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Jennifer S. Hirsch, PhD, Jennifer Higgins, BA, Margaret E. Bentley, PhD and Constance A. Nathanson, PhD

Jennifer S. Hirsch is with the Department of International Health, Rollins School of Public Health, and Jennifer Higgins is with the Program in Women’s Studies, Emory University, Atlanta, Ga. Margaret E. Bentley is with the Carolina Population Center, University of North Carolina at Chapel Hill. Constance A. Nathanson is with the Department of Population and Family Health Sciences, Johns Hopkins University, Baltimore, Md.

Correspondence: Requests for reprints should be sent to Jennifer S. Hirsch, PhD, Department of International Health, Rollins School of Public Health, Emory University, 1518 Clifton Rd, NE, Atlanta, GA 30322 (e-mail: jshirsc{at}sph.emory.edu).

	ABSTRACT

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Objectives. This article explores the social context of the migration-related HIV epidemic in western Mexico.

Methods. Data collection involved life histories and participant observation with migrant women in Atlanta and their sisters or sisters-in-law in Mexico.

Results. Both younger and older women acknowledged that migrant men’s sexual behavior may expose them to HIV and other sexually transmitted diseases.Younger Mexican women in both communities expressed a marital ideal characterized by mutual intimacy, communication, joint decisionmaking, and sexual pleasure, but not by willingness to use condoms as an HIV prevention strategy.

Conclusions. Migrant Mexican women’s commitment to an illusion of fidelity will hinder HIV prevention initiatives targeted toward them. Furthermore, the changing meanings of marital sex may make it harder to convince young couples to use condoms as an HIV prevention strategy. If the chain of heterosexual marital HIV transmission is to be interrupted in this community, prevention programs must target men. (Am J Public Health. 2002;92:1227–1237)

	INTRODUCTION

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The night before her wedding, a girl kneels down to pray. She prays for 3 things:
"Dear God, please make my husband faithful to me.
"Dear God, please keep me from finding out when he is unfaithful to me.
"Dear God, please keep me from caring when I find out he is unfaithful to me."
Joke told in Degollado, Mexico, summer of 1996¹

This article describes the social context of the migration-related HIV epidemic in western Mexico. In recent years, epidemiological and ethnographic research has suggested that an increasing proportion of AIDS cases in Mexico are related to Mexican men’s becoming infected in the United States and then returning home to infect their wives.² A growing body of work has demonstrated cross-cultural variation in people’s ideas and emotions about desire, partner choice, and sexual behaviors,³ and in this article we apply these insights about the social construction of sexuality to study how social context shapes women’s risk of migrationrelated HIV and sexually transmitted disease (STD) infection. Specifically, we show how a shift toward a more companionate marital ideal among women from 2 migrant-sending communities in Mexico has created generational differences in women’s attitudes toward men’s sexual infidelity, and we argue that a growing emphasis on sexual intimacy within marriage may cause young Mexican women to be particularly invested in ignoring evidence of infidelity.

Previous studies of AIDS risk denial have demonstrated how women’s commitment to the illusion of fidelity can increase the risk of infection with HIV.⁴ Here, we document AIDS risk denial in a context in which it has not previously been noted, and we show how it may potentially be exacerbated by changing notions about marital intimacy. We also suggest that the same ideas that hinder women’s recognition of their risk may contain possibilities for culturally relevant prevention messages targeted at men.

As we trace the contours of sexuality in these migrant-sending communities, we discuss differences between older and younger women in terms of how they talk about sexuality, marriage, and infidelity. These generational differences call attention both to the importance of studying how sexuality changes across time and to the ironic possibility that increased communication between married couples about some aspects of sexuality (such as mutual pleasure) does not necessarily imply a greater likelihood of communicating about the risk of infection and the need for prevention. We also describe differences among women in how they interpret this discourse about marital intimacy and the meaning of infidelity, pointing out that changes in the social constructions of sexuality are not uniform across society. In our conclusion, we critique programs that aim to prevent heterosexual HIV transmission by working with married women and make some concrete suggestions on how these findings about sexuality and marriage could be used to shape a culturally relevant prevention campaign for Mexican migrants.

	METHODS

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The data come from a comparative ethnographic study of gender, sexuality, and reproductive health among Mexicans from a migrant-exporting community in rural western Mexico.⁵ The broader study explored the effect of generational and migration-related change on gender and sexuality and the way these changes in gender and sexuality shape reproductive health practices. The primary method of data collection was life history interviews, conducted with 13 women in Atlanta and 13 in the Mexican communities.⁶ The life history informants in Atlanta were recruited from an initial set of research contacts from El Fuerte (a rural community in Michoacan state) and Degollado (a town in Jalisco state) who lived in the Atlanta metropolitan area. The life history informants in the Mexican field sites were the sisters or sisters-in-law of the informants in Atlanta. Tables 1 and 2 summarize the sampling strategy and ethnographic methods. The Mexican field sites consisted of Degollado and El Fuerte. The Census Bureau estimates that the Latino population of the Atlanta metropolitan area is over 175 000; other estimates place the number closer to 250 000.⁹

	US–MEXICO MIGRATION AND THE Migration–HIV Nexus

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There is a long history of labor migration to the United States from western Mexico; some of those interviewed for this study had fathers and grandfathers who had traveled to the United States as temporary labor migrants.¹¹ The proportion of Mexican migrants to the United States that is female has increased in the past decade,¹² but significant numbers of married and unmarried men still travel north for 9 or 10 months every year from towns throughout Mexico, leaving their wives or girlfriends behind. As indicated in Table 1, 14 of the 26 life history informants had experienced these extended marital separations.

Mexican migrants’ relative youth, their loneliness and social isolation, and the fact that many are single or traveling without their spouses may make them likely to seek sexual activity, and low levels of education and limited English may make it harder to reach these migrants with messages about HIV prevention.¹³ Social factors such as more permissive sexual norms, the higher incidence of HIV/AIDS (especially in the states that have been the destinations for great numbers of Mexican migrants), more widespread use of injected drugs, the lack of Spanish-language prevention campaigns, and migrants’ limited access to health services can also increase their vulnerability to HIV.¹⁴ Migration itself, which is a product of the political and economic relationships between the United States and Mexico,¹⁵ may put Mexicans at risk, because men who experience extended separations from their primary partners may be more likely to engage in extramarital sex.¹⁶

Migration has emerged as a risk factor for AIDS in rural Mexico (Figure 1). In 1995, 25% of rural Mexican AIDS cases were among men who had been in the United States, while only 6% of people accounting for the urban cases reported travel to the United States.¹⁷ In Jalisco (where Degollado is located), one study found that half of the individuals reported to have AIDS had traveled to foreign countries,¹⁸ and in neighboring Michoacan, where El Fuerte is located, 39% of those with AIDS had traveled to the United States.¹⁹ Because women account for 20% of rural cases but only 14% of urban ones, it seems especially urgent to explore how life in rural Mexico places women at increased risk.²⁰ Many have argued that seasonal labor migration to the United states is responsible for these urban–rural differences in sex ratios.²¹ If migration-related heterosexual transmission of HIV is to be prevented, it is important to know more about marital sexuality in rural Mexico.

View larger version (9K): [in this window] [in a new window]   FIGURE 1— —Percentage of Mexican AIDS cases classified as rural.

	RESULTS

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Although at the time this study was conducted, the Mexican National AIDS Council data²⁵ had two recorded AIDS cases for the county in which Degollado is located, informants mentioned several cases of people living with AIDS in Degollado and El Fuerte and other instances in which men from the community had reportedly died of AIDS in the United States. Almost all of the life history informants recounted having heard about other women who had gotten an STD other than HIV from their husbands; many of these stories (with no prompting about connections to migration) were about men returning from stints in the north.²⁶ All of the women knew that illnesses can be transmitted through genital contact during sex, but they all denied having had personal experience with sexually transmitted infections.²⁷

Almost all of the life history informants had heard that condoms prevent the transmission of AIDS and other sexually transmitted diseases, but women’s ideas about the technical, sensory, and symbolic aspects of condoms make it unlikely that they would push for condom use. About half of the women had tried condoms as a method of pregnancy prevention, but none favored them, and only a few used them occasionally in combination with rhythm.²⁸ One reason for preferring other methods, these women said, is their belief that condoms are ineffective. Both those who had used them and those who had not made comments such as "no es tan seguro" (it’s not so safe or effective) and "a veces salen medio defectuosos" (sometimes they are defective). Women also talked about how condoms are a barrier to intimacy.²⁹ One woman who had tried using condoms said, "I told him, to have sex every now and then and to do it with a cover, all covered up, no way." Women spoke of not wanting to be "tapado" (covered up), and said that sex with a condom is less natural and less pleasurable (for both women and men). Women saw unprotected sex as the most intimate kind of sex, and thus argued that if a man was going to use a condom, he should use it with his other partners. One migrant’s wife said she had tried to get her husband to use condoms as a method of pregnancy prevention during a surprise homecoming, only to be told by him, "No, then what the hell kind of pleasure would that be? In that case it would be better to go with another damn woman." Men and women reunited after a migrant separation are jokingly said to be de luna de miel, on honeymoon; the romance of this honeymoon period would be considerably dampened by the implication that condoms were necessary because either partner had strayed.

Given the risk posed by a strategy of unilateral monogamy, one approach might be to educate these women about their HIV risk and develop interventions to encourage them to negotiate with their husbands for condom use. Indeed, many of the articles cited in Gayet, Bronfman, and Magis’ review article on HIV and migration³⁰ suggest that programs should focus on increasing women’s condom negotiation skills. In the remainder of this article, we argue against this seemingly obvious response. It is not just that women do not like condoms (although they may not) or that they may not have the power to insist on their use (although, again, they may not). Rather, negotiating for condom use is unthinkable to these women, because they see requesting condom use as tantamount to acknowledging or even giving permission for a husband’s infidelity.

Generational Changes in Marriage and Sexuality
The marital ideal has changed over the course of a generation from one of "respeto" (respect) to one of "confianza" (intimacy). The marital goals of the older generation (as described by the mothers of the life history informants and the older [aged > 35 years] informants) centered on mutual fulfillment of a gendered set of obligations.³¹ Husbands and wives certainly may have felt love and tenderness for one another in the past, but marital success and stability depended on the way the union fulfilled the basic needs of the couple and the wider kin group—production of food, shelter, heirs, and social status—and not on emotional closeness.

Within the new ideal of the Mexican companionate marriage, young couples spend more time together, enjoy a somewhat less strongly gendered division of labor, and claim joint decisionmaking (although frequently with ultimate masculine authority) in many areas of domestic and economic issues. These companionate marriages are not necessarily egalitarian; in fact, the emphasis on the importance of marital ties above all other social connections may make women more isolated and dependent on their husbands. Young women also speak differently than their mothers did about the nature and role of sexuality within marriage. For the older women, marital sex produced children and held a man’s attention, and thus served to direct his resources toward a woman and her children rather than outside the family. The younger women, in contrast, claim that mutually pleasurable sexual intimacy strengthens the confianza that is at the heart of these modern marriages.³² They see sex as a sort of "marital glue," helping a couple’s affective relationship survive through good times and bad.³³

The younger Mexican women in Atlanta shared values about relationships, sexual intimacy, and gender with women in the sending communities, but women in the Atlanta field sites live in very different social circumstances than do their sisters and sisters-in-law in Mexico, and so some women in Atlanta had a great deal more domestic power than did their sisters or sisters-in-law in Mexico.³⁴ The contrast between the shared culture and the distinct social settings of this type of migrant community provides a unique opportunity to explore the way that social and cultural factors shape sexuality.

Infidelity and Companionate Marriage
Women’s attitudes toward male infidelity reflect these broad changes in marital sexuality.³⁵ The older women valued a pretense of ignorance about a man’s extramarital relationships. As one woman said, for a man to "keep some respect for you" would mean that "you don’t know what they are doing . . . that is, that they act as they wish but do it so that you don’t know." Since a man owed his wife first and foremost financial support and secondarily some measure of respect, his sexual behavior was largely his own concern except to the extent that he publicly embarrassed his wife. Older women said that drinking, violence, or laziness were significant problems in a marriage, and there was little dissent from the opinion that the worst quality a man could display was to be "desobligado" (being unwilling or unable to support his family), but none suggested that infidelity might be a reason to leave one’s husband. Blatant male infidelity may certainly have wounded women—as one said, "You don’t say anything to them, but you still feel kind of bad, in your heart"³⁶—but infidelity did not terminate the underlying contract. Furthermore, older women suggested that men physically need to have sex on a regular basis, that this need for sexual release cannot be satisfied by masturbation, and that a man’s sexual involvement with another woman need not threaten a marriage. As one of the older women said in an interview, discussing her husband’s long absences while working in the United States, "I have said to my husband, ‘I can’t say that you did not use [que tú no usaste] some woman, but if you did it, it was because you needed to [porque se te haria necesario]."

Younger women, in contrast, see men’s sexual behavior as inseparable from marital intimacy. If sex is the language of love, then to be sure of their husband’s love they must believe that he is faithful while away. As one young woman in the rancho said, "I wouldn’t feel comfortable with him, knowing he’d been going around with another woman." A man’s sexual infidelity, these younger women said, would weaken or destroy the confianza they have with their husbands. One younger woman told a story about calling her husband in Atlanta from Mexico. The phone rang all night, but he never answered. When she accused him the next day of having been out with another woman, he said he had been home and just not heard the phone. She reflected on this incident with some general comments about infidelity:

When the man doesn’t want to lose you, he tries to fix things, to make it [better]—and I prefer this, to him saying to me, "Well yes, I did go around [with another woman]." ... For me, I prefer that he lie, that it was a slip-up, that he went out, that he just stepped out and came right back, but that he doesn’t admit it like that. ... Though maybe it’s bad, I prefer the lie, if it’s going to be just a dalliance [un pasatiempo] or a thing that just happened, that he drank a lot of beer, and got drunk and all that, better for him to hide it from me, so that he doesn’t hurt me. (italics added)

Women’s commitment to the image of their husbands as sexually faithful, even when confronted by compelling evidence to the contrary, draws on the idea that sexual betrayal indicates a lack of love.³⁷ The new cultural ideal of marital companionship and shared sexual pleasure gives younger women yet another reason not to raise issues of infection and infidelity. The younger couples prided themselves on their communication about sexuality, emotions, and pleasure, in contrast to the older women, for whom open discussions about sexual matters indicated a lack of respect. However, the value these younger couples place on communication about some aspects of sexuality does not mean that the younger women are any more likely than their mothers were to suggest that a man use a condom for disease prevention purposes.

Social Class, Social Context, and Constructions of Sexuality
Within this broad pattern of generational change in sexuality lies a second kind of diversity. The life history informants fell into 4 groups when asked how they might respond, hypothetically, if confronted by evidence of infidelity: those who would leave him, those who would talk it out, those who would go out of their way to make him feel special, and those who would do nothing at all. The different ways that women interpret the ideology suggest that the type of "modern" sexual relationship a woman builds may depend on where she lives and the resources on which she can draw.

Six of the 26 life history informants said that infidelity was grounds for leaving one’s husband.³⁸ Only the women who could support themselves adopted this rights-based language to talk about infidelity³⁹; they all had an independent income, and 5 had at least a high school diploma as well. When asked about men who said that extramarital sex was their right, one woman who lived in Atlanta and contributed as much as her husband to their joint budget said,

. . . just like he could go out [with someone], I could too. How would it seem to him if the tables were turned and if I did that to him? He wouldn’t forgive me, right? We are human beings just like them . . . neither he nor I is made of stone or straw. . . . We both have hearts, we both feel the same.

She argued that in the emotional contract of marriage, both partners have essentially the same set of rights. When asked why women do not put up with infidelity now, she continued, "Before, women did what their husbands said when they got married. The rule was that here the man was boss. . . . Now we both are the boss." These Mexican women have woven together ideas about sexual intimacy as the foundation of marriage with their personal histories and their self-image as modern women to produce a distinct set of attitudes about where to set the limits on men’s sexual freedom.

Others said that they might address the issue by trying to discuss it with their husbands. (The "talk it out" group presented a strategy for dealing with infidelity when forced to do so, not for raising the issue in a preventive health context.) Talking about how she would counsel a friend to act, one said, "The thing is to make him understand, communicate well with her, so that he realizes that his wife is worthwhile." These women share with their sisters the idea that infidelity is a fundamental violation of the marital bargain, but these women seemed particularly skilled at talking about their feelings, and they prized the open communication they have achieved in their marriages. Moreover, they all resided in Mexico. The fact that women in Atlanta and wealthier women in Mexico are so forthright in saying that they would leave their husbands, while their matches in Mexico say that they would do their best to talk things through, shows how emotional closeness can be a strategic resource for a woman who is socially and economically dependent on her husband. Women in Degollado or El Fuerte may have some resources that their peers in Atlanta lack (e.g., broader social networks, a mastery of the language), but these resources do not enable women to live without a man’s economic support. Furthermore, women in Mexico continue to face the issue that "el hombre es el respeto de la casa," that a woman needs a man to be respected,⁴⁰ as well as the stigma of divorce, still strong in rural Mexico.

The idea that these women in Mexico would try to talk it out implies ultimately accepting a man’s infidelity (just as their mothers might have), but saying that they would at least confront the issue allows them to assert that they are women who deal actively with problems and who are free to speak their minds. For both groups of women, infidelity represents a betrayal of the special sexual relationship that married people should share, but the 2 groups use the ideology differently, based on their social and economic circumstances.

Not all women, of course, were so thoroughly invested in these modern strategies for building relationships. The idea that a successful relationship depends on a woman’s ability to keep her man happy, to work through his good side (manejarlo por las buenas), was alive and well among Mexican women in both US and Mexican field sites. The 4 women in this third group focused much more on their feminine ability to please and hold onto a man. A satisfying sex life, they all said, was one of the keys to a good marriage. One responded to the question "If a couple does not get along well in bed, how will they do in the rest of their marriage?" by saying, "Badly, I think, because I have heard that for the man [you need to] have his food ready, his clothes ready, and the bed ready, and he will be all content, and if not, then [he’ll be] a real devil." In the event of actual or suspected infidelity, these women said that they would use their feminine wiles to make themselves irresistible. All of them mention the importance of being more cariñosa, sweeter or more loving. The women in this group are young (under 20) and recently married. Although they lived in both the US and Mexican field sites, none worked outside the home, and the ones in Atlanta were there without any of their own blood relations to count on in an emergency. Their support for this strategy is most likely a product of many factors: age, family histories, their personality and their husband’s, the sort of marriage they have, and their lack of other resources.

Finally, 6 of the life history informants said that they would do nothing in reaction to suspected or confirmed infidelity. None relished the thought, but neither did she argue that it would be grounds for separation. Although this group included women interviewed both in Atlanta and the Mexican field sites, those in Atlanta had spent some, if not all, of the years of their marriage in Mexico; all of the women in this group were older, less educated, with less work experience and fewer opportunities for economic independence. In other words, the women whose material circumstances were most similar to women of the older generation were least likely to embrace this new ideology of sexuality.

	DISCUSSION

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The younger generation’s new ideas about sexual intimacy transform men’s infidelity from a painful reminder of gender inequity—but not necessarily an indication that a marriage is a failure—to a betrayal of the confianza that young women hope lies at the core of their marriage. If infidelity represents a breach of trust—and an STD or HIV is the ultimate evidence of that breach—then every act of sex without a condom is a mutual performance of trust. The confianza of which younger men and women speak implies a shared commitment to pleasure and emotional intimacy, predicated on the unquestioned and unquestionable assumption of mutual monogamy. It does not mean that they are open to discussing issues of risk and infidelity or negotiating condom use. In a marriage with plena confianza (complete trust), a woman might feel freer to initiate sex, to have oral sex, or to don some racy lingerie, but she is no more likely than her mother was to ask spontaneously about her husband’s adventures in el norte.

Whether in Atlanta or in the Mexican field sites, younger women expressed this commitment to marriages of confianza; younger women in Mexico were more similar to younger women in Atlanta than they were to older women in Mexico. The greater a woman’s social and economic resources, however, the less likely she was to say that she would try to work it out if confronted with hard evidence of infidelity. Women’s imagined responses show that social stratification has an important effect on the options women see as being available to them (Table 3).

Our data here support Sobo’s conclusion, but we also extend her work by placing married women’s AIDS risk denial within the context of broader global changes in the meaning of marriage. Ethnographic research from across the developing world has described the evolution of similar ideals about marital companionship and sexual intimacy.⁴³ The similarity of these ideals does not mean that marriage in El Fuerte is exactly the same as marriage in Egypt, but the widespread link between marital sex and emotional intimacy suggests that married women’s AIDS risk denial, combined with persistent gender inequality, may have greater implications for the spread of marital HIV transmission than has previously been acknowledged.

The continuing focus, however, on why women will or will not negotiate for condom use represents an astonishing failure on the part of public health researchers to confront how gender shapes—and constrains—our imagination. The focus on women may be in part a product of scientific knowledge about women’s greater biological risk of sexual infection with HIV,⁴⁴ but this does not explain why we have assumed that women can modify their sexual behavior to press for condom use but that men cannot,⁴⁵ nor does it justify the fact that we have continued to push the message that monogamy is an effective HIV risk reduction strategy⁴⁶ when we know that the assumption that marriage equals monogamy may be costing women their lives.⁴⁷ Men’s sexual behavior presents a public health problem, and thus these men’s behavior is the proper object of our attention. To suggest that we can help married women protect themselves by "empowering" them to negotiate for condom use is to suggest that we can change the outcome of gendered inequalities in power without doing anything about the actual inequality.⁴⁸

Given all that a woman in this community might feel that she stands to gain by ignoring her risk of contracting an STD from her husband, it is small wonder that women do so little to protect themselves. These women would not benefit from programs to help them with condom negotiation; in many areas of their domestic and wider social lives, they are already expert negotiators. Women in this community do not want to use condoms for disease prevention because the emotional cost of acknowledging that sex with their husbands is not safe sex is simply too high. As Karen Mason has pointed out, the idea that women’s empowerment would increase condom use "is plausible only if there is reason to think that women are more motivated than men to use condoms, but are unable to enforce their use in the face of male opposition."⁴⁹ In this particular Mexican case, the cultural logic of marital sexuality suggests that public health efforts to stem a rising tide of migration-related heterosexual transmission of HIV in Mexico should instead concentrate on 2 fronts: the behavior and social circumstances of migrants while they are in the United States, and the wider sources of gender inequality that structure women’s lives.⁵⁰

	CONCLUSIONS

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The research presented here could serve as the basis for a prevention program that builds on the ideas of respect and trust (respeto and confianza) to shape health education messages targeted toward men to promote extramarital condom use. Men and women may not agree on whether men who profess to believe in companionate marriage should ever have outside partners, but they do agree that for a woman to find out about her husband’s infidelity represents both a betrayal of trust and a lack of respect on his part. Health education messages could use these terms to emphasize a man’s responsibility to protect his family from disease and hurt feelings. Telling men that ideally they should have no outside partners, but that if they do they should use a condom to protect the confianza they have with a spouse and to avoid showing her a falta de respeto, a lack of respect, may be one way to frame this important health education message in culturally meaningful terms.⁵¹

Our call for HIV prevention programs for Mexican migrants needs to be considered in the context of Mexican migrants’ generally limited access to health services. In Atlanta, the only way a Mexican migrant is likely to get attention from the Fulton County Health Department is if he has active tuberculosis.⁵² Nationally, Latino immigrants’ limited access to quality US health care services has been well documented.⁵³ At the time of the writing of this article, most of the men who were laying bricks and hanging Sheetrock in the ever-larger suburban minimansions that ring Atlanta, along with their paisanos mowing lawns and planting seasonal flowers, had very limited access to primary health care. These men who spend long months in the cold north may be powerful in relation to their wives, but we should remember that they are not just men—they are poor, dark-skinned, primarily non–English-speaking, sometimes undocumented men. Addressing migration-related HIV in anything other than a superficial way will mean facilitating access to health care in a more general fashion. Affordable clinics with translators and evening hours could create a wide range of opportunities for primary and secondary prevention of STDs and for HIV prevention.⁵⁴

AIDS is an emergency, and the sort of research presented here takes a long time (although partnering with local social scientists and beginning research projects with a firm grounding in the vast ethnographic record can certainly speed this up). However, it is precisely because of the pressing nature of the global pandemic that we must take the time to do careful ethnographic research. In particular, the data presented here speak to the value of anthropological research for drawing connections between culture and changing patterns of social inequality. As we enter the third decade of the epidemic, we must use all the tools within our grasp, including the full range of anthropology’s explanatory power, to address the global challenge of AIDS.

	Acknowledgments

 
J. S. Hirsch gratefully acknowledges support from the Andrew Mellon Foundation through a grant to the Department of Population Dynamics at Johns Hopkins University; the National Science Foundation Program in Cultural Anthropology (SBR-9510069); the International Migration Program at the Social Science Research Council; the Emory AIDS International Training and Research Program, which is funded by a grant from the Fogarty International Center at the National Institutes of Health (1 D43 TW01042-02); and the Department of International Health at the Rollins School of Public Health. J. Higgins gratefully acknowledges financial support from the program in Women’s Studies at Emory University.

We thank Claire Sterk and Carlos del Río and 3 anonymous Journal reviewers for comments and Carlos Magis Rodríguez of the Consejo Nacional de SIDA for generously sharing surveillance data on rural AIDS in Mexico. Our deepest debt is to the women and men who opened their homes and their hearts throughout the course of this study; we cannot acknowledge them by name, but we hope at least to have been true to their stories.

Human Participant Protection
The study described here received approval from the institutional review board at Johns Hopkins School of Hygiene and Public Health, and all subjects provided informed consent before participating in interviews.

	Footnotes

 
J. S. Hirsch was the principal investigator on this project, with primary responsibility for design, collection, analysis, and interpretation of findings. J. Higgins reviewed pertinent bodies of literature and aided with the writing and editing of the manuscript and the interpretation of the data. From the project’s inception through the final versions of the manuscript, M. E. Bentley and C. A. Nathanson provided critical input regarding research design, data collection and analysis, and interpretation of data.

Peer Reviewed

Accepted for publication December 28, 2001.

	Endnotes

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1. This joke was told by a middle-aged woman during a Sunday outing in the car; her husband, sister-in-law, and brother-in-law, and teenage niece all thought it was very funny.

2. M. Bronfman, G. Sejenovich, and P. Uribe, Migración y SIDA en México y América Central (Mexico City: Angulos del SIDA and CONASIDA, 1998); C. Gayet, C. Magis, and M. Bronfman, "Aspectos Conceptuales sobre la Relación entre Migración y SIDA en México," Enfermedades Infecciosas y Microbiología 20 (2000): 134–140.

3. J. Weeks, Sex, Politics and Society: The Regulation of Sexuality Since 1800 (New York: Longman, 1981); C. A. Nathanson, Dangerous Passage: The Social Control of Sexuality in Women’s Adolescence (Philadelphia, Pa: Temple University Press, 1991); R. Parker, Bodies, Pleasures and Passions (Boston, Mass: Beacon, 1991); C. S. Vance, "Anthropology Rediscovers Sexuality: A Theoretical Comment," Social Science & Medicine 33 (1991): 875–884; R. Dixon-Mueller, "The Sexuality Connection in Reproductive Health," Studies in Family Planning 24 (1993): 269–282; J. Hirsch and C. Nathanson, " ‘Some Traditional Methods Are More Modern Than Others’: Rhythm, Withdrawal and the Changing Meanings of Gender and Sexual Intimacy in the Mexican Companionate Marriage," Culture, Health & Sexuality 4 (2001): 413–428.

4. E. J. Sobo, Choosing Unsafe Sex: AIDS-Risk Denial Among Disadvantaged Women (Philadelphia: University of Pennsylvania Press, 1995); Sobo, "Finance, Romance, Social Support, and Condom Use Among Impoverished Inner City Women," Human Organization 54 (1995): 115–128.

5. J. S. Hirsch, Migration, Modernity and Mexican Marriage: A Comparative Study of Gender, Sexuality and Reproductive Health in a Transnational Community [dissertation] (Baltimore, Md: Johns Hopkins University, 1998); J. S. Hirsch and C. Nathanson, "Demografía Informal: Cómo Utilizar las Redes Sociales para Construir una Muestra Etnográfica Sistemática de Mujeres Mexicanas en Ambos Lados de la Frontera," Estudios Demográficos y de Desarollo Urbano [México: El Colegio de México] 12 (1998): 177–199; J. S. Hirsch, A Courtship After Marriage: Gender, Sexuality and Love in a Mexican Migrant Community (Berkeley: University of California Press, forthcoming).

6. The women in Atlanta were systematically selected to represent the range of diversity in Atlanta’s migrant community in terms of social class and resources in their families of origin in Mexico, as well as factors such as age, legal status, English skills, and reproductive and labor force experience. In a systematic ethnographic sample, the goal is a sample that includes the variety of types of people, not one that is statistically representative (which would be impossible due to the lack of sampling frame). Barbara Katz Rothman in The Tentative Pregnancy: Prenatal Diagnosis and the Future of Motherhood (New York: Penguin Books, 1986) has a useful metaphor for explaining the difference: the goal is not to determine that percentage of marbles of each color that are in a jar, but rather to learn what are the colors of marbles in the jar, and to explore the key ways in which they differ (pp. 18–19). In this study, for example, we were interested in seeing if access to resources, social class, or social context affected women’s reproductive health practices, given a set of shared, culturally constructed ideas about gender and sexuality. It was important, therefore, to construct a sample with variety along these 3 axes. By selecting a group of women who varied in terms of their current resources (measured in Atlanta by English skills and driver’s licenses and in both places by current employment), as well as their social class of origin and the context in which they lived (i.e., Atlanta or Mexico), we were able to evaluate the effect of all 3 sets of factors. For a more extensive discussion of methods and findings, including a description of how participant observation contributed to the study findings, see Hirsch and Nathanson, "Demografía Informal" and "Some Traditional Methods," and Hirsch, Courtship After Marriage. For a general discussion of the techniques involved in participant observation, see R. Bernard, Qualitative Research Methods (Newbury Park, Calif: Sage, 1994).

7. Hirsch, Migration, Modernity and Mexican Marriage.

8. Bernard, Qualitative Research Methods.

9. Center for Applied Research in Anthropology (CARA), Georgia State University, Hispanics in Georgia 1998: By County (Atlanta: Center for Applied Research in Anthropology, Departments of Anthropology and Geography, Georgia State University, 1998); US Census Bureau, Population by Race and Hispanic or Latino Origin, for the 15 Largest Counties and Incorporated Places in Georgia: 2000, Census 2000 Redistricting Data (PL 94-171) Summary File, Table PL1.

10. Hirsch, Migration, Modernity and Mexican Marriage; M. B. Miles and A. M. Huberman, Qualitative Data Analysis: An Expanded Sourcebook (Newbury Park, Calif: Sage, 1994).

11. Hirsch, Migration, Modernity and Mexican Marriage; J. Durand, Más Allá de la Línea: Patrones Migratories entre México y Estados Unidos (Mexico City: Consejo Nacional para la Cultura y las Artes, 1994); P. Hondagneu-Sotelo, Gendered Transitions: Mexican Experiences of Immigration (Berkeley: University of California Press, 1994); D. S. Massey, R. Alarcón, J. Durand, and H. González, Return to Aztlan: The Social Process of International Migration From Western Mexico (Berkeley: University of California Press, 1987).

12. W. Cornelius, "Los Migrantes de la Crisis: The Changing Profile of Mexican Migration to the United States," in Social Responses to Mexico’s Economic Crisis, ed. M. González de la Rocha and A. E. Latapí (San Diego: Center for US–Mexican Studies, University of California at San Diego, 1991), 155–194; M. Cerrutti and D. S. Massey, "On the Auspices of Female Migration From Mexico to the United States," Demography 38 (2001): 187–200.

13. Gayet et al., "Aspectos Conceptuales"; K. V. Bletzer, "Use of Ethnography in the Evaluation and Targeting of HIV-AIDS Education Among Latino Farm Workers," AIDS Education and Prevention 7 (1995): 178–191; M. R. Cardenas-Elizalde, "Migración y SIDA en México," Salud Publica de Mexico 30 (1988): 613–618. Many have noted low rates of condom use and limited perceptions of personal risk among migrant men; see M. Bronfman and N. Minello, "Hábitos Sexuales de los Migrantes Temporales Mexicanos a Los Estados Unidos de América: Prácticas de Riesgo para la Infección por VIH," in SIDA en México: Migración, Adolescencia, y Genéro, ed. M. Bronfman, A. Amuchastegui, R. M. Martina, N. Minello, M. Rivas, and G. Rodríguez (Mexico City: Información Profesional Especializada, 1995), 1-90; M. Bronfman and S. Lopez Moreno, "Perspectives on HIV/AIDS Prevention Among Immigrants on the US–Mexico Border," in AIDS Crossing Borders: The Spread of HIV Among Migrant Latinos, ed. S. Mishra, R. Conner, and R. Magaña (Boulder, Colo: Westview Press, 1996), 49–76; J. S. Hirsch, R. Albalak, and C. Nyhus, "Masculinity, Sexuality and AIDS Risk Behavior in a Mexican Migrant Community," paper presented at the Annual Meeting of the Population Association of America, March 23–25, 2000, Los Angeles, Calif; R. Magaña, O. de la Rocha, and J. L. Ansel, "Sexual History and Behavior of Mexican Migrant Workers in Orange County, CA," in AIDS Crossing Borders, 77–94; M. A. Pérez and K. Fennelly, "Risk Factors for HIV and AIDS Among Latino Farmworkers in Pennsylvania.," in AIDS Crossing Borders, 137–156.

14. N. L. Weatherby, H. V. McCoy, L. R. Metsch, K. V. Bletzer, C. B. McCoy, and M. R. de la Rosa, "Use of Ethnography," Substance Use and Abuse 34(1999): 685–706; Bletzer, "Use of Ethnography"; C. B. McCoy, L. R. Metsch, J. A. Inciardi, R. S. Anwyl, J. Wingred, and K. Bletzer, "Sex, Drugs, and the Spread of HIV/AIDS in Bella Glade, Florida," Medical Anthropology Quarterly 10 (1996): 83–93; Magaña et al., "Sexual History and Behavior"; R. W. Weeks, J. J. Schensul, S. S. Williams, M. Singer, and M. Grier, "AIDS Prevention for African-American and Latina Women: Building Culturally and Gender-Appropriate Intervention," AIDS Education and Prevention 7 (1995): 251–263; M. Singer and L. Marxuach-Rodríguez, "Applying Anthropology to the Prevention of AIDS: The Latino Gay Men’s Health Project," Human Organization 55 (1996): 141–148. In comparison with more long-standing migrant-receiving communities, relatively new ones such as those in Georgia may face a particular dearth of second-generation Latinos available to work as translators and advocates; see Access to Health Care by Limited English Proficient Populations in Georgia: A Report of the Bilingual Health Initiative Task Force (Atlanta: Georgia Dept of Human Resources, Division of Public Health, 1994). As migrants continue to travel to more diverse destinations in the United States (D. S. Massey and J. Durand, "Historical Dynamics of Mexican Migrant Destinations, 1920–90," paper presented at the 1998 Meeting of the Latin American Studies Association, September 1998, Chicago, Ill), this issue of regional variation in culturally competent public health infrastructure is likely to grow in importance.

15. D. S. Massey, J. Arango, G. Hugo, A. Kouaouci, A. Pellegrino, and J. Taylor, "Theories of International Migration: A Review and Appraisal," Population and Development Review 19 (1993): 431–466.

16. M. Singer, "AIDS and the Health Crisis of the US Urban Poor: The Perspective of Critical Medical Anthropology," Social Science & Medicine 39 (1994): 931–948; M. Singer, C. Flores, L. Davison, et al., "SIDE: the Economic, Social, and Cultural Context of AIDS Among Latinos," Medical Anthropology Quarterly 4 (1990): 71–114. The fact that men remain in Mexico is of course no guarantee that they will not seek out other partners; one recent analysis of a household survey in Mexico City reported that 15% of men interviewed had had extrarelational sex during the past year; see J. Pulerwitz, J.-A. Izazola-Licea, and S. L. Gortmaker, "Extramarital Sex Among Mexican Men and Their Partners’ Risk of HIV and Other Sexually Transmitted Diseases," American Journal of Public Health 91 (2001): 1650–1652. Furthermore, not all men who spend time in the United States as temporary labor migrants have sex while away from home; preliminary analysis of data from a pilot study with a community-based convenience sample of Mexican migrants in Atlanta reveal that slightly over half of the men (53%) had not had sex (J. S. Hirsch, K. Yount, H. Chakraborty, and C. Nyhus, unpublished data). We focus here on migration, infidelity, and HIV risk because those migrants who do seek out extramarital sex while in the United States are generally at greater risk of HIV infection than are men who remain in Mexico.

17. C. Magis-Rodríguez, A. del Río-Zolezzi, J. L. Valdespino-Gómez, and M. L. García-García, "AIDS Cases in Rural Mexico," Salud Publica de Mexico 37 (1995): 615–623.

18. D. Diaz-Santana and A. Celis, "AIDS and Migration in Jalisco, Mexico: Their Relation With Risk Factors," International Conference on AIDS 5 (1989): 1057 (abstract T.H.H.P.20); M. Bronfman, S. Camposortega, and J. Z. Izazola, "Distribución de la epidemia del SIDA," in SIDA, Ciencia, y Sociedad en México, ed. J. Sepulveda, M. Bronfman, G. Ruíz-Palacios, E. Stanislawski, and J. Valdespino (Mexico City: Fondo de Cultura Economica, 1989).

19. Bronfman et al., Migración y SIDA; T. Pineda, B. Loeza, R. Heredia, N. Vázquez, and V. Hernández, "Perfil del Michoacano Emigrado a Los EUA y el Impacto de la Epidemiologia del VIH/SIDA en la Región," III Congreso Nacional de Investigación Sobre Salud, Mexico, 1992.

20. C. Magis-Rodríguez et al., "AIDS Cases in Rural Mexico"; C. Magis-Rodríguez, A. del Río-Zolezzi, J. Valdespino-Gómez, and M. García-García, "Rural AIDS cases in Mexico," abstract presented at 12th World AIDS Conference, June 28–July 3, 1998, Vancouver, British Columbia; A. del Río-Zolezzi, A. Liguori, C. Magis-Rodríguez, J. Valdespino Gómez, M. GarcíaGarcía, and J. Sepulveda-Amor, "La Epidemia de VIH/SIDA y la Mujer en México," Salud Publica de Mexico, Numero Especial: Doce Años de SIDA en Mexico 37 (1995): 581–591.

21. Bronfman et al., Migración y SIDA; M. Santarriaga et al., "HIV/AIDS in a Migrant Exporter Mexican State," International Conference on AIDS 11 (1996): 414 (abstract Tu.D.2906); Mishra et al., eds., AIDS Crossing Borders; Bronfman and Minello, "Hábitos Sexuales."

22. All the quotations presented here use pseudonyms.

23. All of the women interviewed for this study knew that "SIDA" (the Spanish acronym for AIDS) is transmitted sexually. Most knew that it was not curable, and several noted that someone could be infected with AIDS but look apparently healthy. All the women stated that a woman is safe as long as she has sex only with her spouse. There were no striking generational differences in women’s levels of knowledge, nor did what women know vary much with migration experience.

24. J. Wasonga, "Role of Publications in Disseminating Correct AIDS/HIV Information and Influencing Behavior Among the Youth," International Conference on AIDS 11 (1996): 499 (abstract Pub.D.1393); M. S. Cohen, "HIV and Sexuality Transmitted Diseases: The Physician’s Role in Prevention," Postgraduate Medicine 98 (1995): 52–58, 63–64; H. Soler, D. Quadagno, D. F. Sly, K. S. Riehman, I. W. Eberstein, and D. F. Harrison, "Relationship Dynamics, Ethnicity, and Condom Use Among Low-Income Women," Family Planning Perspectives 32 (2000): 82–88, 101; E. Weiss and G. G. Rao, "The Need for Female-Controlled HIV Prevention, International Conference on AIDS 10 (1994): 46 (abstract SS9).

25. Separata de la Revista SIDA/ETS (Enfermedades de Transmisión Sexual): Situación Epidemiologica del SIDA & Situación Epidemiológica de las ETS, Datos Actualizados Hasta Tercer Trimestre de 1997 (Mexico City: Consejo Nacional de SIDA, Secretaría de Salud, 1997).

26. There is nothing particularly new about the link between migration and infection; one woman recounted how her husband’s grandmother had been infected by her grandfather. Nor is the relationship between STDs and increasing economic and social ties to the world beyond the pueblo an entirely new phenomenon: Luis González describes how the first cases of gonorrhea were diagnosed in San José in the late 1940s, shortly after the highway was completed that connected San Jose to larger towns and cities in Michoacan and beyond; see González, San José de Gracia: Mexican Village in Transition, tr. J. Upton (Austin: University of Texas Press, 1974). Degollado’s highway to Guadalajara was completed around the same time.

27. Women discussed STDs as the focal point of the shame associated with men’s infidelity to their wives. In the words of one woman, "they are shameful [or embarrassing] things [cosas penosas] ... For example, if my husband ... gave me a disease, well I wouldn’t tell anybody. ... People just keep it to themselves."

28. See Hirsch and Nathanson, "Some Traditional Methods."

29. MacCormack and Draper describe people in Jamaica as having similar ideas about condoms as interfering with the social effects of sexual relations; see "Social and Cognitive Aspects of Female Sexuality in Jamaica," in The Cultural Construction of Sexuality, ed. P. Caplan (London: Routledge and Kegan Paul, 1987), 143–165; see also E. J. Sobo, "Bodies, Kin, and Flow: Family Planning in Rural Jamaica," Medical Anthropology Quarterly 7 (1993): 50–73.

30. Gayet et al., "Aspectos Conceptuales."

31. J. S. Hirsch, Migration, Modernity and Mexican Marriage; "En el Norte la Mujer Manda: Gender, Generation and Geography in a Mexican Transnational Community," American Behavioral Scientist42 (1999): 1332–1349; and Courtship After Marriage.[Abstract/Free Full Text]

32. See Hirsch and Nathanson, "Some Traditional Methods"; Hirsch, Migration, Modernity and Mexican Marriage and Courtship After Marriage.

33. A. Giddens, The Transformation of Intimacy: Sexuality, Love, and Eroticism in Modern Societies (Stanford, Calif: Stanford University Press, 1992).

34. Hirsch, "En el Norte."

35. In the fifth interview, the life history informants were asked a number of questions about infidelity, including how they would react if confronted with evidence of their husband’s infidelity and how they would deal with a friend whose husband they knew had another partner. Their mothers were prompted to speak about infidelity through questions about how a man might show respect or disrespect to his wife and about whether there were situations that justified a woman’s leaving her husband.

36. Our discussion of infidelity focuses on men’s extramarital relationships. Attitudes toward female infidelity seem to have changed very little. Men and women regarded it as grounds for divorce, as a terrible thing both in and of itself and because it tarnishes the reputation (and thus the marriageability) of one’s children. Women’s sexuality had a very different value than men’s in the traditional Mexican marital bargain: by committing to support them, men earned unlimited exclusive sexual access to their wives, the positive assurance that all children within the union would be fathered only by them, and the woman’s best efforts at the manifold tasks of social reproduction. A woman’s infidelity meant something different from a man’s because her sexuality, unlike her husband’s, was family rather than individual property; by sharing her body with someone other than her husband, she violated her part of the bargain. Even in the more modern marriages, no one suggested that a husband’s extended absence might justify sexual transgression on the part of his wife, although several women did say that if a woman has a strong sexual appetite her husband should bring her to live with him in the United States so that she is not subject to constant temptation. The unacceptability of female infidelity does not mean, of course, that it never happens—just that women stand to lose more when they are discovered. Furthermore, because married women almost never migrate without a spouse, women’s infidelity occurs in situations in which a woman who has remained in Mexico selects a partner from among the population of nonmigrant men remaining in the village. In these cases, her infidelity is unlikely to carry a great risk for HIV infection. Women’s infidelity is not without sociological interest, but it is unlikely to make a significant contribution to the epidemic of migration-related HIV in rural Mexico.

37. Sobo, "Finance, Romance, Social Support."

38. For the older women, leaving one’s husband under any circumstances meant that one’s reputation—and thus one’s daughter’s marriageability—would be irreparably damaged.

39. R. Petchesky and K. Judd, eds., Negotiating Reproductive Rights: Women’s Perspectives Across Countries and Cultures (London: International Reproductive Rights Action Group and Zed Books, 1998).

40. Hirsch, "En el Norte."

41. Sobo, "Finance, Romance, Social Support."

42. Sobo’s work is part of a growing body of literature that looks at the relative importance of economic, social, and psychological factors in shaping women’s desire and ability to use condoms with different kinds of partners. Some have argued for the primacy of economic factors, while others have shown that a woman’s reluctance to ask for condom use stems from her unwillingness to acknowledge that her relationship falls short of her ideals for monogamous intimacy; see Y. A. Hinkle, E. H. Johnson, D. Gilbert, L. Jackson, and C. M. Lollis, "African American Women Who Always Use Condoms: Attitudes, Knowledge About AIDS and Sexual Behavior," Journal of the American Medical Women’s Association 47 (1992): 230–237; A. Kline, E. Kline, and E. Oken, "Minority Women and Sexual Choice in the Age of AIDS," Social Science & Medicine 34 (1992): 447–457; Sobo, Choosing Unsafe Sex and "Finance, Romance, Social Support"; S. Zierler and N. Krieger, "Reframing Women’s Risk: Social Inequalities and HIV Infection," Annual Review of Public Health 18 (1997): 401–436; A. Morril, J. Ickovics, V. Golubchikiv, S. Beren, and J. Rodin, "Safer Sex: Social and Psychological Predictors of Behavioral Maintenance and Change Among Heterosexual Women," Journal of Clinical Psychology 64 (1996): 819–828; J. S. Santelli, A. C. Kouzin, D. R. Hoover, M. Polascek, L. G. Burwell, and D. D. Celentano, "Stage of Behavior Change for Condom Use: The Influence of Partner Type, Relationship, and Pregnancy Factors," Family Planning Perspectives 28 (1996): 101–107; S. E. Hetherington, R. M. Harris, R. B. Bausell, K. H. Kavanaugh, and D. E. Scott, "AIDS and Prevention in High-Risk African American Women: Behavioral, Psychology, and Gender Issues," Journal of Sex and Marital Therapy 22 (1996): 9–21; L. C. Miller, B. A. Bettencourt, S. C. DeBro, and V. Hoffman, "Negotiating Safer Sex: Interpersonal Dynamics," in The Social Psychology of HIV Infection, ed. J. B. Pryor and G. D. Reeder (Hillsdale, NJ: Lawrence Erlbaum, 1993), 85–123; P. Farmer, M. Connors, and J. Simmons, eds., Women, Poverty, and AIDS: Sex, Drugs, and Structural Violence (Monroe, Me: Common Courage Press, 1996). Both are important in this particular context, as Mexican women’s attachment to the fiction of mutual monogamy is a cultural manifestation of their social and economic dependence on men.

43. M. Inhorn, Infertility and Patriarchy: The Cultural Politics of Gender and Family Life in Egypt (Philadelphia: University of Pennsylvania Press, 1996); Y. Yan, "The Triumph of Conjugality: Structural Transformation of Family Relations in a Chinese Village," Ethnology 36 (1997): 191–212; M. Hollos and U. Larsen, "From Lineage to Conjugality: The Social Context of Fertility Decisions Among the Pare of Northern Tanzania," Social Science and Medicine 45 (1997): 361–372; L. Ahearn, " ‘Love Keeps Afflicting Me’: Agentive Discourses in Nepali Love Letters," paper presented at Annual Meeting of the Anthropological Association of America, 1998, Philadelphia; Hirsch, Courtship After Marriage; H. Wardlow, "All’s Fair When Love Is War: Attempts at Companionate Marriage Among the Huli of Papua New Guinea," paper presented at the 98th Annual Meeting of the American Anthropological Association, 1999, Chicago; J. Gregg, " ‘He Can Be Sad Like That’: Liberdade and the Absence of Romantic Love in a Brazilian Shantytown," paper presented at the 98th Annual Meeting of the American Anthropological Association, 1999, Chicago; W. R. Maggi, "Heart-Struck: Love Marriage as a Marker of Ethnic Identity Among the Kalasha of Northwest Pakistan," paper presented at the 98th Annual Meeting of the American Anthropological Association, 1999, Chicago; L. A. Rebhun, is The Heart is Unknown Country: Love in the Changing Economy of Northeast Brazil (Stanford, Calif: Stanford University Press, 2000); D. J. Smith, "Romance, Parenthood, and Gender in a Modern African Society," Ethnology 40 (2001): 129–151.

44. Farmer et al, eds., Women, Poverty, and AIDS.

45. The majority of programs targeting men’s behavior change have been directed at gay men. There have been several intervention research programs that have either targeted heterosexual and homosexual men together, or else have focused primarily on heterosexual men; see C. Cáceres and A. Rosasco, "An HIV/STD Prevention Program for Homosexually Active Men Who Do not Necessarily Identify Themselves as Gay in Lima," International Conference on AIDS 9 (1993): 111 (abstract WS-D08-4); D. D. Celentano, K. E. Nelson, C. M. Lyles, et al., "Decreasing Incidence of HIV and Sexually Transmitted Diseases in Young Thai Men: Evidence for Success of the HIV/AIDS Control and Prevention Program," AIDS 12 (1998): F29–F36; Mishra et al., AIDS Crossing Borders; A. O’Leary, L. S. Jemmott, F. Goodhart, and J. Gebelt, "Effects of an Institutional AIDS Prevention Intervention: Moderation by Gender," AIDS Education & Prevention 8 (1996): 516–528; P. William and C. Britton, "Understanding the Culture of Masculinity and Creating Effective Prevention Messages," National HIV Prevention Conference 1999 (abstract 116). In general, however, heterosexual men have been relatively neglected as targets of condom promotion programs.

46. For example, K. Q. Abdool, J. E. Mantell, and E. Scheepers, "South Africa’s Response to Preventing HIV/AIDS and Other STDs in Women: Introducing Female Controlled Methods in the Public Sector, International Conference on AIDS 11 (1996): 258 (abstract Tu.D.354); B. S. Obwongo, "Modeling Safe-Sex Practices Among Medical Students Through Peer Education," International Conference on AIDS 11 (1996): 467 (abstract Pub.C.1184); Obwogo, "Sexual Practices Among Nairobi University Freshmen," International Conference on AIDS 12 (1998): 1015 (abstract 60079); Wasonga, "Role of Publications"; Weiss et al., "Findings From the Women"; Weiss and Rao, Female-Controlled HIV Prevention."

47. R. Bolton, "AIDS and Promiscuity: Muddles in the Models of HIV Prevention," Medical Anthropology14 (1992): 145–223.[Medline]

48. More than 10 years ago, Fullilove and Fullilove argued that the debate about which particular social or economic factor is key in helping women negotiate for condom use misses the point that women often do not have the power to negotiate with men regarding how and under what circumstances sexual activity (and relationships) will be conducted; see M. T. Fullilove, R. E. Fullilove III, K. Hayes, and S. Gross, "Black Women and AIDS Prevention: A View Towards Understanding the Gender Rules," Journal of Sex Research 27 (1990): 47–64; in 1995, Amaro wrote that "Risk of HIV infection in women cannot be separated from the unequal status of women in American society and the resulting differences in power between men and women"; see H. Amaro, "Love, Sex and Power: Considering Women’s Realities in HIV Prevention," American Psychologist 50 (1995): 437–447; see also P. Farmer, Infections and Inequalities (Berkeley: University of California Press, 1999). These arguments seem to have had limited impact on public health thinking about women and AIDS.

49. K. O. Mason, "HIV Transmission and the Balance of Power Between Women and Men: A Global View," Health Transition Review supplement 4 (1994): 217–240.

50. By arguing that women in this community and others like it in Mexico are not appropriate targets for campaigns promoting condom use to stem the tide of heterosexual marital transmission, we do not mean to suggest that the same is true for married women everywhere around the world. Data show that married women in South Africa feel differently about the tradeoffs between the emotional risk of acknowledging infidelity and the health risks of not doing so; see I. Susser and Z. Stein, "Culture, Sexuality, and Women’s Agency in the Prevention of HIV/AIDS in Southern Africa," American Journal of Public Health90 (2000): 1042–1048. Across the globe, there may be cultural and social circumstances in which women feel that it is appropriate to take action to protect themselves, and in these settings it certainly makes sense to proceed with intervention research on how to improve women’s condom negotiation skills, and with basic research to develop and make available effective microbicides.[Abstract/Free Full Text]

51. See Weeks et al., "AIDS Prevention."

52. Institute of Medicine, Committee on the Elimination of Tuberculosis in the US, Division of Health Promotion and Disease Prevention, Ending Neglect: The Elimination of Tuberculosis in the United States, ed. L. Geiter (Washington, DC: National Academy Press, 2000).

53. L. R. Chávez, "Undocumented Immigrants and Access to Health Services: A Game of Pass the Buck," Migration Today 12 (1984): 20–24; L. R. Chávez, W. A. Cornelius, and O. Williams, "Mexican Immigrants and the Utilization of US Health Services: The Case of San Diego," Social Science and Medicine 21 (1985): 93–102; L. R. Chávez, E. T. Flores, and M. López-Garza, "Undocumented Latin American Immigrants and US Health Services: An Approach to a Political Economy of Utilization," Medical Anthropology Quarterly 6 (1992): 6–26; C. A. Evans, "Immigrants and Health Care: Mounting Problems," Annals of Internal Medicine 122 (1995): 309–310; J. H. Flaskerud and S. Kim, "Health Problems of Asian and Latino Immigrants," Nursing Clinics of North America 34 (1999): 359–380; R. G. Rumbaut, L. R. Chávez, R. J. Moser, S. M. Pickwell, and S. M. Wishnik, "The Politics of Migrant Health Care: A Comparative Study of Mexican Immigrant and Indochinese Refugees," Research in the Sociology of Health Care 7 (1986): 143–202.

54. J. S. Santelli, R. Lowry, N. D. Brener, and L. Robin, "The Association of Sexual Behaviors With Socioeconomic Status, Family Structure, and Race/Ethnicity Among US Adolescents," American Journal of Public Health90 (2000): 1582–1588.[Abstract/Free Full Text]

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