BERNICE ROBERTS KENNEDY, P H D , A P R N , BC AND
CHALICE C . JENKINS, P H D , L P C
Abstract: African American women, including adolescents and adults, are disproportionately affected by the transmission of Human Immunodeflciency Virus
(HIV) and Acquired Immunodeficiency Syndrome (AIDS). HIV/AID is a health
disparity issue for African American females in comparison to other ethnic groups.
According to data acquired from 33 states in 2005,64% of women who have HIV I
AIDS are African American women. It is estimated that during 2001-2004, 61%
of African Americans under the age of 25 had been living with HIV/AIDS. This
article is an analytical review of the literature emphasizing sexual assertiveness
of African American women and the gap that exists in research literature on this
population. The multifaceted model of^IV risk posits that an interpersonal predictor of risky sexual behavior is sexual assertiveness. The critical themes extracted
from a review of the literature reveal the following: (a) sexual assertiveness is
related to HIV risk in women, (b) sexual assertiveness and sexual communication
are related, and (c) women with low sexual assertiveness are at increased risk of
HIV. As a result of this comprehensive literature, future research studies need to
use models in validating sexual assertiveness interventions in reducing the risk
of HIV/AIDS in African American women. HIV/AIDs prevention interventions
for future studies need to target reducing the risk factors of HIV/AIDS of African
Americans focusing on gender and culture-speciflc strategies.
Key Words: HIV/AIDS, Sexual Assertiveness; African American Women;
Communication
PROMOTING AFRICAN AMERICAN
WOMEN AND SEXUAL ASSERTIVENESS IN
REDUCING H I V / A I D S :
A N ANALYTICAL REVIEW OF THE
RESEARCH LITERATURE
A
frican American women, including adolescents
and adults, are disproportionately affected by
the transmission of^Human Immunodeficiency
Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS). In the United States, health disparities
exist related to HIV / AIDS among African American
females in comparison to other etrmic groups (Arya,
Behforoz, & Viswanath, 2009). HIV/AIDS is rising
among African American women (CDC, 2008; CDC,
2007b). Currently, HIV/AIDS is the leading cause of
death for black women (including African American
women) in the 25-34 years age group. It is the third
Bernice Roberts Kennedy, PhD, APRN, BC, Research Consultant, BRK Healthcare Services Inc., PO
90105, Columbia, South Carolina, 29290. Dr. Kennedy
may be reached at: [email protected]. Chalice C. Jenkins, PhD, LPC, Vessel CounseUng & Consulting, LLCCEO. Dr.jenkinschalice@çmail.com, Cherry Hill, NJ.
Journal of Cultural Diversity • Vol. 18, No. 4
leading cause of death for black women aged 3 5 ^ 4
years and the fourth leading cause of death for black
women aged 45-54 years (CDC, 2008; CDC, 2007b).
African American women are affected with HIV / AIDS
25 times more than white women and four times more
than Hispanic women (Hatcher, Burlev & Lee-Ouga,
2008).
y
& '
Healthy People 2010 Initiative is a set of 10-year health
objectives by the Surgeon General developed to improve the health of the American people (CDC, 2010).
This initiative continues to address the disproportionate impact of HIV/AIDS among certain racial and
ethnic groups such as the African American women
(CDC, 2010). According to data acquired from 33
states in 2005,64% of women who have HIV / AIDS are
African American women (CDC, 2007a; CDC, 2007b).
It is estimated that during 2001-2004, 61% of African
Americans under the age of 25 had been living with
HIV/AIDS.
Having unprotected sex with a man who has HIV is
the most common way African American women acWinter 2011
quire HIV/AIDS (CDC, 2007a; CDC, 2007b). Abstinence,
sexual contact without the exchange of bodily ñuids,
and latex condom use are three ways that women can
protect themselves (Quina, Harlow, Morozoff, & Burkholder, & Deiter, 2000). Yet, sexually acfive women must
assert themselves in heterosexual relationships by communicating information, initiating wanted sex, refusing
unwanted sex, and preventing j)regnancies and sexually
transmitted diseases (Morokoff et al., 1997). While these
options are available to women, the dramatic increase
in HIV/AIDS over the years is evidence that women
are not protecting themselves.
The HIV/AIDS prevention intervention literature,
which has traditionally focused on individual variables,
has been criticized for ignoring contextual variables
(Amaro & Raj, 2000; Logan, Cole, & Leukefeld, 2002;
Mize, Robinson, Bockting, & Scheltema, 2002; Morokoff
et al, 2008; Reid, 2000; Roundtree & Multrancy, 2010;
Sanders-Phillips, 2002; Wingood, 2003; Wyatt, 2009),
such as sexual assertiveness, within the context of a
relationship.
Sex is a mutual act and women must assert themselves to negotiate condom use with the partner. According to Morokoff et al., (1997), sexual assertiveness
is conceptualized as a human right to control over one's
body, one's sexuality, and one's sexual experience. Yet
a study of 904 adolescents and women, ages 14- 26, revealed^ that 20% of the sample felt they did not have the
right to be sexually assertive (Rickert, Sanghvi, & Wiemann, 2002). The problem with the HIV/ AIDS literature
is a gap in the research literature resulting in a lack of
knowledge of the sexual assertiveness characteristics of
African American women.
This article is an analytical review of the literature
on research emphasizing sexual assertiveness in African
American women and the existing disparities of HIV/
AIDS to other ethnic groups. The review is guided by
the Harlow et al. (1993) multifaceted model of HIV risk
in women.
THEORETICAL FRAMEWORK
This multifaceted model of HIV risk examines
whether women sexually assert themselves in the
context of a relationship to protect themselves from
HIV/AIDS. This model has been utilized as a framework guiding studies addressing sexual assertiveness
of women related to the protection from HIV/AIDS.
The factors included in this comprehensive model are
behavioral consisting of psychoattitudinal and interpersonal predictors (Harlow et al., 1993). Guided by the
multifaceted model of HIV risk, the Sexual Assertiveness
Scale was developed. Previous theories and models that
have been applied to HIV prevention have focused on
the individual. However, the multifaceted model of HIV
risk includes variables such as sexual assertiveness that
occur within the context of a relationship.
A basic tenet of the multifaceted model of HIV risk
is that there is no single predictor of women's HIV
risk behavior (Quina et al., 2000). Another tenet of the
multifaceted model of HIV risk is that demographics,
sexual history, interpersonal negative experiences, and
cognitions/ attitudes are important to communication
assertiveness (Quina et al., 2000). Further, the multifaceted model of HIV risk was developed to address
Journal of Cultural Diversity • Vol. 18, No. 4
multiple predictors of women's risky sexual behavior.
It is postulated that due to the compounded nature of
several multiple predictors of HIV risk, an inclusive
approach is needed (Quina et al., 2000). Subsequently,
it is hoped that the multifaceted model of HIV risk will
be utilized to develop effective interventions for risky
sexual behavior (Quina et al., 2000).
In developing a full structural model of HIV risk
in women, Harlow et al. (1993) hypothesized that the
following interpersonal factors predict increase of HIV
risk in women; (a) sexual abuse history, (b) expecting a
negative reaction from a partner in response to a safer
sex request, (c) lack of sexual assertiveness related to
birth control use, (d) lack of sexual assertiveness related
to refusing unwanted sex, and (e) sexual assertiveness related to initiation of sex. Last, demoralization,
hopelessness, lack of meaning, stress, self-efficacy, and
psychosexual attitudes are psychoattitudinal factors that
predict HIV risk.
In summary, the multifaceted model of HIV risk
is a useful model in conceptualizing the levels of assertiveness to prevent HIV/AIDS. In developing a
full structural model of HIV risk in women, Harlow
et al. (1993) hypothesized that the following psychoattitudinal predictions will increase HIV risk in women
to include; (a) low levels of psychosocial functioning,
(b) low levels of psychosexual functioning, and (c) less
self-efficacy for AIDS prevention.
OVERVIEW
The literature review of sexual assertiveness studies
of African American women identified and focused on
the three main themes (a) sexual assertiveness and HIV
risk, (b) sexual assertiveness and communication, and
(c) women with low sexual assertiveness. In a qualitative study of 31 college students, Ferguson, Quinn, Eng,
and Sandelowski, (2006) found that i\frican American
college women reported being unable to negotiate
condom use with a partner due to (a) low self-esteem,
(b) agreeing to have sex without a condom to promote
an emotional relationship with a male, and (c) the fear
of being rejected by a male because of the gender-ratio
imbalance among African American men and women.
Foreman (2003) conducted a qualitative study of 15
African American college students and found that participants classified sexual relationships from casual to
committed relationships, which influenced condom use
and negotiation. For instance, women in long-term committed relationships believed condom use was unnecessary while participants in casual sexual relationships
were more likely to use condoms. In addition, Synovitz,
Herbert, Carlson and Kelly (2005) conducted a sexual
behavior survey study using the Sexual Assertiveness
Scale (SAS). The sample included 1,168 college students
attending four universities in which African Americans
represented 18% of the sample. The following results
were revealed; (a) 41% of the participants reported intentions to discuss HIV/STDs with a sexual partner, (b)
52% of participants reported they would refuse sexual
intercourse without a condom, (c) 25% of participants
planned to get tested for HIV while more than 85%
planned to get tested if they thought they were infected,
(d) more women versus men intended to communicate
avoiding HIV/STDs by limiting sexual activity or refusing sex without a cond^om, and (e) more African AmeriWinter 2011
can participants versus white participants planned to
discuss HIV/STDs, but African American participants
were not as likely as white participants to get an HIV
test if they believed they were infected (Synovitz et al.,
2005). The Ferguson et al.(2006). Foreman (2003), and Ú\e
Synovitz et al, (2005) studies demonstrate the need for
more sexual behavior research amorig women especially
college women. The emerging three main themes in this
literature review are: (a) sexual assertiveness and HIV
risk, (b) sexual assertiveness and communication, and
(c) women with low sexual assertiveness. These themes
will be discussed separately.
Sexual Assertiveness and HIV Risk
Sexual assertiveness
Health care professionals need to be aware that
sexual assertiveness is related to HIV risk in African
American females contributing to the health disparities.
A quantitative study of communication, assertiveness,
and condom use predictors assessed the following: (a)
communication, (b) sexual communication, (c) general
assertiveness, (d) sexual assertiveness, (e) self-efficacy,
(f) sexual risk, and (g) sexual activity (Zamboni, Crawford, & Williams, 20^00). The results revealed a significant correlation with general assertiveness and sexual
assertiveness. But compared with general assertiveness,
results revealed that sexual assertiveness was the most
significant predictor of condom use (Zamboni et al.,
2000). In addition, Zamboni et al. (2000) found that
when an individual exhibited a positive attitude toward
condom use, greater levels of sexual assertiveness were
associated with actual condom use.
The Zamboni et al. (2000) study has made important
contributions to the knowledge base of how sexual
assertiveness is related to condom use. On the other
hand, a majority Caucasian college population was
sampled. Therefore, the study reveals little about communication and assertiveness as predictors of condom
use related to African American women. Further, the
sexual assertiveness subscale of the Sexual Awareness
Questionnaire was employed to measure sexual assertiveness (Zamboni et al., 2000). While this subscale of
the Sexual Awareness Questionnaire has good validity
and reliability, the Sexual Assertiveness Scale may have
revealed more information about the sexual assertiveness characteristics of the sample.
An association exists between sexual assertiveness
and HIV risk. First, in a multicultural study, Onuoha and
Munakata (2005) demonstrated that sexual assertiveness
showed a significant main effect on HIV risk avoidance.
Hence, the Onuoha and Munakata study provided evidence of the association between sexual assertiveness
and HIV risk. Second, the Zamboni et al.; (2000) study
found that sexual assertiveness is a significant predictor
of condom use. In addition, when an individual exhibits
a positive attitude toward condom use, greater levels
of sexual assertiveness are associated with actual condom use (Zamboni et al., 2000). Last, DiClemente and
Wingood (1995) found that women who received sexual
assertiveness training were more sexually assertive and
more likely to consistently use condoms. Regardless
of intoxication, Stoner et al. (2008), in an experimental
study of African American women (N=161) related
to adulthood victimization, sexual assertiveness, and
alcohol intoxication, found the less sexual assertive
Journal of Cultural Diversity • Vol. 18, No. 4
women were, the less these women intended to use a
condom. Results of the findings suggested examining
the sexual assertiveness characteristics of African American women may contribute to reducing HIV risk.
Sexual Assertiveness and Communication
Sexual assertiveness communication
Healthcare professionals need to teach sexual assertiveness communication to African American females
at risk for HIV/AIDS. Women may be able to minimize
HIV risk by communicating HIV risk with a sexual
partner (Quina et al., 2000). But, in order for this behavior to occur a woman must assert herself within the
heterosexual relationship (Quina et al., 2000). Quina et
al. utilized the multifaceted model of HIV risk to investigate assertive communication and sexual assertiveness
in a majority Caucasian community sample. The results
revealed that sexual assertiveness was an important
skill needed to communicate sexual preferences and
information.
Further, assertively refusing sex was significant in the
communication of HIV risk information with a heterosexual partner (Quina et al., 2000) the study has shown
that communicating sexual preferences and information
is a part of sexual assertiveness. The study also utilized
both the Initiation and Refusal subscales of the Sexual
Assertiveness Scale. However, only 9.4% of the sample
consisted of African American women.
Sexual communication and negotiation
Sexual assertiveness strategies (e.g., education,
counseling, group therapy) of African American women
need to focus on sexual negotiation to include condom
use. While there is limited available quantitative sexual
assertiveness research on samples of African American
women, two qualitative studies related to communication and negotiation. First, Wingood, Hunter-Gamble,
and DiClemente (1993) employed focus groups to
discuss sexual communication and negotiation in a
convenience sample of low-income African American
women. A significant theme revealed regarding participants communicating with partners were that mey
felt comfortable initiating a discussion about condom
use, but were unable to negotiate actual condom use
(Wingood et al., 1993). In discussing this theme, the
majority of African American women's self-reported
sexual assertiveness related to condom use ranged from
being: a) non-assertive, b) assertive, c) and demanding (Wingood et al, 1993). For instance, some women
requested condom use while others refused to have sex
without a condom (Wingood et al., 1993).
While the groundbreaking qualitative themes of
sexual communication and sexual negotiation are important to the field of HIV prevention, limitations still
exist (Wingood et al., 1993). First, the sample consisted
of low-income women, which makes it impossible to
know how women of high socioeconomic status (SES)
differ. Second, a convenience community sample was
utilized instead of a random community sample. Utilizing random sampling gives more credibility to a study.
However, the sample size of 18 women strengthened
the qualitative study.
Another qualitative study of 28 low-income and
working class African American teens and adults
investigated gender rules and AIDS prevention (FulliWinter 2011
love, Fullilove, Haynes, & Gross, 1990). A major theme
revealed that sexual negotiation skills varied based on
age, emotional charge, and beauty (Fullilove, Fullilove,
Haynes, & Gross, 1990). For example, older women and
physically attractive women felt triey had the power to
communicate with their partner. But, women who had
not established trust, feared forced sex, or did not plan
condom use in advance felt powerless to communicate
assertiveness with their partner (Fullilove et al., 1990).
The Fullilove et al. (1990) qualitative study has
contributed to the knowledge base regarding the significance of sexual communication, sexual negotiation,
and assertiveness. Yet the generalization of the results
remains limited. First, a convenience sample was utilized. Random assignment of participants would have
given more credibility to the study Second, the low SES
sample limits knowledge about characteristics of higher
income samples. Yet, the exploratory nature of Fullilove
et al. (1990) brought attention to the importance of this
topic of sexual assertiveness and communication. In
acidition, the sample size of 28 women strengthened
the study.
Roundtree and Mulrancy (2010) study further supported the importance of sexual communication and
negotiation. In a qualitative study of African American,
Mexican and Anglo women (N=43) examining partner's
relationships, respondents reported they knew ways
of protecting themselves from infection in non-abusive
relationships, however, it was difficult doing so given
the context of their abusive relationships.
Sexual communication of condom use
Communication about condom use is relevant to
sexual assertiveness (Noar et al., 2002). Health professionals need to promote sexual assertiveness of African
American women when negotiating condom use with a
partner. In a study related to the development of a condom influence quesfionnaire Noar et al. (2002) examined
condom negotiation in heterosexually active men and
women. In addition to other measures, the researchers
utilized the Pregnancy-STD prevention subscale from
the Sexual Assertiveness Scale (Morokoff et al, 1997).
The researchers found the following: (a) that 25% of the
variance of the instrument was accounted for by sexual
assertiveness, (b) that the condom influence strategy of
withholding sex made up 38% of the variance in sexual
assertiveness, and (c) that compared to men, women
employed direct request verbal strategies to negotiate
sex (Noar et al., 2002). Furthermore, direct request is a
form of sexual assertiveness.
The Noar et al.r(2002) study has increased the knowledge of how men and women sexually assert themselves
to negotiate condom use. The importance of the role of
sexual assertiveness in condom negotiation was also
highlighted. On the contrary, out of a total sample of
471 college students only 4% of the sample consisted
of African Americans. The small sample size of African
Americans makes it difficult to compare similarities and
differences between ethnic groups and within ethnic
groups.-HIV risk-related communication plays an integral role in a sexually active woman's level of sexual
assertiveness (Noar et al., 2002; Quina et al., 2000). First,
to decrease HIV risk, women must assert themselves by
communicating HIV risk with a sexual partner (Quina et
al. 2000). For example, direct request is a form of sexual
Journal of Cultural Diversity • Vol. 18, No. 4
assertiveness. Noar et al, (2002) found that compared to
men, women employed direct request verbal strategies
to influence condom use. Second, an important part of
sexual assertiveness and coiitmunication is negotiating
condom use. For instance, Wingood, Hunter-Gamble,
and DiClemente (1993) found that participants were
unable to negotiate actual condom use following initiating a discussion about condom use. Yet, Fullilove
et al.r(1990) found that sexual negotiation skills may
vary among women based on various factors. Bowleg,
Valera, Tefi and Tschann (2009) and Zukoski, Harvey
and Branch (2008) found that heterosexual couples to
include African Americans reported verbal and nonverbal communication in condom use. Bowleg et al. (2009)
reported that women were likely to communicate about
condom verbally, whereas men were more likely to
communicate less verbally. Wyatt (2009) proposed that
traditional HIV prevention programs promote assertive skills for self-protection and verbal communication
between partners to minimize risky practices.
Historically, African Americans nave a pattern of
indirect communication which was established during
slavery because direct interactions were prohibited during this period. In the African American population,
disclosing sensitive information may contradict the
African American cultural and religious values. In this
analytical review of the literature, Wyatt identified the
need for African Americans to redirect communication
skills, learn cultural congruent and conflict-resolution
techniques for clear, non-confrontational sexual and
health-related communication to confrontational health
related communication, learn to integrate factual information into sexual discussions and practice different
communication styles for different people. Therefore,
it is important to understand the sexual assertiveness
characterisfics of African American woman so that variations in sexual negotiation skills can be discovered and
implemented into HIV prevention and intervention.
Women with Low Sexual Assertiveness
Low sexual assertiveness
Assessing African American women's sexual assertiveness characteristics are important for reducing
the spread of HIV. Health professionals need to assess
and screen women for sexual assertiveness in diverse
healthcare organizations. The reason is that women
who are sexually unassertive are at risk for HIV infection. While conducting health and other psychosocial
assessment, health providers need to assess for low
self -esteem. In a study by Dolcini and Catania (2000)
women with risky sexual partners were more likely
to have low sexual assertiveness, less likely to refuse
unwanted sex, and more likely to never use condoms.
In like fashion to the Dolcini and Catania (2000) study,
a study of non- condom use among African American
women revealed that women who were not sexually
assertive were less likely to use condoms (Wingood &
DiClemente, 1998). Furthermore, a quantitative study
measuring thought avoidance related to contacting an
STD revealed that women with low sexual assertiveness
avoided thoughts of STDs, compared to women with
higher sexual assertiveness (Klein & Knäuper, 2003).
Sexually active women who have low sexual assertiveness and risky sexual partners are at risk for HIV
(Dolcini & Catania, 2000) because women who are not
Winter 2011
sexually assertive are less likely to use condoms (Wingood & DiClemente, 1998;.:. .
Wingood & DiClementè, 1997) and more likely to
avoid thoughts of contacting a STD (Klein & Knäuper,
2003). Accordingly, these stxidies demonstrated the need
for HIV prevention that teaches women sexual assertiveness skills. However, the sexual assertiveness scales
utilized in all of the studies (Dolcini & Catania, 2000;
Klein & Knäuper, 2003; Wingood & DiClemente, 1998)
limit the explanatory power of sexual assertiveness.
First, although Kirby's scale of sexual assertiveness (as
cited in Dolcini use"&" Catania, 2000) demonstrated an
acceptable Cronbach's alpha, the five- item instrument
only measured avoidance of unwanted sexual encounters. Second, in the Wingood and DiClemente (1998)
study, sexual assertiveness was measured with seven
questions that related only to demanding condom use.
Last, in the Klein and Knäuper (2003) study a modified
version of the Intimate Relationships Questionnaire was
administered. However, a more robust measurement
of sexual assertiveness is needed to capture the multifaceted sexual assertiveness characteristics of African
American women. Therefore, the Sexual Assertiveness
Scale (Morokoff et al., 1997), which measures information communication, initiation of sex, refusal of sex, and
pregnancy-STD prevention, was a more appropriate
instrument for this research study.
Another facet of sexual assertiveness is a woman's
right to assert herself. In a quantitative study of 904
Caucasian, African American, and Hispanic adolescents
and young adults, Rickert, Sanghvi, and Wiemann (2002)
explored the differences in women's perceived rights to
be sexually assertive. The results revealed that compared
to Caucasian women, African American and Hispanic
women were more likely to believe they did not have the
right to be sexually assertive (Rickert et al, 2002). Thus,
ethnic minority women demonstrated a lack of sexual
assertiveness. Another finding was that compared to
older women, younger women were less likely to ask
about a partner's STD test history (Rickert et al., 2002).
Next, women who had fewer sexual partners were less
likely to believe they had the right to be sexually assertive. Last, approximately 20% of. the sample believed
they did not have the right to be sexually assertive.
Whyte (2006) in a study of low income African American women (N=594), participants reported engaging in
sex to avoid being hurt in the future. Sex to avoid being hurt correlated with both sex to avoid relationship
loss and sex to avoid loss of shelter. These women had
sex not only to avoid harm, but also to maintain their
relationships and standard of living. Results of findings
may be because poverty was an overall patterning of
behavior most often in lower income, younger women.
Therefore, ethnic minority women may demonstrate a
lack of sexual assertiveness by perceiving not having
the right to be sexually asserfive (Rickert et al, 2002;
Whyte, 2006).
Sexual victimization
Healthcare professionals providing psychosocial,
interventions for African American females need to be
aware of the relationship of the risk factors of HIV/
AIDS, sexual assertiveness, and sexual victimization
(Stoner et al., 2008). Sexual victimization is another area
in which women have been found to have low sexual
Journal of Cultural Diversity • Vol. 18, No. 4
assertiveness. Some individuals living with HIV have
been reported in many cases to have had some type of
traumatic event during their lives and may develop
symptoms of posttraumatic stress disorder (PTSD) in
response to this experience (Brief et al., 2004). Numerous studies have reported women who experience less
sexual assertiveness are more likely to report sexual
victimization (Arya Behforoz, & Viswanath, 2009; Classen, Palesh & Aggarwal, 2005; Cohen et al., 2000; Fergusson et al., 1997; Morokoff et al., 2009; Wingood &
DiClemente, 1997).
First, in a quantitative study of protective and risk
factors of sexual victimization, sexual assertiveness was
found to be a protective factor (Greene & Navarro, 1998).
In addifion, prior vicdmization and low sexual assertiveness consistently predicted future victimization (Greene
& Navarro, 1998). Second, in a study of sexual coercion
and rape. Testa and Dermen (1999) found that compared
to women with higher sexual assertiveness women with
low sexual assertiveness experienced sexual coercion.
Next, in a study of sexual assault history and sexual assault risk, VanZile-Tamsen, Testa, and Livingston (2005)
found that women with a history of child sex abuse or
rape were lower in sexual assertiveness compared to
women without a history of sexual victimization.
Further, in a survey study of 497 college women,
Harlow, Quina, Morokoff, Rose, and Grimley (1993)
found that a previous history of child sexual abuse was
positively related to unprotected sex. In another study,
Whitmire et al., (1999) found a relationship between
childhood sexual abuse and little refusal of unwanted
sexual behavior. However, in the development and
validation of the Sexual Asserfiveness Scale (Morokoff
et al., 1997) childhood sexual abuse and adult victimization did not predict any of the variables on the Sexual
Assertiveness Scales. Yet, both were related to other
predictors of sexual assertiveness, such as sexual experience, anticipated negative partner response, condom
self-efficacy, and sexual self-acceptance (Morokoff et
al., 1997). Last, in a study of how women cope with
acquaintance sexual aggression, Macy, Nurius, and
Norris (2006) found that women with greater sexual
assertiveness were less concerned about being sexually
assaulted in an acquaintance relationship.
The small sample of African American women communicates little knowledge of the sexual assertiveness
characteristics of this population. Second, only the Macy
et al.7 (2006), Synovitz et al.; (2005) studies utilized the
comprehensive Sexual Assertiveness Scale (Morokoff
et al., 1997). On the other hand, the Testa and Dermen
(1999) study used the 10-item Health Protective Communication Scale and the Greene and Navarro (1998) study
used the Inventory of Personal Problems assertiveness
subscale, which both have acceptable Cronbach alpha
scores. However, these assertiveness scales may not
provide a comprehensive view of sexual assertiveness.
Women who are sexually unassertive are at risk for
HIV infection due fo numerous risk factors. These risk
factors include: (a) having risky sexual partners (Dolcini
& Catania, 2000), (b) being less likely to use condoms
(Wingood & DiClemente, 1998), (c) aVoiding thoughts
of STDs (Klein & Knäuper, 2003), (d) being more likely
to believe they do not nave the right to be sexually assertive (Rickert, Sanghvi, & Wiemann, 2002, (e) being at
risk for sexual victimization and sexual coercion (Greene
Winter 2011
& Navarro, 1998; Macy, Nurius, & Norris, 2006; Testa
& Dermen, 1999; VanZile-Tamsen, Testa, & Livingston,
2005) and (f) childhood sexual abuse and adult sexual
victimization (Harlow et al., 1993; Quinn et al., 1997;
Vanile-Tamsen et al., 2005). Women may experience low
sexual assertiveness for various reasons. These findings
illustrate the need for the incorporation of sexual assertiveness training in HIV prevention and interventions,
in addition to rape preventions and interventions.
RECOMMENDATIONS FOR IMPROVEMENT
The multifaceted model (Quina et al., 2000) is a useful
model in guiding research studies related to sexual assertiveness in African American women. Future studies
will be useful for healthcare professionals to provide
culture sensitive treatment to African American women
focusing on sexual assertiveness, in addition to identifying solutions in designing treatment programs.
Healthy People 2010 Initiative
Healthy People 2010 Initiative continues to address
the disproportionate impact of HIV/HIDS on minority
groups such as African American females. This initiative addresses numerous health promotion, disease
prevention and disease management strategies. They
are as follows:
1. Reducing death related to HIV / AIDS.
2. Increasing substance abuse treatment facilities
offering HIV/AIDS education, counseling and
support.
3. Reducing the number of new HIV/AIDS cases
by targeting drug injections.
4. Increasing the life expectancy of HIV-infected
person by the time of diagnosis until death.
5. Increasing the public funded counseling and testing sites that screen for common disorders related
to HIV/AIDS (CDC, 2010).
Healthcare professionals who work with African
American females with HIV/AIDS need to address
health promotion and disease prevention strategies.
Screening and assessment of this group will be useful in
identifying risk factors. In addition, case management
will be useful to promote compliance, continuity, and
continuation of treatment. Also, healthcare professionals may use diverse treatment modalities such as patient
education, counseling, group therapy, couple therapy,
and family therapy, focusing on sexual assertiveness in
decreasing the spread of HIV / AIDS in African American
females. Psychosocial strategies have been reported to
be effective in reducing the risk of HIV/AIDS (Crepaz
et al., 2009; Hein et al., 2010).
Assessing Common Risk Factors
Assessing common risk factor is vital when African
American women access care. Current studies reported
a link between substance abuse and HIV/AIDS in African American women (Cook et al., 2008; Cook et al.,
2009; Minkoff et al., 2008). Other studies have linked
depression and post-traumatic stress disorder (PTSD)
(Brief et al, 2004; Hein et al., 2010; Messman-Moore;
Brown, & Koelschu, 2005) with HIV/AIDS risk factors.
Common risk factors such as substance abuse, depression, and post-traumatic stress disorder need to be asJournal of Cultural Diversity • Vol. 18, No. 4
sessed and evaluated in the diverse health care system
accessed by African American women. Research studies
have reported sexual victimization in women linked to
continued substance use (Cook et al., 2008; Cook et al.,
2009; Minkoff et al., 2008). Treatment strategies need to
be geared toward (a) substance use (Brief et al., 2004),
(b) depression (DiC!lemente, Wingood, Rose, Sales,
Lang, Caliendo et al, 2009; Jipguep, Sanders-Phillips,
& Cotton, 2004), (c) victimization. (Morokoff et al., 2009;
Theall, & Sterk, 2004), and (d) PTSD (DiClemente et
al, 2009; Hein et al., 2010) focusing on assertiveness
training such as problem solving and negotiating condom use.
HIV prevention interventions
HIV /AIDS prevention interventions for African
American women need to design programs to address
the individual needs of this group, in addition to targeting risk factors (El-Bassel, Caldeira, Ruglass & Gilbert,
2009; DiClemente et al., 2009). These programs need to
take into consideration the unique life experiences of
African American females (El-Bassel et al., 2009). Current disease control programs among African Americans
have shown no significant changes (Williams, Ekundavo, Udezulu & Omishakin, 2003).
Ethnic, gender specific, cultural specific treatment.
Williams et al. (2003) conducted a study of African
American women examining the attitude, knowledge,
feelings and behavioral factors that affect the incidence,
mortality, and morbidity of HIV/AIDS in the urban and
rural communities in the United States. The level of
knowledge was higher among the urban subjects than
rural ones, their beliefs, attitude/feelings, and potential
for behavioral change did not differ significantly among
women in the two communities. The findings recommended (a) an ethnically sensitive and gender-specific
HIV / AIDS intervention program for African American
women and, (b) a more active involvement participation
of African American leaders, parents, and faith-based
communities for HIV/AIDS prevention and control.
In a study of African American women ages 18 to 50
(N=353), Theall and Sterk (2004) suggested programs
for women need to be cultural appropriate and gender
tailored and interventions geared toward enhancing
HIV prevention behavioral and decreasing victimization. Roundtree and Mulrancy (2010) reported ethnic
differences among African American, Mexican, and
Anglo women participating in focus groups whereas
the major theme arrived from these sessions identified
racial and ethnic differences in the language use when
communicating about sex to partners. However, their
experiences may have many similarities. In addition.
Cao, Marsh, and Shin (2008) identified that racial / ethnic disparities exist in HIV programs and suggested offering substance treatment to reduce HIV-risk behavior,
which include cultural competent service strategies.
Behavioral interventions. Behavioral interventions
have been effective in reducing the risk of HIV/AIDs
(Crepaz et al, 2009; Raiford, Wingood, DiClemente,
2007). Crepaz et al. evaluated the efficacy of HIV behavioral interventions for African American females in
the United States. A comprehensive literature review
of studies published from January 1988 to June 2007
consists of 37 relevant studies which were analyzed using mixed effects models and meta-regression. Results
Winter 2011
of findings reported that behavioral interventions are
efficacious at preventing HIV and STIs among African
American females. As a result of this comprehensive
analysis of studies, the researcher reported the importance of interventions efficacy in studies targeting
gender or cultural materials focusing on (a) female deliverance, (b) empowerment issues, (c) skilled training
on condom use and negotiation of safe sex and (d) roleplaying to teach negotiation skills. Raiford et al. (2007)
suggested HIV Interventions may enhance consistent
condom use among African Americans living with HIV
by targeting women's self-efficacy to communicate with
their partners and women's perception of personal and
partner-related barriers to condom use.
CONCLUSIONS
To conclude, there is a limited amount of research
of the sexual assertiveness characteristics of African
American women from all socioeconomic statuses and
education levels. Previous researchers have found that
African American women tend to display discomfort
with sexual assertiveness. More research is needed on
strategies for promoting sexual assertiveness of African
American women with future hopes of reducing HIV/
AIDS infections. Future studies need to utilize models
guiding research studies validating sexual assertiveness interventions in reducing the risk of HIV/AIDS
in African American women. In addition, more studies
need to address the link between sexual assertiveness,
victimization experience and HIV/AIDS in African
American females.
REFERENCES
Amaro, H., & Raj, A. (2000). On the margin: Power and women's
HIV risk reduction strategies. Sex Roles, 42 (7/8), 723-749.
Arya, M. Behforoz, H. L. & Viswanath, K. (2009). African American women and HIV/IDS: A national call for targeted health
communication strategies to address a disparity. AIDS Care,
19 (2), 79-84.
Bowleg, L. Valera, P. Teti, M. & Tschann, J. M. (2009). Silences,
gestures, and words: Nonverbal and verbal communication
about HIV / AIDs and condom use heterosexual relationships.
Health Communication, 25 (1) (80-90), 1532-7027.
Brief, D. J., Bollinger, A. R., Vielhauer, M. J., Berger-Greenstein,
Morgan, S. M. Buondonno, L.M. & Keane, T.M. (2004). Understanding interface of HIV, trauma, post-traumatic stress
disorder, and substance use and its implications for health
outcome (2004). AIDS Care, 16, 97 -120.
Cao, D., Marsh, J. & Shin, H. (2008). Gender and racial/ethnic
disparities in the impact of HIV prevention programming
in SAT. American Journal of Drug and Alcohol Abuse, 34, 730740.
Centers for Disease Control and Prevention (2010) Developing
healthy people 2020. Retrieved June 15, 2010, from http:/ /
www.cdc.gov / nchs / healthy_people.htm
Centers for Disease Control and Prevention (CDC). (2007a). HIV/
AIDS and African Americans. Retrieved from http://www.
cdc.gov / hiv / topics / aa / index.htm.
Centers for Disease Control and Prevention. (CDC) (2007b). The
impact on African Americans. Retrieved from http://www.
cdc.gov / hiv / topics / aa / affecting.htm
Center for Disease Control and Prevention (CDC) (2008). HIV
Prevalence Estimate- United States, 2006,15,1073-1076.
Classen, C. C, Palesh, O. G. Aggarwal, R. (2005). Sexual revictimization: A review of empirical literature. Trauma, Violence,
andAbuse. 6,103-129.
Journal of Cultural Diversity • Vol. 18, No. 4
Cohen, M., Deamant, C. Barkan, S., Richardson, J., Young, M.,
Holman, S, Anastos, K., Cohen, J. & Melnick, S. (2000). Domestic violence and childhood sexual abuse in HIV infected
women and women at risk for HIV. American Journal ofPublic
Health, 90, 560-565.
Cook, J., Burke-Miller, J., Cohen, M., Cook, R. Vlahov, D., Wilson,
T.E.,Golub, E.T., Schwartz, R.M., Howard, A.A., Ponath, C,
Plankey, M.W., & Grey, D.D. (2008). Crack cocaine, disease
progression, mortality in a multi-center of HIV-1 positive
women. AIDS, 22,1355-1363.
Cook, R. L., Zhu, E, Belnap, B. H., Weber, k.. Cook, J. A., Vlahov
D., Wilson, T.E., Hessol, N.A., Plankey ,M., Howard, A.A.,
Cole ,S.R. , Sharp, G.B., Richardson, J.L., Cohen, M.H.
(2009). Longitudinal trends in hazardous alcohol consumption among women with human immunodeficiency virus
infection, 1995-2006, American Journal of Epidemiology 169
1025-1032.
Crepaz, N., Marshall, K. J., Aupont, L. W., Jacobs, E. D., Mizuno,
Y, Kay, L. S. & McCree, D. H. (2009). The efficacy of HIV/STI
behavioral interventions for African American females in the
United States: A meta analysis. American Journal
of Public Health, 99(11), 2069-2078.
DiClemente, R. J., & Wingood, G. M. (1995). A randomized controlled trial of an HIV sexual risk- reduction intervention
for young African American women. Journal of the American
Medical Association, 274. (16), 1271-1276.
DiClemente, R. J., Wingood, G. M., Rose, E.S., Sales, J. M., Lang,
D., & Caliendo, A.M. (2009). Efficacy of sexual transmitted
disease/human immunodefiency Virus sexual risk-reduction intervention for African American adolescent females
Seeking sexual health service: A randomize controlled trial.
Archives Pédiatrie Adolescent Medical, 163 (12), 1162-1163.
Dolcini, M. M., & Catania, J. A. (2000). Psychosocial profiles of
women with risky sexual partners: The national AIDS behavioral survey (NABS). AIDS and Behavior, 4(3), 297-308.
El-Bassel, N., Calderia, Ruglass, L. M. & Gilbert, L. (2009). Addressing the unique needs of African American women in
HIV prevention. American Journal of Public Health, 99 (6)
996-1001.
Foreman, F. E. (2003). Intimate Risk: Sexual risk behavior among
African American College women. Journal of Black Studies
33(5), 637-653.
Ferguson, Y O., Quinn, S. C, Eng, E., & Sandelowski, M. (2006).
The gender ratio imbalance and its relationships to risk of
HIV/AIDS among African American women at a historical
Black colleges and universities, AIDS Care, 19 (4), 323-331,
Retrieved from the Academic Search Premier database.
Fullilove, M. T., Fullilove, R. E., Haynes, K., & Gross, S. (1990).
Black women and AIDS prevention: A view towards understanding the gender rules. The Journal of Sex Research, 27(1)
47-64.
Greene, D. M., & Navarro, R. L. (1998). Situation- specific assertiveness in the epidemiology of sexual victimization
among university women. Psychology of Women Quarterly
22, 589-604.
Hatcher, S. S., Burley, J. T., & Lee-Ouga, W. I. (2008). HIV programs
in the black church: A viable health promotion resource for
African American women. Journal of Human Behavior in
Social Environment, 27 (2), 100-105.
Hammonds, E. M. (1997). Seeing AIDS: Race, gender, and representation. In Goldstein, N. & Manlowe, J.L. (Eds.). The
gender politics of HIV/AIDS In women (pp. 113-126). New
York University Press.
Harlow, L. I., Quina, K., Morokoff, P, Rose, J. M. & Grimley, D.
M. (1993) A multifaceted model. Journal of Applied biobehavioral Research, 1 3-38.
Hein, D. A., Jiang, H., Campbell, A., Hu, M. C, Miele, G. M.
Cohen, L. R., Brigham, G.S., Capstick, C, Nunes, & Nunes,
E.V. (2010). Do treatment improvements in PTSD severity
Winter 2011
affect substance use outcomes? A secondary analysis from
randomized clinical trial in NIDA's clinical network. American Journal of Psychiatry, 167, 95-101.
Jipguep, M. C, Sanders-Phillips, K., & Cotton, L. (2004). Another
look at HIV in African American women: The impact of psychosocial and contextual factors. Journal of Black Psychology,
(30) 3, 366-385.
Klein, R., & Knäuper, B. (2003). The role of cognitive avoidance
of STIs for discussing safer sex practices and for condom
use consistency. The Canadian Journal of Human Sexuality,
12(3-4), 137-149.
Logan, T. K., Cole, J. & Leukefeld, C. (2002) Women, sex, and HIV:
Social and contextual factors, meta- analysis of published
interventions, and implications for practice and research.
Psychological Bulletin 128 (6), 851-885.
Macy, R. J., Nurius, P. S., & Norris, J. (2006). Responding in
their best interests: Contextualizing women's coping with
acquaintance sexual aggression Violence Against Women,
12(5), 478- 500.
Messman-Moore, T. I., Brown, A, L., & Koelsch, 2005). Posttraumatic symptoms and self-dysfunction of sexual revictimiza• tion. Journal of Traumatic Stress, 18 (5), 253-256.
Mize, S. J. S., Robinson, B. E., Blockting, W. O., & Schelterma, J. E.
(2002). Meta-analysis of the effectiveness of HIV prevention
interventions for women, AIDs Care, 14,163-180.
Morokoff, P. J., Quina, K., Harlow, L. L., Whitmire, L., Grimley, D.
M., Gibson, P R., & Burkholder, G. J. (1997). Sexual Assertiveness Scale (SAS) for women: Development and validation.
Journal of Personality and Social Psychology 73(4), 790-804.
Morokoff, P J., Redding, C. A., Harlow, L. L., Cho, S., Rossi, J. S.
& Meier, K. S. (2009). Associations of sexual victimization,
depression, and sexual assertiveness with unprotected sex:
A test of the multifaceted Model of HIV risk across gender.
Journal of Applied Behavioral Science. 14 (1), 30-54.
Minkoff, H., Zhong, Y, Strieker, H. D., Watts, D. H., Palefsky, J. M.,
Levine, A.M., D'sSouza, G., Howard, A., Plankey, M. Massad,
S. & Burk, R. (2008). The relationship between cocaine use
and human papillomavirus infections in HIV-seropositive
and HIV-seronegative women. Infectious Diseases in Obstetrics
and Gynecology, 2008:587082.
Noar, S. M., Morokoff, P J., & Harlow, L. L. (2002). Condom
negotiation in heterosexually active men and women: Development and validation of a condom influence strategy
questionnaire. Psychology and Health, 17(6), 711-735.
Onuoha, F. N. & Munakata, T. (2005). Correlates of adolescent
assertiveness and HIV avoidance in four- nation's sample.
Adolescence, 40 (138), 525-538.
Quina, K., Harlow, L. L., Morokoff, P J., & Burkholder, G. &
Deiter, P. J, (2000). Sexual communication in relationships:
When words speak louder than actions. Sex Roles, 42(7/8),
523-549.
Raiford, J. L., Wingood, G. M. & DiClemente, R. J. (2007). Correlates of consistent condom among HIV positive African
American women. Women & Health. 46 (2/3), p.41-58).
Reid, P T. (2000). Women, ethnicity, and AIDS: What's love got
to do with it? Sex Roles, 42(7/8), 709-722. Retrieved July, 9,
2006, from ProQuest Psychology Journals.
Rickert, V. I., Sanghvi, R., & Wiemann, C. M. (2002). Is lack of
sexual assertiveness? Among adolescent and young adult
women a cause for concern? Perspectives on Sexual and Reproductive Health, 34(4), 178-183.
Roundtree, M. A. & Multraney, M, (2010). HIV/AIDS risk reduction intervention for women who have experienced intimate
partner violence. Clinical Social Work Journal, 207-216.
Sanders-Phillips, K. (2002, May/June). Factors influencing HIV/
AIDS in women of color Public Health Reports, 1,117.
Synovitz, L. Herbert, E., Carlson, G., & Kelley, R. M. (2005). College students' sexuality education, sexual behaviors, and
sexual behavior intent. American Journal of Health Studies,
Journal of Cultural Diversity • Vol. 18, No. 4
20(1), 47-57. Retrieved from the Academic Search Premier
database.
Testa, M., & Dermen, K. H. (1999). The differential correlates of
sexual coercion and rape. Journal of Interpersonal Violence,
14(5), 548-561. Retrieved August 2, 2006, from the SAGE
Publications Database.
Testa, M., VanZile-Tamsen, C, & Livingston, J. A. (2007). Prospective prediction of women's sexual victimization by intimate
and nonintimate male perpetrators. Journal of Consulting and
Clinical Psychology, 75(1), 52-60.
Theall, K. L. & Sterk, C. E. (2004). Past and new victimization
among African American Female drugs users who participated in an HIV risk-reduction intervention. The Journal of
Sex Research. 44 (4), 400-407.
Stoner, S. A., Norris, J., George, W. H., Morrison, D. M., Zawachi,
T, Davis, K. C, & Hessler, D. M. (2008). Women's condom
use assertiveness and sexual risk-taking: Effects of alcohol
intoxication and adult victimization. Addictive Behavior, 33,
1167-1176.
VanZile-Tamsen, C, Testa, M., & Livingston, J. A. (2005). The
impact of sexual assault history and relationship context on
appraisal of and responses to acquaintance sexual assault
risk. Journal of Interpersonal Violence, 20(7), 813-832.
Whitmire, L. E., Harlow, L. L., Quina, K., & Morokoff, P J. (1999).
Childhood trauma and HIV: Women at risk. Philadelphia: Brunner/Mazel.
Wingood, G. M. (2003). Feminization of the HIV epidemic in the
United States: Major research findings and future research
needs. Journal of Urban Health: Bulletin of the New York Academy
of Medicine, 80(A), 67-76.
Wingood, G. M., & DiClemente, R. J. (1998). Partner influences
and gender-related factors associated with noncondom use
among young adult African American women. American
Journal of Community Psychology, 26(1), 29-51.
Wingood, G.M., & 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(6), 1016-1018.
Wingood, G. M. Hunter-Gamble, D., & DiClemente, R. J. (1993). A
pilot study of sexual communication and negotiation among
young African American women. Journal of Black Psychology,
19 (2), 190-203.
William, P B., Ekundavo, Udezulu, 1. E., & Omishakin, A. M.
(2003). An ethnically sensitive and gender-specific HIV / AIDS
African American women; A comparative study of urban
and rural American communities. Family and Community
Health, 26,108-124.
Whyte, J. (2006), Sexual Assertiveness in Low-Income African
American Women: Unwanted sex, survival, and HIV risk.
Journal of Community Heath Housing ,23(4) 235-244.
Wyatt, G. E. (2009). Enhancing cultural and contextual intervention strategies to reduce HIV/AIDS among African Americans. American Journal of Public Health. 99 (11), 1941-1945.
Zak-Place, J., & Stern, M. (2004). Health belief factors and dispositional optimism as predictors of STD & HIV preventive
behavior Journal of American College Health, 52(5), 229-236.
Zamboni, B. D., Crawford, I., & Williams, P. G. (2000). Examining
communication and assertiveness as predictors of condom
use: Implications for HIV prevention. AIDS Education and
Prevention, 12(6), 492-504.
Winter 2011
Copyright of Journal of Cultural Diversity is the property of Tucker Publications, Inc. and its content may not
be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written
permission. However, users may print, download, or email articles for individual use.