Print version ISSN 0034-7450
rev.colomb.psiquiatr. vol.39 suppl.1 Bogotá Feb. 2010
Drugs, Women and Violence in the Americas: U.S. Results of a Multi-Centric Pilot Project (Phase 1)
Drogas, mujeres y violencia en el continente americano: resultados de un proyecto piloto multicéntrico en Estados Unidos (Fase 1)
Rosa María González-Guarda1
1 Ph.D., M.PH., R.N., C.PH. School of Nursing and Health Studies, University of Miami. Coral Gables, FL, USA.
2 Dr PH, RN, FAAN. School of Nursing and Health Studies, University of Miami. Coral Gables, FL, USA.
3 Ph.D. Social Solutions International, Inc. Silver Spring, MD, USA.
Conflicto de interés: los autores manifiestan que no tienen ningún conflicto de interés en este artículo.
Correspondencia Susanna Nemes Social Solutions International Suite 201 8070 Georgia Avenue Silver Spring, MD 20910 Estados Unidos firstname.lastname@example.org
Recibido para evaluación: 16 de mayo del 2010 Aceptado para publicación: 5 de agosto del 2010
Objectives: To explore the collective and individual experiences that Latin American females in the U. S. have with substance abuse, violence and risky sexual behaviors. Methods: This study was conducted in two phases that were carried out from July 2006 to June 2007 in south Florida. This paper covers Phase 1. In Phase 1, focus groups were conducted among 93 women in English, Spanish and Portuguese. Through content analyses of the focus group transcriptions, major themes were identified. Results: Participants identified substance abuse, violence and risky sexual behaviors as closely related problems of great concern in Latina women in the U.S. Three important themes emerged from the focus groups. These included "Living in the US and the Devaluing of Latino Culture," the "Vicious Cycle of Abuse" and "Breaking the Silence". Conclusions: The results from this study suggest that substance abuse, violence and HIV should be addressed in an integrative and comprehensive manner. Recommendations for the development of policies, programs and services addressing substance abuse, violence and risk for HIV among Latinos are provided.
Key words: Substance abuse, violence, sexually transmitted diseases, HIV, women.
Objetivo: explorar las experiencias colectivas e individuales que mujeres latinoamericanas experimentan en los Estados Unidos en relación con el abuso de sustancias, violencia y conductas sexuales de riesgo. Métodos: el estudio se realizó en dos fases que se llevaron a cabo entre julio de 2006 y junio de 2007 en el sur del estado de la Florida (Estados Unidos). Este documento recoge la Fase 1, en la cual se llevaron a cabo grupos focales entre 93 mujeres, en inglés, español y portugués. A través de análisis de contenido de las transcripciones del grupo focal, se identificaron los principales temas. Resultados: Los participantes identificaron el abuso de sustancias, violencia y conductas sexuales de riesgo como problemas íntimamente relacionados de gran preocupación en las mujeres latinas en los Estados Unidos. Tres importantes aspectos surgieron de los grupos focales: "Vivir en los Estados Unidos y la devaluación de la cultura latina", el "círculo vicioso del abuso" y "rompiendo el silencio". Conclusiones: Los resultados de este estudio sugieren que el abuso de sustancias, violencia y VIH debe abordarse de una manera integrada y global. Se dan recomendaciones para el desarrollo de políticas, programas y servicios referidos a abuso de sustancias, violencia y riesgo de VIH entre los latinos.
Palabras clave: Trastornos relacionados con sustancias, violencia, enfermedades de transmisión sexual, VIH, mujeres.
Globalization is changing the demographics of the U.S., making the Hispanic/Latino population in the U.S. an important group to target when addressing the health of the Americas. Being the nation's new biggest minority, Latinos make up 13.3% of the U.S. population, a proportion of the U.S. population that continues to rise as a result of higher birth rates and immigration (1). In fact, as predicted by the United Stated Census Bureau, by the year 2050, one out of every four persons in the United States will be of Hispanic ethnicity (1). Latinos are far from being a homogenous population, having diverse cultural and historical backgrounds, languages, immigration patterns, acculturation levels, and a host of other social, cultural and political factors that influence their health. For this reason it is important to study and compare various Latino populations found throughout Latin America and the United States, particularly those targeting Latino women. This paper summarizes the research related to substance abuse, violence and HIV among Latinas in the U.S., summarizes findings of a qualitative study exploring the experiences of Latino women in the U.S. with regards to these conditions (2) and provides recommendations to governments, researchers and service providers.
In the 2004 National Survey on Drug Use and Health, it was noted that substance abuse and dependence among Latinos in the U.S. (9.8%) were higher than whites (8.3%) (3). Similarly, reported alcohol use among Latinos (40.2%) was higher than that reported by other ethnic minority groups including Asians (37.4%), Blacks (37.1%) and American Indians or Alaskan Natives (36.2%) (3). Although there is a higher rate of substance abuse among Latino men when compared to their female counterparts, Latinas from lower socioeconomic backgrounds have two to three times higher substance abuse rates than Latinas with a higher SES (4). Additionally, Latinas are indirectly affected by their partner's substance abuse because of its close association with IPV perpetration and HIV risk behaviors (4,5).
A great deal of what is known about substance abuse among Latinas has been taken from studies including various racial/ethnic groups in the U.S. In a study conducted by the Substance Abuse Mental Health Service Administration (SAMHSA) between 2002 and 2003 surveying women with a history of abuse and cooccurring substance abuse and mental health disorders, it was found that almost half of the women reported serious physical illnesses that frequently restricted their activities of daily living and required them to use assistive equipment (3). Women also rated their health status as only fair or poor (6). Research specifically targeting Latinos have documented the impact that level of acculturation to the U.S. culture has on the use of alcohol and/or drugs. In fact, U.S.-born Latinos report higher rates of drug use/abuse and dependence than Latinos that are non-U.S. born (7). Others have also noted that substance abuse places Latinas at risk for intimate partner violence (IPV) and HIV (4,5).
Various intervention studies have targeted Latinos, some of which have been proven to be effective in preventing substance abuse and increasing protective factors among participants. However, to date there have been very few randomized control trials evaluating substance abuse interventions specifically targeting Latinas (7), especially in the area of prevention Studies that aim to develop prevention interventions targeting substance abuse among Latinas are urgently needed.
There is conflicting evidence indicating whether Latinas experience higher rates of intimate partner violence (IPV) than other racial and ethnic groups. While the U.S. Department of Justice's Bureau of Justice Statistics (1) reports no significant difference in intimate partner victimization between Hispanic and non-Latinos, the Violence Policy Center's Latinos and Firearm Violence Studies (8) reported Latinas in intimate relationships had the highest rates of domestic violence when compared to other ethnic/racial groups in the U.S. In this study, while white women had a domestic violence rate of 117 per 1,000 couples and blacks had a rate of 166 per 1,000 couples, Latinos had a rate of 181 per 1,000 couples (8). In a more recent study reporting on the five year course of IPV among a nationally representative sample of married and cohabitating White, Black and Latino couples in the U.S., Latinos and Blacks were found to experience more than twice the incidence of IPV (each 14%) than Whites (6%), even controlling for socioeconomic variables. Over the five year period, Latino couples also experienced a higher reoccurrence rate of IPV (58%) than Blacks (52%) and Whites (37%) (9). Differences in these statistics may be the results of methodological differences in screening for IPV and differences in risk factors and reporting behaviors found among the different Latino groups sampled.
Studies examining violence among Hispanic women have traditionally focused on screening for IPV and barriers to reporting abuse (10-13) rather than specific factors that may be associated with an increased risk. Those that have focused on risks have documented the relationship between violence, depression, substance abuse and risky sexual behaviors. For example, in a study examining the relationship between substance abuse, mental health and IPV, perpetrators were 2.5 more likely to report heavy drinking and more than 4 times more likely to report other drug use than nonperpetrators (14). Although IPV victimization was only predicted by depression, the perpetration of IPV was predicted by depression, heavy drinking and illicit drug use (14). Others have noted that substance abusing men reporting being abusive to an intimate partner are 2.6 times more likely to have sex with an injection drug user, almost three times more likely to have unprotected anal sex, and 4 times more likely to have more than one intimate partner and than their counterparts (15). Alcohol abuse, illicit drug use and risky sexual behaviors have also been documented in victims of child abuse (16).
There is little research supporting the efficacy of interventions focused on the prevention and treatment of family violence and IPV among Hispanics. Moreover, the majority of the existing family and intimate partner violence programs have focused on the batterers, which have found to only have a modest or little effect in preventing future abuse (17). Research aiming to develop prevention of child, adult and partner abuse among Latinos is urgently needed.
HIV/AIDS disproportionately affects Latinos in the U.S. Although Latinos represent only 14% of the total U.S. population, Latino adolescents and adults accounted for 18% of the new HIV infections in 2004 and 19% of AIDS cases since the beginning of the epidemic. In fact, in 2004 the HIV incidence rate for Latinos (2.5 cases per 100,000) was almost three times the rate for whites (7.1 per 100,000) (18). When AIDS rates are stratified based on gender, Latinas are found to experience the biggest disparity. In fact the AIDS rate among Latino females (12.2/100,000) is six times that of white females (2.1/100,000) (19).
Latinos are also disproportionately impacted by HIV/AIDS mortality. A smaller proportion of Hispanics (72%) are alive at 9 years after their diagnosis than whites (74%) and Asians (81%). While HIV/AIDS is the firth leading cause of death for white women between the ages of 35 to 44, it is the fourth leading cause of death among Latinas within this same age category (19).
Various research studies have targeted HIV among women. These have documented the devastating effects that a diagnosis has among women. In fact, females with HIV suffer from poorer psychosocial outcomes when compared to their male counter parts (20), have a high prevalence of anxiety, depression, and suicidal ideation (21), and experience impaired functional status after being diagnosed with the disease (22). However, few of these studies have specifically focused on Latino women. Although a few promising HIV prevention interventions have been developed for specific Latino groups such as Puerto Rican and Mexican women from the inner-city (23) and adolescent youth (24), it is unknown if these are efficacious with other Latino groups. More research is needed to develop and/or modify existing promising HIV prevention programs to target Latinas from varying countries of origin, ages, acculturation levels and demographic areas in the U.S.
This pilot project was part of a multi-centric research project including various countries in Latin America and the U.S. The study was conducted in two phases and utilized both qualitative (phase one) and quantitative methods (phase two) to gather data on the experiences Hispanic women in the U.S. have with substance abuse, violence and risky sexual behaviors. This paper reports on the results from the first, qualitative phase of the project, which included 9 focus groups with Spanish speaking and Portuguese speaking Latinas.. The results of the Spanish speaking focus groups have been reported elsewhere (2). However, a more detailed description of the perspectives Spanish speaking Latinas provided in these groups (n=8), which includes additional quotes supporting the central themes, and the results of the Portuguese speaking focus group (not published previously) are provided in the subsequent sections.
Sample & Setting
In order to be eligible for the study, participants had to be women of Hispanic/Latino decent, Spanish, English or Portuguese speaking (according to country) and between the ages of 18 and 60. Non-Brazilian study participants (n=81) were primarily recruited from a community agency in Broward County, where they were recruited with flyers. Additional participants from the Dade and Broward counties were recruited through an article in the local newspaper that described the study and provided readers with contact information and through snowballing sampling methods in where participants encouraged their friends and relatives to also participate. CICAD/OAS (Inter-American Drug Abuse Control Commission, Office of American States) and SENAD (National Anti-Drug Organization in Brazil) required that we purposely recruit and enroll 10 Brazilian women into the study. This component of the sample (n=10) was recruited by a Brazilian research assistant who placed flyers in Portuguese at Brazilian grocery stores and businesses and approached perspective participants in these areas.
Phase One Methodology
In the first phase of the study, focus groups were used to explore the collective experience that Latinas have with substance abuse, violence and intimate relationships. The goal of this first phase of the study was to gain insight into the unique experience that Hispanic women in the U.S (or country of interest) have with substance abuse, violence and sexual relationships.
Analytical Methods-Phase 1 (Qualitative Data)
Nine focus groups with 7 to 12 participants were conducted (N=93). Eight of these were conducted in Spanish (n=81) and one of these in Portuguese (n=12). The focus groups were transcribed, translated and analyzed using content analysis (25). Because the purpose of this study was to describe the experiences of Latina women with substance abuse, violence and HIV risk behaviors from an "emic" perspective, the qualitative approach to content analysis was taken. Six investigators reviewed the 7 of the 8 Spanish focus group transcriptions transcripts (N=72) making sure that each focus group transcript was analyzed by two investigators and that every investigator analyzed two or more transcripts to assist in reliability of the results (26). After reviewing and coding the transcripts, the investigators met to discuss their findings and come to a consensus about the major themes that emerged. The last focus group, the Portuguese focus group, was reviewed by one coder, following the same steps for content analysis provided above, after the original six coders met to discuss the themes of the Spanish focus groups. The results from this analysis will be reported separately because different themes emerged and warrant special attention.
Results and Analysis
Qualitative Results of Spanish Focus Groups
The participants of the study were diverse in terms of country of origin, socio-economic status and years living in the U.S. They represented almost all the countries in Latin American, had various occupations ranging from housekeeping to attorneys and church ministers, and had lived in the U.S. from a few months to their entire lives (see Table 1 and 2 for demographic details). These demographics are characteristic of the Hispanic population living in the Miami geographic area. Three central themes emerged from the analysis. These included "living in the US and the devaluing of Latino culture, "the cycle of abuse," and "rompiendo el silencio-breaking the silence." Various categories were embedded in these themes. Within the overarching theme of living in America, participants described the impact that immigration had on the family, how the more liberal American values influenced the upbringing of their children, how they struggled to maintain their culture and how their lives were plagued with various forms of discrimination. Within "the vicious cycle of abuse," participants discussed various types of abuse, their causes and risk factors, difficulties in obtaining help, how self-esteem was an important component of this cycle and various facets of the cycle itself. The last theme, "breaking the silence," was characterized by participants by the importance of obtaining information about rights and services in the community, the role that paying attention to oneself played in breaking the silence, the value of communicating with partners, children and friends about violence, substance abuse and sex, the value of breaking cultural norms and taboos and the significance that support played in the process of "breaking the silence" (2).
Living in the United States & the Devaluing of Latino Culture
Participants provided detailed descriptions of their experiences immigrating to the U.S. and the familial impact. Among the factors that impacted the family was a struggle to preserve their traditional cultural and family values amidst a society where their work responsibilities challenged the time they dedicated to their families. As one woman described:
"In this country, there is no time for them [ the children] , it's not like before. In spite of the fact that in our countries we live bad, we didn't have that work, that pay from work, but it was different. It terminates the responsibilities that parent have with their children."
Focus group participants repeatedly spoke about how children in their countries of origin were more respectful than American kids and the importance of maintaining one's own culture.
In addition to the struggle described in trying to maintain one's culture, participants described the discrimination they faced because of not speaking English. They also felt discrimination at work. Many were professional in their origin countries and had to assume service jobs such as housekeeping because of not speaking the language and how they felt discriminated against because of this experience. As one women said, "...majority of us are professionals in our country that here in this country if we do not speak English, we are nothing. people working, people like lawyers, engineers, these people are working in construction or in the cleaning industry... totally changed their lives not because they want more or less, no, simply because of their language. That is why there is discrimination against us."
The Vicious Cycle of Abuse
Of the three conditions addressed, Spanish speaking participants focused most of their attention on IPV and spoke about substance abuse and HIV risks as risk factors and consequences of victimization. Personal experiences with physical abuse were discussed, as women identified gruesome accounts of pushing, punching, chocking and aggravated assault. Sexual abuse was also described as a problem by participants. While some participants described more aggressive forms of sexual abuse such as rape, most spoke about more subtle forms of sexual abuse, such as having sex with ones husband out of obligation. As one woman described it, "Because there is also something, there are violations between married couples, that the women perhaps that, because your husband obligates you to have sex. And that obligation that they grab you by force to have sex, despite that he is your husband. That is not an obligation, that is abuse." special attention was given to psychological forms of abuse. They characterized this type of abuse by describing power and control tactics used by their partners to control their behavior and their minds.. As one woman described it, "They make you victims, that is, they make you feel like victims as if you were at fault of certain things, they use you and dominate you. There is a thing that is called the mind and they control it." Other women spoke about their partners minimizing them and threatening to harm themselves if they would leave them. One woman said, "When I started my divorce procedures, when he made fun of me because I told him, 'I am divorcing you', talking about chauvinistic, and he told me not to talk about things that I couldn't do." Another woman described how her husband would threaten to kill himself if she left him. The young woman said, "Yes, he threatens me, always, he threatens to kill himself, if you leave me I will kill myself, if I leave him, he manipulates me in every way." Participants also spoke about the causes and risk factors for the different types of abuse they described. They identified these as also being related to substance abuse and HIV risks. Machismo was a term that frequently was used by the participants to describe these risks. Women described how their husbands and sexual partners treated them like property, especially when it related to sexual intercourse. They believed that this "macho" perspective in men often lead to sexual abuse, unprotected sex, promiscuity and infidelity, behaviors they identified as placing them at risk for for HIV. One woman said, "He [ my husband] told me that he likes prostitutes. Can you imagine? So many years of marriage and you think about it (to ask him to use a condom) so many years of marriage to come to that, it is distressing. You are the bad one." It is apparent from these descriptions, that although Latinas identify condom use as something that would protect them against their partner's infidelity, they did not feel they had condom negotiating power.
Participants described how machismo and traditional gender norms promoted substance abuse in men (e.g., getting drunk after work to relax) but made substance abuse among women less socially accepted. They also identified substance abuse as a risk factor for IPV. As one women adescribed it , "Because when one uses drugs, one does things, like that one becomes another person and that makes one do what one would not do with ones five senses."
Other risks for abuse included the actual immigration experience, in where women noted that their partners became more aggressive in the U.S., notable age differences between partners, in where having a partner who was significantly older placed one at risk for being victimized, and coming from a family where violence was the norm. Some women shared their belief that IPV was the fault of not only the aggressor, but also the victim. As described by one participant, Not only does domestic violence come from the man's part, but also from the women, above all from Latinas. each chick is after the man, until reaching a point, there are men that are violent just because, but there are women that they bother, they bother that man so much, that they reach a point that they make the man violent, see?"
Participants described the various obstacles their community faced in addressing substance abuse, violence and HIV. One of the barriers was lack of information about the nature of these problems, their legal rights and how to access help. One woman described how lack of information influences parenting in Latino homes. As she shared, "Many of us, the Latinos, tend to lose control of our children because of lack of information." Some stated not knowing what forms of discipline were allowed in the U.S. and complained about the focus that U.S. had on child abuse. As one woman said, "I think that many of us, Latinos, tend to lose dominion and control of our children because of lack of information. Because the majority of us think that in correcting, in correcting our children in a manner, well convenient, logical, we are putting ourselves in problems, because the first thing that they teach children when they go to school is 911."
Economic barriers were also described as both a risk factor for abuse and a reason why women tolerated abuse. One woman described how she stayed in an abusive relationship because she had little economic resources. She said, "'And I will not pay you,' and that's what he began to tell me, and because I still earned very little, I still do not have the valor to leave because of the economic part." The economic dependency on their partners was described in countless ways by the participants throughout every focus group.
One of the main reasons why participants in abusive relationships did not access help was to conserve the traditional family unit. They focused more on the effects that violence and divorce may have on their children than the effects on themselves. As one woman shared, "I think that sometimes, there are women that do not take the decision and they stay there, for that, to conserve the family." Another woman said, "One tolerates, tolerates beatings, tolerates maltreatment, tolerates insults, tolerates everything, they stay for their children."
Another barrier was lack of police support. Women described situations where they contacted the police for domestic violence and received no support. They believed that a woman had to be seriously injured before they took action. As one woman said, "You have to be seriously injured, bleeding for them (the police) to give you attention." One woman described a situation when she went to the police and they told her, "No woman, we can do absolutely nothing. You are not bruised, you do not have blood."
A major barrier to accessing services when one was in an abusive relationship was being undocumented and the risk of not obtaining legal status if one divorced a "legal" abusive partner. One woman said, "There is a very serious problem and it's that they are at a point of obtaining their legal papers and then she can't separate herself from him because then what happens to her papers? You understand me? It is not a conflict that can be resolved, to say, 'see you later, I am leaving you partner and this is it, no, you have to hold on."
Self-esteem emerged as an important category within this vicious cycle. Participants believed that when women had a low self-esteem they allowed their partners to abuse them physically, sexually and psychologically. In fact, they identified the deterioration of self-esteem as part of the victimization process. One woman said, "Because men always know how to prepare the scene and they start by lowering your self-esteem." Another woman also said, "Because many times the abuser is so intelligent, so controlling and so manipulative, that he shows a different side of himself in public and he portrays you as the bad one and not himself.your self-esteem is lowered, so low that you don't value yourself anymore." Lastly, participants described the actual cycle as being related to an escalation of violence over time and how violent behaviors are transmitted from the perpetrator to the victim, to the perpetrator's children and to the community. One woman described how she became violent after years of victimization. As she said, "Because he was aggressive and I became aggressive, and one day he went to hit me and I got a knife and I told him, 'Leave, leave, that I am going to kill you.' And I was going to kill him. I was going to kill him. I was crazed." Another woman described her concern about the example her abusive situation was giving her children. She explained, "And when I found myself in a difficult situation, I said, I can't leave this example for my children, especially her because she is a woman, because her example, her image is of me, and also for my little one (her son), because he is going to think that his father is perfect, and he is going to do the same."
Another woman described how violence at home turns into community violence and then returns back home. As she described, "I have an experience that violence starts at home and then travels to schools and to the streets and returns back home, that has been proven that violence starts in the home. A kid goes to school, the kid is violent in school and goes on to be violent in the street and he goes home and continues to be violent at home, it is a cycle."
Rompiendo el Silencio (Breaking the Silence)
Participants repeated "romper el silencio," numerous times during the focus group discussions when referring to not only breaking the cycle of abuse, but also breaking cultural norms and taboos. In order to break the silence, they highlighted the importance of having access to information about their rights in the U.S. and how to access services in the community, especially if they were undocumented. They also highlighted the importance of knowing where to go for help. This was crucial to their success in the U.S.
Paying more attention to oneself was an important aspect involved in being able to "break the silence." This included paying more attention to one's physical appearance, following their own intuitions and fostering their own independence. One woman described the day that she decided to leave her abusive relationship, saying, "Then, I took a day. I sat down and asked myself, okay; I looked at myself in the mirror, 'What is it that you want from life? You want your life or to continue in this relationship or that he comes one day and kills the son or kills me? Or you want to change your life?' And that was it. I took the decision. I got my bags, got everything. I took them out. I called him on the telephone. He didn't answer. I called his sister and I told her, 'come get his stuff because I will take him out with the police. I am no longer scared. You understand me?'"
Part of breaking the silence is also increasing effective communication between partners. Some participants described their belief that if there is good communication between partners and address problems before they arise, abuse will never result. As one woman said, "If you have good communication, you will never get into a situation. You will never get into domestic violence." Part of partner communication was being able to break the silence behind sex and being able to negotiate condom use. Participants expressed concern about the possibility of their partners being unfaithful and how they were embarrassed to ask them to use condoms. One participant expressed concerned about her sister who had a husband that was being unfaithful to her. She said, "My sister says that after twelve years of marriage how can she ask her own husband that he has to use condoms? No!"
It was also important for participants to increase communication to children in order to break cultural taboos and norms. One woman described how she decided to break the silence that she experienced as a child and talk openly to her daughter about important taboos such as sex. She said, "I married very young and I came from a professional family household, nevertheless, they never talked to me about anything of this, I don't want to repeat this pattern, so I talk to my daughter, she is a Christian and she has another point of view, different from other girls, I think that you must talk to your daughters openly and with all sincerity on how things are."
Another woman talked about how her mother took the decision to break the cultural norm of abuse in her household. As she described, "I decided to break the pattern, break the pattern, my family is full of domestic violence, abusive men that beat. My mother decided, and those are the words that are engraved in me from my mother." Support from friends, professionals and God all helped these participants to make the final decision to "break the silence."
Qualitative Results for Portuguese Focus Groups
Many of the same themes identified in the previous section also emerged in the Portuguese focus group. Like in the other focus groups, participants described their experiences living in the U.S. and the struggles they faced trying to maintain ones culture. One woman called this the "culture shock." Participants were also concerned with how work in the U.S. consumed the family and often lead to the neglect of one's children, which in turn left them vulnerable to risks such as substance abuse, violence and HIV risks. They were also concerned with the "freedom" in the U.S. and how this also left children vulnerable to drugs, sex and violence.
Although there were similarities between the Portuguese and Spanish focus groups, especially with their immigration experiences, there were notable differences in the areas that they focused on during their discussions. One of these differences was their major focus on drug use, promiscuity and prostitution. While in the Spanish focus groups these issues did arise, they mostly emerged in the context of their partner behaviors or as a consequence of poor self-esteem and victimization. The participants of the Portuguese speaking focus group, on the other hand, spent a great deal of the time describing details relating to drug use and prostitution in their community.
The drugs the participants identified as commonly used in their communities, included marijuana, cocaine, acid and ecstasy. When talking about drugs, they described factors that placed women at risks. While some participants blamed the individual's upbringing and parents, the majority of the participants believed that personality traits were the most determining factors.
Some women described their own experiences with drugs and identified their behaviors as a just a phase they went through. Other participants identified drug use and selling drugs as a way to cope with loneliness and survive economically. Although participant did perceive drug use as a problem for women, they believed that it was more of a problem for men. As one woman said, ".because I used to go to a nightclub, my husband worked in a restaurant at night and the majority was man. They feel lonely, so they do drugs.". Another woman said, "The majority of women in the United States are working to support their families. They are working. The men work too, but it is easier for them to get involved with drugs." They added that this difference existed because "men are much weaker than women," and more easily "seduced by anything".
Promiscuity and prostitution were major concerns for the Brazilian participants. In fact, one woman stated, "The worst problem for Brazilian women here in the United State is that they come here to make money, and they go to clubs to become prostitutes, and to dance." Participants explained that prostitution was a means to economic survival among Brazilian women in the U.S. As the participants described, drugs were often used to help prostitutes and dancers feel more comfortable with their behaviors. One woman was talking about a friend of hers who was an exotic dancer and said, "She has to smoke marijuana and sniff cocaine to do all those things without feeling shame."
Although substance abuse and prostitution did consume the majority of the focus group, participants also described issues relating to abuse. As with the Spanish focus groups, participants described having little access to help, especially when the victim was not documented, and concern for the well-being of their children as barriers to reporting abuse. When talking of her own experience with IPV, a woman said, "I was married for twenty-two years, and I suffered domestic violence, um.more verbal, right? Is it verbal? Then, I took it, took it. I have, now, a seventeen-year old son. I hung on, hung on, hung on because.um.I am going to be alone in this country. and my husband also threatened to report me to Immigration and if I would leave him he would take y son away. He was going to report me to immigration because I was working without authorization, this and that."
Some women attributed their increased vulnerability to economic dependence and undocumented status. As with the Spanish focus group, they identified God a source of strength that helped those who had experience abuse, survive.
The Brazilian participants also discussed condom negotiation. As with the Spanish speaking focus group, they described their partners as "chauvinist" and related this back to their resistance against condom use. One woman said, "Brazilians are chauvinist.their pleasure comes before our pleasure, so they want to feel pleasure before we do. Then with condoms they cannot feel pleasure first." Participants related this chauvinism to an innate difference between men and women where men "have sperms in their heads," and want to have sex no matter what. When the participant was describing this difference she said, "I already talked to my husband that I want quality not quantity." All the participants applauded her words. She continued, "I am not a toilet bowl."
Some women also stated their belief that condoms were not needed when you were married. However, many participants did not agree with this. In fact, one woman shared a story about how her friend contracted HIV from her husband. She said, "But this friend of mine died of HIV, right? She was married, but her husband had an affair with another man...She didn't know...She died but he is alive because the virus was not reactive on him, but what about her?" It was clear from this discussion that HIV and other STIs were a big concern for participants.
The results from the focus groups stress the need of addressing substance abuse, violence and risky sexual behaviors among Latinos in the U.S. Although participants of the study did not report high levels of substance abuse among the Latina community, this was identified as a problem of great importance for men. This is concerning considering that results from the second phase of the study identified that partner alcohol use and drug use was related to partner physical and sexual abuse (27). As evidenced in the focus group discussion, participants of this study were particularly concerned with IPV and risk for HIV and perceived substance abuse to be a contributor to these problems. Many of the risk factors identified (e.g., machismo, lack of communication) were common to all the condition being discussed (i.e., substance abuse, violence and risk for HIV). This suggests that programs need to be developed to target substance abuse, IPV and HIV in an integrative matter by addressing these common risk factors. While the results of this study suggest that for women these programs should focus more heavily on IPV for Spanish speaking women and HIV for Portuguese speaking women, this study and others suggest that substance abuse is of higher priority for Latino men (28).
As recommendations in research and service provision, we recommend the following. Partner substance abuse increases Latinas' risks of becoming a victim of abuse and being exposed to HIV and other STDs. Therefore, substance abuse, violence and HIV risks among Latinas in the U.S. cannot be addressed without also targeting their male partners. Preventing substance abuse among Latino males may also prevent violence and STIs among Latinas. Research is needed to develop and test substance abuse prevention programs targeting men.
Acculturation to the U.S. culture increases Latina's risks of abusing drugs and participating in more high risk sexual behaviors. It is therefore important to target research, programs/services and policies to more highly acculturated Latinas in the U.S. Additional research is needed to understand the process involved in becoming acculturated to the U.S. culture and how this process encourages the development of high risk behaviors among Latinos. Until the acculturation process is further understood, programs targeting Latinos in the U.S. must include content relating to how acculturation increases risks for substance abuse, violence and HIV and teach skills that will help them adapt positively to a new environment (e.g., how to access community resources). These programs must also teach participants risk reduction techniques (i.e. condom negotiation, communicating with children) that they can use if they start participating in higher risk behaviors.
Agencies serving Latinas should consider universal screening for abuse among the clients they serve and providing referrals to community organizations that provide assistance to victims. Those screening for violence must be trained to conduct the screening in a safe, culturally-competent manner and must be trained in helping clients to develop a safety plan. Nurses can play an important role in screening for abuse and training other health professionals in community agencies to do so. Although laws exist to protect undocumented immigrants whom are victims of domestic violence, these laws are unknown to the public. Local governments in the U.S. that are populated by a highimmigrant population must develop a plan of disseminating this information. Partnering with community agencies serving immigrant populations may facilitate this process. Organizations and programs that serve Latinos must also develop a plan to disseminate information about their services, how to access these and who is eligible for these services. Organizations that provide services anyone, regardless of documentation status, must also inform the community that no formal identification is needed.
Psychological distress (e.g., poor self-esteem, depression) were related to abuse among women. Services targeting victims of abuse must also consider providing treatment and therapy that aim to improve the psychological well-being of survivors. Breaking the cycle of abuse was important to the women of this study. As suggested by the participants of this study, programs aiming to prevent abuse among Latinos need to help women raise their children in a way that promotes healthy adult intimate relationships. Participants described the importance of communication in the prevention of substance abuse, violence and HIV/ STIs. Programs directed towards Latinos in the U.S. need to teach effective communication at various levels (i.e. between partners, between friends) and parenting skills. Cultural factors relating to traditional gender roles and inequalities (i.e. machismo, infidelity) need to be addressed in programs targeting Latinos. By addressing positive behaviors and values ascribed to being a male in the Latino culture (i.e. protecting the family, respecto-respect, confianza-trust), Latinos may begin to understand how machismo and infidelity interferes with being the "man" of the house. Latinas must be taught condom negotiating skills and other risk reduction techniques to manage both their own risk behaviors and their partners' (i.e. infidelity, sex with other men).
In summary, this study contributes to the current state of knowledge by providing an in-depth analysis of the experiences Latinas have with substance abuse, violence and risk for HIV. This knowledge can serve as the basis for future research, the development of health programs and services targeting Latino populations in the U.S. and in Latin America and guide the development of policies directed towards this population. This paper provides specific recommendations to researchers, service providers and policy makers that can lead to more culturally appropriate programs and services addressing risk behaviors among Latinos.
The investigators in the U.S. collaborated closely with researchers in Latin America, who were also studying substance abuse, violence and risky sexual practices among women in their communities. This collaboration began as a result of a CICAD / OAS (Inter-American Drug Abuse Control Commission, Office of American States) and SENAD (National Anti-Drug Organization in Brazil) initiative that aimed to target drugs and violence among various countries in Latin America and the U.S.
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