Sexual Attitudes, Reasons for Forgoing Condom Use, and the Influence of Gender Power among Asian-American Women: A Qualitative Study

Background and purpose—HIV/AIDS prevalence among Asian-American Pacific Islanders (APIs) is low yet rapidly increasing. Prior research from other populations indicates that HIV risk behaviors are associated with specific adverse/risk factors including depression, drug use, history of child sexual abuse, and forced sex. However, no studies have explored the attitudes about sexual risk behaviors and condom use between API women with adverse experiences versus women without such experiences. This qualitative study compares descriptions of sexual history and condom use between the two groups of women.

HIV/AIDS [1]. Even though the rate of HIV/AIDS among Asian American Pacific Islander (API) women is low where this group comprises only 1% of the HIV/AIDS cases among women in the U.S. [2], there are two compelling reasons to study HIV/AIDS among APIs.
First, according to the Centers for Disease Control [2], while APIs have the lowest overall prevalence of HIV, the API population was the only group with a significant percentage increase in HIV (44%), compared to Black (11%), Hispanic (21%), and White (16%) populations [3] between [2004][2005][2006][2007]. Second, heterosexual contacts were the greatest reason for HIV transmission among API women. Specifically, between 2001 and 2008, the heterosexual transmission rate was 86% for API women, compared to 65% for white women, 74% for Black women, and 69% for Hispanic women [4]. Therefore, it is critical to understand the attitudes toward sexual behaviors and HIV/STIs as well as the reasons for forgoing condom use among API women.

Adverse experiences and risk factors of HIV among women
A number of research studies indicate that HIV risk behaviors among women are associated with certain adverse life experiences and risk factors such as depression, drug use, history of child sexual abuse, and forced sex. Specifically, Lehrer et al. found that in a nationally representative sample of adolescent females, a higher level of depressive symptoms was associated with higher odds of sexual risk behaviors including condom disuse and birth control disuse during their most recent intercourse, and having more than two sexual partners in the past year [5]. Brener et al. found through the National College Health Risk Behavior Survey that female students who had been forced to have sexual intercourse were significantly more likely to report a wide range of health-risk behaviors [6]. Illicit drug use was correlated with high-risk sexual behaviors. Female adolescents with a history of child sexual abuse were significantly more likely to have high-risk sexual behaviors including having had sex before the age of fifteen, having had more than two sexual partners, and having ever been pregnant [7].
Despite such evidence, there have been no empirical studies that investigate the attitudes towards sexual risk behaviors and reasons for not using condoms among API women who experience these types of adverse events. Hence, in the qualitative study presented in this article, among the sample of 24 sexually active API women who all reported being sexually active, 16 women were selected to participate in the study based on their histories of ever having a lifetime suicidal attempt, ever using an illicit drug besides marijuana, ever having been a victim of sexual abuse, or ever having been forced into having sex. For those who were never exposed to any of these 4 adversities, 8 women were categorized as a nonadverse group for control purposes. We are particularly interested in exploring the similarities and differences between women who belong to the adverse group and those who belong to the non-adverse group in regards to their descriptions of sexual histories, histories of condom use, reported reasons for not using condoms, and how gender power might have influenced their decisions to use condoms.

Conceptual framework
Theory of gender and power (TGP)-This study employs the Theory of Gender and Power (TGP), developed by Connell [8], in order to shed additional light on API women's vulnerability to HIV/STIs in the context of sexual inequalities and the gender and power imbalances experienced by API women. TGP emphasizes that sexual inequalities and gender and power imbalances are largely embedded within contextual factors characterized as societal and structural forces. TGP posits that three major structures comprise gender and sexual power: the sexual division of labor, the sexual division of power, and the structure of cathexis (social norms and affective attachments). These three structures are also rooted in the societal level (e.g., historical and sociopolitical) and the institutional level (e.g., families, school, and media). Applying this theory and the major structures addressed by the theory, Wingood and DiClemente examined HIV-related exposure, risk factors, and effective interventions for women. The identified risk factors included being an ethnic minority woman, poor assertive communication skills, poor condom-use skills, perceived invulnerability to HIV/AIDS, a history of depression and psychological distress, and conservative gender norms, cultural norms, and traditional beliefs [9]. Pulerwitz et al. found that gender-based power is a significant factor particularly among lower income Latina women's ability to negotiate safer sexual practices (Latinas with high levels of relationship power were five times more likely to report consistent condom use compared to women with low levels of relationship power) [10].
Unlike previous studies by Wingood and DiClemente, and Pulerwitz et al. who tested Black and Hispanic women for the association between the gender power and sexual risk behaviors, our recent study [11] focused on the gender power and sexual risk behaviors among Asian-American women. Using our survey data, we found that whether or not women perceived a high level of control in their relationships did not affect women's first sexual experience or safe sex practices. However, women who had lower perceived gender control were much more likely to be involved in anal sex, to have had multiple sex partners, to have experienced forced sex, and to have ever had potentially risky sexual partners. These results highlight the importance of targeting women who have lower gender power control and understand why and how lower gender power is associated with HIV risk behaviors. It is possible that Asian-American women with lower relationship power might have been exposed to some types of adversities in their pasts. Thus, exposure to the adversities may lower gender power, in turn resulting in a higher level of HIV risk behaviors. This article takes the next step in exploring the attitudes about sexual behaviors of a small sample of women who reported exposure to adversities (adverse group). We specifically compare their descriptions with descriptions from women who have not been exposed to the specific adversities (non-adverse group) in terms of their sexual histories, the reasons for condom use, and whether or not gender power is related to women's decision to use condom.

Research questions
This exploratory qualitative study compares the attitudes of 16 women who belong to the adverse group and 8 women who belong to the non-adverse group. Four research questions were addressed: 1. What were these women's prevailing attitudes about being sexually active?

2.
To what degree did this group of women use condoms or engage in other HIV risk behaviors during intercourse?

3.
What were the reasons for not using condoms?

4.
Are the gender-power dynamics described associated with decisions regarding condom use?
Responses are reported in a narrative form in order to capture the content, tone, and context of women's views about these issues.

Data collection
This is part of a larger mixed-methods study entitled the Asian-American Women's Sexual Health Initiative Project (AWSHIP), MA, US. The eligibility criteria to participate in the study included: (1) Women between the age of 18-35, (2) Un-married, (3) Self-identified as Chinese, Vietnamese, Korean, or a mix of these ethnicities, (4) A child of immigrants (1.5 and 2 nd generation), and (5) A current resident of the greater Boston area.
Women who met the criteria were invited for Computer Assisted Self-Interview (CASI) surveys. The survey took approximately 45-60 minutes to complete and the respondents received twenty dollars in compensation. Boston University's Institutional Review Board (IRB) approved all protocols and procedures. A total of 501 participants completed the Computer Assisted Self-Interview (CASI) surveys by July 2010. More specific data collection methods are available in our previously published articles [11].
In the survey consent form, participants were asked if they were interested in in-depth interviews, for which an additional thirty dollars was offered as compensation. Ninety nine percent of the women in the survey agreed to participate in the in-depth interviews. Out of the 501 survey participants, a sample of 16 women belonging to an adverse group and 8 belonging to a non-adverse group were selected to participate in in-depth in-person interviews of 60 minutes to 180 minutes. To conduct a comparative analysis between women who had adverse experiences and those with non-adverse experiences, we applied four criteria in our survey to discern the characteristics of the adverse group. These criteria were: 1) Ever having a lifetime suicidal attempt, 2) Ever using an illicit drug besides marijuana, 3) Ever having been a victim of sexual abuse, or 4) Ever having been forced into having sex. Women in the non-adverse group were composed of women who did not have any of these four experiences. These four criteria have been used in existing research to understand health risk behaviors [7,11,12].
Specifically, the study describes these women's perceptions about their sexuality, whether or not they used condoms, and reasons for their decision to not use condoms. Two investigators, including the principal investigator of this study, interviewed all 24 women. All interviews were audiotaped and then transcribed verbatim.

Data analysis and validation
To ensure the trustworthiness of the study and its themes, our analysis employed investigator triangulation and data triangulation [13]. For investigator triangulation, our team comprised of 5 trained researchers and research assistants who worked extensively to validate each other's data interpretations. Our process included 1) A system to review our data interpretation, and 2) Discussions to contextualize our interpretations and themes of our data.
In constructing a system, the members collaboratively developed a list of codes based on a preliminary analysis of the interview data. Based on these codes, the team members conducted open coding on transcripts that were preliminarily analyzed by another member using coding software called Atlas TI. Then, based on these open codes, the members used axial coding to further analyze and interpret the most relevant themes of the study.
In order to situate and contextualize our coding, the team members rigorously discussed and reviewed each other's inferences, summaries and interpretations in relation to the interview data. Such extensive discussions allowed the team to focus on the relationship between the codes from the analysis and the context of each interview participant. Efforts to ascertain trustworthiness, including a system of reviewing each other's analysis and rigorous discussions, were employed extensively in constructing our study's recognized categories and themes.
Lastly, data triangulation [13] was also employed where we validated our analysis using quantitative data as well as qualitative data. Given that we had survey data that were quantitatively analyzed and interview data that were qualitatively analyzed; we ensured the validity of our findings by comparing the two. Each subject's reported risk behaviors in the in-depth interviews were also verified using the survey data.

Results
The sample of 24 women was divided into two groups based on their adverse experiences: an adverse group (n=16) and a non-adverse control group (n=8). Thirteen women were Chinese, 5 were Korean, 1 was Vietnamese, and 5 were multi-ethnic. Thirteen women had at least completed high school, 7 had received a college degree, and 4 had completed graduate or advanced degrees.

Descriptions of sexual histories
Theme 1. Casual attitudes about sex among the adverse group-The most consistent themes in these interviews was that the women in the adverse group both had more complex sexual histories, were more likely to describe using alcohol and drugs when having sex, and also described these histories in a more casual manner compared to the nonadverse group. Specifically, 14 out of the 16 women in the adverse group compared to 4 out of the 8 women in the non-adverse group described using alcohol and illicit drugs when having sex. These 14 women also had significantly more complex sexual histories and were more likely to describe their sexual risk behaviors in a casual manner compared to the control group.
For example, one Korean woman from the adverse group describes her rationale for engaging in a casual "one night stand" as the physical attractiveness of the man, rather than an emotional trait, indicating that her sexual preferences were based on a short-term, immediate need.
Participant: "But now, [4 second pause] uh… I guess…like, if I were to do the, like one night stand, I would rather choose the guy with a better-shaped body." A Chinese woman in the adverse group describes the casualness of the sexual encounters that she has had with her partners. She explains her encounters not as relationships, but as one or two-night stands.
Participant: Umm, you know, I met them in high school, you know. And then the other two were my friend's boyfriend's friends and we just hung out with each other a lot and, you know, one thing led to another and there you go. Like it's like a one-nights stand or twonight stand or whatever. I wouldn't consider dating. We were just hanging out friends… Yeah, it's just like friends and like you hang out with a certain friend for long enough and like you're, you know, you're hanging out and you're single and you're like, "Oh, you're cute. Uh, let's just have some fun." [laughs] Another Korean woman in the adverse group takes a different approach in describing her sexual activities, and describes how she provided for herself financially through college and graduate school through pole-dancing, phone sex, and escort services jobs. Her explanation of the services that she provided was pragmatic and straightforward.
Interviewer: how did you get a job as a phone sex operator?
Participant: There was like-there are like websites with adult jobs, and that's… Interviewer: So you just call them?
Participant: So I called, and I was like, "Hi, umm, I can do a bunch of accents, and whatever."…And so, yeah, I did that for a while.
Interviewer: And you'd do that from home?

Participant: Yeah.
Interviewer: Or did you go to an office?
Participant: You can do it from home…Yeah, it was pretty cool.
She also explains that her relationships with partners were never monogamous and that she actively cheated on her partners.

Participant:
Cheated-all of them.
Interviewer: With who, like people you'd just meet?
Interviewer: Like hook up at…?
Participant: Hook up from bars, hook up with friends, yeah.
Interviewer: And then…And they were just one night kind of things?
A second Chinese woman from the adverse group explains her exposure to illicit drug use while engaging in sexual activities as a product of her first relationship. She also states that she has continued using illicit drugs while having sex: Interviewer: Mm-hmm, mm-hmm. Were you-does this-does this hap-like how often does that happen and was it when you guys were using together and then just kind of…?
Participant: It was back-umm, you know, just every now and then, sometimes, umm, we used to be really, really happy…Together and then we'd do that.
A third Chinese woman in the adverse group talks about her experience engaging in casual oral sex with multiple partners and that it may have been risky for her health.

Interviewer:
We started talking about relationships and then the sexual relationships but have you had a partner that was not, you were not in a relationship with?

Participant: Mm
Interviewer: And I guess how old were you when that happened and um…? On the other hand, the sexual histories from the 8 women in the non-adverse group are descriptions about a few longer relationships. One Chinese woman who has only been in two sexual relationships describes herself as both being extremely careful, and that her one sexual encounter outside a relationship was a bad choice.
Participant: "Umm, and I [chuckles], this is a little extreme, but I would ask them to take a test before I would-I would have sex with them. [laughs] Interviewer: Uh-huh. And so is this-so you would do this for, umm, people you are dating as well as people you're not dating?
Participant: Umm, I haven't really had much outside a relationship, just once, and it was kind of a bad decision, so-A multi-ethnic woman states that she has only been in long-term relationships.

Participant:
Yeah. I've always been in long-term relationships. I've only had two in my whole life…. But they were long, I don't-I'm not the type to date ar-I don't date around, I don't-I'm very like private, umm, you know. I mean that kind of happen like in the past, but I've always dated two guys and… Well regardless of what they've done in the relationship, I've always been faithful, I've always been good.
A Korean woman describes herself having a strong negative attitude about casual sex and her preference for sexual encounters that extend past immediate physical gratification.
Participant: Because-I mean, first of all, it's also because you don't want to be known as like the slut. You don't want to be like that and I think sex is more than just like physical pleasure now. Like you should share with someone you really care about or you at least know that they respect you and they know you. It should… [not] be with like a random, complete stranger that you don't know what they have, you don't know where they've been.
As the quotes show, women from the adverse group tend to have more casual attitudes toward sexual intercourses and women from the non-adverse group are more likely to view sexual intercourses within the context of longer term relationships.

Condom use
Theme 2. Inconsistent condom use for both groups-Women in neither the adverse nor the non-adverse groups reported consistent condom use. Specifically, only 6 out of the 16 women in the adverse group and 2 out of the 8 women in the non-adverse group reported having used condoms the last time they had intercourse. Analysis of the interview data did not show any differences between the adverse group and non-adverse group regarding consistent condom use.
First, a Chinese woman in the adverse group reports using condoms every time she engaged in sexual intercourse, responding to the question of "how often would you use condoms?" with: Participant: All-every single time we did it.
A Korean woman in the non-adverse group also states that she and her partner used condoms every time: Interview: Mm-hmm. Like how-how long into the relationship?
Participant: Six months, seven months.
Interviews: Uh-huh. Umm, so when you were-did you guys use a condom?
Another Chinese woman from the adverse group describes her history of condom use by stating that she "just [doesn't] do unprotected sex…that much anymore." On the other hand, another multi-ethnic woman in the non-adverse group states that she also chooses to not use condoms and that she did not use condoms in her past relationships.
Interviewer: And then all those three, you did not use condom?

Participant: Yep.
Interviewer: Oh. And then that was based on your decision as well, or-

Participant: Yeah.
Interviewer: It's because they didn't want to use.
Participant: Uh, no; it was consensual.
Hence, these quotes from women in both the adverse and non-adverse groups demonstrate that women in both classifications engaged in inconsistent condom use. These women also describe two key reasons for forgoing condom use: a "cleanliness rationale (the authors' definition)," and "trust in the context of monogamy." Reasons for forgoing condom use Theme 3. Cleanliness rationale for adverse group-We derived the concept of Cleanliness Rationale as our subjects' justifications for forgoing condoms. This rationale indicates that sexual partners are assumed to be "clean" from HIV or STIs and are thus perceived to be safe. Women in the study tend to perceive their partners to be "clean" when their partners were from familiar peer networks, from prestigious universities, seemed neat, or seemed to be the "bread winner." Thus, this rationale was used to prove that not using condoms was safe. The cleanliness rationale was a much more common theme among the adverse group in that 7 out of the 16 women in the adverse group of women used the cleanliness rationale as an argument behind decisions to forgo condom use. On the other hand, only 2 out of the 8 women in the non-adverse group used the cleanliness rationale.
One Chinese woman in the adverse group expresses a sense of safety ("no one has diseases") that she felt on a college campus.
Participant: Umm, I think most of the time when people think about hooking up with someone they don't think about like diseases or anything like that because… I guess 'cause we're in the same… at least on college campus I feel really safe. I feel like everyone in the community is like-like for some reason there's a sense that like no one has diseases, which I'm sure in untrue, umm, but it's just that sense of like being on a… like in a bubble world." Another Chinese woman from the adverse group assumes that her partners are clean because they are part of her peer network. Her logic exhibits a common pattern among the participants in that they perceive her peer networks to be clean or, in other words, at low risk to contracting HIV/STIs. With respect to the two women in the non-adverse group who use the "cleanliness rationale," one Chinese woman justifies her decision to not use condoms with her boyfriend whom she knew to be cheating by assuming that his partners would be clean. Based on the fact that her boyfriend attended an elite university, she assumes that all the other women that he may cheat with would be safe partners. Participant: Aren't really-yeah, aren't really as like-as pro-like promiscuous as-Theme 4. Trust due to assumptions of monogamy among the non-adverse group-While the "cleanliness rationale" is a common theme among the adverse group, "trust due to monogamy" is a predominant theme among the non-adverse group: 7 out of the 8 in the non-adverse group of women have at some points in their lives decided to not use condoms based on what they describe as trust established within monogamous relationships. One Vietnamese woman from the non-adverse group states that her decision to not use condoms or be concerned of her partner's sexual health was based on the fact that she had known him for some time, which led her to "trust" him. In a similar vein, a multi-ethnic woman in the non-adverse group also describes not using condoms based on her trust of her partner and herself. She frames her trust for her partner within the context of how she does not "[go] around a lot," meaning that she stays loyal and monogamous within her relationships. Her logic suggests that she assumes longer-term relationships to be monogamous and that not using condoms signifies one's tendency to stay monogamous.

Participant:
If you're someone that goes around a lot, then probably, but I usually like just stick with one person-Interviewer: Uh-huh.

Participant: You know what I mean?
Interviewer: I see. Monogamous relationship.
Another non-adverse multi-ethnic woman cites that forgoing condom use only comes from having a monogamous relationship. Much like the other subjects, she has strong convictions that she needs to know her partner's sexual history and to be exclusive with her partner. Therefore, condoms were only necessary when engaging in sex with lesser-known partners. Trust, she believes, was a prerequisite for deciding against condom use.

Participant:
Yeah, I'm confident with umm-I'll say like what I definitely want to use a condom, like 'cause-then also like, umm, recently with like this new guy that I've been seeing I say "Well you need to use one every single time, unless if I'm dating you exclusively, and it's been like a couple years, and no, you're not"-

Interviewer: Okay
Participant: "We're never gonna do it without a condom" type of thing.

Gender power dynamics and condom use
Both the adverse and non-adverse groups of women talk about joint or independent decisions on condom use. Specifically, 12 out of the 16 women in the adverse group and 8 out of the 8 in the non-adverse group report either that they themselves were actively choosing whether or not to use condoms or that the choice was consensual. However, 4 out of the 16 women in the adverse group show the lower gender power levels reflected in how they describe decision-making regarding condom use. These 4 women describe that their sexual partners made decisions about condom use and that these women accommodated to their partners' choices.
Joint or independent decisions among the adverse and non-adverse group One of the Chinese women in the adverse group explains how using condoms was her independent choice regardless of her partner's preference. The other women in the adverse group decided to forego condom use once they felt more comfortable with their sexual partners. Another Chinese woman explains how using a condom seemed unnecessary once she was in a relationship.

Interviewer:
Okay. And what was the, I guess, what were y-what was the thinking behind, I guess, stopping the-the condoms or the barrier protection?
Participant: Umm, it was just, you know, I trusted him more and it was more familiar and I didn't think it was necessary to use a condom.
The decision to forgo condom use based on an independent or joint decision among the nonadverse group is even more pronounced than among the women in the adverse group. All 8 women in the non-adverse group who have ever forgone using condoms express that they decided to forgo condom use either independently or jointly with their partners. A Chinese woman describes how she and her partner came to the decision to not use condoms together. She expresses ease in bringing up the topic of condom use or sexual health with her partner.
Participant: mm, we did so I was on birth control but at first we decided to try to use, umm, like contraceptives in terms of condoms but then we stopped doing that.
Interviewer: Uh-huh. Can you tell me why you, uh, stopped using them?
Participant: Umm, I think, yeah, just the idea of like the physical, umm, how that feels.
Interviewer: Mm-hmm, and is that more on your part or on his part about how it feels, or both?
Interviewer: Mm-hmm. So it was-okay. Okay. Umm, and when you-okay, let me see. Did you guys have discussion about like past partners or getting-Participant: Umm, we did a little bit, not too much. Umm, I mean, I did definitely ask him about whether he's been tested and when that was.
Another common pattern is that women consensually decided to not use condoms after having been in a relationship for a long time. Another Chinese woman from the non-adverse group states that she decided to discontinue using condoms after she had been in a relationship with her partner for half a year.

Participant: But we would use protection [condoms] for-
Interviewer: Mm-hmm.
Participant: Until like-it was very far along in the relationship when I stopped using, but I would still take oral contraceptives.
Interviewer: Mm-hmm. S-so then, okay, so you would use protection. And how long did you-you said until you were further along in the relationship. How, I guess-

Participant:
It was like half a year or something.
From her statements, it is unclear whether the decision to not use condoms was made jointly or independently, but she speaks with great agency when she says, "I stopped using." Hence it implies that she had power in deciding to not use condoms. A Korean woman from the non-adverse group speaks of her independent decision to only have sex when her boyfriend is wearing a condom. She describes the decision making process about condom use in the following manner: Interviewer: Okay. Umm, what is it like to talk about using a condom with-with this last boyfriend? How did-Participant: Oh, it wasn't even like a talk because of we-it was an obvious choice. Like, it wasn't even a debate. It was like, "If you're not-if you don't have a condom, we're not having sex." Interviewer: Umm, I'm also curious about how you guys made decisions.

Participant: Umm, decisions-like sexual?
Interviewer: Umm, well both sexual as well as in general.
Participant: Umm, I mean, we talk a lot. He knows exactly what I'm thinking and I know what he's thinking and, umm, communication.
Interviewer: Like you said you both like to be in the driver's seat.

The partner as the decision maker
The common theme among 4 of the women in the adverse group is that they experienced a heightened sense of anxiety in bringing up the issue of safe sex, and thus were more likely to let their partners dictate condom use or to forgo condoms to please their partners. One Chinese woman regrets giving into her partner's wishes to not use condoms.
Participant: Inside relationships, um… [pause] you know, sometimes people would say… you know, let's just do it for a little bit without a condom. Um, and I'm mad at myself but sometimes I would say "Okay, as long as you weren't… finishing inside of me without a condom." Again like, I wish I had been more… [sigh] I guess, confrontational or I-I just, I wish I had stood up for myself more. Um… 'cause I felt like I definitely let them take at least a little bit advantage… um, of me in those sort of situations. Um… Interviewer: So they just didn't want to wear it because it didn't feel comfortable to them?
Participant: Yeah, like they just-it was never, they never gave me a reason besides they just didn't really like it.
In the same interview, she goes on to describe her discomfort with bringing up the topic of condom use in fear of her partner's reaction to the topic. Thus she yielded the decisionmaking power to her partners in the condom usage. Another Chinese woman also describes not using condoms because her sexual partner didn't enjoy using them. During the intercourse, she wouldn't ask her partner to use condoms because she was concerned that it may turn him off. She was insecure about her relationship with her sexual partners and sought validation from the partner through accommodating to his desires. In doing so, she focused on his desires and wishes more than her own, ultimately letting her sexual partner be the sole decision maker. She says: These last quotes suggest that unlike the majority of women in both the adverse and the nonadverse groups, a small number of women in the adverse group (n = 4) often chose to not use condoms in order to please their partners, and let their partners to be the sole decision makers about deciding condom use during sexual intercourses.

Discussion
This qualitative interview study with a small sample of young Asian-American women describes these women's sexual attitudes, the extensiveness of HIV risk behaviors, condom use, reasons for not using a condom, and how gender power issues were associated with some of the women's decision to use a condom. This study also illustrates the similarities and differences of above descriptions between two groups of women: women who had specific adverse life experiences (ever having a lifetime suicidal attempt, ever using an illicit drug, ever having been a victim of sexual abuse, ever having been forced into having sex) and women without these adverse experiences. Notably, the two groups show clear differences in attitudes toward sex and reasons for forgoing condoms. First, with respect to the women in the adverse group, 14 out of 16 women in the adverse group reported having a number of casual sexual encounters, and used words to describe their sexual history such as "hooking up" and "one-night stands" which they put in the contexts of college, meeting people after work, on vacation, with friends, and while using illicit drugs or alcohol. None of the 8 women in the non-adverse group described their sexual history in this manner.
Second, inconsistent condom use was another theme, and for this theme women in both groups reported inconsistent condom use. However, the reasons between the two groups with respect to why condoms were not used during intercourse were vastly different. While the adverse group uses the "cleanliness rationale" to justify not using condoms, the nonadverse group did not use condoms when they felt that the relationships were stable and trustworthy. The cleanliness rationale used among the adverse group was strongly connected to the ideal image of their romantic partners and the women's assessments of their partners being "clean," and led to assumptions of disease-free partners. For these participants, a "clean" boyfriend not only indicate not being exposed to sexually transmitted diseases but also academic success (attending Ivy League schools), neatness: "if they seem pretty clean cut, or you know… not a complete slob," "a future breadwinner," and acceptance by Asian immigrant parents-interviewees' pervasive desire to please their parents.
In regard to the theme of "trust based on assumption of monogamy" among the non-adverse group, condoms were used initially, but after having been in a relationship for a certain period of time (women in this study used time periods ranging from 3 months-2.5 years), a decision was made to not use condoms anymore. This theme of trustworthiness as a reason for not using condoms was also found to be an important factor in Chin's qualitative study [14]. Similar to our finding, Chin discovered that the amount of time spent with a sexual partner reduced the motivation and effort to engage in safer sex behaviors, and this may be because levels of familiarity, intimacy, and comfort with sexual partner increase over time. However, our study clarified that this pattern of association between trust based on the assumption of monogamy and forgoing condom use was more pronounced among the nonadverse group as a strategy to help establish a potentially serious relationship. Considering young women's strong needs to build trust within the relationship, HIV preventive program should include continuous risk assessment based on open and candid communication with partners that also promotes trust and comfort within the relationship.
The gender power dynamics that influenced the sexual decision making process for one fourth of the women in the adverse group was another important finding. For 4 out of 16 women in the adverse group, decisions about using condoms seemed directly influenced by their romantic partners' wishes and comfort levels. These women also felt reluctant to have direct sexual communication and negotiation with their partners. Specifically, their desires to please their sexual partners and the fear of rejection were discussed as key reasons for why condoms were not used. It is important to highlight that not all the women in the adverse group showed lower gender power dynamic within the relationship that led to the forgoing condom. However, the women who had lower gender power in the adverse group were much more willing to accommodate for their partners sexual needs despite the women's awareness of potential risks. This may have occurred because this particular group of women may require greater needs for security, approval, and affirmation from their partners. This finding is similar to Corbett's study in that women who were at "high risk individuals" defined by those who had illicit drug users, partners of injection-drug users, and commercial sex workers had little desire or interests to use and insist condoms within the relationship, at the cost of their health [15]. Collectively, our study finding and Corbett's study suggest that women who had more adverse life histories were more likely to participate in a range of risk behaviors despite their awareness of potential harm.
Our study has the following limitations in regards to the data. First, we used small and nonrepresentative samples of women to do the qualitative inquiry. Because of the small sampling size, the meaningful ethnic comparison of sexual risk behaviors is not feasible. Specifically, it would appear that Chinese women are at higher risk for adverse sexual behaviors and attitudes towards sexual encounters; however, it is important to note that we had disproportionately higher numbers of Chinese women in both the adverse (10 out of 16) and the non-adverse groups (3 out of 8). Thus, ethnic comparison of sexual behaviors between these ethnic groups is inconclusive. However, we have documented ethnic differences of HIV risk behaviors in our previous quantitative study based on the survey data from 400 API women (Korean = 81, Vietnamese = 71, Chinese = 220, mixed-ethnic = 28) [16]. Among the four HIV risk behaviors in this study, there were no differences between these ethnic groups of women in ever having had anal sex and having sex before the age of 17. Among the four HIV risk behaviors studies, there were no differences between these ethnic groups of women in ever having had anal sex and having sex before the age of 17. However, with respect to ever having had sex with a potentially risky partners and having had more than one sex partner in the past 6 months, women who were multiethnic were at a statistically significant higher risk compared to Koreans.
Second, the respondents are part of a larger study using a convenience sample of Asian-American women. Third, since we had more women in adverse group (n = 18) than nonadverse group (n = 8), the comparison was not well balanced. Finally, the samples were drawn from Massachusetts in U.S. therefore; it is not reasonable to generalize the findings to all Asian-American women in the U.S. Despite the above limitations, this is the first study targeting 1.5 and 2nd generation of Asian-American women (women who immigrated when they were children or adolescents or were born in the U.S.), that suggests that there may be critical differences in the sexual attitudes, sexual risk behaviors, reasons for condom use, and the influence of power dynamics between women who have experienced specific adversities in their life compared to those women who have not had these experiences.
Given the casual attitudes about sex among the adverse group, and a small number of women who relied on their partners to make decisions about condoms, women in the adverse group may potentially be at higher risks of HIV. However, the consistent theme among the women in both groups was that they were highly inconsistent about using condoms and therefore both groups of women are at risks of HIV/STIs. This finding suggests that HIV intervention for Asian-American women needs to address the general population rather than to target only the adverse group.
This study raises several important questions for future studies. First, considering the vastly different attitudes, reasons for forgoing condom use, and gender power levels between these two groups; are Asian-American women with HIV/STIs more likely to have experienced the adversities focused on in this paper? Second, are there differences within ethnic groups among Asian-American women with respect to the relationship between having a history of