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Sex and the 'recently single': perceptions of sexualityand HIV risk among mature women and primary carephysiciansKathryn Grant a; Kathleen Ragsdale ba Department of Sociology and Anthropology, University of North Florida, USAb Department of Sociology, Anthropology and Social Work, Mississippi StateUniversity, USA

Online Publication Date: 01 June 2008

To cite this Article: Grant, Kathryn and Ragsdale, Kathleen (2008) 'Sex and the 'recently single': perceptions ofsexuality and HIV risk among mature women and primary care physicians', Culture, Health & Sexuality, 10:5, 495 —511

To link to this article: DOI: 10.1080/13691050801948094URL: http://dx.doi.org/10.1080/13691050801948094

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Sex and the ‘recently single’: perceptions of sexuality andHIV risk among mature women and primary care

physicians

KATHRYN GRANT1 & KATHLEEN RAGSDALE2

1Department of Sociology and Anthropology, University of North Florida, USA, and 2Department of

Sociology, Anthropology and Social Work, Mississippi State University, USA

AbstractPrimary care physicians may mistakenly conclude that sexual issues are unimportant to divorced orwidowed mature women, based on age and gender biases. Although research suggests that manysingle mature women are sexually active, physicians are often reluctant to discuss sexual matters withthem. Structured and open-ended interviews explored perceptions regarding mature women’ssexuality and HIV-related risk for patient-physician communication among 44 ‘recently single’mature women aged 45–68 and 31 primary care physicians. Age and ethnic group comparisons withthe mature women suggest that younger and African-American women reported higher HIV and STIrisk perception than older and White women. Many mature women (64%) believed that they were at-risk for HIV and STIs, whereas physicians considered younger patients most at-risk and that riskdeclined with patients’ advancing age and with female status. Mature women and physicians haddifferent expectations regarding initiation of clinical sexual health discussions, with 44% of themature women placing the onus of responsibility on the patient, whereas 74% of physicians believed itwas the role of both doctors and patients to bring up these topics. The findings are instructive toprimary care physicians and healthcare policy makers, indicating that sexual health issues are relevantto mature women’s continued health and well-being.

ResumeLes medecins en soins primaires peuvent considerer a tort, en se basant sur leurs perceptions de l’ageet du genre, que les questions de sexualite n’ont pas d’importance pour les femmes divorcees ou pourles veuves d’age mur. Bien que la recherche suggere que beaucoup de femmes seules et d’age mursont sexuellement actives, les medecins sont souvent reticents a l’idee d’aborder ces questions avecelles. Des entretiens structures et ouverts ont permis d’explorer les perceptions sur la sexualite desfemmes d’age mur et les risques lies au VIH, dans le cadre de la communication entre patients etmedecins, chez 44 femmes d’age mur, « seules depuis peu » et agees de 45 a 68 ans, et chez 31medecins en soins primaires. Concernant les 44 femmes d’age mur, les comparaisons par tranchesd’age et par groupes ethniques suggerent que les taux de perceptions des risques lies au VIH et auxIST sont plus eleves chez les femmes les plus jeunes et chez les Afro-Americaines que chez les femmesles plus agees et les femmes de race blanche. Beaucoup de femmes d’age mur (64 %) considerentqu’elles sont exposees au VIH et aux IST; alors que les medecins croient que seules les plus jeunespatientes sont les plus exposees et que ces risques diminuent en fonction de l’age et du statut desfemmes. Concernant l’initiation des discussions sur la sante sexuelle, les femmes d’age mur expriment

Correspondence: Kathryn Grant, Department of Sociology and Anthropology, University of North Florida, 1 UNF Drive,

Jacksonville, 32224, USA. Email: kathryn.grant@unf.edu

Culture, Health & Sexuality, June 2008; 10(5): 495–511

ISSN 1369-1058 print/ISSN 1464-5351 online # 2008 Taylor & Francis

DOI: 10.1080/13691050801948094

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des attentes differentes de celles des medecins, 44 % d’entre elles considerant qu’il revient auxpatientes d’initier ces discussions, et 74 % des medecins considerant qu’il est du role aussi bien desmedecins que des patientes d’aborder ces questions. Les resultats sont instructifs pour les medecinsen soins primaires et les responsables des politiques des soins: ils indiquent que les questions de santesexuelle sont tout a fait pertinentes dans le domaine du maintien de la sante et le bien-etre des femmesd’age mur.

ResumenLos medicos de atencion primaria pueden llegar a la conclusion erronea de que los problemas sexualesno son importantes para mujeres maduras divorciadas o viudas basandose en prejuicios de edad ygenero. Aunque los estudios indican que muchas mujeres maduras solteras son sexualmente activas,con frecuencia los medicos son reacios a hablar con ellas sobre temas sexuales. Mediante entrevistasestructuradas y abiertas a 44 mujeres maduras solteras con edades comprendidas entre los 45 y 68 anosy 31 medicos de atencion primaria, se analizo que percepciones tenıan de la sexualidad de mujeresmaduras y el riesgo de infeccion del virus del sida y cual era la relacion comunicativa medico-paciente.Las comparaciones realizadas en funcion de la edad y el grupo etnico entre las mujeres maduras indicanque las mujeres mas jovenes y de origen afroamericano eran mas conscientes del riesgo de contagio delVIH y de infecciones de transmision sexual que las mujeres mas mayores y de raza blanca. Muchasmujeres maduras (64%) creıan que corrıan riesgos de contagiarse del virus del sida y de infecciones detransmision sexual mientras que los medicos pensaban que las pacientes mas jovenes corrıan masriesgos y que este riesgo disminuıa si los pacientes era mas mayores y mujeres. Las mujeres maduras ylos medicos tenıan expectativas diferentes en cuanto al inicio de charlas sobre salud sexual: el 44% de lasmujeres maduras pensaban que era responsabilidad del paciente, mientras que el 74% de medicoscreıan que eran los medicos y las pacientes quienes debıan ocuparse de hablar de estos temas. Estosresultados son instructivos para los medicos de atencion primaria y los responsables de la polıticasanitaria porque indican que las mujeres maduras tambien tienen problemas de salud sexual y que sonimportantes para su salud y el continuo bienestar.

Keywords: HIV/AIDS, risk perception, patient communication, older women, STIs

Introduction

Interest in exploring the dynamics of provider-patient communication about sexuality

issues has taken on new significance in the wake of the HIV epidemic. This interest is

apparent in patient-service provider communication studies that address sensitive topics

and behaviours, including those that may be difficult to articulate, embarrassing or

stigmatising among populations that vary by gender, age, ethnicity and sexual orientation

(Makadon and Silin 1995, Kerr et al. 1996, Haas and Coe 1997, Skiest and Keiser 1997,

Epstein et al. 1998, Coates 1999, Wilson and Kaplan 2000, Rich 2001, Roter et al. 2002,

Nusbaum et al. 2002, Lindau et al. 2006, Smith et al. 2007). Such studies have explored

physicians’ communication behaviours with patients in terms of sexual function and

sexual health (such as HIV prevention) within the clinical setting; physician and patient

attitudes towards discussing sexual health issues within clinical contexts; and the impact

of physician or patient characteristics (i.e. age, gender, ethnicity). However, many of

these studies on HIV prevention and/or sexual communication within clinical contexts

have not delineated all findings by age, gender or ethnicity and most have primarily

focused on young populations historically at higher risk for HIV (Makadon and Silin

1995, Kerr et al. 1996, Haas and Coe 1997, Epstein et al. 1998, Coates 1999, Nusbaum et

al. 2002).

Indeed, what often comes to mind when the dating scene and HIV/STI risk are

mentioned are people in their 20s and 30s. Yet many mature women and men remain

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sexually active well into their later years, practicing a full range of sexual behaviours

(Stall and Catania 1994, American Association of Retired Persons (AARP) 1999, 2003,

Winningham et al. 2004, Lindau et al. 2006, Smith et al. 2007). As baby boomers age,

research on mature sexuality is expected to take on more social and clinical importance

(Yates et al. 1999). Despite this projected trend within the USA, cultural emphasis on

sexuality in youth, and the implication that older persons should not be concerned

about sexuality (or the potential health risks associated with some sexual behaviour),

does not prepare older persons or their healthcare providers for clinical communication

about sexual issues. This paper presents data from research that focused on mature

women’s concepts of sexuality and their notions about HIV and STI risks, comparing

those concepts with those of primary care physicians in an urban north Florida

community.

Background

Within the USA, healthcare providers would seem an ideal source of HIV prevention

information, since adults average almost three visits a year to a physician and physicians are

believed to be highly credible sources of health information (Makadon and Silin 1995,

Haas and Coe 1997). Indeed, most patients surveyed indicate that they would like to talk

with physicians about sexual health concerns, including HIV and AIDS (Makadon and

Silin 1995, Nusbaum et al. 2002, Smith et al. 2007). However, this resource often goes

untapped due, in part, to physicians’ perceptions of what constitutes appropriate medical

care, their discomfort with discussing sensitive issues, such as sexuality and intravenous

drug use, limited conceptions about who is at risk for HIV and time and resource

constraints (Strombeck and Levy 1998). Additionally, some physicians’ ageist attitudes

towards mature adults preclude the notion that older women and men can be at risk for

HIV infection (Strombeck and Levy 1998). Yet, the continuing rise of HIV cases among

populations not traditionally considered at high risk of infection indicates that physicians

may be interacting ‘with HIV-positive patients and other patients who are at risk for

infection that may not fall into the ‘‘traditional’’ high-risk categories’ (Haas and Coe 1997,

p. 403).

Although reported cases of HIV and AIDS decreased among children and persons aged

25–34 years between 1998 and 2002, they increased among persons aged 45 and older

(CDC 2002). In 2003, 9% of all people living with HIV/AIDS in the USA were aged 55

and older (CDC 2003). In Florida, the site of the present study, persons aged 50 and over

account for 15% of AIDS cases and 11% of the HIV (not AIDS) cases; non-Hispanic

Blacks account for 52% of all seniors (age 50 and over) diagnosed with AIDS, as compared

with 32% of non-Hispanic Whites and 16% of Hispanics (Florida Department of Health

2004). African-American women in all age groups have been severely affected by HIV and

AIDS in Florida, representing 69% of all AIDS cases and 66% of all HIV cases in women

(Florida Department of Health 2006a).

The primary mode of transmission for all adult women is through heterosexual contact,

accounting for 86% of HIV cases in Florida (Florida Department of Health 2006b).

Despite growing concern about female-to-female HIV transmission (CDC 2006),

heterosexual transmission continues to be the area of greatest concern for women aged

50 and older, particularly among those re-entering the dating scene after divorce or

widowhood (Rich 2001, Florida Department of Health 2004). Furthermore, HIV risk

perceptions, rates of testing and consistent condom use are relatively low among mature

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persons (Mack and Bland 1999, Theall et al. 2003, Zablotsky and Kennedy 2003,

Paranjape et al. 2006).

Given that HIV transmission is increasing among older people, research on mature

sexuality should address how sociocultural factors mediate and moderate effective

patient-physician communication regarding HIV- and STI-related risk. This research

was designed to address the following questions: Do physicians hold age- and/or gender-

based assumptions about discussing sexuality and/or HIV and STI-related topics with

mid-life and older women? Do physicians feel their education prepared them to address

HIV and STI-related topics with their mature women patients? Are physicians’ concepts

about sexuality and aging different from women’s own sexuality and aging concepts? Are

there differences in women’s perceptions about discussing sexuality issues in clinical

contexts based on age, marital/partner status and ethnicity? Are there differences in

women’s HIV and STI risk perceptions based on age, marital/partner status and

ethnicity?

Methods

Qualitative and quantitative data were collected from a sample of 44 recently divorced,

widowed or separated mature women (referenced here as ‘recently single’ due to their

marital status and recent participation in a displaced homemaker programme) and a sample

of 31 primary care physicians, in the same north Florida community. Recently single

participants completed a demographic survey and in-depth interview. Physician partici-

pants completed a demographic/practice characteristics survey and some also completed an

in-depth interview. The details of each method are described below.

Recently single participants

The 44 recently single women aged 45–68 years were recruited through a state-

sponsored displaced homemaker programme between October 2002 and June 2004.

Interviews with programme staff indicated that most of the women attending the

programme had been single for six months to a year, though this information was not

systematically collected. The female investigator conducted the interviews with

participants in their homes, places of work or at the community college campus where

the displaced homemaker programme was conducted. The investigator attended sessions of

each three-week programme that occurred during the recruitment period. Eligible

participants met the following inclusion criteria: they were > 45 years of age and divorced,

widowed, separated or had ended a long-term heterosexual consensual union (women who

had lived with a man in a long-term consensual union for periods ranging from about 5–15

years, but had never married). Eligible women who did not complete the interview on the

spot were interviewed later at a pre-arranged time and place of their choosing. The

Institutional Review Board of the University of Florida approved the consent procedures

for this project, which included informing participants of the sexuality theme of the

research and their right to refuse to answer any question or to terminate the interview at any

time. Participants were also assured that no individual identifiers would be associated with

their interview responses in data reports. Respondents were compensated for their

participation with a US$20 gift certificate.

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Physician participants

The majority of the physicians recruited into the study were resident or attending

physicians at a university-based family practice clinic that serves an urban, low-income,

largely African-American neighbourhood. Their female patient population is made up of

all age groups and is approximately 70% African-American and 30% White. Between June

2003 and June 2004, 28 physicians were recruited through a family practice residency

programme, and three physicians were from other primary care departments in the same

university-based hospital. The inclusion criteria for physicians were: a patient base that

included women aged 45 and older; and training in a primary care speciality (i.e. family

medicine, general medicine, internal medicine, obstetrics/gynaecology, etc.). All 31

physicians completed the survey and 18 also participated in one-on-one interviews. The

approved consent procedures were largely the same as those for the recently single

women, except for clarification regarding level of participation (survey only or both survey

and interview) and compensation based on level of participation (survey only participants

received a US$10 gift certificate and survey/interview participants received a US$20 gift

certificate).

Recently single participant survey

The structured survey for the recently single women elicited information in the following

areas: sociodemographic data on age, ethnicity, marital status, number of children, number

in current household, level of education, years lived in the area, health status, most recent

doctor visits and type of doctor visited. For purposes of analysis, the following variables

were recoded as follows: ethnicity was dichotomised as White or African-American; ages

were grouped as 45–55 versus 56-or-above; ‘divorced’ and ‘ended consensual union’ were

combined into one variable.

Physician participant survey

The structured survey for the physicians elicited information in the following areas: age;

status as a resident or attending physician; recentness of medical training; type of practice;

demographic profile of physicians’ patient population (percentages based on age, gender

and ethnicity); perceptions of medical education and HIV/STI prevention preparedness;

perceptions of patients’ HIV knowledge; sexual health risk for their patients aged 45 and

older; and opinions about patient and physician responsibility regarding discussing sexual

health issues.

A five-point Likert scale format was used for the following questions: (1) ‘How well

informed are the majority of your adult patients (aged 45 and older) about HIV and other

STIs?’ (ranging from ‘well informed’ to ‘not at all informed’); and (2) ‘Do you feel that

your medical education adequately prepared you for addressing current sexuality issues

(including STIs and HIV) with a wide range of patients?’ (ranging from ‘strongly agree’ to

‘strongly disagree’). The following multiple-choice question was used: ‘Do you think it is

primarily the patient’s or the physician’s responsibility to bring up sex life issues in a clinical

encounter?’ Responses codes were ‘doctor’s’, ‘patient’s’ or ‘both’.

The initial survey included a question about the percentage of adult patients that

physicians considered at-risk. Early interviews with physicians suggested that they deemed

men to be at higher risk than women, which prompted a revision to the survey to assess

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this difference. Therefore three of the physicians were not asked this question in the

survey or interview format. The revised version of the survey asked physicians (n518) to

rate their patients’ HIV and STI risk with: ‘Generally, what percentage of your adult

patients do you consider at-risk for HIV or other STIs?’ (males …%, females …%). A

further revision of the survey was given to eight of the physicians, which asked them to

address the differences in risk by age groups. Additional data on age/gender risk

perceptions was gleaned from interviews.

Recently single participant interview

All interviews were audio taped with the participants’ permission. Interviews required

between 30 and 60 minutes to complete. Some qualitative interview data was coded for

quantitative analysis using responses from the following questions related to HIV and

AIDS knowledge and risk: (1) ‘Tell me a little bit about what you know about HIV and

AIDS’; (2) ‘Do you think that you are at-risk for HIV or other STIs?’ (responses coded

as ‘yes’, ‘no’ or ‘don’t know’, even though responses often included qualification for

why they gave the responses they gave); and (3) ‘Do you think that other recently single

women your age and older think that they are at-risk for HIV or other STIs?’ (responses

coded as ‘yes’, ‘yes, most’, ‘no’, ‘no, not most’, ‘don’t know’). All responses to closed-

ended questions listed above and were followed by probes, such as, ‘Why do you think

that you are (or are not) at risk?’ To determine how these women felt about physicians

talking to their older patients about sexual health issues, participants were asked: (1)

‘Do you think that doctors should assume their mature patients are sexually active?’

(responses coded as ‘yes’ or ‘no, don’t assume, ask’); (2) ‘Do you think doctors ought

to address the topic sexually transmitted infections with their mature patients?’

(responses coded as ‘yes’ or ‘no’); and (3) ‘Do you think that it is the patient’s or the

doctor’s responsibility to bring up sex life issues?’ (responses coded as ‘doctor’s’,

‘patient’s’ or ‘both’). Probes followed the questions above to assess the reasons for their

answers.

Physician participant interview

The physician participant interviews were used to elicit information about physicians’ age-,

gender-, marital status- and ethnicity-based perceptions regarding mature sexuality. The

interview schedule included the following questions and probes related to HIV-risk

perceptions and discussing sexual health issues with mature patients: (1) ‘Do you think

physicians should assume that all of their mature patients are sexually active?’ (responses

coded as ‘yes’ or ‘no, don’t assume, ask’); (2) ‘When do you think sexuality issues should be

addressed between physician and patient?’; and (3) ‘What percentage of your patients do

you consider at-risk for HIV or other STIs?’ Follow-up probes included, ‘Why this

number?’ and ‘Does their age/ethnicity/sex/sexual orientation influence risk status?’ Data

collected from these qualitative questions were not quantified for statistical analysis.

Data analyses

SPSS 12.0 (Chicago, Il) was used for analysis of quantitative data. Standard inferential

tests were used to assess significance within groups and between-groups using two-by-two

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comparison tables for Fisher’s Exact Test with two-sided significance (p-values only). Only

findings from those tests that yielded significance are reported. Percentages of comparisons

with multiple variables are given without further statistical analysis because of sample size

limitations on Pearson Chi-Square statistics. NUD*IST qualitative software was used

primarily as an organizing tool to sort the interview data for coding of relevant themes.

Themes were identified by the primary researcher and supported with the assistance of her

dissertation committee. Comments on a given theme were supported by a minimum of a

fifth of participants for each sample (physicians or ‘recently’ single women) mentioning a

topic to be considered a theme for analysis. Qualitative data presented here maintains the

confidentiality of the respondents and serves to support and clarify the statistical data and

percentage data.

Results

Recently single participants

Sociodemographic characteristics. Table 1 shows the sociodemographic characteristics of the

recently single participants. Recently single women ranged in age from 45–68 years

(M552.23, SD55.31) and all were either divorced/ended a long-term consensual union,

separated or widowed. Slightly more than half of the participants self-identified as White

Table 1. Sociodemographic characteristics – recently single women sample (n544).

Sociodemographic characteristics n (%)

Self-defined ethnicity

White/Euro-American 24 55

Black/African-American 20 45

Marital status

Divorced/ended union 25 54.5

Widowed 11 25

Separated 9 20.5

Education

Some high school 5 11.4

High school/GED 8 18.1

Vocational education/some College education 23 52.3

College graduate/graduate school 8 18.2

Employment

Full-time 13 29.5

Part-time 6 13.6

Unemployed 18 40.9

Social security income (SSI) 5 11.4

Retired/Other 2 4.6

Self-rated health status

Excellent 9 20.5

Good 19 43.2

Average 8 18.2

Fair 5 11.4

Poor 3 6.8

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(including one Middle-Eastern woman who self-identified as ‘other’) and 45% identified

as African-American. More than half had vocational training or some college education

and about a fifth were college graduates or had advanced degrees. Nine percent of

African-American women had not completed high school compared to 2% of White

women, but African-American women were more likely to have some college or

vocational training (60%) than were white women (43.5%). Almost two-thirds rated their

health as ‘good’ or ‘excellent’, just under a fifth rated their health as average and the

remaining fifth reported their health was ‘fair’ or ‘poor’. A slight majority was

unemployed or on Supplemental Security Income (a Federal income programme

funded by general tax revenues for people who are aged, disabled or unable to generate

sufficient income for food and shelter) and 43% were working either part- or full-time.

Since the primary purpose of the displaced homemaker programme is to assist women

with gaining employment after marital disruption, the low employment rate is not

surprising.

Twenty-three percent (n510) of the participants were in new sexual relationships with

steady partners, 15.9% (n57) were in new sexual relationships with non-steady partners,

6.8% (n53) had recently ended a dating/sexual relationship within the past two weeks to a

month, 36.4% (n516) were single and were not actively pursuing a new sexual

relationship, but would consider dating the ‘right person’ and 15.9% (n57) expressed no

interest in finding a new sexual partner or dating. These categories were gleaned from

interview data to best reflect the variety of responses to a question (and probes) regarding

current partner status.

Dating and HIV/STI risk among recently single participants. Sixty-four percent said that

they considered themselves to be ‘at risk’ for HIV and other STIs. Partner status was

important in determining their risk perception, with 82.4% of those with partners

declaring that they believed they were at risk, as compared to 51.9% of those without a

current partner. Women between 45 and 55 years of age (70.6%, n524) were more likely

to report that they were ‘at risk’ than women 56 years of age or above (40%, n54) and

African-American women were slightly more likely to think that they were at risk (70%,

n514) than White women (58.3%, n514), but these difference were not statistically

significant.

Explanations of HIV/STI risk perceptions. In the interviews, some of the women cited

infidelity by husbands and lovers for their risk perception and some mentioned the

uncertainty of knowing a partner’s status:

‘… even if you’re in a monogamous relationship, just because you are doesn’t mean that …your

partner isn’t, you know, going someplace.’ (divorced woman with steady partner in her

mid-50s)

Other reasons focused on the newness of safer sex practices:

‘Well, I have never had sex with a condom – never had to … That’s going to be a whole new

experience for me when that comes to pass. Asking, you know, ‘let’s use protection,’ [or] ‘do you

have any?’ Or going to a store and buying some condoms to keep in my nightstand – totally

something that I have never done and never expected to do.’ (separated woman in her mid-50s

without a current partner)

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Some of the women without a current sexual partner who felt that they were at-risk for HIV

and STIs explained that they did not intend to remain single and that they were cognizant

of the risks involved with sexual relationships:

‘Yes, I will be [at-risk], ‘cause I’m planning on getting back into the game.’ (separated woman in

her mid-50s)

Some participants without partners who did not consider themselves at risk explained that

they were not sexually active and had no interest in finding a partner:

‘No ma’am, because it’s like I told you, I’m scared and I don’t want to be bothered. And um, I

don’t like, what do you call it, protection [condoms]? I don’t care for that.’ (divorced woman in her

late 50s)

Tested for HIV. Forty-one percent (n518) of recently single women spontaneously

volunteered during interviews that they had been previously tested for HIV; 59% (n510)

of women with partners or in dating relationships had been tested, as compared to 29.6%

(n58) of women without partners. Though not statistically significant, women between the

ages of 45 and 55 (47.1%, n516) and African-American participants (55%, n511) were

more likely than participants over 55 years of age (20%, n52) and White participants

(29.1%, n57) to report that they had been previously tested for HIV. HIV testing was

motivated by fear of exposure and inconsistency in using condoms, although in some cases

it was also related to having personal knowledge of someone with HIV or who had died of

AIDS. The following quote summarized several of the issues raised in the interviews about

dating, safer sex practice and reasons for HIV testing:

‘So many people like me are divorced and we date and we’re not always careful. We don’t like

condoms. We hardly ever use them … We take chances, thinking that, well, it doesn’t happen in

my age group or in my class, but it does. But when you have a steady boyfriend, you don’t think of

yourself, and you don’t know what he’s doing on the days he’s not seeing you, and I don’t trust

men anymore, so I figure they’re going to be out doing something … I know myself, and I’ve lied to

men before about other men, so if I’ll do it, then I’m sure they’ll do it ‘cause I’m not that different

… But I’ve had myself tested.’ (divorced woman in her early 60s)

Knowing someone with HIV and HIV testing. Table 2 shows the impact of knowing

someone with HIV on having a test for HIV. Fifty percent of the participants (n59) who

reported that they had been tested for HIV also volunteered that they knew someone with

Table 2. Know/knew someone with HIV, ethnicity and HIV tested.

Knows/knew

someone with HIV

n (%)

Does not know

anyone n (%)

Fisher’s Exact Test

2-sided significance

African-American 8 (40.0) 12 (60.0) .028

Euro-American 2 (8.3) 22 (91.7)

HIV tested 9 (50.0) 9 (50.0) .001

Not HIV tested 1 (3.8) 25 (96.2)

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the disease or who had died of AIDS, whereas only one of the participants that knew

someone with the disease had not been tested. On the other hand, the majority of those

who did not mention being tested (96.2%) did not know anyone with HIV (p5.001).

Knowing someone with HIV was significantly related to ethnicity with 40% of African-

American participants as compared to 8.3% of White participants knowing someone who

has or had HIV (p5.028).

Perceptions of HIV risk for self and other recently single women. In response to the question,

‘Do you think that other recently single women your age and older think that they are at

risk for HIV?’, 57.5% (n523) said ‘yes’ or ‘yes, most’ as compared to 42.5% (n517) who

said ‘no’ or ‘no, not most’. Respondents often qualified their ideas about the perceptions

of others by saying that they think that they know of the risk, but do not consistently take

steps to protect themselves and that emotional and socioeconomic issues also come into

play:

‘Probably in the back of their minds [they know of the risk], but they really don’t … think that it

can happen to them. They don’t want to face reality, ‘cause they want to live for the moment.’

(divorced woman in her early 50s)

‘I think we’re a lot more cognizant than any of us would have been 10 years ago. Maybe not as

vigilant as we probably should be.’ (separated woman in her mid-40s)

‘Yes, I think we’re more at risk than some of these young people because we’re more settled …

Then especially when you’re unemployed, lost a loved one and depression, low self-esteem,

sometimes you can just fall into a lurch where you just don’t think sometimes.’ (widow in her mid-

40s)

Physician participants

Characteristics. Table 3 shows the demographic and practice characteristics of the primary

care physician sample. Physicians (attending physicians n513; and resident physicians

n518) ranged in age from 27–57 years (M539.42, SD58.71). Attending physicians were

older on average than residents, with a mean age of 48 for attending physicians and 34 for

residents. Slightly more than half were male. Over half were White, but three of those that

self-identified as ‘White’ also reported Latino/Hispanic ethnicity and another two

Table 3. Demographic and practice characteristics – physician sample (n531).

n %

Attending/resident

Attending physician 13 41.9

Resident physician 18 58.1

Gender

Female 14 45.2

Male 17 54.8

Self-reported ethnicity

White/Euro-American 17 54.8

Black/African-American 2 6.5

Asian/Pacific Islander 7 22.6

Other 5 16.1

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identified with a Latin American nationality without selecting the ‘White’ identity as well.

Almost one quarter identified themselves as Asian/Pacific Islander, two identified with a

middle-eastern nationality, two identified as African-American and one identified as ‘West

Indian’.

Physicians’ perceptions of HIV risk for their patients. All of the physicians surveyed and

interviewed work in an area serving mostly a lower income population that is largely

African-American. Forty-three percent of the physicians (n513) considered the majority of

their patients aged 45 years or older ‘partially informed’ about HIV and STIs, while 36.7%

(n511) considered these patients ‘poorly informed’, 10% (n53) considered them

‘moderately informed’ and 10% (n53) considered them ‘well informed’. There were no

significant differences by gender or attending/residency status on this topic. Despite

physicians’ sense that many of their mature patients lacked adequate knowledge about HIV

risks, few physicians considered them at significant risk for HIV and STIs.

Interview and survey follow-up questions suggested that physicians’ perception of

HIV and STI risk generally declined with patients’ increasing age, female status and

intact marriage. Eight physicians completed a revised version of the survey that asked

them to give percentages of patients they considered at risk by gender and age group.

Averages from percent rankings showed that these physicians considered 29.38% of

their male patients aged 45–64 years at risk, as compared to 24.38% of their female

patients in the same age group, and 18.13% of their male patients aged 65 and older at

risk, as compared to 15.63% of their female patients in the same age group. Although

mature women and men were considered to be at a similar risk for HIV and STIs for

these age groups, risk for men was slightly higher. When asked which patient sub-

population they considered most at risk, several physicians mentioned either sex

workers and their clients, or drug users, whereas others referred to patients with

‘multiple sex partners’ or those they believed were not in a ‘committed monogamous

relationship’. Only one physician mentioned her population of gay male patients. As

indicated in the percentages above and interview comments about mature men with

multiple partners, visiting sex workers, etc., physicians were slightly more likely to

consider their mature male patients to be at greater HIV risk than mature female

patients.

Age and marital factors in risk perceptions for patients. Although physicians acknowledged that

most of their patients have some degree of risk for HIV and STIs, several felt that younger

patients and single patients were more at-risk:

‘It’s like, you’re young, you’re healthy you’re out there … so for me it’s probably more age and

general physical abilities … although I had a patient who was in her 80’s in a wheelchair with a

chronic Foley catheter who was still having intercourse and I just wasn’t frankly thinking that that

was in her life, but it was.’ (attending physician in mid-40s)

A few physicians also raised the topic of ethnicity when discussing their patients’ risk for

HIV and STIs. A resident physician in his early 30s voiced the opinion that the largely poor,

African American community that these physicians serve in their clinic might affect their

views about who is at risk.

Medical education and HIV prevention readiness. On a Likert-scale survey question regarding

how physicians felt about their medical training and HIV prevention, most (58%, n518)

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attending and resident physicians reported that their medical training had prepared them

well to address HIV and STIs with a variety of patients. However, attending physicians

were more likely to ‘disagree’ (38.5%, n55) with the statement that their ‘training had

prepared them well’ than were resident physicians (11.1%, n52). Thirty-three percent

(n56) of the resident physicians selected ‘neutral’ in response to this question compared to

none of the attending physicians.

Responsibility of physicians or patients to raise sexuality topics. Physicians (74.1%, n520) were

much more likely to consider ‘both’ patients and physicians responsible for raising sexual

health issues compared to 27.9% (n512) of the recently single women. About one quarter

(25.9%, n57) of both the physicians and the women (27.9%, n512) placed the onus on the

physician, whereas 44.2% of the women believed that the patient was responsible,

compared to none of the physicians. Qualitative analysis of the interview data showed that

many of the women who said it was the responsibility of the patient to raise sexual health

topics also commented that physicians needed to ‘open the door’ to make patients feel it

was ‘OK’ to talk about it. Even though all of the physicians felt that either physicians alone

or both physicians and patients were responsible for raising sexual health topics, their

comments revealed that some actually place more responsibility on the patient: ‘I think the

patient will bring it up if there’s an issue’; or ‘The physician can’t be expected to just dig for

everything’; or ‘They [patients] have a responsibility, particularly if they have questions or

concerns … to bring it to the physician’s attention and not expect us to be a magician’.

In response to probes following questions about sexual health communication, several

physicians commented that it was ‘usually’ or ‘always’ appropriate to discuss sexual health

risk issues with their patients. However, some physicians also acknowledged that they

seldom raise the topic with their mature patients, citing time constraints, concerns about

offending mature patients or a belief that patients will raise the topic if it is something they

want to discuss. Generally, they talk to those they think are at risk, which tends to be

younger, unmarried patients and those they believe might engage in some high-risk

behaviours. These perspectives and practices point to their perceptions about who is

sexually active and potentially at risk for HIV and STIs.

Assuming mature patients are sexually active. Among the 18 physicians who participated in

the interview, 83.3% (n515) believed that doctors should assume that their mature

patients are sexually active, compared to 51.2% (n522) of the recently single women

(p5.023) (see Table 4). Although physicians overwhelmingly agreed that they should

assume mature patients are sexually active, a few acknowledged that they had on occasion

made the wrong assumption and stereotyped mature patients as sexually inactive:

‘I tend to assume, too often, that they are not sexually active. I think this is kind of a stereotype that

goes on in my mind.’ (attending physician in early 50s)

Table 4. Women and physicians assuming older patients are sexually active.

Yes, assume

n (%)

No, or don’t assume,

ask n (%)

Fisher’s Exact Test

2-sided significance

Recently single women 22 (51.2) 21 (48.8) .023

Physicians 15 (83.3) 3 (16.7)

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‘I think we should assume it because … we’ve had older patients with HIV that people just

assumed weren’t sexually active. And you know, I had a patient with syphilis and I just assumed

that she wasn’t sexually active.’ (attending physician in mid-40s)

Although half of the recently single women did not want physicians to assume mature

patients were sexually active, many said that physicians should ask their patients about it to

be sure:

‘No, because like I said, in assuming, you don’t really know … It’s better to be sure than assume,

because with assumptions sometimes you miss out on something that’s important.’ (divorced

woman in her mid-40s)

‘I don’t think a doctor should make that assumption. But I think they could bring [it] up.’ (widow

in her early 50s)

Some of the women who thought physicians should assume their patients are sexually

active expressed the sentiment that ‘it’s better to be safe than sorry’ and that ‘appearances

can be deceiving’ when is comes to sexual activity:

‘We’re all human … Yes, they should assume that they’re sexually active. They may not be, but if

they’re not right now they probably will be later’ (widow in her late 40s with a new partner)

In addition, 88.6% (n539) of the recently single women thought that physicians should

discuss HIV/STIs issues with their mature patients.

Discussion

The sexual health risks of mature women have generally been ignored in both medical

literature and practice. That HIV and other STI risks are not confined to younger, male or

other identified groups remains poorly recognized among healthcare professionals and

the general public. The present study collected qualitative and quantitative data from

mature women and primary care physicians regarding clinical communication about

sexual health and HIV and STI-related risks. Findings suggest that physicians bring

societal age and gender biases to their perceptions regarding which patients are sexually

active (and therefore possibly at risk for heterosexual HIV and STI transmission) that

influence their communication about sexual health issues with mature female patients.

Mature women and physicians also differ in their perceptions of responsibility to initiate

sexual health communication within the clinical encounter, which may play an important

role during the process of physician/patient communication about this particular health

risk.

Previous research showed a low perception of risk among mature women (Binson et al.

1997). More recent research suggests that more mature women believe they are at-risk for

HIV than earlier cohorts (Zablotsky and Kennedy 2003) and that mature African-

American women are more likely than White women to report making behavioural changes

to reduce their risk of exposure (Lindau et al. 2006). The present analysis suggests that

personal HIV risk perception was high among the recently single women included in this

sample. The higher-than-expected risk perception was linked to dating status, with those in

new relationships expressing the most concern over HIV and STI-related risk. Several

factors may have influenced risk perception among this sample of women: (1) the particular

‘relationship’ circumstances of the women interviewed for this project, in that this study

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focused specifically on recently single women, who might be more likely to have

experienced partner infidelity than women in previous studies; (2) the newness of condom

use and/or inconsistency in safer sex practices; (3) changes that have occurred in the

demographics in the spread of the disease since some of the earlier studies were conducted

in the early 1990s; and (4) having personal knowledge of someone with HIV or who has

died of AIDS.

Younger women and African-American women reported higher HIV and STI risk

perception than older women and those who were White. This may be due to the fact that

HIV is more prevalent among African-Americans (Florida Department of Health 2006a,

CDC 2007); that several African-American women in the study reported personal

knowledge of a friend or family member who was living with HIV or had died of AIDS; and

that several had been tested for HIV. Consistent with previous research, younger women

and African-American women were the most likely to reveal that they had been tested

(Mack and Bland 1999, Florida Department of Health 2003, Theall et al. 2003). Although

perception of being at sexual risk may have motivated some women to have an HIV test,

their narrative comments suggest that risk perception may not be motivating the

participants to engage in safer sex practices. Specific data on condom use was not

collected, but the interview data suggests that condom use may be low or inconsistent

among this sample of mature women, which corresponds with previous research (Binson et

al. 1997, Zaboltsky 1998; Mack and Bland 1999, Yates et al. 1999, AARP 2003, Theall et

al. 2003, Zaboltsky and Kennedy 2003, Lindau et al. 2006).

Several respondents reported that age influenced women’s knowledge of sexual health

risk and safer sex behaviour and, therefore, doctors should address sexual health risks with

their mature patients. In contrast, although physicians also considered age an important

factor in patient knowledge of HIV and risk for HIV, they tended to perceive that married

patients and older patients were generally not at risk for HIV and STIs and, therefore,

many physicians were reluctant to discuss sexual risk due to concerns about offending

mature patients. Such misperceptions among physicians have been reported previously

(Makadon and Silin 1995, Kerr et al. 1996, Haas and Coe 1997, Skiest and Keiser 1997,

Epstein et al. 1998). Despite the apparent disinclination to discuss sexual health issues

with certain patients, most physicians thought that they were adequately prepared for such

discussions. Resident physicians were less likely to feel that their medical education failed

to prepare them for clinical communication about sexual health issues and HIV and STI

risks, though the pattern was not as strong as that reported by Haas and Coe (1997), who

found that 78% of more recently trained physicians felt that they were better prepared by

their medical education to address HIV- and AIDS-related topics than physicians trained

earlier.

Most of the recently single women believed that physicians should discuss HIV and STI

issues with their older patients, but close to half of the women participants placed the

responsibility of raising sexual health topics on patients, whereas a majority of physicians

believed that both parties were responsible. However, the recently single participants also

thought that physicians had a responsibility to create a favourable atmosphere for sexual

discussions within the clinical setting.

This study has several limitations. First, it was conducted among a small purposive sample of

recently single women and a small convenience sample of physicians. Although non-

representative sampling is regularly used in qualitative studies (Bernard 1995, Handwerker

2001), care is needed when generalizing results to other recently single women and other

primary care physicians. Given that the recently single participants were seeking guidance

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through a state sponsored programme, these findings may not be representative of other

recently single women who do not choose to participate in such programmes. Second, data on

the length of time between divorce, widowhood or separation and participation in the

programme was not systematically collected either by the programme staff or the project

researcher, which may be an important factor in explaining differences between participants.

Third, multiple domains of HIV risk perception may limit the utility of comparing findings

across studies (see Theall et al. 2003). Fourth, the sociodemographic characteristics of the

recently single participants were somewhat different from the patients of the physician

participants. The physicians treat a largely low-income, African American population of all

ages, whereas the recently single women participants were all aged 45 and over and came from

a range of socioeconomic backgrounds.

The present study adds to the scant literature on mature women’s HIV and STI risk

perceptions and some of the factors that affect it. The focus on a sample of divorced,

separated and widowed mature women provided unique information about an under-

studied segment of the population in HIV and STI prevention studies. These findings

suggest that factors such as the age, gender and ethnicity of patients are important factors in

physician perceptions about sexuality and sexual health risks. Physician perceptions about

marital/partner status are also important factors in physicians’ HIV risk perceptions for

their patients and all of these factors influence the discussion of sexual issues in clinical

contexts. Physicians’ preconceptions of ‘at risk’ populations appear to limit their

perceptions, such that they may miss important primary prevention opportunities among

populations not traditionally conceived as vulnerable to HIV and STIs. This study suggests

that physicians may need to revisit their perceptions regarding mature sexuality in order to

better address HIV risks among mature women patients. The findings are instructive to

primary care physicians, healthcare delivery programmes and policy makers that sexual

health issues are not only important to mature women, but also extremely relevant to

mature women’s continued health and well-being.

Acknowledgements

This paper is based upon research supported by the National Science Foundation under

Grant No. 0241675 and a Woodrow Wilson/Johnson and Johnson Dissertation Grant in

Women’s Health. We are grateful to Celia B. Fisher for insightful perspectives and

commentary during the development of this manuscript and to Kathryn Grant’s

dissertation committee (James P. Stansbury, Leslie Sue Lieberman, Sharleen Simpson

and Barbara Zsembik) for invaluable assistance with funding proposals and critical analysis.

We would also like to thank the recently single women and the physicians who participated

in this study. The participants’ generosity in sharing their time and perspectives made this

research possible.

References

American Association of Retired Persons (AARP) (1999) Sexuality study ‘AARP/Modern Maturity’. Available

from: http://www.aarp.org/research/reference/publicopinions/aresearch-import-726.html, full report: http://

assets.aarp.org/rgcenter/health/mmsexsurvey.pdf [Accessed 26 January 2008].

AARP (2003) Lifestyles, dating and romance: a study of midlife singles (Washington DC: AARP).

Bernard, R. H. (1995) Research methods in anthropology: qualitative and quantitative approaches (Walnut Creek, CA:

AltaMira).

Culture, Health and Sexuality 509

Dow

nloa

ded

By:

[Gra

nt, K

athr

yn] A

t: 14

:17

22 J

une

2008

Binson, D., Pollack, L. and Catania, J. (1997) AIDS-related risk behaviours and safer sex practices of women in

midlife and older in the United States: 1990–1992. Health Care for Women International, 18, 343–354.

Centers for Disease Control and Prevention (CDC) (2007) Fact Sheet: HIV/AIDS among African Americans.

Available from: http://www.cdc.gov/hiv/topics/aa/resources/factsheets/aa.htm [Accessed 4 October 2007].

CDC (2006) HIV/AIDS among women who have sex with women. Available from: http://www.cdc.gov/hiv/topics/

women/resources/factsheets/wsw.htm [Accessed 4 October 2007].

CDC (2003) HIV/AIDS surveillance report, 2003. Volume 15 (Atlanta, GA: CDC).

CDC (2002) HIV/AIDS surveillance report 2002. Volume 14 (Atlanta, GA: CDC).

Coates, T. J. (1999) HIV prevention in clinical practice. AIDS Clinical Care, 11(1), 1–4.

Epstein, R. M., et al., (1998) Awkward moments in patient-physician communication about HIV risk. Annals of

Internal Medicine, 128, 435–442.

Florida Department of Health (FDOH) (2006a) HIV/AIDS among blacks: 2006 fact sheet. FDOH, Bureau of HIV/

AIDS. Available from: http://www.doh.state.fl.us/Disease_ctrl/aids/updates/facts/2006_Black_Fact_Sheet.pdf

[Accessed 28 September 2007].

FDOH (2006b) HIV/AIDS among women: 2006 fact sheet. FDOH, Bureau of HIV/AIDS. Avail-

able from: http://www.doh.state.fl.us/Disease_ctrl/aids/updates/facts/2006WomenFactsheet.pdf [Accessed

28 September 2007].

FDOH(2004) HIV/AIDS among persons age 50+ in Florida, 2004. FDOH, Bureau of HIV/AIDS. Available from:

http://www.doh.state.fl.us/disease_ctrl/aids/updates/facts/BW04_50.pdf [Accessed 30 June 2005].

FDOH (2003) Florida behavioural risk factor data. Available from: http://www.floridacharts.com/charts/brfss.aspx

[Accessed 7 May 2004].

Haas, D. M. and Coe, R. M. (1997) Do physicians discuss HIV and AIDS with patients? A survey of physician

practices. Journal of Community Health, 22(6), 401–416.

Handwerker, W. P. (2001) Quick ethnography. Walnut Creek, CA: Altamira.

Kerr, S. H., et al., (1996) Primary care physicians and their HIV prevention practices. AIDS Patient Care, 10(4),

222–235.

Lindau, S. T., et al., (2006) Older women’s attitudes and communication about sex and HIV: a community-based

study. Journal of Women’s Health, 15(6), 747–753.

Mack, K. A. and Bland, S. D. (1999) HIV testing behaviours and attitudes regarding HIV/AIDS of adults aged

50–64. Gerontologist, 39(6), 687–694.

Makadon, H. J. and Silin, J. G. (1995) Prevention of HIV infection in primary care: current practices, future

possibilities. Annals of Internal Medicine, 123(9), 715–719.

Nusbaum, M. R. H., Gamble, G. R. and Pathman, D. E. (2002) Seeking medical help for sexual concerns:

frequency, barriers and missed opportunities. Journal of Family Practice, 51(8), 706–710.

Paranjape, A., et al., (2006) Effect of relationship factors on safer sex decisions in older inner-city women. Journal

of Women’s Health, 15(1), 90–97.

Rich, E. R. (2001) Negotiation of HIV preventive behaviours in divorced and separated women re-entering the

sexual arena. Journal of the Association of Nurses in AIDS Care, 12(4), 25–35.

Roter, D. L., Hall, J. A. and Aoki, Y. (2002) Physician gender effects in medical communication. Journal of the

American Medical Association, 288(6), 756–764.

Skiest, D. J. and Keiser, P. P. (1997) Human immunodeficiency virus infection in patients older years: a survey of

primary care physicians’ beliefs, practices and knowledge. Archives of Family Medicine, 6, 289–294.

Smith, L. J., et al. (2007) Sex after seventy: a pilot study of sexual function in older persons. Journal of Sexual

Medicine, 4, 1247–1253.

Stall, R. and Catania, J. (1994) AIDS risk behaviours among late middle-aged and elderly Americans. Archives of

Internal Medicine, 154, 57–63.

Strombeck, R. and Levy, J. (1998) Educational strategies and interventions targeting adults age 50 and older for

HIV/AIDS prevention. Research on Aging, 20(6), 912–936.

Theall, K. P., et al., (2003) Perceived susceptibility to HIV among women: differences according to age. Research

on Aging, 25(4), 405–432.

Wilson, I. B. and Kaplan, S. (2000) Physician-patient communication in HIV disease: the importance of patient,

physician and visit characteristics. Journal of Acquired Immune Deficiency Syndromes, 25(5), 417–425.

Winningham, A., et al., (2004) The changing age of HIV: sexual risk among older African American women living

in rural communities. Preventive Medicine, 39, 809–814.

Yates, M. E., et al., (1999) The importance of AIDS-related knowledge for mid-life and older women. AIDS

Education and Prevention, 11(3), 224–231.

Zaboltsky, D. L. (1998) Overlooked, ignored and forgotten: older women at risk for HIV infection and AIDS.

Research on Aging, 20(6), 760–775.

510 K. Grant and K. Ragsdale

Dow

nloa

ded

By:

[Gra

nt, K

athr

yn] A

t: 14

:17

22 J

une

2008

Zablotsky, D. L. and Kennedy, M. (2003) Risk factors and HIV transmission to midlife and older women:

knowledge, options and the initiation of safer sexual practices. Journal of Acquired Immune Deficiency

Syndromes, 33, S122–S130.

Culture, Health and Sexuality 511