, H. A., Heise, L., Watts, C. H., GarciaMoreno, C., & WHO Multi-country Study on Women’s Health and Domestic Violence against Women Study Team (2008). Intimate partner violence and women’s physical and mental health in the WHO multi-country study on women’s health and domestic violence: An observational study. Lancet, 371, 1165–1172. doi:10.1016/S0140-6736 (08)60522-X Ellsberg, M. C., Winkvist, A., Pena, R., & Stenlund, H. (2001). Women’s strategic responses to violence in Nicaragua. Journal of Epidemiology and Community Health, 55, 547–555. doi:10.1136/jech.55.8.547 Flake, D. F. (2005). Individual, family, and community risk markers for domestic violence in Peru. Violence Against Women, 11, 353–373. doi:10.1177/1077801204272129 Frye, V., Ompad, D., Chan, C., Koblin, B., Galea, S., & Vlahov, D. (2011). Intimate partner violence perpetration and condom use-related factors: Associations with heterosexual men’s consistent condom use. AIDS and Behavior, 15, 153–162. doi:10.1007/s10461-009-9659-2 Garcia-Moreno, C., Jansen, H., Ellsberg, M., Heise, L., & Watt, C. (2005). WHO Multi-country Study on Women’s Health and Domestic Violence against Women. Geneva: World Health Organization. Gilbert, L., El-Bassel, N., Wu, E., & Chang, M. (2007). Intimate partner violence and HIV risks: A longitudinal study of men on methadone. Journal of Urban Health, 84, 667–680. doi:10.1007/s11524-007-9214-2 Gupta, G. R. (2000). Gender, sexuality, and HIV/AIDS: The what, the why, and the how. Canadian HIV/AIDS Policy & Law Review, 5(4), 86–93.
1417
Heise, L., Ellsberg, M., & Gottmoeller, M. (2002). A global overview of gender-based violence. International Journal of Gynaecology & Obstetrics, 78(Suppl 1), S5–S14. Hor, L. B., Detels, R., Heng, S., & Mun, P. (2005). The role of sex worker clients in transmission of HIV in Cambodia. International Journal of STD & AIDS, 16, 170–174. doi:10.1258/0956462053057567 Jewkes, R. K., Dunkle, K., Nduna, M., & Shai, N. (2010). Intimate partner violence, relationship power inequity, and incidence of HIV infection in young women in South Africa: A cohort study. Lancet, 376(9734), 41–48. doi:10.1016/S0140-6736(10)60548-X Jewkes, R., & Morrell, R. (2010). Gender and sexuality: Emerging perspectives from the heterosexual epidemic in South Africa and implications for HIV risk and prevention. Journal of the International AIDS Society, 13, 6. Jewkes, R., Nduna, M., Levin, J., Jama, N., Dunkle, K., Puren, A., & Duvvury, N. (2008). Impact of stepping stones on incidence of HIV and HSV-2 and sexual behaviour in rural South Africa: Cluster randomised controlled trial. BMJ, 337, a506. doi:10.1136/bmj.a506 Johri, M., Morales, R. E., Boivin, J. F., Samayoa, B. E., Hoch, J. S., Grazioso, C. F., … Arathoon, E. G. (2011). Increased risk of miscarriage among women experiencing physical or sexual intimate partner violence during pregnancy in Guatemala City, Guatemala: Cross-sectional study. BMC Pregnancy and Childbirth, 11, 49. doi:10.11 86/1471-2393-11-49 Johri, M., Morales, R. E., Hoch, J. S., Samayoa, B. E., Sommen, C., Grazioso, C. F., … Arathoon, E. G. (2010). A cross-sectional study of risk factors for HIV among pregnant women in Guatemala City, Guatemala: Lessons for prevention. International Journal of STD & AIDS, 21, 789–796. doi:10.1258/ijsa.2009.009355 Kayibanda, J. F., Bitera, R., & Alary, M. (2012). Violence toward women, men’s sexual risk factors, and HIV infection among women: Findings from a national household survey in Rwanda. Journal of Acquired Immune Deficiency Syndromes, 59, 300–307. doi:10.1097/ QAI.0b013e31823dc634 McKinney, C. M., Caetano, R., Ramisetty-Mikler, S., & Nelson, S. (2009). Childhood family violence and perpetration and victimization of intimate partner violence: Findings from a national population-based study of couples. Annals of Epidemiology, 19(1), 25–32. doi:10 .1016/j.annepidem.2008.08.008 Moore, T. M., & Stuart, G. L. (2005). A review of the literature on masculinity and partner violence. Psychology of Men & Masculinity, 6(1), 46–61. doi:10.1037/1524-9220.6.1.46 MSPAS. (2009). V Encuesta Nacional de Salud Materno Infantil (ENSMI) 2008-2009 [V National maternal and child health survey]. Guatemala City: Author. MSPAS. (2011). Plan Estratégico Nacional 2011–2015 para la prevención, atención y control de ITS, VIH y Sida [National strategic plan 2011–2015 for the prevention, care and control of STI, HIV and AIDS]. Guatemala City: Author. Pleck, J. H., & O’Donnell, L. N. (2001). Gender attitudes and health risk behaviors in urban African American and Latino early adolescents. Maternal and Child Health Journal, 5, 265–272. doi:10.1023/A:1013084923217
Downloaded by [Florida State University] at 22:04 04 October 2014
1418
J. Hembling and K. Andrinopoulos
Pronyk, P. M., Hargreaves, J. R., Kim, J. C., Morison, L. A., Phetla, G., Watts, C., … Porter, J. D. (2006). Effect of a structural intervention for the prevention of intimatepartner violence and HIV in rural South Africa: A cluster randomised trial. Lancet, 368, 1973–1983. doi:10.1016/ S0140-6736(06)69744-4 Raj, A., Reed, E., Welles, S. L., Santana, M. C., & Silverman, J. G. (2008). Intimate partner violence perpetration, risky sexual behavior, and STI/HIV diagnosis among heterosexual African American men. American Journal of Men’s Health, 2, 291–295. doi:10.1177/1557988308320269 Raj, A., Santana, M. C., La Marche, A., Amaro, H., Cranston, K., & Silverman, J. G. (2006). Perpetration of intimate partner violence associated with sexual risk behaviors among young adult men. American Journal of Men’s Health, 96, 1873–1878. doi:10.2105/ajph.2005.081554 Renner, L. M., & Slack, K. S. (2006). Intimate partner violence and child maltreatment: Understanding intra- and intergenerational connections. Child Abuse & Neglect, 30, 599–617. doi:10.1016/j.chiabu.2005.12.005 Sabido, M., Lahuerta, M., Montoliu, A., Gonzalez, V., Hernandez, G., Giardina, F., … Casabona, J. (2011). Human immunodeficiency virus, sexually transmitted infections, and risk behaviors among clients of sex workers in Guatemala: Are they a bridge in human immunodeficiency virus transmission? Sexually Transmitted Diseases, 38, 735–742. doi:10.1097/OLQ.0b013e31821 596b5 Santana, M. C., Raj, A., Decker, M. R., La Marche, A., & Silverman, J. G. (2006). Masculine gender roles associated with increased sexual risk and intimate partner violence perpetration among young adult men. Journal of Urban Health, 83, 575–585. doi:10.1007/s11524-006-9061-6
Shearer, C. L., Hosterman, S. J., & Gillen, M. M. (2005). Are traditional gender role attitudes associated with risky sexual behavior and condom-related beliefs? Sex Roles, 52, 311–324. doi:10.1007/s11199-005-2675-4 Silverman, J. G. (2010). Key to prevent HIV in women: Reduce gender-based violence. Lancet, 376(9734), 6–7. doi:10.1016/S0140-6736(10)60971-3 Silverman, J. G., Decker, M. R., Kapur, N. A., Gupta, J., & Raj, A. (2007). Violence against wives, sexual risk and sexually transmitted infection among Bangladeshi men. Sexually Transmitted Infections, 83, 211–215. doi:10.1136/sti.2006.023366 Townsend, L., Jewkes, R., Mathews, C., Johnston, L. G., Flisher, A. J., Zembe, Y., & Chopra, M. (2011). HIV risk behaviours and their relationship to intimate partner violence (IPV) among men who have multiple female sexual partners in Cape Town, South Africa. AIDS and Behavior, 15(1), 132– 141. doi:10.1007/s10461-010-9680-5 Vu, L., Tun, W., Karlyn, A., Adebajo, S., & Ahonsi, B. (2011). Attitudinal and behavioral factors associated with extramarital sex among Nigerian men: Findings from a national survey. International Journal of Sexual Health, 23, 258–268. doi:10.1080/19317611.2011.617810 Walsh, K., Latzman, N. E., & Latzman, R. D. (2013). Pathway from child sexual and physical abuse to risky sex among emerging adults: The role of trauma-related intrusions and alcohol problems. Journal of Adolescent Health, 54, 442– 448. doi:10.1016/j.jadohealth.2013.09.020 WHO. (2010). Preventing intimate partner and sexual violence against women: Taking action and generating evidence. Geneva: Author.
AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/caic20
Evidence of increased STI/HIV-related risk behavior among male perpetrators of intimate partner violence in Guatemala: results from a national survey a
John Hembling & Katherine Andrinopoulos
a
a
Department of Global Health Systems and Development, Tulane School of Public Health and Tropical Medicine, New Orleans, LA, USA Published online: 06 May 2014.
To cite this article: John Hembling & Katherine Andrinopoulos (2014) Evidence of increased STI/HIV-related risk behavior among male perpetrators of intimate partner violence in Guatemala: results from a national survey, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 26:11, 1411-1418, DOI: 10.1080/09540121.2014.913766 To link to this article: http://dx.doi.org/10.1080/09540121.2014.913766
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
AIDS Care, 2014 Vol. 26, No. 11, 1411–1418, http://dx.doi.org/10.1080/09540121.2014.913766
Evidence of increased STI/HIV-related risk behavior among male perpetrators of intimate partner violence in Guatemala: results from a national survey John Hembling* and Katherine Andrinopoulos Department of Global Health Systems and Development, Tulane School of Public Health and Tropical Medicine, New Orleans, LA, USA
Downloaded by [Florida State University] at 22:04 04 October 2014
(Received 27 October 2013; accepted 4 April 2014) Intimate partner violence (IPV) is a significant public health problem with a demonstrated link to increased sexually transmitted infection (STI)/HIV-related risk and vulnerability. While IPV is an important issue in Central America, the link to STI/HIV risk has not been explored in this region. In this study, the relationship between emotional and physical/ sexual IPV and the STI/HIV-related risk behaviors of sex worker patronage and infidelity is assessed among male IPV perpetrators using data from a national survey conducted in 2009 in Guatemala (n = 4773 married/partnered men). Bivariate associations between background characteristics and emotional and physical IPV perpetration were explored. Logistic regression models were run to test associations between IPV for each sexual risk behavior. Perpetration of emotional and physical/sexual IPV was more common among married/partnered men who were older than 24, had more education, lived in urban areas, or were in common law versus married unions. Reports of past-year emotional IPV perpetration increased as wealth quintile increased. After adjusting for demographics and other characteristics, physical/ sexual IPV perpetration was associated with past-year infidelity (AOR 1.9, 95% CI: 1.1–3.6). Lifetime emotional IPV (AOR 1.4, 95% CI: 1.1–1.7) and physical/sexual IPV 1.6 (95% CI 1.2–2.0) were positively associated with a history of sex worker patronage. Endorsement of traditional gender role norms showed a marginally positive association with pastyear infidelity in the adjusted model (AOR 1.3, 95% CI 1.0–1.8). The study findings from Guatemala reinforce the growing evidence globally that male IPV perpetrators are more likely to engage in risky sexual behavior, including sex worker patronage and main partner infidelity. The concurrency of violence and increased STI/HIV risk may compound the health risks for female victims of IPV who also face injury and psychological trauma. Integration of prevention and screening of IPV and STI/HIV prevention services should be adopted in Guatemala and other similar contexts.
Keywords: intimate partner violence (IPV); sexually transmitted infection (STI); HIV; male perpetration; sexual risk behavior; Guatemala
Introduction Violence against women by their male intimate partners is a global public health problem (Garcia-Moreno, Jansen, Ellsberg, Heise, & Watt, 2005; Heise, Ellsberg, & Gottmoeller, 2002; Silverman, 2010). The World Health Organization (WHO, 2010) defines intimate partner violence (IPV) as “behavior within an intimate relationship that causes physical, sexual, or psychological harm, including acts of physical aggression, sexual coercion, psychological abuse, and controlling behaviors.” Studies consistently demonstrate that physical and sexual IPV victimization is associated with multiple negative outcomes, including poorer mental, self-reported physical and reproductive health outcomes. (M. Ellsberg et al., 2008; Silverman, 2010). Increased sexually transmitted infection (STI)/HIV risk among female victims of IPV has also been documented in studies from sub-Saharan Africa (Campbell et al., 2008; Dunkle et al., 2006; R. K. Jewkes, Dunkle, Nduna, & Shai, 2010) and South Asia (Decker, Seage, Hemenway, Raj, et al., 2009; Silverman, *Corresponding author. Email: [email protected] © 2014 Taylor & Francis
Decker, Kapur, Gupta, & Raj, 2007). There is a high prevalence of IPV throughout Central and South America (Bott, Guedes, Goodwin, & Mendoza, 2012; M. C. Ellsberg, Winkvist, Pena, & Stenlund, 2001; Flake, 2005), yet limited research exists on its potential link to STI/HIV risk in the region. This gap presents a potentially significant missed opportunity for STI/HIV prevention among men and women. An increased likelihood of STI/HIV risk behavior among male IPV perpetrators versus non-perpetrators has been found in the USA (El-Bassel, Gilbert, Wu, Chang, & Fontdevila, 2007; Frye et al., 2011), South Asia (Decker, Seage, Hemenway, Gupta, et al., 2009; Silverman et al., 2007), and sub-Saharan Africa (Dude, 2011; Dunkle et al., 2007; Kayibanda, Bitera, & Alary, 2012; Townsend et al., 2011; Vu, Tun, Karlyn, Adebajo, & Ahonsi, 2011). In these contexts, male IPV perpetrators are more likely to report STI/HIV risk behaviors, such as multiple partnerships, sex worker patronage, and inconsistent condom use, than non-perpetrators.
Downloaded by [Florida State University] at 22:04 04 October 2014
1412
J. Hembling and K. Andrinopoulos
The increased risk among male IPV perpetrators may also extend to their female spouses or partners, playing a role in the feminization of concentrated epidemics. The likelihood of STI/HIV infection is even greater for victims of sexual violence that results in genital lacerations. Increased STI/HIV risk of female sexual partners and IPV victims may also stem from their limited control over sexual relationships, including condom negotiation (Decker, Seage, Hemenway, Gupta, et al., 2009; Raj et al., 2006). Raj et al. (2006) indicate that traditional masculine gender role norms, or the perceptions of how men should behave in relationships and society, may underlay the relationship between IPV perpetration and risky sexual behavior. These masculinity norms may prioritize “sexual entitlement and multiple partnering, and physical and sexual domination of female partners” (Decker, Seage, Hemenway, Gupta, et al., 2009), which may lead to both IPV perpetration (Moore & Stuart, 2005) and STI/HIVrelated sexual behaviors (Pleck & O’Donnell, 2001; Shearer, Hosterman, & Gillen, 2005). Endorsement of traditional gender role norms was positively associated with unprotected vaginal sex and IPV perpetration among a US-based male clinic sample (Santana, Raj, Decker, La Marche, & Silverman, 2006). The role of IPV as an STI/HIV risk factor in Latin America, and Guatemala in particular, has not been explored in the literature. IPV represents a major problem in Guatemala, with 30% of women reporting lifetime physical/sexual IPV victimization (MSPAS, 2009), and there is evidence of increased miscarriage among pregnant women who experienced IPV (Johri et al., 2011). Guatemala has a national HIV prevalence of less than 1%. The epidemic is characterized as being concentrated among key populations, including female sex workers, and as steadily feminizing, potentially due to partner risk behavior (MSPAS, 2011). Among a large sample of pregnant Guatemalan women, Johri et al. (2010) found HIV infection to be associated with partner characteristics, including perceived infidelity. Some models suggest that bridge populations, including male clients of female sex workers, play an important role in the feminization of HIV (Hor, Detels, Heng, & Mun, 2005). Among male clients of sex workers in Escuintla, Guatemala, HIV prevalence was nearly twice the national prevalence estimate (Sabido et al., 2011). In that sample, 60% of male clients also reported having sex with stable female partners. This study utilized data from a national sample of Guatemalan men to assess the link between IPV perpetration and STI/HIV risk behavior. The STI/HIV risk behaviors of infidelity and sex worker patronage are described in relation to the perpetration of emotional and sexual/physical IPV among men currently in union. This study addresses an important research gap and describes
the role of IPV perpetration as a potential STI/HIV risk marker of the perpetrators and their female victims. Methods This study used the men’s data of the 2009 Guatemala Encuesta Nacional de Salud Materno Infantil (ENSMI). This nationally representative survey utilized a multistage cluster sampling design. A household questionnaire was completed for 10,324 out of the 10,995 selected households. A male respondent was randomly selected from a household roster to complete an individual questionnaire. Out of 7893 eligible men, 7086 were interviewed, for an overall response rate of 84.3%. The study received ethical approval from Guatemala’s Ministry of Public Health and Social Assistance. Ethical procedures included informed consent, specialized interviewer training to ask sensitive IPV-related questions and to ensure privacy, and the termination of the IPV module if the interview was interrupted (MSPAS, 2009). The sample was restricted to currently married/ partnered men and excluded 21 cases not meeting the privacy criteria, reducing the sample size to 4773. The survey questionnaires were interviewer administered in Spanish or one of four Mayan languages. All measures were self-reported (MSPAS, 2009). Given Guatemala’s concentrated HIV epidemic, the dichotomous dependent variables were past-year infidelity and lifetime sex worker patronage. Past-year sex worker patronage was not asked in the survey. Infidelity was defined as a married/partnered man who reported more than one sex partner in the past 12 months. Respondents who ever paid money or in-kind for sex, were classified as having a history of sex worker patronage. IPV perpetration was measured with four variables – lifetime and past-year emotional IPV perpetration and lifetime and past-year physical/sexual IPV perpetration. The ENSMI’s IPV module was adapted from the WHO multi-country domestic violence study (Garcia-Moreno et al., 2005; MSPAS, 2009). It contained five questions on emotional IPV perpetration, including whether the respondent has threatened, insulted, humiliated, or intimidated his partner. Similarly, the module contains six questions on physical IPV perpetration, including whether the male respondent hit or threw things at his partner, pushed, cornered, or pulled her hair, hit her with his fist or another object, kicked, dragged, or beat her, tried to strangle or burn her, or threatened to use or used a knife or a gun against her. Respondents were asked whether their partners ever had sex with them out of fear or whether they had forced their partners to have sex. Committing any of the eight acts was classified as lifetime physical/sexual IPV perpetration. Respondents who reported ever committing these acts of violence and past-year perpetration and were categorized accordingly.
Downloaded by [Florida State University] at 22:04 04 October 2014
AIDS Care Important control variables considered for this analysis were based on the existing literature, including age at first sex (Dunkle et al., 2006), excessive alcohol use (Frye et al., 2011; Raj, Reed, Welles, Santana, & Silverman, 2008), holding traditional gender role attitudes (Decker, Seage, Hemenway, Gupta, et al., 2009; Raj et al., 2006; Santana et al., 2006), and childhood maltreatment (McKinney, Caetano, Ramisetty-Mikler, & Nelson, 2009; Renner & Slack, 2006; Walsh, Latzman, & Latzman, 2013). A binary variable was created from a series of six yes/no questions to gauge men’s attitudes toward traditional gender role norms (Cronbach’s alpha = 0.53). Measures included “a good wife should always obey her husband even if she does not agree with him” and “the man has to demonstrate that he is in charge of his home.” A median split of the aggregate number of accepting attitudes was used to create categories of high (3–6 attitudes) and low (0–2 attitudes) endorsement of traditional gender role norms. Although the internal reliability of the scale was low, the measure was included in analysis for theoretical purposes and based on the literature (R. Jewkes & Morrell, 2010; Raj et al., 2006). Early sexual debut was defined as having reported first sexual intercourse before the age of 15. Having returned home drunk at least once in the past 30 days served as a measure of excessive alcohol consumption. To measure childhood maltreatment, men were asked if they were ever hit or physically abused before the age of 15.
Statistical analysis To account for the complex sampling design the analysis was adjusted for differential selection probabilities, clustering, and the sampling stratification. Analyses were conducted using STATA SE 12.0 (Stata Corp., College Station, TX). Unadjusted associations were assessed with Pearson χ2 analyses; significance for all statistical tests was set at p < 0.05. Multivariate logistic regression was used to test for associations between the dichotomous outcomes and emotional and physical/sexual IPV perpetration, controlling for potential confounders. Lifetime IPV variables were included in the model for lifetime sex worker patronage. The model predicting past-year infidelity included past-year IPV variables. Predicted probabilities were calculated from the results of the logistic regressions to show the effect of IPV perpetration on the outcome variables. Results are presented as percentages for ease of interpretation. Bivariate probit models were run for each sexual risk behavior and respective IPV perpetration variables, and no endogeneity was found in the models.
1413
Results Background characteristics and emotional and physical/sexual IPV perpetration IPV perpetration was prevalent among men currently in union. Nearly half (47.6%) reported ever perpetrating emotional IPV and almost a fifth (19.7%) reported the behavior in the 12 months prior to the survey. Lifetime physical/sexual IPV was reported by 17.0% of men and 3.1% in the past 12 months. Statistically significant bivariate associations were found between several sociodemographic characteristics, and past-year emotional and physical/sexual IPV (see Table 1). Reports of both emotional and physical/sexual IPV perpetration were higher among older age men, and among men with a higher level of education. Similarly, wealth quintile was positively associated with emotional IPV perpetration but not associated with past-year physical/sexual IPV perpetration. Men living in urban versus rural areas were more likely to report past-year emotional IPV and past-year physical/sexual IPV perpetration. Fewer married men reported past-year emotional or physical/sexual IPV than men in common-law union. There was no association between ethnicity and either form of IPV. Excessive alcohol use, early sexual debut, and childhood maltreatment were positively associated with past-year emotional and physical/sexual IPV perpetration. No association was found between high endorsement of traditional gender role norms and either form of IPV.
HIV/STI-related risk behavior and IPV Table 2 shows the results of the unadjusted and adjusted associations between past-year infidelity and select independent variables. Past-year emotional IPV perpetration was positively associated with infidelity in bivariate analysis, but this association did not remain statistically significant after controlling for sociodemographic and other risk factors. However, in both the unadjusted and adjusted models, past-year physical/ sexual IPV perpetration was positively associated with infidelity (AOR 1.9, 95% CI 1.1–3.6). There was a 4.1% difference in past-year partner infidelity attributed to physical/sexual IPV perpetration in the adjusted model (9.4% vs. 5.3%; Figure 1). Endorsement of traditional gender role norms showed a marginally positive association with past-year infidelity in the adjusted model (AOR 1.3, 95% CI 1.0– 1.8). The odds of infidelity were 2.2 (95% CI 1.5–3.0) times higher for men reporting excessive alcohol use and 3.27 (95% CI 2.40–4.45) times higher for men reporting early sexual debut. There was no association between child maltreatment and infidelity.
1414
J. Hembling and K. Andrinopoulos
Table 1. Background characteristics of 4733 married/partnered Guatemalan men and associations with past-year emotional and physical/sexual IPV perpetration, 2008–2009.
Downloaded by [Florida State University] at 22:04 04 October 2014
Characteristics
Emotional Total sample IPV (past Physical/sexual distribution, 12 months), IPV (past %b %a 12 months), %b
Total N/A 19.7 Age 15–24 13.1 12.3*** 25–44 59.0 21.2 45–59 27.9 28.5 Education None 18.8 15.5*** Primary 53.2 17.7 Secondary/ 28.0 26.2 superior Wealth quintile 1 (lowest) 22.5 16.1* 2 21.5 19.1 3 19.5 18.8 4 20.3 22.9 5 (highest) 16.2 22.5 Ethnicity Indigenous 49.8 18.9 Non-indigenous 50.2 20.5 Residence Urban 42.3 23.0*** Rural 57.7 17.2 Marital status Married 64.0 17.9** Common law 36.0 22.9 High endorsement of traditional gender roles No 65.9 19.2 Yes 35.1 20.6 Excessive alcohol use (past 30 days) No 86.8 18.2*** Yes 13.2 29.9 Early sexual debut No 78.4 18.5** Yes 21.6 23.5 Childhood maltreatment No 47.5 14.9*** Yes 52.5 24.0
3.1 1.0*** 3.4 6.4 1.9*** 2.8 4.6
3.3 3.1 2.4 3.9 2.7 2.9 3.4 4.0* 2.5 2.5* 4.3 2.8 3.8 2.7*** 6.3 2.7* 4.6 2.1** 4.0
a
Column percent; brow percent. *p < 0.05; **p < 0.01; ***p < 0.001.
Results of the unadjusted and adjusted associations between lifetime sex worker patronage and lifetime IPV perpetration are shown in Table 3. In both unadjusted and adjusted models, emotional IPV was positively associated with a history of sex worker patronage (AOR 1.4, 95% CI: 1.1–1.7). In the multivariate analysis, the odds of sex worker patronage were 1.6 (95% CI 1.2–2.0) times higher for men who reported lifetime physical/sexual IPV perpetration compared to
Table 2. Unadjusted and adjusted associations between pastyear IPV perpetration and infidelity among 4733 married/ partnered Guatemalan men, 2008–2009. %
OR (95% CI) AOR (95% CI)a
Infidelity 5.5 – – (total sample) Past 12 months physical/sexual IPV No 5.2 Ref. Ref. Yes 14.1 3.0 (1.7–5.3) 1.9 (1.1–3.6) p Value 0.000 0.000 0.043 Past 12 months emotional IPV No 4.7 Ref. Ref. Yes 8.6 1.9 (1.4–2.6) 1.3 (0.9–1.8) p Value 0.000 0.000 0.131 High endorsement of traditional gender roles No 5.9 Ref. Ref. Yes 4.8 0.8 (0.6–1.1) 1.3 (1.0–1.8) p Value 0.188 0.970 0.08 Drunkenness (past 30 days) No 4.7 Ref. Ref. Yes 10.8 2.4 (1.7–3.4) 2.2 (1.5–3.0) p Value 0.000 0.000 0.000 Early sexual debut No 3.3 Ref. Ref. Yes 13.3 4.5 (3.3–6.0) 3.3 (2.4–4.5) p Value 0.000 0.000 0.000 Childhood maltreatment No 6.0 Ref. Ref. Yes 5.0 0.8 (0.6–1.1) 0.8 (0.6–1.1) p Value 0.191 0.191 0.165 Note: aMultivariate logistic regression controls for age, education, urban/rural residence, wealth quintile, early sexual debut, experienced child maltreatment, ethnicity, and partner type.
non-perpetrators. Based on the adjusted model, there was a 5.6% difference in sex worker patronage associated with emotional IPV perpetration (29.1% vs. 23.5%) and an 8.7% difference related to physical/sexual IPV perpetration (34.8% vs. 26.1%; Figure 2). Endorsement of traditional gender role norms was not associated with sex worker patronage in either model. Excessive alcohol use and early sexual debut were positively associated with sex worker patronage. Childhood maltreatment was marginally associated with the sex worker patronage in the adjusted model.
Discussion Using a nationally representative sample of men, the study’s findings demonstrate that IPV perpetration is high in Guatemala, with nearly half of men currently in union reporting any emotional IPV perpetration and nearly 20% reporting any physical/sexual IPV perpetration. Relative to their non-abusive counterparts, men who reported perpetration of emotional or physical/sexual
Downloaded by [Florida State University] at 22:04 04 October 2014
AIDS Care
1415
Figure 1. Change in past-year infidelity associated with pastyear IPV perpetration. Adjusted model controls for age, education, urban/rural residence, wealth quintile, early sexual debut, experienced child maltreatment, ethnicity, partner type. *p < 0.05.
Figure 2. Change in lifetime sex worker patronage associated with lifetime IPV perpetration. Adjusted model controls for age, education, urban/rural residence, wealth quintile, early sexual debut, experienced child maltreatment, ethnicity, partner type. **p < 0.01; ***p < 0.001.
IPV were more likely to have paid for sex, which is consistent with studies in other regions (Decker, Seage, Hemenway, Gupta, et al., 2009; Gilbert, El-Bassel, Wu, & Chang, 2007; Vu et al., 2011). Physical/sexual IPV
perpetrators were more likely to engage in infidelity affirming results of other studies (Silverman, 2010; Townsend et al., 2011). This study is the first to assess the relationship between male IPV perpetration and STI/ HIV risk behavior in Central America. The results of this study may inform efforts to target STI/HIV and IPV prevention programming in Guatemala. Although female sex workers have been targeted for HIV prevention interventions, in general, women have been considered a low-risk and thus low-priority population in STI/HIV programming. However, Guatemala has seen a steady feminization of the epidemic (MSPAS, 2011). Female victims of IPV should be targeted for HIV programming given their potential increased risk of infection from their violent partners (Decker, Seage, Hemenway, Raj, et al., 2009). In terms of targeting for men, the results of this study indicate that male perpetrators of IPV in Guatemala practice higher STI/HIV-related risk and are more often older (25 years +), have a higher level of education, are wealthier, live in urban areas, and are in common-law versus formal unions. In addition to examining characteristics of male IPV perpetrators and direct links with STI/HIV risk behavior, this study also explored attitudes toward traditional gender role norms. Such accepting attitudes may underlay the clustering of HIV risk behavior and IPV perpetration as suggested in other studies (R. Jewkes & Morrell, 2010; Raj et al., 2006; Santana et al., 2006). However, this relationship was not found in the present analysis. Only the adjusted model for past-year infidelity included a marginally significant positive association between the endorsement of traditional gender norms and risky sexual behavior. The lack of association may be due to measurement issues. Gender role norms are highly context specific. The scale used to measure the
Table 3. Unadjusted and adjusted associations between lifetime IPV perpetration and lifetime sex worker patronage among 4733 married/partnered Guatemalan men, 2008–2009. %
OR (95% CI)
Total 26.3 – Lifetime physical/sexual IPV No 23.9 Ref. Yes 37.9 1.9 (1.6–2.4) p Value 0.000 0.000 Lifetime emotional IPV No 20.9 Ref. Yes 32.3 1.8 (1.5–2.1) p Value 0.000 0.000 High endorsement of traditional gender roles No 27.2 Ref. Yes 24.6 0.87 (0.72–1.1) p Value 0.159 0.159 Drunkenness (past 30 days) No 24.6 Ref. Yes 37.3 1.8 (1.5–2.3) p Value 0.000 0.000 Early sexual debut No 21.0 Ref. Yes 45.5 3.1 (2.5–3.9) p Value 0.000 0.000 Childhood maltreatment No 25.1 Ref. Yes 27.4 1.1 (0.9–1.3) p Value 0.205 0.226
AOR (95% CI)a – Ref. 1.6 (1.2–2.0) 0.000 Ref. 1.4 (1.1–1.7) 0.001 Ref. 1.1 (0.92–1.4) 0.167 Ref. 1.5 (1.2–3.0) 0.001 Ref. 2.4 (1.9–3.1) 0.000 Ref. 1.2 (0.9–1.4) 0.096
Note: aMultivariate logistic regression controls for age, education, urban/rural residence, wealth quintile, ethnicity, partner type and the other variables in the table.
Downloaded by [Florida State University] at 22:04 04 October 2014
1416
J. Hembling and K. Andrinopoulos
construct had not been validated in Guatemala and had low internal reliability. Further qualitative and quantitative research is needed to understand how gender role norms may be associated with men’s perpetration of IPV and sexual risk behaviors and the magnitude of this association (Decker et al., 2012; Raj et al., 2006). This study bolsters calls to address the dual problems of IPV and STI/HIV through integrated services (Anderson, Campbell, & Farley, 2013) and interventions targeted at root causes of both IPV and STI/HIV risk, such as adherence to traditional male gender norms (Dworkin, Treves-Kagan, & Lippman, 2013; Pronyk et al., 2006). In terms of integration, it is important to incorporate screening for STI/HIV risk in IPV interventions and vice versa, as well as referral processes for prevention across services. Several structural interventions have been implemented to modify male gender norms and promote more equitable relationships to reduce violence and STI/HIV risk behavior (Anderson et al., 2013; Gupta, 2000). For example, an impact evaluation of the Stepping Stones Program in South Africa, demonstrated the effectiveness of integrated programs at reducing STIs, IPV perpetration, transactional sex, and problem drinking (R. Jewkes et al., 2008). An impact evaluation of the Somos Diferentes, Somos Iguales Program in Nicaragua found that greater exposure to the program’s gender and HIV messages resulted in increased gender equitable attitudes among men, increased knowledge and use of HIV-related services and improved interpersonal communication between partners about HIV prevention and sexual behavior (Dworkin et al., 2013). More program evaluations of interventions that address IPV and related STI/ HIV risk behavior in the Latin America region are needed to assess their impact and identify appropriate program models and formats. Limitations The current findings should be considered in light of limitations. The wording of survey measures prohibits the ability to determine if the IPV and sexual behavior reported occurred in the context of the respondents’ current primary partnership. The study’s cross-sectional design prohibits conclusions about the temporality of the relationships uncovered. Longitudinal work is needed to understand the sequencing of IPV and high-risk behaviors on STI/HIV infection and transmission to female partners. The data are based on self-report and subject to social desirability and recall biases. Social desirability bias likely resulted in underreporting of IPV perpetration (11% of married/partnered women reported past-year physical/sexually IPV victimization in the ENSMI, while only 3% of men reported IPV perpetration). Additionally, the influence of sexual IPV perpetration could not
be assessed separately from physical IPV due to the low number of cases reported in the survey. Conclusion Despite these challenges, the study findings from Guatemala reinforce the growing evidence from Africa and South Asia that male IPV perpetrators are more likely to engage in risky sexual behavior, including sex worker patronage and infidelity. The concurrency of violence and increased STI/HIV risk may compound the health risks for female victims of IPV who face greater risk of HIV infection in addition to injury and psychological trauma compared to non-victims. These data suggest the importance of further exploring associations between masculinity norms and IPV perpetration, male sexual risk behavior, and HIV infection among female partners. Additionally, this study strengthens the claim for integrating prevention and screening of IPV and STI/HIV prevention programming. Acknowledgments We would like to thank Dr Paul Hutchinson for his review of initial drafts of the manuscript.
References Anderson, J. C., Campbell, J. C., & Farley, J. E. (2013). Interventions to address HIV and intimate partner violence in sub-Saharan Africa: A review of the literature. Journal of the Association of Nurses in AIDS Care, 24, 383–390. doi:10.1016/j.jana.2013.03.003S1055-3290(13)00080-0[pii] Bott, S., Guedes, A., Goodwin, M., & Mendoza, J. (2012). Violence against women in Latin America and the Caribbean: A comparative analysis of population-based data from 12 countries. Washington, DC: Pan American Health Organization. Campbell, J. C., Baty, M. L., Ghandour, R. M., Stockman, J. K., Francisco, L., & Wagman, J. (2008). The intersection of intimate partner violence against women and HIV/ AIDS: A review. International Journal of Injury Control and Safety Promotion, 15, 221–231. doi:10.1080/174573 00802423224 Decker, M. R., Seage, G. R., 3rd, Hemenway, D., Gupta, J., Raj, A., & Silverman, J. G. (2009). Intimate partner violence perpetration, standard and gendered STI/HIV risk behaviour, and STI/HIV diagnosis among a clinic-based sample of men. Sexually Transmitted Infections, 85, 555–560. doi:10.1136/sti.2009.036368 Decker, M. R., Seage, G. R., 3rd, Hemenway, D., Raj, A., Saggurti, N., Balaiah, D., & Silverman, J. G. (2009). Intimate partner violence functions as both a risk marker and risk factor for women’s HIV infection: Findings from Indian husband-wife dyads. Journal of Acquired Immune Deficiency Syndromes, 51, 593–600. doi:10.1097/ QAI.0b013e3181a255d6 Decker, M. R., Wirtz, A. L., Baral, S. D., Peryshkina, A., Mogilnyi, V., Weber, R. A., … Beyrer, C. (2012).
Downloaded by [Florida State University] at 22:04 04 October 2014
AIDS Care Injection drug use, sexual risk, violence and STI/HIVamong Moscow female sex workers. Sexually Transmitted Infections, 88, 278–283. doi:10.1136/sextrans-2011-050171 Dude, A. M. (2011). Spousal intimate partner violence is associated with HIV and other STIs among married Rwandan women. AIDS and Behavior, 15(1), 142–152. doi:10.1007/s10461-009-9526-1 Dunkle, K. L., Jewkes, R., Nduna, M., Jama, N., Levin, J., Sikweyiya, Y., & Koss, M. P. (2007). Transactional sex with casual and main partners among young South African men in the rural Eastern Cape: Prevalence, predictors, and associations with gender-based violence. Social Science & Medicine, 65, 1235–1248. doi:10.1016/j. socscimed.2007.04.029 Dunkle, K. L., Jewkes, R. K., Nduna, M., Levin, J., Jama, N., Khuzwayo, N., … Duvvury, N. (2006). Perpetration of partner violence and HIV risk behaviour among young men in the rural Eastern Cape, South Africa. AIDS, 20, 2107–2114. doi:10.1097/01.aids.0000247582.00826.52 Dworkin, S. L., Treves-Kagan, S., & Lippman, S. A. (2013). Gender-transformative interventions to reduce HIV risks and violence with heterosexually-active men: A review of the global evidence. AIDS and Behavior, 16, 181–202. doi:10.1007/s10461-013-0565-2 El-Bassel, N., Gilbert, L., Wu, E., Chang, M., & Fontdevila, J. (2007). Perpetration of intimate partner violence among men in methadone treatment programs in New York City. American Journal of Public Health, 97, 1230–1232. doi:10.2105/ajph.2006.090712 Ellsberg, M., Jansen, H. A., Heise, L., Watts, C. H., GarciaMoreno, C., & WHO Multi-country Study on Women’s Health and Domestic Violence against Women Study Team (2008). Intimate partner violence and women’s physical and mental health in the WHO multi-country study on women’s health and domestic violence: An observational study. Lancet, 371, 1165–1172. doi:10.1016/S0140-6736 (08)60522-X Ellsberg, M. C., Winkvist, A., Pena, R., & Stenlund, H. (2001). Women’s strategic responses to violence in Nicaragua. Journal of Epidemiology and Community Health, 55, 547–555. doi:10.1136/jech.55.8.547 Flake, D. F. (2005). Individual, family, and community risk markers for domestic violence in Peru. Violence Against Women, 11, 353–373. doi:10.1177/1077801204272129 Frye, V., Ompad, D., Chan, C., Koblin, B., Galea, S., & Vlahov, D. (2011). Intimate partner violence perpetration and condom use-related factors: Associations with heterosexual men’s consistent condom use. AIDS and Behavior, 15, 153–162. doi:10.1007/s10461-009-9659-2 Garcia-Moreno, C., Jansen, H., Ellsberg, M., Heise, L., & Watt, C. (2005). WHO Multi-country Study on Women’s Health and Domestic Violence against Women. Geneva: World Health Organization. Gilbert, L., El-Bassel, N., Wu, E., & Chang, M. (2007). Intimate partner violence and HIV risks: A longitudinal study of men on methadone. Journal of Urban Health, 84, 667–680. doi:10.1007/s11524-007-9214-2 Gupta, G. R. (2000). Gender, sexuality, and HIV/AIDS: The what, the why, and the how. Canadian HIV/AIDS Policy & Law Review, 5(4), 86–93.
1417
Heise, L., Ellsberg, M., & Gottmoeller, M. (2002). A global overview of gender-based violence. International Journal of Gynaecology & Obstetrics, 78(Suppl 1), S5–S14. Hor, L. B., Detels, R., Heng, S., & Mun, P. (2005). The role of sex worker clients in transmission of HIV in Cambodia. International Journal of STD & AIDS, 16, 170–174. doi:10.1258/0956462053057567 Jewkes, R. K., Dunkle, K., Nduna, M., & Shai, N. (2010). Intimate partner violence, relationship power inequity, and incidence of HIV infection in young women in South Africa: A cohort study. Lancet, 376(9734), 41–48. doi:10.1016/S0140-6736(10)60548-X Jewkes, R., & Morrell, R. (2010). Gender and sexuality: Emerging perspectives from the heterosexual epidemic in South Africa and implications for HIV risk and prevention. Journal of the International AIDS Society, 13, 6. Jewkes, R., Nduna, M., Levin, J., Jama, N., Dunkle, K., Puren, A., & Duvvury, N. (2008). Impact of stepping stones on incidence of HIV and HSV-2 and sexual behaviour in rural South Africa: Cluster randomised controlled trial. BMJ, 337, a506. doi:10.1136/bmj.a506 Johri, M., Morales, R. E., Boivin, J. F., Samayoa, B. E., Hoch, J. S., Grazioso, C. F., … Arathoon, E. G. (2011). Increased risk of miscarriage among women experiencing physical or sexual intimate partner violence during pregnancy in Guatemala City, Guatemala: Cross-sectional study. BMC Pregnancy and Childbirth, 11, 49. doi:10.11 86/1471-2393-11-49 Johri, M., Morales, R. E., Hoch, J. S., Samayoa, B. E., Sommen, C., Grazioso, C. F., … Arathoon, E. G. (2010). A cross-sectional study of risk factors for HIV among pregnant women in Guatemala City, Guatemala: Lessons for prevention. International Journal of STD & AIDS, 21, 789–796. doi:10.1258/ijsa.2009.009355 Kayibanda, J. F., Bitera, R., & Alary, M. (2012). Violence toward women, men’s sexual risk factors, and HIV infection among women: Findings from a national household survey in Rwanda. Journal of Acquired Immune Deficiency Syndromes, 59, 300–307. doi:10.1097/ QAI.0b013e31823dc634 McKinney, C. M., Caetano, R., Ramisetty-Mikler, S., & Nelson, S. (2009). Childhood family violence and perpetration and victimization of intimate partner violence: Findings from a national population-based study of couples. Annals of Epidemiology, 19(1), 25–32. doi:10 .1016/j.annepidem.2008.08.008 Moore, T. M., & Stuart, G. L. (2005). A review of the literature on masculinity and partner violence. Psychology of Men & Masculinity, 6(1), 46–61. doi:10.1037/1524-9220.6.1.46 MSPAS. (2009). V Encuesta Nacional de Salud Materno Infantil (ENSMI) 2008-2009 [V National maternal and child health survey]. Guatemala City: Author. MSPAS. (2011). Plan Estratégico Nacional 2011–2015 para la prevención, atención y control de ITS, VIH y Sida [National strategic plan 2011–2015 for the prevention, care and control of STI, HIV and AIDS]. Guatemala City: Author. Pleck, J. H., & O’Donnell, L. N. (2001). Gender attitudes and health risk behaviors in urban African American and Latino early adolescents. Maternal and Child Health Journal, 5, 265–272. doi:10.1023/A:1013084923217
Downloaded by [Florida State University] at 22:04 04 October 2014
1418
J. Hembling and K. Andrinopoulos
Pronyk, P. M., Hargreaves, J. R., Kim, J. C., Morison, L. A., Phetla, G., Watts, C., … Porter, J. D. (2006). Effect of a structural intervention for the prevention of intimatepartner violence and HIV in rural South Africa: A cluster randomised trial. Lancet, 368, 1973–1983. doi:10.1016/ S0140-6736(06)69744-4 Raj, A., Reed, E., Welles, S. L., Santana, M. C., & Silverman, J. G. (2008). Intimate partner violence perpetration, risky sexual behavior, and STI/HIV diagnosis among heterosexual African American men. American Journal of Men’s Health, 2, 291–295. doi:10.1177/1557988308320269 Raj, A., Santana, M. C., La Marche, A., Amaro, H., Cranston, K., & Silverman, J. G. (2006). Perpetration of intimate partner violence associated with sexual risk behaviors among young adult men. American Journal of Men’s Health, 96, 1873–1878. doi:10.2105/ajph.2005.081554 Renner, L. M., & Slack, K. S. (2006). Intimate partner violence and child maltreatment: Understanding intra- and intergenerational connections. Child Abuse & Neglect, 30, 599–617. doi:10.1016/j.chiabu.2005.12.005 Sabido, M., Lahuerta, M., Montoliu, A., Gonzalez, V., Hernandez, G., Giardina, F., … Casabona, J. (2011). Human immunodeficiency virus, sexually transmitted infections, and risk behaviors among clients of sex workers in Guatemala: Are they a bridge in human immunodeficiency virus transmission? Sexually Transmitted Diseases, 38, 735–742. doi:10.1097/OLQ.0b013e31821 596b5 Santana, M. C., Raj, A., Decker, M. R., La Marche, A., & Silverman, J. G. (2006). Masculine gender roles associated with increased sexual risk and intimate partner violence perpetration among young adult men. Journal of Urban Health, 83, 575–585. doi:10.1007/s11524-006-9061-6
Shearer, C. L., Hosterman, S. J., & Gillen, M. M. (2005). Are traditional gender role attitudes associated with risky sexual behavior and condom-related beliefs? Sex Roles, 52, 311–324. doi:10.1007/s11199-005-2675-4 Silverman, J. G. (2010). Key to prevent HIV in women: Reduce gender-based violence. Lancet, 376(9734), 6–7. doi:10.1016/S0140-6736(10)60971-3 Silverman, J. G., Decker, M. R., Kapur, N. A., Gupta, J., & Raj, A. (2007). Violence against wives, sexual risk and sexually transmitted infection among Bangladeshi men. Sexually Transmitted Infections, 83, 211–215. doi:10.1136/sti.2006.023366 Townsend, L., Jewkes, R., Mathews, C., Johnston, L. G., Flisher, A. J., Zembe, Y., & Chopra, M. (2011). HIV risk behaviours and their relationship to intimate partner violence (IPV) among men who have multiple female sexual partners in Cape Town, South Africa. AIDS and Behavior, 15(1), 132– 141. doi:10.1007/s10461-010-9680-5 Vu, L., Tun, W., Karlyn, A., Adebajo, S., & Ahonsi, B. (2011). Attitudinal and behavioral factors associated with extramarital sex among Nigerian men: Findings from a national survey. International Journal of Sexual Health, 23, 258–268. doi:10.1080/19317611.2011.617810 Walsh, K., Latzman, N. E., & Latzman, R. D. (2013). Pathway from child sexual and physical abuse to risky sex among emerging adults: The role of trauma-related intrusions and alcohol problems. Journal of Adolescent Health, 54, 442– 448. doi:10.1016/j.jadohealth.2013.09.020 WHO. (2010). Preventing intimate partner and sexual violence against women: Taking action and generating evidence. Geneva: Author.
