Theoretical Implications of Gender, Power, and Sexual Scripts for HIV Prevention Programs Aimed at Young, Substance-Using African-American Women

Abstract

HIV continues to be a major public health problem for African-American (AA) women, and the burden of new cases to our society is significant because each case is at risk of infecting others. Substance use worsens the risk of HIV transmission to AA women. We provide specific recommendations to move the concept of tailoring HIV prevention interventions for substance users forward by focusing on young, sexually active, substance-using AA women and applying a culturally relevant revision to existing theoretical frameworks to include the Sexual Script Theory and the Theory of Gender and Power. We encourage use of these theories to guide adaptation of interventions to demonstrate efficacy within this hard-to-reach population. Consistent use of theories designed to exploit powerlessness and sexual scripts as barriers to adoption of protective sexual behaviors has potential to permeate sexual and substance use networks among African-Americans. This recommendation is being made because this theoretical framework has not been used in HIV prevention interventions targeting young, sexually active, substance-using AA women.

Gender and race as correlates of high risk sex behaviors among injection drug users at risk for HIV enrolled in the HPTN 037 study

“…Future interventions that are tailored to AA women would benefit from adaptations that include strategies aimed at challenging unhealthy sexual scripts. Interventional adaptations are needed to encourage women to behave in ways that are in direct conflict with scripts by which they have grown accustomed (Mallory and Stern, 2000; Semaan et al, 2010), such as engaging in transactional sex and multiple sex partners, are imperative to reducing HIV risk (Hill et al, 2016).…”

“…However, few researchers have evaluated the impact of gender roles on ‘high-risk’ sexual acts (Wagstaff et al, 1995). Both the SST and TGP help to explain how the relationship between gender and sexual risk has relevance for injection drug-using populations (Hill et al, 2016). In particular, SST describes the process whereby sexual experiences establishes ‘normal sex’ scripts.…”

“…Scripts provide widely shared gender and culture-specific guides for sexual behaviors (Bowleg et al, 2015; Hill et al, 2017). They also offer a blueprint of predictable responses to sexual cues and dictate how men and women behave sexually (Hill et al, 2016; McLellan-Lemal et al, 2013; Roye et al, 2013;).…”

“…Stephens and Phillips (2005) led the focus of females' sexual script development research on AA women. Qualitative research has found that within sexual scripts among AA women, the power in the heterosexual relationship favors the man (McLellan-Lemal et al, 2013), supporting a dynamic where women may be vulnerable to the decisions made by her male partner (Hill, et al, 2017; Hill et al, 2016; Martyn and Hutchinson, 2001; McLellan-Lemal et al, 2013). This illustrates the intersectionality of the SST and TGP.…”

“…Few research agendas have explored demographic correlates of high risk sex behavior with a hypothesis that stems from a theoretical framework comprised of the SST and TGP (Hill and Andrews, 2017; Hill et al, 2017; Hill et al, 2016). In a study where 44 heterosexually active men and women aged 18-25 years were interviewed, men preferred recreational sex, valued sex over relationships, and sought out multiple sex partners, while women preferred sex in the context of commitment and monogamy and sought emotional intimacy and trust with sex (Masters et al, 2013).…”