Contents*

• Demographics and a Brief Historical Perspective 877

1. Basic Sexological Premises 878
2. Religious, Ethnic, and Gender Factors Affecting Sexuality 880
3. Knowledge and Education about Sexuality 881
4. Autoerotic Behaviors and Patterns 881
5. Interpersonal Heterosexual Behaviors 881
6. Homoerotic, Homosexual, and Bisexual Behaviors 882
7. Gender Diversity and Transgender Issues 882
8. Significant Unconventional Sexual Behaviors 883
9. Contraception, Abortion, and Population Planning 883
10. Sexually Transmitted Diseases and HIV/AIDS 884
11. Sexual Dysfunctions, Counseling, and Therapies 886
12. Sex Research and Advanced Professional Education 886
13. References and Suggested Readings 886

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Demographics and a Brief Historical Perspective

A. Demographics

ROBERT T. FRANCOEUR**

Puerto Rico is the easternmost island of the West Indies archipelago known as the Greater Antilles. Cuba, Hispaniola (Haiti and the Dominican Republic), and Jamaica are larger islands in this group. Puerto Rico is a commonwealth of the United States. It is bordered by the Atlantic Ocean on the north and the Caribbean Sea in the south. Puerto Rico has a landmass of 3,515 square miles (9,104 km²), and is slightly smaller than the state of Rhode Island in the U.S. The climate is tropical marine and mild with little seasonal temperature variation. Three quarters of the island’s land surface is mountainous, and the coastal plain belt has been used for urban development and contains most of the metropolitan area. Most of the municipalities and small towns are located in the mountainous area.

In July 2002, the island of Puerto Rico had an estimated population approaching 3,816,901 persons, based on data provided by the State Planification Board. An additional estimated 2.7 million Puertoricans [or Puertorricans] live in the United States mainland, mainly in the New York and northern New Jersey metropolitan area, where they are known as NYRicans [also Nuyoricans/Newyoricans] or Jerseyricans. There are Puertoricans throughout all the states, including Hawaii, where a large group was established between the 1940s and 1950s. Major migration to the New York area occurred in the 1950s and 1960s because the people were looking for better occupational opportunities. Since the mid-1970s, there has been a reverse migration back to the island. The present report will combine insights on the sexual behavior and beliefs of people living in the island commonwealth and in the New York/New Jersey metropolitan area. Puertoricans on the island maintain constant contact with relatives in the eastern U.S. cities where the HIV infection rate is high (Robles et al. 1990). The so-called yo-yo migration between the island and the mainland is a significant factor in the incidence and prevalence of the AIDS (SIDA) epidemic in Puerto Rico (Castro-Alvarez & Ramirez de Arellano 1991). (Unless otherwise noted, all data in this section are July 2002 estimates from The World Factbook 2002, CIA).

**The reader is encouraged to check the other chapters in this Encyclopedia, which provide different perspectives on the varieties of Latino culture that complement those provided here, specifically the chapters on Argentina, Brazil, Colombia, Costa Rica, Cuba, and Mexico, and the discussion of Latinos in mainland United States.

B. A Brief Historical Perspective

CARMEN RIOS

Christopher Columbus and his crew were the first Europeans to discover the island of Puerto Rico. Arriving in November of 1493, during their second voyage to the New World, they found the island populated by about 60,000 Arawak natives, peaceful people thriving on their fishing and agricultural skills. In 1508, Spanish colonists arrived and the Arawak natives were either decimated by diseases brought from Europe by the colonists or quickly killed off by the colonists.

The Spanish newcomers originally named the island San Juan Bautista in honor of St. John the Baptist, and named the capital Puerto Rico, which means rich port. Later, the names were switched, making the capital San Juan and the island Puerto Rico. Puerto Rico also includes four other smaller islands (Vieques, Culebra, Mona, y Caja de Muerto). The city was later used as a transshipment port for gold being mined in Puerto Rico and gold and silver from South America being stored in the city for shipment on to Spain.

Concerned about threats from European enemies, Spain began constructing massive defenses around the city of San Juan in 1521. The strengthening of El Morro, San Cristóbal, San Gerónimo, and El Cañuelo forts, as well as the city walls, were the stronghold elements of these successful defenses. Sugar cane was introduced to the island in 1515 and became Puerto Rico’s most important agricultural product, helping establish a thriving economy. African slaves were imported in 1518 to handle the cane harvest. Puerto Rico’s gold mines were exhausted by the late 1500s. During the 1600s, Puerto Rico’s settlements expanded with the establishment of such areas as Arecibo, San Blas de Illescas (later renamed Coamo), and Ponce. The 1700s brought hurricanes, droughts, plagues, and a constant threat of attack on the island’s shores, because the British, Dutch, and French were intent on capturing Spain’s possessions in the New World. By 1776, the official census reported the population had grown to 70,210 people.

In 1809, Puerto Rico was recognized as an overseas province of Spain with the right to send representatives to the Spanish government. Political unrest characterized this era and, in 1868, a small group of landowners in Lares rose up in arms against Spain. The uprising was quickly put down, and is now commemorated as “El Grito de Lares.” In 1897, Puerto Rico was granted a Letter of Autonomy from Spain, allowing it to enter into free commerce with the United States and European colonies. In 1898, following the Spanish-American War, Puerto Rico became a territory of the United States. Legend has it that in 1898, just before the last Spanish governor of Puerto Rico surrendered to the U.S. troops at the end of the Spanish-American War, he took a last look at La Fortaleza (the executive mansion) grandfather clock and hit it dramatically with his sword, thus stopping it at the exact moment the Spanish lost power over Puerto Rico.

The 20th century saw phenomenal growth for the island. In 1917, the U.S. Congress granted Puertoricans U.S. citizenship. Two decades later, U.S. President Franklin D. Roosevelt launched the Puerto Rican Reconstruction Administration, which provided agricultural development, public works, and electrification of the island. By 1951, Puerto Rico acquired the right to establish a government with its own constitution and, in 1952, was declared a semi-autonomous commonwealth territory of the United States. The island then entered two decades of unprecedented economic development as it heavily promoted and attracted manufacturing plants primarily from the U.S. mainland. By the 1960s, the development was being referred to around the world as the “Puerto Rico Miracle,” as other developing economies looked to the island as an example of industrialization. The 1970 census showed Puerto Rico was mostly urban for the first time in its history.

During the last quarter of the 1900s, as Puerto Rico’s economy diversified into commerce and services, the island’s status once again dominated its politics. The Pro-Commonwealth Consensus that had ruled since 1952 broke down. Supporters of commonwealth and statehood are now at rough parity, with independence holding a 5% share of electoral support. Status plebiscites in 1993 and 1998 were inconclusive, and both the public and political leadership remain deeply divided. This dispute has not hindered the island from growing, however, because life in Puerto Rico largely resembles most U.S. mainland states in business, education, commerce, dining, day-to-day activities, and more.

The role of the women as political leaders is marked at the second half of the 20th century. San Juan, the capital of Puerto Rico, has the first mayor woman, Doña Felisa Gautier Benítez. Puerto Rico’s first woman governor, Doña Sila María Calderón, was elected in 2000. Today, a large number of women have entered politics as a career. Mayors, senators, and representatives are changing from an almost exclusively men’s area to gender equality.

1. Basic Sexological Premises

A. Character of Gender Roles

In describing the sexological premises commonly ascribed to by Puertoricans, it should be noted at the onset that differences still exist within the society where the population tends to agree with the more traditional values. Puertorican culture, like other Latino societies, stresses a very strong gender difference from birth on that is reflected in every aspect of sexual expression and male-female interaction. The predominant value of machismo sees males as superior and females as sexual objects whose aims are to fulfill men’s desires and needs (Burgos & Diaz-Perez 1985). Outside the Latino cultures, the terms macho and machismo carry a common pejorative implication of a chauvinistic, tyrannical male domination. However, in Spanish, the terms refer to male pride. Machismo has been defined as the set of attitudes and beliefs that sees males as physically, intellectually, culturally, and sexually superior to females (Pico 1989). Puertorican boys are indoctrinated in the importance of being macho from a very early age. New realities have emerged in the last 15 years. Formal sex education programs contribute to and increase the trends toward the quality of life for both men and women. In the professional population, the trend is that a larger group of women are elected, designated, and occupy positions at the same level and over men.

One way the male child is socialized and reminded of his maleness in the rural cultures of Puerto Rico and the Dominican Republic is by his parents and other adults admiring and fondling the baby’s penis. Little boys are valued for being male from the moment they are born into the family. Even if there are older sisters, the male sibling is the dominant figure, both in the eyes of the parents and in sibling interactions. Mothers train their daughters early on to play “little women” to their fathers, brothers, and husbands, while they train their sons to be dominant and independent in relationships with their wives as well as other women (Medina 1987). Education within the family supports and maintains traditional male and female roles, but at the school level, the equality is evident between males and females. Also, throughout the educational system, the number of female teachers is higher than for male teachers.

Research about machismo carried out before 1975 demonstrated that males were having sex with as many females as possible. By emphasizing their capacity as procreator and their willingness to have as many children as possible, preferably males, Puertorican males demonstrated their machismo (Mejias-Picart 1975). There was practically no societal control over male sexual behavior. Meanwhile, female sexuality was openly repressed. It was expected that the males assume the active role, initiate sexual activity, and be responsible for the satisfaction of the female. This aspect of the sexuality has evolved in recent years. Females have become more active and assertive. One detail that demonstrates this trend is the attitude toward the protection from STD and condom use. Sex education in Puerto Rico promotes equal responsibility between males and females.

The female equivalent of machismo is etiqueta, a complex value system that requires Latinas to be both feminine and pure and, at the same time, very sensual and seductive. Little girls are taught to hide their genitals and not to focus much attention on their vagina. Yet girls are valued for and taught to enhance their sexual appeal. From birth on, girls are adorned with earrings, bracelets, and special spiritual amulets. Their very feminine dress makes Latina girls extremely seductive and even provocative. However, a woman’s virginity is highly valued, and families are careful to protect the virginity of their daughters.

When Puerto Rico was dominated by the Catholic Church, girls were constantly reminded of their inferiority and weakness, since a vital aspect of etiqueta is the concept of marianismo, the model of the obedient and docile female. Maria is by far the most popular female name. It was common that several daughters in the same family have the first name Maria and a different second given name, a reminder that all women should model themselves on the Virgin Mary, the mother of Jesus. Women were expected to sacrifice their own needs for the sake of their children and husband (Comas-Diaz 1985). Under an incorrect interpretation of Church rules, men expected their wife not to enjoy sex or to seek it—she was there simply and solely to please her husband. Females were expected to be passive, ready to respond to the male requirements, and not to assume responsibility for their own pleasure. A good woman was always ready for her man, but she should never be comfortable with sexual issues or with sexual intercourse. To do otherwise suggests a lack of feminine virtue. In a recent survey, almost 80% of the husbands surveyed were found to initiate sexual activities almost all of the time, while 90% of household chores (cooking and cleaning) were carried out by the wives (Vazquez 1986). All of these expectations and values are part of the history of sexual repression of Puertorican women. Today an increasing number of people in Puerto Rico accept that women are more than a sexual artifact. The sex educator promotes and claims that the women must enjoy sexual activities and Puertoricans must change this negative aspect of their sexual attitudes.

The Church promotes a strong pronatalist value in Puerto Rico. However, small families with one-to-three children are preferred. The surveillance statistics in Puerto Rico for girls who have a child outside marriage is 19.2%, alongside of which we have a common sexual education in pregnancy. Abortion in Puerto Rico is legal. There are some female healthcare clinics that provide counseling about choices. The clinics offer the opportunities for pregnant women to get into an adoption program if they so choose. Abortion is common among married women and among religious people. The pronatalist value is supported by the anticontraception and antiabortion position of the Catholic Church. Nevertheless, both contraception and abortion are commonly used by Puertoricans.

The Civil Rights Commission in 1973 concluded that discrimination against women outside and inside the home existed and subtle discriminatory practices occurred. In 1984, a study done by the Puertorican Senate found that the same pattern of discrimination continued to exist ten years later. Although there have been some changes in the recent past, oppression, control of women, male power, and heterosexuality continue as the dominant parameters of the Puertorican society (Zorrilla et al. 1993). The controversies about abortion, marriage, contraceptive devices and treatments, homosexuality, and sexual education, are ongoing.

Women themselves are in part responsible for the preservation of this situation, since they continue to accept the sole responsibly for childrearing, and play an essentially domestic role. However, this situation is changing, and the men are becoming more responsible in participating in childcare. There are laws that make women and men responsible to provide resources for childcare even if they do not live with the other parent. But this form of sexism is also “imprinted” in children who are socialized to accept the stereotypic roles from early childhood, where the main role of the female is to be mother, in spite of also working outside the home. Dependency, obedience, and submission are reinforced in daughters, while independence, aggression, and lack of emotion are reinforced in males (Burgos & Diaz-Perez 1985; Mock 1984). Females are socialized to be submissive, passive, attractive, compliant, obedient, and dependent, and they are expected to behave this way in their sexual interactions (Santos-Ortiz 1990). The fight against these stereotypes occurs continually on the professional level. Many psychologists, physicians, religious teachers, and a large group of professionals work in favor the elimination of the sexual stereotypes and look for the compliance of responsibility associated with the position of their job.

During the school years, gender roles are reinforced by a biased curriculum. A study on the illustrations and content of social sciences texts used in primary schools (Pico 1989) found that men were portrayed as relevant and superior, while females were relegated to a secondary role, and when depicted appeared in more-traditional stereotypical roles. Men and boys appeared more frequently than girls and women, in spite of the fact that females constitute over half of the population. Women appeared mostly working in their home or engaged in passive activities, such as reading, praying, and playing with dolls, and were rarely depicted outside of the home. This is epitomized by a page in a text under the title, “What I most enjoy doing.” There are pictures of sliding, swimming, bicycle riding, skating, and other activities—all of them performed by boys; not a single girl appears in those activities. Although this research was done in the early 1980s, there is no reason to think that the pervasiveness of the gender stereotypes has changed at all. At the same time, in 1992, the State Department of Education established a program to train its personnel and to develop gender-equal curricula for sexual education in schools (Mock 1992).

Fortunately, today, education professionals exist who can manage the information and teach about the qualities of male and female. The Puertorican sex educators, counselors, and therapist associations, and nonprofit organizations, prepare and offer training to a large group of teachers about sex education. A group of teachers have been certified as sex educators and, under the concept “train the trainer,” they are offering training to their peers. The State Education Department is requesting that all teachers get into the continuing education program to satisfy and increase their knowledge according to their needs as educators. For the last 15 years, the University of Puerto Rico at Cayey has been offering a University Sexual Education Symposium focusing on teachers and health professionals. The symposium provides the newest information about sex education trends and treatments for sexually related conditions. This training and education is offered free to the community in Puerto Rico and the United States.

B. Sociolegal Status of Males and Females

The number of common-law partnerships has increased consistently during the last few decades, in spite of the fact that they are not recognized and consequently do not have any of the entitlements of legally married couples. Children, however, are recognized as legitimate offspring of the parents and have the right to be supported by them until they are 21 years old. Legal custody of children is almost always awarded to the mother, but legal responsibility is shared. No matter who has the child custody, the other parent has to provide economic support.

C. General Concepts of Sexuality and Love

The basic values of machismo, marianismo, and etiqueta are evident in various sexual behaviors. In a 1985 survey, 60% of working-class women and 50% of professional women reported faking orgasm in order to end intercourse soon or to avoid the husband’s questioning about their achieving orgasm. The great majority of women surveyed did not disapprove of self-pleasuring, and very few women engage in autoeroticism, or admit to this in surveys (Burgos & Diaz-Perez 1985). Things have been changing. It is now common that women and men buy sex toys, films, and publications to improve their sexual lives and autoerotisms. The number of stores that offer this kind of merchandise is increasing rapidly. One of the stores, Condom World®, has expanded to 20 stores in the past decade on the island.

Latino men still often express their discomfort with sex in ridicule and rejection of anything that hints of homosexuality. Even in the Latino culture of Brazil, where boys are encouraged to explore everything sexual, all men—even those who in the United States would be considered bisexual or homosexual—see themselves as homens, men in the sense of always taking the active phallic sexual role (Medina 1987; Parker 1987). Attitudes toward homosexuality are changing. The homosexuals are leaving the closeted life and gaining their place in Puertorican society. Like other Puertoricans, they pay taxes, have a job, and form families headed by a same-sex couple. There are cases in which homosexual couples have adopted a child legally. The State Department of Family is against adoption by homosexual families. The court, however, has been hearing cases under state law applied or created for heterosexual couple relationships. Today, there are homosexuals in all organizations, agencies, public and private institutions, professional roles, and in the churches.

As more women enter the workforce and pursue an education, the traditional maternity role has changed and continues to change. This is evidenced by the large number of Puertorican women who postpone marriage and childbearing until their late 30s. As mentioned before, out-of-wedlock partnerships have increased in popularity, especially among white-collar workers and educated Puertoricans.

2. Religious, Ethnic, and Gender Factors Affecting Sexuality

A/B. Source and Character of Religious and Ethnic Values

The early pre-colonial inhabitants of Puerto Rico migrated either from Florida in the north or from the Orinoco River delta in Columbia, South America. When the Spaniards arrived in 1493, the island was inhabited by the peaceful Arawaks who were being threatened by the neighboring Carib Indians. The island was finally invaded and conquered for Spain in 1509 by Juan Ponce de Leon.

Introduction of sugar cane cultivation in 1515 was quickly followed by the importation of African slaves to work the cane fields. Although slavery was finally abolished in 1873, the impact of the forced African immigration can still be felt today in Puertorican society. Indigenous, Spanish, and African elements permeate Puertorican culture even today, with the Spanish influence dominant, since they occupied and controlled the island for nearly 400 years, until 1898.

It appears that in the island pre-Colombian societies, women had more power and were highly respected. Pre-Colombian women are also believed to have had an active sexual life. Men, especially those in the upper classes, were allowed to be polygynous.

Later on, the Spaniards introduced their patriarchal society with its values of machismo, marianismo, etiqueta (emphasizing female virginity), and a pronatalist familism. The popular traditions and doctrines of Catholicism introduced by the Spanish have played a major role in the shaping of the society’s sexual values and attitudes. However, this influence, as will be seen, is more formal than real when it comes to some private decisions. Even though 80% of Puertoricans today identify themselves as Catholic, most are not highly active in the Church (Burgos & Diaz-Perez 1985).

Although the culture seems sexually repressive, in reality Puertorican society is quite erotic and exalts sexuality in pervasive and subtle ways. Sexual themes permeate Puertorican popular music and dance (salsa), radio and television communication, as well as nonverbal communications. Perhaps because of this, research about sexuality is uncommon in Puerto Rico, and there are very few written articles about sexuality. Consequently, very little is known about sexual behavior and attitudes of Puertoricans (Burgos & Diaz-Perez 1985; Cunningham 1991). (See parallel discussion of machismo and Cuban values in the chapter on Cuba).

The reproductive function of sexuality is seen as its natural goal, while its pleasurable aspects are viewed as a necessary incentive for accomplishment of this goal. All other sexual behaviors apart from penile-vaginal intercourse are generally seen as immature and undesirable (Mock 1984). At the same time, for most Puertoricans all versions of sexuality and sex are acceptable inside the marriage, with the sole provision that they be mutually accepted by the couple. Nevertheless, sexuality is commercialized and widely available in both pornography and prostitution (Mock 1984). Pornography and prostitution are against the law in Puerto Rico. Recently, the prostitution houses were closed by governmental order, but prostitution still exists.

As stated before, although the influence of the Catholic Church is felt in all aspects of sexuality, studies indicate that Catholics have as many abortions as non-Catholics (Ortiz & Vazquez-Nuttall 1987), and that religious affiliation has no bearing on the use of contraceptive methods, including sterilization and the pill (Herold et al. 1989).

3. Knowledge and Education about Sexuality

A. Government Policies and Programs

As a result of marianismo, the Church’s opposition, and the reluctance of society and families to acknowledge female sexuality openly, many girls experience their menarche with no formal education about it. And although males are expected to have their first sexual experience before marriage, they do not receive any formal sex education either. Obviously, neither females nor males have any knowledge about the health implications of various sexual practices (Burgos & Diaz-Perez 1985).

There are no systems or districtwide sexuality education programs such as exist in most, if not all, the mainland States. A program to train sexuality education teachers has been proposed and was being developed in 1994. As in other places where formal programs have not been developed, individual teachers may take the initiative into their own hands and incorporate various aspects of sexuality education into their standard courses, such as biology and health.

B. Informal Sources of Sexual Knowledge

The media also plays a role in perpetuating sexist stereotypes and prejudices against women. A study found that articles in the popular media usually portrayed women as submissive, and presented acts of violence against women as normal (Maldonado 1990).

The same kind of sexual information portrayed in movies, television, and radio in the mainland United States is also available in the commonwealth island of Puerto Rico. The ready access to cable television and videotapes has permitted islanders to be exposed to the same kind of information that is available to individuals living on the mainland.

[Update 1999: In September 1999, concerned about the rising rates of pregnancy, AIDS, and chlamydia among adolescents aged 13 to 29 years, Puerto Rico’s governor proposed a bill that would “give adolescents access to sex education and treatment for reproductive health, including contraceptive methods, without the knowledge or consent of their parents.” The bill would require the health and education departments to offer STD treatment, reproductive health services, counseling, prenatal care, and birth control. The bill provoked a storm of protest from conservatives. Leaders in the Legislature predicted the bill would go nowhere, but the Health Secretary and Education Secretary vowed a fight in the Capitol to push the bill through. In the end, it was rejected, and the community programs have picked up the requested services. (End of update by Carmen Rios)]

4. Autoerotic Behaviors and Patterns

When asked about self-pleasuring in a 1985 survey, a great majority of women did not disapprove of it. However, they reported not practicing it themselves. A survey of 191 adolescents found that 32% (61) of them engaged in self-pleasuring, 53 of them males and only 8 of them females (Burgos & Diaz-Perez 1985). But, self-pleasure has been promoted as a practice to prevent HIV infection, either alone or within the couple relationship. The discovery of erogenous areas in each person’s body as a sexual therapeutic technique is recommended to increase the couple’s sexual relationship. A common cause of divorce exists when couples do not understand their bodies and do not recognize that there are other sexual behaviors besides vaginal intercourse that promote a healthy couple relationship.

5. Interpersonal Heterosexual Behaviors

A. Children

Childhood sexual rehearsal play and sexual exploration no doubt occur in private as they do in many other cultures, but there are no statistics or information on their incidence or extent. There is some indirect information about sex education and activities for and in childhood. Some teachers are including sex education concepts in the classroom, because the knowledge about sexuality is available on TV, Internet, radio, and, in general, in the media. Teachers know that there are needs; they know about the incidence of adolescent pregnancy and are reacting by promoting sex education and sex hygiene. Outreach programs have also seen that the sexuality information provided at home and in schools is not adequate, and most of the time, it is erroneous when it is offered out of the classroom by unprepared people in the community. Sex education projects are offering services in the community to prevent STD and pregnancy.

B. Adolescents

Premarital Sexual Activities and Relationships

Studies of adolescents in public schools have found that a good number of them are sexually active before the age of 15 and that most of them do not use contraceptives to prevent pregnancy and/or sexually transmitted diseases (Mock & Ramirez 1993). Adolescent pregnancy is 19.2% as reported in surveillance statistics for 2002. The government policies are against comprehensive sex education and they have requested that schools include abstinence education as the rule. The contraceptive education is offered outside of the academic services. We believe that comprehensive sex education has to be offered if we want to control the adolescent-pregnancy incidence. In those areas where the adolescent pregnancy rate is high, the schoolteachers are assuming responsibility and are offering sex education.

As mentioned before, the fact that more females are postponing marriage and that more couples are opting for common-law partnerships as opposed to legal marriage, has resulted in an increase of individuals engaging in premarital sex. It is estimated that almost 50% of young Puertoricans are sexually active (Cunningham 1991). The general trend in the world is to establish couple relationship with freedom for all components. Puerto Rico, for instance, has a swingers group, based in Puertorican values that accept this sexual behavior.

Premarital Courtship, Dating, and Relationships

Courtship and dating behavior is governed by strong and clear gender-dimorphic roles and rules. It is very difficult for young people, particularly young women with older brothers or male cousins, to escape the pervasive pressure and surveillance of family members that enforces the dual standards of behavior expected of Puertorican males and females. The custom of a chaperone’s accompanying a young woman disappeared long ago, since no one young or old recalls it.

Young Puertoricans attending colleges and universities are very similar to their student counterparts elsewhere in the world. However, some relevant differences are worth addressing here. Surveys done by Cunningham and collaborators (1991), with randomly selected students at the University of Puerto Rico, show that almost half of them are sexually active, 70% of the males and 40% of the females. Of those sexually active, 80% had experienced vaginal intercourse, more than 50% had tried oral intercourse, and over a third had tried anal intercourse.

Eighty-five percent of those practicing vaginal intercourse and 84% of those practicing oral sex reported having only one partner during the three-month period before the study. With respect to the use of condoms, 55% of the sample declared they had used one at least once; only 16.8% of the males and 13.6% of the females declared they always used a condom (Cunningham & Rodriguez-Sanchez 1991).

C. Adults

Marriage and the Family

It used to be that the divorce rate was very low, probably because of the strong influence of the Catholic religion. However, there has been a dramatic increase in the rate of divorce during the past decade, as well as an increase in the number of households headed by women. In 1960, it was 18.7%; by 1980, the incidence was 25% (Vasquez-Calzada 1989). More recently, an increasing numbers of single mothers have been noticed (20.9% in 1980 to 32.9% in 1989) (Castro-Alvarez & Ramirez de Arellano 1991). In 1988, the percentage of teenagers giving birth was 17.4%, while those out of wedlock reached 32.8%.

Extramarital Sex, Cohabitation, and Single Mothers

As in any strongly patriarchal culture, the double moral standard allows males much more freedom than it does females. Macho men, but not women, are allowed and expected to have extramarital sexual relationships. However, as is happening in other cultures, the increasing incidence and recognition of cohabitation and single mothers is definitely weakening this pattern.

Sexuality and Disabled and Older Persons

There is little if any discussion, and no statistics, on the sexual needs or behaviors of physically and mentally challenged persons and older persons.

Incidence of Oral and Anal Sex

Unexpectedly, 35% of university students surveyed in 1989 and 37% of those surveyed in 1990 had participated in anal intercourse. Approximately 40% of the males who had engaged in this activity were homosexual. And although those who practice anal intercourse do it less frequently and tend to use condoms in higher percentages, they also tend to have more partners than those who practice other types of sexual activity. Results show that almost 36% of those who practice anal intercourse (22% of the females and 46.5% of the males) had two or more partners during the three months previous to answering the survey. The reasons for engaging in this practice were different for males and females, while the males reported they did it for pleasure, females reported that they did it mostly to satisfy their partners.

No data are available on the attitudes towards or the incidence of either anal or oral sex among non-university students, and single or married adults.

6. Homoerotic, Homosexual, and Bisexual Behaviors

In Puerto Rico, as in most societies of the world, being openly gay carries a negative stigma and in consequence, most of the gay community remains “invisible.” Thus, no reliable information about the percentage of the population with homosexual or bisexual orientation or experience is available (Cunningham & Cunningham 1991).

There is a strong rejection of homosexuality, especially male homosexuality. [Comment 2003: Lesbians face even more discrimination and persecution than gay men in the island’s culture. Lesbians lead even more-hidden lives than gay men, particularly if they have custody of their children. Under Puertorican law, lesbians can lose custody of their children. As of early 2003, repeated efforts by many groups to remove this law from the books have all failed, and the law remains in effect. (End of comment by Carmen Rios)] This negative attitude is present even in Puertorican males living in the New York area. In fact, law-enforcement officials tend to harass those who have sexual relationships with someone of their own gender or commit a crime “contrary to nature.”

Because of the AIDS (SIDA) epidemic, homosexuals affected by the disease have organized support groups and have started to acknowledge their sexual orientation publicly. Within these groups, two distinct reactions have been observed: One group of individuals has reacted by increasing their sexual activity, while others have abstained almost completely from it (Ortiz-Colon 1991). However, in Puerto Rico, the main mode of transmission of HIV has been through intravenous drug use and increasingly through heterosexual contact.

There is a history of more than 20 years of gay and lesbian civil rights movements. The Comunidad de Orgullo Gay (Pride Gay Community) was founded in 1973; since then, other organizations have been established. The Coalicion Puertoriquena de Lesbianas y Homosexuales, created in 1991, publishes a bimonthly magazine dealing specifically with issues of discrimination and encouraging support among lesbians and gays. Because of the AIDS epidemic, other groups that deal specifically with this issue have been established in different parts of the island.

7. Gender Diversity and Transgender Issues

As in other parts of the world, transvestites and transsexuals do exist in Puertorican society. Transvestites have been portrayed in the media and television for a long time, and this style of dressing has become a style of street life. There are transvestites in school, universities, and in social night style. There are male sex workers who cross-dress at night and revert back in the morning. Transsexuals are not common in Puerto Rico. But their small group makes a loud noise, with some transsexuals appearing on television and participating in top television shows to demonstrate the lifestyles and changes faced by transvestites and transsexuals. Some physicians have participated on television shows to talk about the anatomical, social, psychological, and physiological changes involved in transsexualism.

[Comment 2003: Many transgender Puertoricans visit the United States to participate in the annual Fantasia Festival in Provincetown on Cape Cod and other transgender events in the New York metropolitan area. Transgender Puertoricans also maintain and participate in Internet websites, and network with transgender groups on the mainland. Transgender persons living in California and Mexico travel to the island and have been particularly supportive by helping establish transgender support groups on the island. However, scientific data on the extent of this population and its practices are unavailable. (End of comment by Carmen Rios)]

8. Significant Unconventional Sexual Behaviors

A. Coercive Sex

Sexual Abuse and Incest

There are no reliable statistics about the incidence of family violence, including the sexual abuse of women and children and incest, but a center to protect victims of family violence, Casa Protegida Julia de Burgos, reported almost 500 cases of spouse abuse in 1984 and the Department of Social Services reported over 5,000 cases of abuse and neglect of children in 1985. The Centro de Ayuda a Victimas de Violación reported 181 cases of rape and 21 cases of incest for the period 1984-1985 (Burgos & Diaz Perez 1985).

Sexual Harassment

This is a relatively new concept that has not been widely accepted in Puertorican society. Most people believe that these are the natural behavioral patterns in the relationships between men and women (Alvarado 1987). Sexual innuendoes, jokes, and repeatedly asking for dates are all expected in male-female interactions (Martinez et al 1988).

Recent studies have found harassment rates of 44% among women attending a conference on women in the workplace, to as high as 73% for women working in the healthcare sector (Alvarado 1987; Martinez et al. 1988). The great majority of these women had been harassed by supervisors (over 60%) or coworkers (almost 30%). Although more than 60% of the women confronted the harasser, only 13% reported the situation to their superiors (Alvarado 1987).

Although there is no specific law in Puerto Rico against sexual harassment in the workplace, there is a law that prohibits discrimination in any form at the workplace. Current efforts focus on raising the public’s awareness of the nature, pervasiveness, and social unacceptability of sexual harassment in a culture where it has been universally accepted and expected as an important part of the behavior of macho males.

Rape

Outside of the scattered and nonrepresentative statistics mentioned above on incest, child sexual abuse, and spouse abuse, no data exist on the incidence of rape.

B. Prostitution

As in other parts of the world, prostitution is tolerated in Puertorican society, although it is considered illegal and immoral. Males are encouraged to seek prostitutes as sexual outlets so as to maintain the purity of those whom they will eventually marry. This, however, is changing, as more and more young adults are engaging in premarital sexual relationships. Prostitution is not as common throughout the island as it is in metropolitan areas. Prostitution places have been eliminated in San Juan by a governmental action. However, street prostitution has increased as the control loosened. For many years, health education programs, STD prevention programs, and HIV testing were available to the prostitutes and their clients in places devoted to prostitution. With the elimination of brothels, there is now no site to offer these services.

In the early 1990s, the increase in AIDS among heterosexuals was attributed in part to heterosexual men having sex with prostitutes (Mock & Ramirez 1993). This is no longer true, because the homosexual has been alerted and taken control with prevention programs focused on their lifestyle. While some heterosexuals keep with their risky style, they are also exposed to another main transmission mode, IV-drug use.

C. Pornography and Erotica

Erotic elements appear to be very common in writings (novels), and popular songs and dances. Pornography, however, is not as developed as it is on the mainland. Pornographic magazines and television channels, such as the Playboy Channel and other adult channels, are also available with cable television easily available. There is little, if any, indigenous pornographic material since a variety of such material is easily brought home by Puertoricans traveling back and forth between the island and the mainland to visit family and relatives. There is no frontier boundary between Puerto Rico and the world. For some people, pornography as erotic material is accepted, but others are concerned about how pornographic material affects young people. There are no controls for cable television Adult stores with pornographic material are common in Puerto Rico, but at the same time, some rules do exist. For instance, by custom, most stores do not sell adult material to people under 21 years old, or young people in student dress or school uniform.

9. Contraception, Abortion, and Population Planning

A. Contraception

The first attempts to establish birth control services in Puerto Rico date to 1925, when a group of professionals, headed by Jose A. Lanauze Rolon, a physician, founded the Liga para el Control de la Natalidad (Birth Control League) in the city of Ponce. This venture paralleled Margaret Sanger’s efforts on the mainland. In fact, Mrs. Sanger sent Dr. Lanauze the necessary forms and information for them to affiliate with the American Birth Control League. The goals were then the same: dissemination of information for women regarding safe and available contraceptives and maintaining appropriate statistics and studies demonstrating the negative consequences of overpopulation. Consequently, the league was very active in providing public birth control services, arguing not only from the negative consequences of overpopulation, but also from the positive outcome of reducing the high rate of abortion. However, because of strong opposition from the Church and the lack of funds, the clinic founded by the league, as well as two others founded in San Juan in the early 1930s, were eventually closed.

Federal agencies established contraceptive services in the 1930s, but these were also closed during the later years of the Roosevelt Administration because of dissatisfaction with their results and the strong opposition of the Catholic Church.

Today, contraceptive use in Puerto Rico is widespread. It is estimated that three fourths of Puertorican women have used contraceptives at least once (Davila 1990). Despite the purported influence of the Catholic Church, religious affiliation has no bearing on contraceptive use. Data show that Catholics use contraceptives as often as non-Catholics. Furthermore, studies have found that the level of contraceptive use is similar across socioeconomic classes, educational levels, and urban versus rural regions (Vazquez-Calzada 1988; Herold et al. 1989). It should be noted, however, that a significant number of university students were found to have little knowledge of contraception, especially regarding barrier methods that may decrease the spread of STDs and AIDS (Irrizarry 1991). Overall, birth control usage reflects the prevalent belief that birth control is the main responsibility of women (Davila 1990).

The most widely used contraceptive by women who intend to have more children is the pill. Studies indicate that about half of the married women have used the pill at least once (Davila 1990). The pill is less popular nowadays, with usage decreasing from 18.9% in 1968 to 11.9% in 1982 (Vazquez-Calzada 1988).

The IUD and the diaphragm are used significantly less than the pill (Robles et al. 1990). It has been reported that about one-third of the women had used these methods once (Davila 1990). The rhythm method is used much less, 18%. However, it should be noted that the popularity of the rhythm method increased from 2.9% in 1968 to 7.7% in 1982 (Vazquez-Calzada 1988). The use of condoms is not very high. About 6.6% of women reported that their partners used condoms as a means of birth control in 1968. About the same rate was reported in 1976 and again in 1982 (Vazquez-Calzada 1988). Researchers have suggested that religious beliefs and culture norms in Puerto Rico may be responsible for men’s low usage of condoms and women’s inability to demand the use of condoms from their partners (Menendez 1990). The HIV/AIDS epidemic has become a way to promote the use of condoms, not only as a contraceptive method, but for HIV and STD prevention. Finally, the female condom is now available, and its use is increasing.

B. Teenage Unmarried Pregnancies

Statistics for the year 1985 show that 17% of all pregnancies occurred among adolescents between the ages of 10 to 19 years (Mock & Ramirez 1993). The rate increased dramatically; 19.2% of pregnant Puertorican women are adolescents (2002).

C. Abortion

It has been estimated that between 50,000 to 75,000 abortions are performed every year in Puerto Rico (Pacheco-Acosta 1990). Abortion is more common in single than in married mothers. Furthermore, studies have found no differences between Catholics and non-Catholics in abortion incidence (Herold et al. 1989). It has been suggested that Catholics may prefer abortions to contraceptives because the former involves only one violation or sin and one confession, while the ongoing use of contraceptives requires repeated confessions in which absolution might be refused because of the lack of true repentance and the unwillingness to discontinue using contraceptives. If the abortion can be kept secret, the person in question can continue to go to church, whereas if the pregnancy were brought to term, everybody would know about it (Ortiz & Vazquez-Nuttall 1987).

D. Population Control Efforts

Population-control policies in conjunction with migration—almost a third of Puertoricans live outside their country—have been long-term basic tenets of economic development on the island. This has permitted constant experimentation with contraceptives among Puertorican women. They served as human “guinea pigs” for testing the first contraceptive hormonal pill that was later withdrawn from the market because of its severe negative side effects (Davila 1990).

During the 1940s and 1950s, family planning and population control were supported by the government, and sterilization became a common practice. By the 1970s, Puerto Rico had one of the highest rates of sterilization in the world, and it was estimated that at least 35% of the women of reproductive age were sterilized (Acosta-Belen 1986; Robles et al. 1988). Data from recent decades indicate that sterilization increased from 56.7% in 1968 to 58.3% in 1982 (Vazquez-Calzada 1988). Sterilization remains the most accepted method of family planning among Puertorican women and the island continues having one of the highest rates in the world (Vasquez-Calzada et al. 1989; Robles et al. 1988). The same study showed that women who had Cesarean sections also requested tubal ligation. Despite the strong influence of the Catholic Church, sterilization is as prevalent among Catholics as it is among non-Catholics (Herold et al. 1989).

It has been suggested that the high incidence of female sterilization is another manifestation of machismo/marianismo; since women are not expected to enjoy sexuality, they are not expected to give much importance to their sexual organs (Burgos & Diaz-Perez 1985).

Vasectomy seems to be more common now than it was a few decades ago. There has been an increase from 2.4% in 1968 to 6.6% in 1982 (Vazquez-Calzada 1988). Vasectomy is more popular among educated males living in urban areas.

10. Sexually Transmitted Diseases and HIV/AIDS

A. Sexually Transmitted Diseases

Only partial data on the incidence of sexually transmitted diseases are available. The rate for syphilis (all stages) was 33.92 per 100,000 in 2001-2002. Available data on the absolute number of cases show a decline from 1,526 cases in 1998 to 1,292 cases in 2002. The rate for gonorrhea in 2002 was 13.65 per 100,000. The cumulative number of cases reported for four years show a dramatic increase from 388 cases in 1998 to 520 cases for 2002.

The greater proportion of reported cases of sexually transmitted disease is chlamydia. The cumulative number of cases reported for the last four years shows an increase from 2,008 cases in 1998 to 2,867 cases for 2002 (data obtained from Vigilancia de Enfermedades de Transmisión Sexual, Departamento de Salud de Puerto Rico, OCASET, División de Epidemiología 2002).

The statistics also indicate that sexually transmitted diseases occur most frequently among adolescents and young adults (15 to 45 years). Adolescents and young single adults are a common high-risk group in most societies today, where barriers to adolescent sexual behavior are falling without society’s recognition of the need for education in reducing the risks of sexually transmitted diseases (Mock & Ramirez 1993).

B. HIV/AIDS/SIDA

Adolescent and Adult HIV/AIDS

The first case of AIDS in Puerto Rico was reported in 1982 and the vigilance/prevention program was started in 1983. Initially, because of physicians’ reluctance to report the cases they diagnosed as being HIV-positive or having AIDS, the reported rates were very likely serious underestimates of the true number of cases. By December 2002, a total of 24,700 cases had been reported.

The greater proportion of deaths from AIDS on the island occurred among people between 20 and 39 years of age, an age of great productivity and active social and sexual life. In 1987, it was reported that AIDS was the primary cause of death for women between ages 25 and 39 and for males between 30 and 39 years of age (Cunningham 1991). In 1989, 3.7% of all deaths in Puerto Rico were because of AIDS. However, in comparison to those living on the island, Puertoricans living in New York City have a five-times greater chance of dying from AIDS—this is true both for men and women (Menendez 1990).

In Puerto Rico, the use of intravenous drugs constitutes the most important risk factor in the development of AIDS (Marrero-Rodriguez et al. 1993). In fact, the largest concentration of intravenous (IV) drug users among AIDS cases in the United States is found in Puerto Rico (Colon, Robles, & Sahai 1991). It is estimated that more than 51% of AIDS patients on the island are addicted to intravenous drugs. Among males, 54% of AIDS cases are associated with IV-drug use compared to only 38% for mainland women (until December 2002). The relevance of this risk factor makes the epidemiology of AIDS different in Puerto Rico from what is encountered in other parts of the world. It is estimated that there are 100,000 drug addicts in Puerto Rico, 2.7% of the total population, 80% of who are IV-drug users (Rivera et al. 1990).

Most of the 100,000 drug users are young heterosexual and homosexual males, who continue being sexually active and practicing high-risk behaviors. Thus, one can expect that their partners would be infected through sexual contact. Epidemiological data show that IV-drug user’s male partners account for 84% of heterosexual transmission in women. It has been suggested that the geography of Puerto Rico, which is a relatively small island, creates an opportunity for knowing and contacting a lot of people, and thus facilitating the spread of the disease. Furthermore, given the high rate of sterilization among women, a significant number may find no incentives to use barrier methods that may decrease the risk for contracting AIDS and other STDs (Robles et al. 1990). An additional factor may be that men expect women to be responsible for birth control, and these may prefer the use of methods, particularly the pill, which in turn may decrease the possibility of men using condoms (Davila 1990).

The second most common mode of HIV transmission, and one that is on the rise, is heterosexual activity. The data until December 2002 show that heterosexual infection increased from 6% in 1988 to 24% in 2002. By 2002, heterosexual transmission had increased to 6,533 cases, 3,753 (60%) of whom were women. Heterosexual transmission in women is increasing at a much faster rate than in men. The problem of heterosexual transmission seems to be worsened by the existence of machismo and the subordinate role that women are expected to play in sexual matters. Within such cultural beliefs, women have little power to negotiate safer sexual behavior with their partners. Yet, women who become infected must care for and financially support their infected male partners as well as their children (Santos-Ortiz 1991). See Tables 1 and 2.

The cumulative cases of AIDS in Puertorican adults and children on the island as of January 1, 2002, were:

As of July 31, 2003, Puerto Rico had 28,637 confirmed cases of AIDS. In the west, Aguadilla had 881 cases and Mayaguez 1,378. In Mid-island, Arecibo had 2,003 cases, Ponce 4,827, and Bayamou 4,804. In the east, San Juan had 6,911, cases, Area Metro 3,362, Caguas 3,395, and Fajardo 934 (Vigilancia SIDA División de Epidemiología).

Pediatric AIDS

The first pediatric AIDS case in Puerto Rico was reported in the San Juan Municipal Hospital in 1984. By November 1991, 190 cases had been reported. This figure clearly underestimates the magnitude of pediatric AIDS, because for every one diagnosed case, there are between two and ten children who are infected, but have not been diagnosed (Beauchamp et al. 1991).

It has been estimated that 1.4% of the cumulative AIDS (1998-2002) cases are acquired perinatally. Pediatric AIDS occurs equally in female and male newborns, with a ratio of one to one. The profile shows that more than 93% of the pediatric cases acquired the disease from their infected mothers. A protocol was developed in Puerto Rico to treat serological-positive to HIV pregnant women to prevent mother-to-newborn infection.

Interestingly, most of the HIV-infected children who have been orphaned by AIDS now live with their extended family members—aunts, uncles, and grandparents. Apparently, prior to their death, infected parents make private arrangements with extended family members to insure that their children will be taken care of and legal custody established. The care of HIV-infected children is often burdensome to an extended family that may be overwhelmed by the extra services and care needed by the orphan. Shelter care for HIV-infected children is often unavailable.

On the mainland, mothers infected with HIV are treated with a great variety of drugs to maintain low levels of the viral load. Before and during pregnancy, these treatments reduce significantly the vertical transmission of HIV.

Pediatric cases among school-age children present an additional challenge in Puerto Rico. There is a law that protects the confidentiality of all persons with HIV/AIDS. Students, teachers, and administrative personnel do not have to inform others of their status about serological conditions. On the other hand, state and federal regulations request that any school or employer provide information and workshops about blood pathogens including, HIV/AIDS and hepatitis. Employers are asked to establish a program to advise, prevent, and protect their employees against blood pathogens. In Puerto Rico, as on the mainland, prejudice and discrimination exist, so that some schools have tried to protect confidentiality by denying access to the records of children who have revealed that they are HIV-infected. Nonetheless, it should be noted that the Department of Education in Puerto Rico has an AIDS (SIDA) policy that adequately addresses the needs of HIV-infected children in the schools.

11. Sexual Dysfunctions, Counseling, and Therapies

A. Concepts of Sexual Dysfunction

The data on types of sexual dysfunction are limited to small nonrandom samples. A 1985 report by Mock states that the most common sexual dysfunction among males was erectile dysfunction, followed by lack of sexual desire and premature ejaculation. For females, the most common problem was inhibited female orgasm, relationship problems, and lack of sexual desire.

In Mock’s opinion, the male dysfunctions are in part because of three main factors: the belief that it is the male’s responsibility to satisfy his partner, masculinity as defined by the ability to obtain and sustain erection, and the fear of homosexuality. In the case of the female, issues such as inhibitions to express their sexuality freely and the fear of losing a partner seem to play important roles in sexual dysfunctions.

B. Availability of Counseling, Diagnosis, and Treatment

There are several private practitioners in Puerto Rico, most of whom have been trained in the United States and possess doctoral degrees as well as certification as sex counselors and/or therapists. Most of them are members of professional organizations in the United States, such as the Society for the Scientific Study of Sexuality (SSSS), the American Association for Sex Educators, Counselors, and Therapists (AASECT), and the Society for Sex Therapy and Research (SSTAR).

12. Sex Research and Advanced Professional Education

Human sexuality courses are part of the academic offerings in the colleges and universities in Puerto Rico. Major universities, such as the Universidad de Puerto Rico, conduct research in sexuality and AIDS (SIDA).

In the past 15 years, sex education has become a real need for teachers who deal with children and adolescents who have needs, problems, and questions related to their sexuality. The universities have prepared and offered courses in sexuality to satisfy the needs of the teachers. The University Sex Education Symposium provides the opportunities for educators and health professionals to obtain continuing education in sexuality. Unfortunately, most helping professionals do not have the opportunity of benefitting from formal courses in sex education, because there is a deficiency of such courses in the professional curricula. Efforts are underway in Puerto Rico to introduce a sex education curriculum into the professional schools in the universities.

Because of the relevance of AIDS in Puerto Rico, there are numerous organizations and centers providing services and conducting ongoing research in this area. Worth mentioning are two publications: El SIDA en Puerto Rico, edited by a group of scholars working at Rio Piedras of the Universidad de Puerto Rico (Cunningham et al. 1991), and the second one by Mock & Ramirez (1993) titled SIDA: Crisis o Reto Transformador.

The most important center for research on general aspects of sexuality is the Instituto Puertorriqueno de Salud Sexual Integral (Address: Center Building, Oficina 406, Avenida de Diego 312, Santurce, Puerto Rico 00909; telephone: 809-721-3578). There are also several centers and associations that deal with specific aspects of sexually transmitted diseases and AIDS (SIDA).

Final Comments

In summary, sexual behavior and attitudes in Puertorican society reflects the social, political, and economic conditions of the country. A model of economic development based in population control and immigration has resulted in high rates of sterilization and the use of its population, especially the female, as involuntary experimental subjects for contraceptives such as the pill. This same pattern has been reported with the use of hormones to feed poultry and livestock, which has also had an impact on the health status of the inhabitants of the island.

The so-called yo-yo migration and high rates of intravenous drug use have resulted in a high incidence of AIDS (SIDA), with heterosexual transmission being more important than other means of contracting the virus.

The institutionalized inequality of women on the island contributes not only to high rates of AIDS (SIDA) among them and their newborn, but also to the repression of their sexuality and their engagement in high-risk behaviors only to satisfy their partner or because of a fear of losing them.

References and Suggested Readings