EXECUTIVE SUMMARY

New research reveals that reproductive health providers are more likely to ask Black women than white women about their sexual risk behavior and condom use.

  • The study found Black women were two times more likely to be offered testing for sexually transmitted infections.
  • Even when age, marital status, educational background, and other factors were considered, Black women were more likely to face these questions.
  • Providers need a standard assessment tool or approach to asking patients about their risk behaviors.

Results of a new study revealed Black women are more likely to be asked about their sexual risk behavior and condom use than are white women in sexual health counseling settings.1

Researchers studied provider conversations with Black and white women about reproductive health. They specifically sought information on how often sex and sexual health were mentioned in conversations with clinicians, says Ashley Townes, PhD, MPH, post-doctoral research fellow with the Centers for Disease Control and Prevention. Townes conducted the study while at Indiana University.

“When sexual health does come up in conversation, what is the nature of the conversation?” Townes asks. “What types of questions are asked?”

The study relied on self-reported data by women in a survey. It revealed Black women were two times more likely to be offered testing for sexually transmitted infections (STIs).1

“Most often, there was no difference in Black and white women in talks about birth control and being sexually active,” Townes says. “The differences came out when questions were about condom use with partners, how many partners a person had, and questions about whether they would like to be tested for STIs.”

Investigators found after adjusting for age, social determinants of health, educational background, and marital status, Black women still were more likely to be offered STI tests and more likely to have a conversation about condoms. They also were more likely to receive condoms for future use, Townes says.

“Once we had this data, we had to go back into the literature to explain why this is happening,” she adds. “Nationally, the priority is to decrease new STIs and decrease unintended or unwanted pregnancies.”

“Since there is a disparity between Black and white women in rates of unintended pregnancies, maybe the reason why Black women are asked more often is to help with meeting national goals,” Townes says. “Data show that Black women have a higher rate of unintended pregnancies and higher rates across STIs, including chlamydia, syphilis, and others.”

The literature suggested a possible reason for the disparity. “Maybe because of STI disparities, providers are being encouraged to have these conversations with Black women,” Townes says. “What we discuss is that while this is important and providers should be having these conversations with Black women, they’re not having these discussions at the same rate with white women. This could result in unintended negative consequences. Women of other races might not receive the same sexual healthcare. They might not be asked these questions, tested as often, or given condoms for future use.”

The discrepancy in how providers approach sexual health questions also could negatively affect Black patients.

When Black patients feel they are targeted by a particular provider’s questions and practice, this also can be detrimental, Townes notes.

“If they go into a sexual healthcare provider appointment and they feel like they’re being judged or there’s a stereotype about them when they discuss their sexual health behaviors, then that could cause some internal stigma for that Black woman,” she explains. “It could make her perceive that the provider is showing her some bias. It could make her distrustful.”

This could contribute to ongoing stereotypes in healthcare settings and break down that provider-patient communication, she adds.

“This study did not ask if Black women felt targeted,” Townes says. “I did another study that is under consideration. I asked women about their experiences with more in-depth questions.”

She discovered that some women reported they felt the provider was stereotyping them or judging them. The findings suggest that many reproductive health providers do not follow a set script or checklist when asking questions.

“My own experiences when going to different providers is that sometimes the doctor will ask those questions; sometimes the nurse will ask the questions,” Townes says. “It’s not standard, and not all providers follow the same routine. That’s kind of the problem.”

If each provider followed a standard way of inquiring about patients’ sexual risk behaviors and reproductive health, then patients would accept these questions with each visit. They would know their experience is no different from any other person’s experience, and that would help reduce disparity, she adds.

A standardized approach to sexual risk assessment and counseling also would be better for all women. If some women are perceived as less at risk without being asked about their experiences, then clinicians are not providing them with the highest quality sexual healthcare services. Some women may be at risk that is not identified, Townes says.

“There shouldn’t be one population that is receiving this healthcare service and other populations are not,” she says. “There may be missed opportunities.”

Some providers might take issue with standardizing questions. But they could look into several different sexual history tools and guides.

“It’s up to the providers to use them or adopt something of practice or policy and procedure of how it’s implemented or used,” Townes says.

Providers can think about this issue by acknowledging that part of their job is to prevent sexually based disease and illness. Can they accomplish this by selecting only certain patients to ask the tough questions about risk behavior?

“There is a perception that certain women are more or less at risk without the provider asking them about their behavior,” Townes says. “Then, you find providers who are surprised that a patient is going blind because they have had syphilis for years. If we just regularly ask like we check patients’ blood pressure, then everyone knows they’ll be asked this and it will be made standard, reducing that feeling of discomfort.”

Townes suggests providers make this part of their check-in process. When patients come in and sign a consent form, clinicians can ask patients why they’re there and what problems or dysfunctions they want to address. Then, patients go back into a room to meet with the provider, who reviews the medical chart and asks about the patient’s risk behaviors.

“We can’t change how people feel about these questions being asked,” she notes. “But it makes the conversation between the provider and patient better.” Asking standard questions routinely also saves time.

Also, condoms should be offered to all patients, Townes says. Black women were offered condoms more often than white patients, but all should be given this option.

“We don’t know people’s lifestyles. Just because someone is or is not wearing a wedding band, we still don’t know what that person’s behaviors are,” she explains. “There are some assumptions about their sexual life that need to be taken out of the equation.”

Providers should remove their assumptions and just ask questions of everyone, Townes adds.

REFERENCE

  1. Townes A, Rosenberg M, Guerra-Reyes L, et al. Inequitable experiences between black and white women discussing sexual health with healthcare providers: Findings from a U.S. probability sample. J Sex Med 2020;17:1520-1528.