Puerto Rico
(Estado Libre Asociado de Puerto Rico)

Luis Montesinos, Ph.D., and Juan Preciado, Ph.D.


  1. Demographics and a Historical Perspective*
  2. Basic Sexological Premises
  3. Religious and Ethnic Factors Affecting Sexuality
  4. Sexual Knowledge and Education
  5. Autoerotic Behaviors and Patterns
  6. Interpersonal Heterosexual Behaviors
  7. Homoerotic, Homosexual, and Ambisexual Behaviors
  8. Gender Conflicted Persons
  9. Significant Unconventional Sexual Behaviors
  10. Contraception, Abortion, and Population Planning
  11. Sexually Transmitted Diseases
  12. HIV/AIDS
  13. Sexual Dysfunctions, Counseling, and Therapies
  14. Research and Advanced Education
  15. References and Suggested Readings

Demographics and a Historical Perspective*

* The reader is encouraged to check the other chapters in this Encyclopedia which provide different perspectives on the varieties of Latino culture that complement that provided here. Of specific interest are the chapters on Argentina, Brazil, and Mexico, and the brief discussion of Latinos on the mainland of the U.S.A. in Section 2 of the chapter on that country.

A. Demographics

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. This island commonwealth of 3,435 square miles has the Atlantic Ocean to the north and the Caribbean sea to the south. Three quarters of the island are mountainous, forcing most of the people to live in a broken coastal plain.

Sixty-seven percent of Puerto Rico’s 3.8 million people (1994 estimate) live in the island’s urban areas. Life expectancy at birth in 1994 was 71.5 years for males and 78.4 years for females. The sex ratio favors females by 51 percent to 49 percent. Most of the population is young with a median age of 26.8 years of age, with 11.1 percent under the age of 5 and about 4.7 percent age 65 and over (Castro-Alvarez and Ramirez de Arellano 1992). The 1995 per capita domestic product was $6,360.

An additional estimated 2.7 million Puerto Ricans live on the United States mainland, mainly to the New York metropolitan area. Major migration to the mainland occurred in the 1950s and 1960s. Since 1974, there has been a reverse migration flow back to the island. The present report will focus on the sexual behavior and beliefs of people living in the island commonwealth. It could be pointed out, however, that 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 and Ramirez de Arellano 1991). Puerto Ricans have constant contact with residents of eastern U.S. cities where the HIV-infection rate is high (Robles et al. 1990).

The birthrate in 1994 was 19 per 1,000 and the death rate 8 per 1,000. The infant mortality rate was 14.3 per 1,000 live births. The total fertility rate was 2.4 in 1988. The literacy rate was 89 percent and 8.2 percent of the gross national product is committed to education.

B. A Brief Historical Perspective

The island now named Puerto Rico was first visited by Columbus on his second voyage in November 1493. Puerto Rico was originally named Borinquen after the indigenous Arawak Indian name Boriquen. Fifteen years later, Spanish colonists arrived, and the Arawak natives were quickly killed off.

Sugarcane was introduced to Puerto Rico in 1515, and slaves were imported three years later to work the cane harvest. The Spaniards fought off a series of British and Dutch attempts to take over. Slavery was abolished in 1873.

In 1898, the territory was ceded by the Spaniards to the United States after the Spanish-American War, and since then, Puerto Rico has been an island commonwealth of the West Indies associated with the United States. In 1952, its inhabitants became United States citizens, and travel between the island and the continent has increased dramatically since then. Thus, in addition to the influence of the Spanish colonial times, being part of the United States has also had an impact in the life and sexuality of Puerto Rico’s society.

In the late 1940s, Puerto Rico began its famous “Operation Bootstrap” to change its status as “The Poorhouse of the Caribbean” to an area with the highest per capita income in Latin America. Although manufacturing and tourism are very successful, the per capital income is low compared with that of the mainland United States. In 1991, an 89-year bilingual policy in which English and Spanish served as joint official languages ended, when Spanish became the only official and legal language of the island.

1. Basic Sexological Premises

A. Character of Gender Roles

In describing the sexological premises commonly ascribed to by Puerto Ricans, it should be noted at the onset that major differences exist within the society, where most of the low-income population agree with the more-traditional values, and more-educated single females, and to a lesser extent males, tend not to fit the stereotypical feminine role.

Puerto Rican 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 and 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). Puerto Rican boys are indoctrinated in the importance of being macho from a very early age.

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; and train their sons to be dominant and independent in relationships with their wives as well as other women (Medina 1987).

Males express machismo by having sex with as many females as possible, and by emphasizing their capacity as procreator and willingness to have as many children as possible, preferably males (Mejias-Picart 1975). There is practically no societal control over male sexual behavior, while female sexuality is openly repressed. It is expected that the males assume the active role, initiate sexual activity, and be responsible for the satisfaction of the female.

The female equivalent of machismo is etiqueta, a complex value system that requires Latina women 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, 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. Because girls are taught to be sensual and seductive, chaperons have the responsibility of making certain that young women who are being courted do not stray.

Latina girls are 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 is not uncommon for several daughters in the same family to 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 are expected to sacrifice their own needs for the sake of their children and husband (Comas-Diaz 1985). A wife is not expected to enjoy sex herself or to seek it - she is there to please her husband. Females are expected to be passive, ready to respond to the male requirements and not to assume responsibility for their own pleasure. A good woman is 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 percent of the husbands surveyed were found to initiate sexual activities almost all of the time, while 90 percent of household chores (cooking and cleaning) were carried out by the wives (Vasquez 1986).

A strong pronatalist value also underlies Puerto Rican culture. Large families with many children are preferred. The family is not structured as the American or European nuclear family tends to be. A girl who has a child out of wedlock is initially frowned on for violating marianismo and etiqueta, but she and her child will usually be quickly accepted by her whole family because of her child. The pronatalist value is supported by the anticontraception and antiabortion position of the Catholic Church. Nevertheless, both contraception and abortion are commonly used.

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 Puerto Rican Senate found that the same pattern of discrimination continued to exist. 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 Puerto Rican society (Zorrila et al. 1993).

Women themselves are in part liable for the preservation of this situation, since they continue to accept the sole responsible for child rearing and play an essentially domestic role. But this form of sexism is also “imprinted” in children who are socialized to accept the stereotypical 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 and 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).

During the school years, gender roles are reinforced by a biased curriculum. A study on the illustrations and contents 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 frequently working in their home, engaged in passive activities such as reading, praying, playing with dolls, and were rarely depicted outside of it. 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 stereotype has changed at all.

It has been only recently that the Department of Education on the island has established a program to train its personnel and to develop curricula for sexual education in schools (Mock 1992). Before that, with very few exceptions; such programs did not exist.

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.

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 percent of working-class women and 50 percent of professional women reported faking orgasm in order to end intercourse soon or to avoid the husband’s questioning about their achieving orgasm or not. While the great majority of women surveyed did not disapprove of self-pleasuring, very few women engage in autoeroticism, or admit to this in surveys (Burgos and Diaz-Perez 1985).

For Latino men, this uncomfortableness with sex is expressed 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).

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 Puerto Rican 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 people.

2. Religious and Ethnic Factors Affecting Sexuality

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

The early 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 threatened by the neighboring Carib Indians. The island was finally invaded and conquered for Spain in 1509 by Ponce de Leon.

Introduction of sugarcane 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 the Puerto Rican society. Indigenous, Spanish, and African elements permeate the Puerto Rican culture even today, with the Spanish influence dominant, since they occupied and controlled the island for nearly four hundred years.

In 1898, Spain ceded Puerto Rico to the United States as part of the treaty of Paris that ended the Spanish-American War. In 1952, the people voted for self-government as a Commonwealth of the United States.

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 polygamous.

Later on, the Spaniards introduced their patriarchal society with its values of machismo, marianismo, and etiqueta, which emphasize 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 percent of Puerto Ricans today identify themselves as Catholic, most are not highly active in the Church (Burgos and Diaz-Perez 1985).

Although the culture seems sexually repressive, in reality Puerto Rican society is eroticist and exalts sexuality in pervasive and subtle ways. Sexual themes permeate Puerto Rican popular music and dances (salsa) as well as nonverbal communications. Perhaps because of this, there are very few written articles about sexuality in Puerto Rico, and very little is known about sexual behavior and attitudes of Puerto Ricans (Burgos and Diaz-Perez 1985; Cunningham 1991).

In keeping with its strong Christian roots, Puerto Rican males today hold a superior and dominant role, reflected in the saying “females are expected to have babies and males are expected to make history.” 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). Nevertheless, sexuality is commercialized and widely available in both pornography and prostitution (Mock 1984).

As stated before, although the influence of the Catholic Church is felt in all aspects of sexuality, studies indicated that Catholics have as many abortions as non-Catholics (Ortiz and 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. Sexual Knowledge and Education

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 formal education either. Obviously, neither females nor males have any knowledge about the health implications of various sexual practices (Burgos and Diaz-Perez 1985).

There are no systems or district-wide 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 play 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 video tapes has permitted islanders to be exposed to the same kind of information that is available to individuals living on the mainland.

4. Autoerotic Behaviors and Patterns

When asked about self-pleasuring in a 1985 survey, a great majority of women do not disapprove of it. However, they reported not practicing it themselves. A survey of 191 adolescents found that 32 percent (61) of them engaged in self-pleasuring, 53 of them males and only 8 of them females (Burgos and Diaz-Perez 1985).

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.

B. Adolescents

Puberty Rituals

There are no public rituals to mark menarche for girls or the onset of puberty for boys.

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 and Ramirez 1993).

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 percent of young Puerto Ricans are sexually active (Cunningham 1991).

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 enforce the dual standards of behavior expected of Puerto Rican 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 Puerto Ricans 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 Cunning-ham and collaborators (1991), with randomly selected students at the Universidad de Puerto Rico, show that almost half of them are sexually active, 70 percent of the males and 40 percent of the females. Of those sexually active, 80 percent had experienced vaginal intercourse, more than 50 percent had tried oral intercourse, and over a third had tried anal intercourse.

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

C. Adults

Marriage and the Family

It used to be that the divorce rate was very low, probably due to 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 percent; by 1980, the incidence was 25 percent (Vasquez-Calzada 1989). More recently, increasing numbers of single mothers have been noticed (20.9 percent in 1980 to 32.9 percent in 1989) (Castro-Alvarez and Ramirez de Arellano 1991). In 1988, the percentage of teen births was 17.4 percent, while those out of wedlock reached 32.8 percent.

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 percent of university students surveyed in 1989 and 37 percent of those surveyed in 1990 had participated in anal intercourse. Approximately 40 percent 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 percent of those who practice anal intercourse (22 percent of the females and 46.5 percent 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 is available on the attitudes towards or the incidence of either anal or oral sex among nonuniversity-students, and single or married adults.

6. Homoerotic, Homosexual, and Ambisexual 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 and Cunningham 1991).

There is a strong rejection of homosexuality, especially male homosexuality. This negative attitude is present even in Puerto Rican 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.”

Due to the AIDS (SIDA) epidemic, homosexuals affected by the disease have organized support groups and started to acknowledge their sexual orientation publically. Within these groups, two distinct reactions have been observed: a group of individuals have 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 twenty 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. Due to the AIDS epidemic, other groups that deal specifically with this issue have been established in different parts of the island.

7. Gender Conflicted Persons

As in other parts of the world, transvestites and transsexuals do exist in Puerto Rican society. However, scientific data on the extent of this population and its practices are unavailable.

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 centers 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 Violacion reported 181 cases of rape and 21 cases of incest for the period 1984-85 (Burgos and Diaz Perez 1985).

Sexual Harassment

This is a relatively new concept that has not been widely accepted in Puerto Rican society. Most people believe that these are the natural behavioral patterns in 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 percent among women attending a conference on women in the work place, to as high as 73 percent for women working in the health-care sector (Alvarado 1987; Martinez et al. 1988). The great majority of these women had been harassed by supervisors (over 60 percent) or coworkers (almost 30 percent). Although more than 60 percent of the women confronted the harasser, only 13 percent 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 behavior of macho males.


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 or permitted in Puerto Rican 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.

The recent increase in AIDS among heterosexuals has been in part attributed to the male contact with an infected prostitute (Mock and Ramirez 1993).

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, although access to magazines and television channels, such as the Playboy Channel, is possible through cable TV. There is little if any indigenous pornographic material, since a variety of such material is easily brought home by Puerto Ricans traveling back and forth between the island and the mainland to visit family and relatives.

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 pursuing public birth control services, arguing not only from the negative consequences of overpopulation, but from the positive outcome of reducing the high rate of abortion. However, due to 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 and in Mayaguez in the early 1930s, were closed.

Federal agencies established contraceptive services in the mid-1930s, but these were also closed during the later years of the Roosevelt Administration due to 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 Puerto Rican 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 contraceptive level of 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, as usage decreased from 18.9 percent in 1968 to 11.9 percent 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 percent). However, it should be noted that the popularity of the rhythm method has increased from 2.9 percent in 1968 to 7.7 percent in 1982 (Vazquez-Calzada 1988).

The use of condoms is not very high. About 6.6 percent 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).

B. Teenage Unmarried Pregnancies

Statistics for the year 1985 show that 17 percent of all pregnancies occurred among adolescents between the ages of 10 to 19 years (Mock and Ramirez 1993).

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 contraceptives. If the abortion can be kept secret, the person in question can continue to go to Church, whereas if the pregnancy is brought to term, everybody would know about it (Ortiz and Vazquez-Nuttall 1987).

D. Population Control Efforts

Population-control policies in conjunction with migration - almost a third of Puerto Ricans live outside their country - have been long-term basic tenets of economic development on the island. This has permitted constant experimentation with contraceptives among Puerto Rican women. They served as human “guinea pigs” for 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 percent 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 percent in 1968 to 58.3 percent in 1982 (Vazquez-Calzada 1988). Sterilization remains the most accepted method of family planning among Puerto Rican 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 opted for sterilization. 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 and 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 percent in 1968 to 6.6 percent in 1982 (Vazquez-Calzada 1988). Vasectomy is more popular among educated males living in urban areas.

10. Sexually Transmitted Diseases

Only partial data on the incidence of sexually transmitted diseases is available. The rate for syphilis (all stages) was 25.4 per 100,000 in 1984, which was more than twice as high as that of the mainland for the same year (12.2 per 100,000) (Sexually Transmitted Diseases 1984). While rates are not available for the last three years, available data on the absolute number of cases show a decline from 2,551 cases in 1989 to 1,940 cases in 1991 (MMWR 1989; 1990; 1991).

The rate for gonorrhea in 1984 was 103.6 per 100,000 (Sexually Transmitted Diseases 1984). This rate is less than one third that of the United States for the same year (374.8 per 100,000). Once again, rates were unavailable for the last three years. However, the cumulative number of cases reported for the last three years show a dramatic decrease from 1,513 cases in 1989 to 668 case for 1992 (MMWR 1989; 1990; 1991).

The statistics also indicate that sexually transmitted diseases occur most frequently among adolescents and young adults. 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 and Ramirez 1993).


A. 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 due to 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 October 1991, a total of 6,732 cases had been reported, of which 4,336 (63 percent) had already died.

The most recent data on the reported number of AIDS cases per 100,000 population through June 1992 show that Puerto Rico has a 50.9 rate per 100,000, among the highest in the world. It was estimated that by 1993, the number of new cases would reach 11,000, due in part to the changing diagnostic criteria that added tuberculosis, cervical cancer, and recurrent pneumonia to the AIDS syndrome in January 1993.

The greater proportion of deaths from AIDS on the island occurred among people between 25 and 34 years of age, an age of great productivity and an active social and sexual life. In 1987, it was reported that AIDS was the primary cause of death for women between ages 25 and 29, and for males between 30 and 39 years of age (Cunningham 1991). In 1989, 3.7 percent of all deaths in Puerto Rico were due to AIDS. However, in comparison to those living on the island, Puerto Ricans 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 IV drug users among AIDS cases in the United States is found in Puerto Rico (Colon, Robles, and Sahai 1991). It is estimated that more than 63 percent of AIDS patients on the island are addicted to intravenous drugs. Among males, 59 percent of AIDS cases are associated with the use of drugs, compared to only 19 percent for mainland United States. 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 percent of the total population, 80 percent of whom are intravenous drug users (Rivera et al. 1990).

Most of the 100,000 drug users are young, heterosexual 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 users’ male partners account for 84 percent 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 in Puerto Rico, and one that is on the rise, is heterosexual activity. The data show that heterosexual infection increased from 6 percent in 1988 to 10 percent in 1991. By 1993, heterosexual transmission had increased to 1,350 cases, 854 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).

B. Pediatric AIDS (SIDA)

Unfortunately, Puerto Rico has one of the highest incidences of pediatric AIDS (SIDA), with a higher incidence in urban areas. 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 diagnosed case, there are between two and ten children who are infected but have not been diagnosed (Beauchamp et al. 1991).

The most comprehensive epidemiological picture of pediatric AIDS cases emerges from a study conducted in the San Juan Municipal Hospital (Quiroz et al. 1991). It has been estimated that 90 percent of the AIDS cases are acquired perinatally. Pediatric AIDS occurs more commonly in females than in males, with a ratio of three to two. The median age for onset of full AIDS symptoms is 5 years. The profile shows that more than 80 percent of the pediatric cases acquired the disease from their infected mothers. The main risk factor identified was being born to an intravenous drug-user mother (67.2 percent, born to an infected mother) or father (65 percent), and having a parent with multiple partners (27 percent). The marital profile revealed that most of these mothers were “not legally married” (42.4 percent), or were never married (33.3 percent), and only a small number were “legally married” (15.2 percent). Many of the mothers have completed 12 years of education (64.6 percent), with an average schooling of 11.39 years.

Interestingly, one study found that 40.3 percent of the HIV-infected children who lost their parents live with their extended family members - aunts, uncles, and grandparents (Beauchamp et al. 1991). Apparently, prior to their death, infected parents made private arrangements with extended family members to insure that their children would be taken care of. Legal custody was declared in approximately 14 percent of the cases, suggesting that most parents made private arrangements. 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 them. Shelter care for HIV-infected children is often unavailable.

Pediatric cases among school-age children present an additional challenge in Puerto Rico. Schools need to know the serologic status of students in order to provide appropriate student services. In Puerto Rico, as on the mainland, prejudice and discrimination exist, so that some schools have tried to deny access to parents whose children have revealed that they are HIV-infected. Hence, parents are sometimes reluctant to disclose their children’s sero-logical status to school officials. 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.

12. Sexual Dysfunctions, Counseling, and Therapies

A. Concepts of Sexual Dysfunction

The data on types of sexual dysfunction is 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 due in part to 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).

13. Research and Advanced 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).

Due to 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 the Recinto de Rio Piedras of the Universidad de Puerto Rico (Cunningham et al. 1991), and the second one by Mock and Ramirez (1993) titled SIDA: Crisis o Retor 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 Puerto Rican society reflects the social, political, and economic conditions of the country. A model of economic development based on 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 impacted 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 engagement in high-risk behaviors only to satisfy their partner or because of the fear of losing them.

References and Suggested Readings

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