C 2005) AIDS and Behavior, Vol. 9, No. 2, June 2005 ( DOI: 10.1007/s10461-005-3899-6
Intimate Partner Violence and Monogamy among Women in Methadone Treatment Kimberly D. Hearn,1 Lucia F. O’Sullivan,2,4 Nabila El-Bassel,3 and Louisa Gilbert3 Received April 3, 2003; revised November 11, 2004; accepted January 29, 2005
It is now becoming clear how important it is to understand women’s HIV risk in the context of their sexual relationships with male partners, particularly among more vulnerable populations of women such as drug-involved women and women with physically abusive partners. Drawing from in-depth interviews with a sample of 38 ethnically diverse women, this study explores the meanings of monogamy and concurrent sexual partnerships in the relationships of women in methadone treatment with a history of physical abuse. Moreover, the ways in which having a history of intimate partner violence influences women’s desire and ability to insist on monogamy is addressed. The women’s narratives indicated that the majority valued monogamy and reported practicing it; however, many women were indifferent to this ideal or were unable to challenge non-monogamous partners for fear of severe reprisals. In addition, men’s suspicions about violations of monogamy on the part of the women often resulted in extreme violence. KEY WORDS: monogamy; sexual risk behavior; HIV prevention; domestic violence; methadone.
INTRODUCTION
who believe that they are protected from risk within committed, monogamous relationships. Yet, many women face greater risk from their primary sexual partners than they do from casual sexual partners (Dolcini et al., 1995; Susser and Stein, 2000). Burgeoning HIV rates in heterosexual women and men is in large part due to the participation of both women and men in concurrent sexual partnerships. In general, national and international studies indicate that both single and married men have higher rates of concurrent sexual partnerships than do their female counterparts. In a nationally representative sample of over 2000 adults, Wiederman (1997) found that 23% of men and 12% of women reported lifetime experience of concurrent sexual partnerships. In a survey of women living in lowincome housing developments in five U.S. cities, 14% reported two or more male sexual partners in the preceding 2 months (Sikkema et al., 1996). Notably, 40% of women with one regular sexual partner and 68% of those with two or more sexual partners believed that their partners had engaged in sex with others during the preceding year. Of note, in a study of approximately 1600 women, women
Women who may be most at risk of HIV infection are those who experience a host of social, cultural, and economic adversities, such as racial and ethnic minority women, poor women, women who experience intimate partner violence, and women who engage in sex trade for drugs or money. When faced with more immediate threats to their health and basic needs (e.g., violence, addiction, poverty), the need to insist upon safer sex practices may not seem urgent or even particularly salient (Roberts et al., 2003; St. Lawrence et al., 1998; Weeks et al., 1999). This might be especially true among women 1 Borough
of Manhattan Community College, The City University of New York, NY. 2 HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, New York, NY. 3 Social Invervention Group (SIG), Columbia University School of Social Work, New York, NY. 4 Correspondence should be directed to Lucia F. O’Sullivan, PhD, HIV Center for Clinical and Behavioral Studies, 1051 Riverside Drive, Unit 15, New York, NY 10032-1007; e-mail:
[email protected].
177 C 2005 Springer Science+Business Media, Inc. 1090-7165/05/0600-0177/0
178 with a past or current experience of intimate partner violence in their primary relationships were more likely to report having more than one sexual partner and more likely to report a past or current STI, inconsistent condom use and a partner with known HIV risk factors compared to women who had not experienced intimate partner violence by their primary partner (Wu et al., 2003). Ultimately, both their own and their partner’s sexual activity outside of their primary relationship, unless protected consistently on every occasion, dramatically increase the chances of introducing infection into the primary relationships. Although researchers are becoming increasingly aware that relationships are an important context of risk for women in particular (El-Bassel, Krishnan et al., 1998; St. Lawrence et al., 1998; Wingood and DiClemente, 1997), little is known about the personal meanings that disenfranchised women give to their own or their partner’s concurrent sexual partnerships. Both men and women report distress, jealousy, and rivalry over the knowledge or suspicion of their partner’s participation in concurrent sexual relationships (Cann et al., 2001). Such information often threatens the stability of the primary relationship and violates normative expectations, often implicit, that one’s partner will not be sexually or romantically intimate with others. Individuals’ distress over partner infidelity may vary on the basis of gender with women responding more negatively to the prospect of their partner’s romantic involvement with other women, and men responding more negatively to the possibility of their partner’s sexual involvement with other men (Buss et al., 1999; Cann et al., 2001). If so, it may be important to take a gendered perspective in understanding the personal meanings of concurrent sexual relationships. The range of viable responses (e.g., demanding condom use, angry retreat) to a partner’s extradyadic sex is likely to be restricted for women in abusive relationships, women who use drugs, and for economically disadvantaged women (Saul et al., 2004; Weeks et al., 1999; Wingood and DiClemente, 1998). Violence and fear of violence are two contextual factors, in particular, that are critical for understanding women’s HIV risk from heterosexual transmission (Amaro and Raj, 2000). Women in physically abusive relationships are unlikely to report using condoms (El-Bassel et al., 1998; Gilbert et al., 2000), even when they know that their primary partner is not monogamous (Beadnell et al., 2000). They often risk further abuse when they attempt to negotiate or
Hearn, O’Sullivan, El-Bassel, and Gilbert insist upon condom use (Wingood and DiClemente, 1998). Because of the proximal risk of violence, some women will not broach the subject of HIV protective behaviors (e.g., condom use) with their male partners (El-Bassel et al., 2000). Gender theory provides a useful framework for understanding how traditional gender roles reinforce differentials in power and autonomy, which favor men in their sexual relationships, thereby leaving women at heightened risk of infection (Amaro, 1995; Zierler and Krieger, 1997). Using this framework, violence is viewed as a pervasive threat in the lives of women and reinforced by beliefs and attitudes that accept such violence. Moreover, women’s economic and social power are compromised in many traditional relationship arrangements, so that women often are required to defer to male authority. In the sexual arena, traditional gender roles emphasize male pleasure and reinforce men’s power and leverage in sexual relationships with women and women’s submission to men (O’Sullivan and Byers, 1995). As such, many women are left unable to effectively control the extent to which they will participate in risky sexual encounters. Understanding women’s heightened HIV risk in the context of their lives, particularly among the most disenfranchised groups, will further our efforts to counteract advancing rates of infection. To this end, the current study explores the meanings of concurrent sexual partnerships in the relationships of an extremely disenfranchised group: physically abused women in methadone treatment. To date, both this population and topic have been largely overlooked by research. We used qualitative methods to explore the meanings that women give to concurrent sexual partnerships and monogamy, their reactions to their primary partner’s involvement with other sexual partners, and the women’s explanations for their own sexual involvement with others outside their primary relationship. A special emphasis was placed on how the context of intimate partner violence shapes these meanings and practices.
METHODS Participants Data were drawn from a larger study to examine the relationships among HIV-risk behavior, drug abuse and intimate partner violence in women enrolled in methadone maintenance treatment
Intimate Partner Violence and Monogamy programs (MMTPs). We recruited women from three MMTPs in New York City. We conducted 20-min, structured screening interviews with 251 women to determine whether they met eligibility criteria. To qualify, women needed to report that they were between the ages of 18 and 55; had been on methadone for at least 3 months; had an intimate sexual partner in the past year; and had experienced physical or sexual abuse by someone who they considered to be a boyfriend, spouse, father of their children, or ex-spouse. A woman was considered to have experienced intimate partner violence if she reported one of the items on the physical aggression, sexual coercion or injury subscale of the Revised Conflict Tactics Scale (Straus et al., 1996). Of the 251 women screened, 82% (n = 206) had sexual intimate partners in the past year and 42% (n = 106) were eligible. Of the 106 eligible women, we randomly selected a subsample of 38 (35.6%) women to participate in the in-depth individual interviews. The average age of the 38 women who participated in the in-depth individual interviews was 38 with a mean of 11 years of education. The majority was African-American (30%) or Latina (52%). All were in current relationships ranging from less than 1–22 years in duration. More than one-third had children under the age of 18. Of the total sample, most (94%) were unemployed in the past year, 83% received public assistance, and 22% were homeless in the past year. Less than 10% were incarcerated in the past year. Of the total sample, more than two thirds used some type of illicit drug in the preceding 90 days. In addition, the majority (n = 31) in this study reported an intimate partner violence event in the preceding 90 days. Women reporting a recent intimate partner violence event had varied drug use and sexual risk histories. Almost one-third had used heroin in the past 90 days and 41% had used crack/cocaine. More than one-third reported drinking alcohol one or more times per week. One-fifth indicated that they had injected drugs in the past year. Nearly two-thirds reported that their partner had a substance use problem. Three-quarters reported having had sex in the past 90 days. Almost two-thirds had never used a condom with their main intimate partner. One in five women indicated that they had exchanged sex for money or drugs during the past 90 days. Another fifth indicated that they had had sex with more than one partner in the past 90 days and 16.1% reported having had sex with an HIV-positive partner.
179 Procedures Trained female research assistants conducted interviews in private rooms on-site at the methadone clinic. The interviews lasted approximately 2 hours. During the first 15 min, the interviewer read a consent form to the participants, which detailed the purpose of the study, confidentiality procedures, and their rights as research participants. The last 15 min of the interview were reserved as a debriefing period. During this time, the interviewers assessed needs and made referrals to women who exhibited signs of distress during the interview or who requested help. All women received a handbook of services (e.g., housing, domestic violence services, job training, counseling, gynecological care) in their communities and were encouraged to call if they needed further help with referrals. At the end of the interview, participants were paid $20 as compensation. Data Collection The interview protocol was designed to explore a number of aspects relating to women’s intimate relationship histories. The portion of the interview used in this study covered a range of topics designed to illuminate aspects of the personal biographies of the respondents and their intimate sexual partners, each of their histories of substance use and HIV risk behavior, the history and nature of their intimate relationships, and the nature of their social networks. Audiotapes of the interview sessions were transcribed verbatim, and random transcripts were checked for accuracy. The meaning and practice of monogamy were assessed by two questions: “Is/Was your sexual relationship with [partner] monogamous or (do/did) either of you have other sexual partners?,” and “Some of the women that we have spoken with have told us that they know their long-term partners have slept with other people, but they put up with this behavior because they know they are the most important person in their partner’s life regardless of what he/she does with others. What do you think about what these women have told us?” Follow-up probes were used to elicit more detailed meanings attributed to monogamy, and information about the participants’ and their partners’ beliefs and behaviors regarding concurrent sexual partnerships, such as whether monogamy was important to the participants and whether they or their partner had any knowledge or suspicions of extradyadic sexual involvement.
180 Data Analysis All sections of the interviews pertaining to monogamy and concurrent sexual partnerships were excerpted for analysis. Two analysts coded all the data independently and analyzed the data in several stages using the guidelines for qualitative data analysis (Dey, 1993). After carefully reviewing these excerpts, the two analysts generated an initial template based on 20% of the excerpts to diagram the analytic categories based on recurrent themes in the participants’ responses. They then extensively discussed the analytic categories and refined the template using all additional excerpts. Extensive reviews ensured that the full range of participants’ responses was captured by the themes, and the template was modified accordingly throughout the process. Any inconsistencies in the coding were discussed between the two analysts. Coding discrepancies were typically due to oversights of elements of the text or disagreements in assignment of subcategories rather than disagreements between raters in the criteria for assignment of major categories. All discrepancies in coding were settled by discussing the coding decisions and modifying the coding criteria accordingly until an agreement was reached about the appropriate coding.
RESULTS Issues of monogamy arose in a number of different contexts of the women’s lives, but it is important to stress that many of their descriptions related to their partners’ accusations of infidelity, frequently as a precursor to abuse, and often after one or both had used drugs or been drinking excessively. The women provided vivid depictions of beatings while pregnant, forced sexual encounters, long-term hospitalizations to recuperate physically, extensive histories of child sexual and physical abuse, and abuse from men with whom they were exchanging sex for drugs or drug money. Thus, our understanding of the meanings that these women have given to monogamy must be understood in this context. Three mutually exclusive typologies emerged from the women’s transcripts, which were used to classify women’s reports regarding their beliefs and practices regarding monogamy and concurrent sexual partnerships. We have described these three classes of beliefs and practices as follows: Type 1 Monogamy is important and believed practiced by both; Type 2 The practice of monogamy is doubted;
Hearn, O’Sullivan, El-Bassel, and Gilbert and Type 3 Monogamy is not important or not practiced.
Typology of Women’s Monogamy Beliefs and Practices Type 1: Monogamy is Important and Believed Practiced by Both One of the overriding themes across participants was that many women strongly valued the concept of sexual monogamy in a relationship, but largely provided an idealized version of its meaning. Women equated monogamy with ideals of love, honesty, faithfulness, and truthfulness and viewed these components in tandem as essential to a committed relationship. For some participants, monogamy signified the willingness (and even desire) to forgo other sexual partners for the sake of the relationship. One woman said, “[Monogamy] shows love, I think. You have to be able to sacrifice.” Another woman said, “But there ain’t no honesty in a relationship and respect, then there ain’t no relationship there at all.” Further, many women used the phrase “it’s just me and him” to describe their understanding of monogamy in their relationship, emphasizing a view of an inviolable bond that cemented their relationship and isolated or sequestered the partners from others in a sense. These women explained that they either intuitively “knew” that their partner did not have concurrent sexual partners, or were convinced from evidence, such as staying free of STIs, monitoring their partner’s time or whereabouts, or receiving repeated reassurances from their partner of his monogamy and commitment. Others simply appeared completely invested in maintaining this belief, “It’s a monogamous relationship and even though the counselors say that’s not good enough, you should still use condoms, you know, but I don’t. And I’m comfortable with that, because I know, I know, I know.” The majority of the women who endorsed monogamy as an ideal also reported that they did not have concurrent sexual partnerships and provided a range of reasons for practicing monogamy. Of particular interest, beyond morality reasons, women were also likely to refer to gendered societal constraints that permitted less sexual freedom to women compared to men. Several women mentioned that it was unacceptable for anyone, especially a woman, to have concurrent sexual partners. One woman said, “If I’m having sex with him and seeing someone else,
Intimate Partner Violence and Monogamy you know he won’t respect me. I won’t respect him either. I call him ‘you a gigolo,’ even though a man don’t lose, a woman does lose her reputation like that.” Several women echoed this sexual double standard. Another woman said, “You know a woman cannot go out there and lay up with this person and that one without the first thing everybody say, ‘She’s a ho, she’s a this, she’s a that.”’ The prevailing manifestations of gender inequality appeared to guide the choice to have just one sexual partner. Of particular relevance for this sample, underlying many women’s explanations regarding their own practice of monogamy was the possibility of reprisals from their male partners. As might be expected, fear of their primary partners’ reactions if they were to discover that the women had secondary sexual partners was a significant constraining factor. One woman said, “I don’t believe in doing a man dirty, you kidding me? If [he] was to find out, I wouldn’t be here talking to you.” Another said, “He always say ‘If I ever catch you messing around, I’ll kill you. And I believe he would.” Women often worked hard to assure their partners of their fidelity, avoiding occasions that might appear suspicious, but often to no avail. “You don’t really have the time to be involved with anyone else. He’s constantly aware of your time. He is very jealous. Extremely jealous. I talk to his friends too much. And if he’s drinking, he starts staying that. Accusing me of having relationships with his friends.” Others viewed men’s jealousy and suspicion as a key component in their abuse—often an excuse to abuse the women further or a means of torturing the women: How could he sit there and knock me down and call me names and make me feel such hurt about myself, then he wants to sit there and kiss on me and stuff? One time, I was just laying there, and he goes, ‘What?! Did you do somebody else?’ He stuck his fingers in me and starts smelling his fingers. He turned around, ‘Yeah, it smells like you were with somebody.’ He said, ‘You whore! You were with somebody! Now you’re gonna do me! You wanna go ‘f’ somebody else? Now you’re gonna do me.’
Typically, the male partners of these women were involved with drug dealing and other crimes, and so frequently spent time in jail. Of particular note, some of the women described the difficulty of assuring an incarcerated partner of their fidelity over a long period of time. One woman told her interviewer, “And I don’t pull that kind of shit, you know what I mean? That’s the—that’s the abuse. I told him, ‘Why you
181 keep. . . banging me around, call me a bitch and ‘you low down trash’ just because somebody told you shit that’s not true?’ ” Two women described being surprised by their partners’ release from jail, learning the news only when the men burst into the women’s homes, apparently expecting to find them with other men. Thus, the women’s choice of monogamy in these cases was clearly a survival strategy in relationships characterized by abuse.
Type 2: The Practice of Monogamy is Doubted Although the majority of the women valued monogamy as an ideal for their relationships, some also simultaneously expressed uncertainty or lacked conviction that this standard was maintained. One woman, in describing her relationship with her male partner, said, “He can’t see nobody, and I can’t see nobody. Just me and him. He’s my only sex partner, and I’m his only sex partner.” Moments later she continued, “. . . to share my body with somebody else, you know, I don’t think it’s right. I don’t find it right at all. Hey, I don’t know about him, I never asked him that question. No, I never asked that.” Women differed in their willingness to accept the probability of their partner’s extradyadic sexual behavior. Several women who suspected that their male partner had concurrent sexual partnerships said that it was difficult to know with any certainty. As one woman said, “But you know, I could never prove it ‘cause at least he didn’t do it in my face, you know let anybody in the neighborhood find out or anything.” Some described being comforted by the fact that their primary male partner might simply be discrete in his extradyadic sexual relations. They did not want to experience the shame of being told by friends or neighbors that their partners were having sex with other women or appearing as if they were not “woman enough” to take care of his needs. Many of these explanations made it clear that they were reluctant to confront their partners with concerns, suspicions, or evidence, making the possibility of insisting on condom use even remoter. Other women chose to confront their male partners, although the partner usually denied the accusations: Interviewer: Did [he] have sex with other people while you were together? Participant: I have a feeling that he did. Interviewer: You do, and what makes you say that?
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Participant: Well, because I caught a disease from him. I had caught herpes, and actually it was from him, so I know you get herpes from having other relations, you know, sex. So I. . .even though he said, ‘No, no,’ that he don’t know how he got it, but I took him to the hospital, and yes he was the one who passed it to me.
sexual relationships, this was not always the case. For example, one woman explained:
These women described becoming suspicious when the quality of the relationship with their primary partner changed in some way, they were arguing with their partner more frequently, they contracted an STI from their male partner, or they noticed other signs of extradyadic sexual involvement (e.g., hickeys, other women’s clothing found in their apartment, his socks or T-shirt being inside out at the end of the day). Others sought such evidence by following the men, asking around, or picking up the phone when he was on the line. As might be expected, accusing their partners of infidelity often led to severe beatings and frequently did not spare them infection with STIs, including HIV. “Yeah, he denied it and hit me, too, because he can’t accept to tell me the honest truth. How you gonna bring home infection to your wife?” Even so, the women were often furious about men’s violations. In the context of suspected and confirmed extradyadic sexual behavior, some women described both their partners and themselves as becoming highly possessive and sexually jealous. Some women reported that they would rather end the primary relationship than tolerate extradyadic sexual partners. One woman said, “. . . I don’t want him sleeping with anybody else. I’m a very possessive woman. I don’t want my man with anybody else. I don’t and that’s it, and I told him that if he ever is with somebody, it better be the best f–k he ever had because he’s never coming back to my house again.” However, the women usually could not end the relationship or quickly took the men back. Although it was often the case that the women suspected their primary male partner of being involved in concurrent sexual partnerships, some women also reported engaging in outside sexual relationships themselves. They often minimized these relationships or dismissed them as “flings” or explained that these secondary partnerships fulfilled needs that were left otherwise unfulfilled in their primary relationships, such as a desire for companionship and intimacy. Although some of the women seemed unaware of the contradictions in their stated values of monogamy and their own participation in concurrent
Other women had trouble acknowledging their involvement in concurrent sexual partnerships, regardless of their motives. One woman said:
Ah, man, this is like a Catch 22 question because it is important to me, but then again as far as I see it, I was the one who broke the trust all right, and maybe I broke the trust because I wasn’t getting the sex that I was desiring all that time. But then maybe I broke the trust ‘cause he was in jail, and I wasn’t expecting him back no way.
Let me tell you how often I did that. . . . It wasn’t even a lot. . . . I mean it was only about no more than five times in 2 years, 3 years, you know, but like I said, if he was suspicious you know . . . then if you do something that makes him think again, it’s gonna keep coming back.
As this quote illustrates, some participants were concerned about eliciting distrust from their primary male partner, which often manifested in violent outbursts from the partner. Those who had been “caught in the act” typically described the most severe forms of physical abuse by their primary partner, often in the presence of the secondary sexual partners or other bystanders, none of whom typically intervened on the women’s behalf. At other times, women described their partner as acting calm in public upon discovering them with other men (often innocently so), and then erupting when the two were alone. Some women speculated that the men projected their suspicions onto the women on the basis of the men’s own extradyadic sexual behavior. As one woman said, “That was basically a relationship where he was messing around, and when the person be messing around, they think that their partner is messing around.” In situations where the women caught their partners with other sexual partners, they described becoming jealous and confronting or attacking “the other woman,” insulting her, occasionally physically attacking her, but rarely retaliating against the men themselves. A few women, however, could matter-of-factly present their extradyadic sexual experiences without any reference to moral judgments of behavior. One woman reported that both she and her partner had extradyadic sexual partners, although her partner denied it: Interviewer: Why do you think he has denied it? Participant: I guess it’s because he wants to make it seem like if he’s the better partner or
Intimate Partner Violence and Monogamy better man because I don’t care. I’ll tell him the truth you know. If another person come up and tell him, ‘Listen! I saw your wife with such a guy walking down the street; I saw her walking into a hotel with some other guy,’ I always told him before we go back. I sit down and I tell him. I said, ‘I had a sexual relationship with this guy.’ Type 3: Monogamy is Not Important or Not Practiced Although many women held steadfast to their beliefs about monogamy, the issue of the value of monogamy in the women’s relationships was not always a clearly defined one. For some, informal agreements were established at the beginning of the relationship or the circumstances under which the relationship developed set the stage for what was considered acceptable or expected thereafter with regard to multiple sexual relationships. As one woman explained: Before anything I told him, ‘Are we gonna have an open relationship? Are you gonna be faithful? You know, if we want an open relationship let’s talk about it now.’ He said no, that he only wanted it with me and that was it. I said, ‘Okay, fine. That’s the way I want it.’ ‘Cause I’m a kind of person that I like to give in completely. I don’t like to have you here, another man over there, and another man you know.
This woman, like several others, suggested that a dialogue take place early in the relationship where both partners express their expectations, and establish an agreement before the relationship advanced. However, some women indicated that if this agreement was broken by the other, then as one woman said, “all bets are off,” and they were free to be with whomever they chose and often deliberately reacted by seeking other sexual partners in retaliation. A number of women discussed that they had concurrent sexual partnerships because they needed to exchange sex for drugs or money. When these women were addicted to drugs or were living in poverty, locating sexual partners who could supply these commodities was necessary to their basic and economic survival even when it went against their ideals. “First of all, I wouldn’t want to be with anyone else. I love him, you know? And I loved me, too. If I had to be with another man, it was either for money or drugs. That vicious cycle again – drugs, sex, money, drugs.” Even men who pushed their partners
183 to have sex with other men for money occasionally beat the women for doing so: “His friends would say, ‘How could you be out there with your lady and letting her go off in the car knowing that when you see her pulling off she getting ready to go suck another man’s dick or whatever and you standing there when she come back?’ So I was belittling him, lowering his manhood.” A less common theme that emerged from the interviews was that monogamous relationships were not important to the women. At times, women devalued monogamy because their primary male partner clearly had other sexual partners and they felt powerless to change the situation. As such, concurrent sexual partnerships were at times seen as independent from the men’s love for and commitment to their primary female partners. Women cited as evidence that “he always came back” to them. A few women blamed themselves for their partner’s straying, explaining that the men sought extradyadic sexual partners because they were not adequately satisfying the men’s sexual needs or were lacking in other ways. Their explanations often reflected the powerlessness and dejection that abused individuals often feel: “Yeah, I got syphilis, crabs, and things like that behind it. And I didn’t talk about it with him, you know? I just blocked it out and went through the motions.” A few women reported that monogamy was not important to them because they were not ready for that type of commitment. Other women said that they did not care about monogamy because their primary relationships were deteriorating in some way. For example, one woman said, “We were always very monogamous together, but he started to have an affair with someone and that was actually fine with me because we weren’t having good sex.” Of particular note, many women viewed the relationship as so terrible that their partners’ fidelity had lost all meaning. For example, one woman explained, “I was sick and tired of having rough sex or getting hit and then getting kissed, so it all destroyed us even more.” A few expressed wishing that there were other women in their partners’ lives so that the men would leave, seeing no other way to end the abusive relationship. Even long-term jail sentences seldom terminated their connection. DISCUSSION This study used qualitative methods to explore the meaning of monogamy and concurrent sexual partnerships, and associations with partner jealousy
184 and/or violence among physically abused women in methadone treatment. A two-fold prevention strategy, heavily endorsed in the past for women, has been to both reduce the number of partners with whom they are sexually involved, and to establish an agreement with their partners about maintaining mutual monogamy. However, this strategy has been of limited use given the differential power structure in women’s relationships with men, rendering many women unable to effect these ends. In fact, this strategy may have been harmful to women by increasing the chances of exposure to partner violence (El-Bassel, Gilbert et al., 1998). The women in this study may have been especially vulnerable given their histories of relationship abuse and their additional vulnerability of drug use histories and impoverished backgrounds. Similar to other studies of abused women (Roberts et al., 2003), few reported using condoms in any regular fashion, and none indicated that they did on every sexual encounter. Our findings provide insight into the meanings ascribed by a unique sample of women and also highlight the variance within these women’s values regarding monogamy. Some women overlooked indisputable evidence (e.g., contracting STIs) of their partner’s participation in outside sexual relationships, illustrating the lack of power to insist upon monogamy (or consistent condom use). Others have also noted, as we did here, that some women believe that their long-term relationship imparts protective effects (Afifi, 1999; Sobo, 1995; St. Lawrence et al., 1998). It must also be noted that a firm belief in a partner’s fidelity may be an adaptive response when there is no possibility of successfully negotiating safety from risk. Other women described initially wanting a monogamous relationship, but losing this value with the deterioration in the quality of their relationship over time. In these cases, they may have lost motivation to maintain their vigilance, or no longer valued the relationship enough to actively maintain it after experiencing sustained abuse. Still others explained that monogamy was not important to them at all, devaluing this standard altogether. These women exhibited in many respects feelings of helplessness and hopelessness common among abused women. Overall, it is clear that there is are complex relationships between women’s values regarding monogamy, the meanings ascribed to this concept, and the extent to which they or their partners actually practiced monogamy. Gender theory suggests that given the context of intimate partner violence, the women in
Hearn, O’Sullivan, El-Bassel, and Gilbert this study may not have had the power required to be able to bargain for their sexual health and sexual rights. Moreover, women’s choices to leave non-monogamous relationships may have been hampered because partner violence often escalates when abused women try to leave their relationships (Barnett, 2001; Mechanic et al., 2002). Clearly, given the high rates of STIs, including HIV, and the high rates of extradyadic sex, relying on an apparently exclusive relationship is not working for women. Taken together, women’s reports of their own and their partner’s involvement in concurrent sexual partnerships suggest that the women in this study are at heightened risk for HIV. There are a number of limitations to this study. As with all qualitative research, the purpose is not to generalize beyond the scope of the experiences described by the sample within, but to generate new perspectives on a topic, which are best then investigated more closely using quantitative means. As such, we do not purport that these perspectives characterize all physically abused women in methadone treatment, but they do provide some important insights into the experiences of one sample of such women. A limitation of the methods employed, however, is that some women referred to their experiences that were current, whereas others referred to past experiences in their relationships. However, studies of recovery after the aftermath of intimate partner violence suggest that painful feelings, such as the inability to trust others and fear of violence, may carry over into subsequent relationships (Smith, 2003). It is possible that some of the accounts we obtained were more subject to biases in recall than others. The results of this study suggest that interventions should target two specific groups of women who might be at increased risk for HIV: those women who have other sexual partners or suspect that their primary partner has extradyadic sexual partners, and those women who are ambivalent about the importance of monogamy in their primary relationships. Interventions targeting the first group of women may consider using couple-based approaches to help partners disclose any HIV risks (i.e., injecting drug use or having sex with outside partners) that may give the women a more accurate appraisal of their HIV risk. Such a couple-based approach may enable the women and their partners to work through sensitive issues in a safe, supportive environment and to negotiate a safer sex plan that takes into full account the risks in the relationship. However, given
Intimate Partner Violence and Monogamy the potential difficulties in negotiating male condom use in violent relationships, women at risk may be better able to protect themselves if they had access to female-controlled methods, such as female condoms or vaginal microbicides. These methods require less male cooperation and potentially can be used without the man’s knowledge. Women in violent relationships were found to be more accepting of a vaginal microbicide than either type of condom (Saul et al., 2004). Interventions targeting the second group of women should focus on raising their awareness of the HIV/STI risk of having sex with more than one partner and on increasing their sexual communication and negotiation strategies and skills, which they may effectively use with different partners, taking into account the likelihood of potential intimate partner violence in each situation. In both cases, efforts to improve women’s options to leave abusive relationships, enhance their sense of personal worth, and seek treatment likely supercede any attempts to incorporate prevention strategies in such abusive relationships. Given the multiple challenges that women face, it is essential to offer programs that take into account the context of women’s lives. Focusing exclusively on women to enact change, however, is unfair (St. Lawrence et al., 1998), especially given the importance of partner dynamics in abusive relationships. Male dominance and control isolate abused women and prevent them from seeking support (El-Bassel et al., 2001). Proponents of gender theory assert that it is traditional gender roles and the relative acceptability of violence toward women that contribute to increased risk of HIV infection (El-Bassel et al., 2000). Interventions designed to free women from the impact of destructive gender and sexual norms, not just transform gender roles or create more equitable relationships, are desperately needed (Gupta, 2000). Programs that improve women’s access to information, skills, services, and support systems may serve to redress the imbalance of power between women and men in their relationships. In fact, Melendez et al. (2003) found that a gender-specific intervention among women reporting intimate partner violence was successful in helping women engage in safer sex negotiation with their male partners, without an increase in reports of abuse. Perhaps in addition, such programs may serve to establish a group identity among women who experience abuse, one that provides them with additional sources of strength, support, and information.
185 ACKNOWLEDGMENTS This research was funded by the National Institute on Drug Abuse (DA11027; Principal Investigator: Nabila El-Bassel, D.S.W.). We also acknowledge the support of the following grants from the National Institute of Mental Health: K01-MH01689 (Principal Investigator: Lucia F. O’Sullivan, Ph.D.); T32MH19139 (Principal Investigator: Anke A. Ehrhardt, Ph.D.); and P50-MH43520 (Center Principal Investigator: Anke A. Ehrhardt, Ph.D.).
REFERENCES Afifi, W. A. (1999). Harming the one’s we love: Relational attachment and perceived consequences as predictors of safe-sex behavior. The Journal of Sex Research, 36, 198–206. Amaro, H. (1995). Love, sex, and power: Considering women’s realities in HIV prevention. American Psychologist, 50, 437– 447. Amaro, H., and Raj, A. (2000). On the margin: Power and women’s HIV risk reduction strategies. Sex Roles, 42, 723– 749. Barnett, O. W. (2001). Why battered women do not leave, part 2: External inhibiting factors—social support and internal inhibiting factors. Trauma Violence and Abuse, 2, 3– 35. Beadnell, B., Baker, S. A., Morrison, D. M., and Knox, K. (2000). HIV/STD risk factors for women with violent male partners. Sex Roles, 42, 661–689. Brimlow, D. L., and Ross, M. W. (1998). HIV-related communication and power in women injecting drug users. In N. L. Roth and L. K. Fuller (Eds.), Women and AIDS: Negotiating safer sex practices, care and representation (pp. 71–80). New York: Haworth Press. Buss, D. M., Shackelford, T. K., Kirkpatrick, L. A., Choe, J. C., Lim, H. K., Hasegawa, M., Hasegawa, T., and Bennett, K. (1999). Jealousy and the nature of beliefs about infidelity: Tests of competing hypotheses about sexual differences in the United States, Korea, and Japan. Personal Relationships, 6, 125–150. Cann, A., Mangum, J. L., and Wells, M. (2001). Distress in response to relationship infidelity: The roles of gender and attitudes about relationships. The Journal of Sex Research, 38, 185–190. Dey, I. (1993). Qualitative data analysis: A user-friendly guide for social scientists. London: Routledge. Dolcini, M. M., Coates, T. J., Catania, J. A., Kegeles, S. M., and Hauck, W. W. (1995). Multiple sexual partners and their psychosocial correlates: The population-based AIDS in multiethnic neighborhoods (AMEN) study. Health Psychology, 14(1), 22–31. El-Bassel, N., Gilbert, L., Krishnan, S., Schilling, R., Gaeta, T., Purpura, S., and Witte, S. (1998). Partner violence and sexual HIV risk behaviors among women in an inner-city emergency department. Violence and Victims, 13, 377–393. El-Bassel, N., Gilbert, L., Rajah, V., Foleno, A., and Frye, V. (2000). Fear and violence: Raising the HIV stakes. AIDS Education and Prevention, 12, 154–170. El-Bassel, N., Gilbert, L., Rajah, V., Foleno, A., and Frye, V. (2001). Social support among women in methadone treatment who experience partner violence. Violence Against Women, 7, 246–274.
186 El-Bassel, N., Krishnan, S., Schilling, R., Witte, S., and Gilbert, L. (1998). Acceptability of the female condom among men and women attending STD clinics. AIDS Education, 105, 465– 480. Gilbert, L., El-Bassel, N., Schilling, R. F., Wada, T., and Bennet, B. (2000). Partner violence and sexual HIV risk behaviors among women in methadone treatment. AIDS and Behavior, 4, 261–269. Gupta, G. R. (2000, July). Gender, sexuality, and HIV/AIDS: The what, the why, and the how. Plenary address at the XIIIth International AIDS Conference, Durban, South Africa. Mechanic, M. B., Weaver, T. L., and Resick, P. A. (2002). Intimate partner violence and stalking behavior: Exploration of patterns and correlates in a sample of acutely battered women. In K. E. Davis and I. H. Frieze (Eds.), Stalking: Perspectives on victims and perpetrators (pp. 62–88). New York, NY: Springer. Melendez, R. M., Hoffman, S., Exner, T., Leu, C., and Ehrhardt, A. A. (2003). Intimate partner violence and safer sex negotiation: Effects of a gender-specific intervention. Archives of Sexual Behavior, 32, 499–511. O’Sullivan, L. F., and Byers, E. S. (1995). Gender differences in responses to discrepancies in desired level of sexual intimacy. Journal of Psychology and Human Sexuality, 8, 49– 67. Roberts, A. C., Wechsberg, W. M., Zule, W., and Burroughs, A. R. (2003). Contextual factors and other correlates of sexual risk of HIV among African-American crack-abusing women. Addictive Behaviors, 28, 523–536. Saul, J., Moore, J., Murphy, S. T., and Miller, L. C. (2004). Relationship violence and women’s reactions to male- and femalecontrolled HIV prevention methods. AIDS and Behavior, 8, 207–214. Sikkema, K. J., Heckman, T. G., Kelly, J. A., and Eileen, S. (1996). HIV risk behaviors among women living in lowincome, inner-city housing developments. American Journal of Public Health, 86, 1123–1128. Smith, M. E. (2003). Recovery from intimate partner violence: A difficult journey. Issues in Mental Health Nursing, 24, 543– 573.
Hearn, O’Sullivan, El-Bassel, and Gilbert Sobo, E. J. (1995). Choosing unsafe sex: AIDS-Risk denial among disadvantaged women. Philadelphia: University of Pennsylvania Press. St. Lawrence, J. S., Eldridge, G. D., Reitman, D., Little, C. E., Shelby, M. C., and Brasfield, T. L. (1998). Factors influencing condom use among African American women: Implications for risk reduction interventions. American Journal of Community Psychology, 26, 7–28. Straus, M., Hamby, S. L., Boney-McCoy, S., and Sugarman, D. B. (1996). The Revised Conflict Tactics Scales (CTS2): Development and preliminary psychometric data. Journal of Family Issues, 17, 283–316. Susser, I., and Stein, Z. (2000). Culture, sexuality, and women’s agency in the prevention of HIV/AIDS in Southern Africa. American Journal of Public Health, 90, 1042–1048. Weeks, M. R., Grier, M., Radda, K., and McKinley, D. (1999). AIDS and social relations of power: Urban African-American women’s discourse on the contexts of risk and prevention. In W. N. Elwood (Ed.), Power in the blood: A handbook on AIDS, politics, and communication (pp. 181–197). Mahwah, NJ: Lawrence Earlbaum Associates. Wiederman, M. W. (1997). Extramarital sex: Prevalence and correlates in a national survey. The Journal of Sex Research, 34, 167–174. Wingood, G. M., and DiClemente, R. J. (1997). The effects of an abusive primary partner on the condom use and sexual negotiation practices of African-American women. American Journal of Public Health, 87, 1016–1018. Wingood, G. M., and DiClemente, R. J. (1998). Partner influences and gender-related factors and gender-related factors associated with noncondom use among young adult African American women. American Journal of Community Psychology, 26, 29–51. Wu, E., El-Bassel, N., Witte, S., Gilbert, L., and Chang, M. (2003). Intimate partner violence and HIV risk among urban minority women in primary health care settings. AIDS and Behavior, 7, 291–301. Zierler, S., and Krieger, N. (1997). Reframing women’s risk: Social inequalities and HIV infection. Annual Review of Public Health, 18, 401–436.
