Black women with high levels of stress are more likely to experience sexually transmitted infections (STIs) and poor sexual and reproductive health, according to the authors of new research.

“Black women have higher stress and higher STIs and are at risk of both,” says Joy D. Scheidell, PhD, MPH, research scientist in the department of population health at New York University School of Medicine.

“The motivation behind the research is we see stress in samples of Black and African American women are related to adverse birth outcomes: low birth weight, early delivery, and others,” Scheidell says. “There has been little known about the effect of stress on STIs, which also play a role in adverse birth outcomes.”

Researchers used data about Black and white female participants from Wave IV of the National Longitudinal Study of Adolescent to Adult Health. They examined stress scores from the Perceived Stress Scale, calling scores of six or more as high stress.1

Since 1984, the researchers of the study have collected information from individuals every eight to 10 years as part of a follow-up. Each new wave of the study introduces new participants, who also will be followed, Scheidell explains.

“We used the fourth wave of the survey with people in their 20s, and we measured their stress using a validated scale of perceived stress,” she says. “The wave we use had data collected in 2008 and 2009.”

Then, they compared the association of high stress scores with a self-reported, past-year chlamydia diagnosis; combined, curable STI; and lifetime pelvic inflammatory disease.1

Before this study, most of the literature focused on samples from Black women, which made it difficult to assess whether this was a phenomenon only in Black women, Scheidell notes.

“We examined questions around stress, STI, and stressful life events,” she says. “We wanted to look at a research sample — ad hominem — and see confirmation from prior studies and specific groups to draw conclusions about it.”

Investigators also decided to examine risk on a ratio scale to determine elevated risk for those with high stress vs. low risk.

“Those with high stress had two times the risk,” Scheidell says. “That doesn’t tell you about the burden of infection, the real prevalence difference, and the number of cases we might be able to prevent.”

After analyzing data, researchers found Black women experienced a higher prevalence of chlamydia in the past year, as well as any past-year STI, including syphilis, gonorrhea, and trichomoniasis, she says.

“Those with higher stress levels have higher prevalence of sexually transmitted infections. Absolute stress levels are higher among Black women,” she adds.

When investigators studied prevalence ratios, including whether prevalence is greater in high stress vs. low stress, they saw an adjusted analyses model that showed the prevalence ratio is the same. “Whether you’re white or Black, if you had a higher stress load, you had two to three times the prevalence of chlamydia and the curable STIs, as well,” Scheidell says.

The prevalence of stress was tricky to define, she notes. “This is a scale where a higher score equals higher stress,” she explains. “We chose a cut point, so if someone had a score greater than six, they have high stress.”

But with just the cut point and scores, it is difficult to determine whether the prevalence is higher in one group or another, Scheidell says.

“The mean of the perceived stress scale is higher for Black women than for white women,” she explains. “They did have higher stress for Black women when compared to white.”

Reproductive health clinicians can help patients reduce stress and the risk of STIs through a twofold approach, she suggests. “Sexual health clinicians should be incorporating more understanding of the stress their patients might be dealing with because those could impact their risk,” Scheidell says. “This scale we used has only four items; it’s very brief, so they could screen for stress among their patients to get a sense of whether they need to be a little more targeted in STI prevention.”

The second approach is for behavioral health providers, who are seeing individuals dealing with stress, to talk with their patients about STI risk, she adds.

The results of the new study do not answer the question of why Black participants experienced more stress. “We need more research with other means of studying stress, as well,” Scheidell says. “We don’t know what the stressors are.”

It is likely that a stressor for a Black woman in America is quite different than what white women experience. “We controlled for confounding effects and a range of other factors,” Scheidell says. “Maybe those who are stressed have lower socioeconomic attainment or prior trauma. We did an analysis to control for those things.”

What they found was that even accounting for all of these other factors, including poverty and trauma, it did not make a difference in the correlation between stress and STIs among Black women. But there was a difference for white women.

“For white women, what we saw when we accounted for those factors was a relationship between stress and STI had greatly reduced in strength, or it went away entirely,” Scheidell says. “It might be all of these concurring things in white women.”

For Black women, there is something unexplained about their stress. It is possible Black women experience stress that was not captured in the survey questions. For instance, this could be stress related to racism. “The weathering hypothesis says the levels of stress Black women experience over time are impacting their bodies in a real way,” Scheidell says. “The accumulation of stress might be different between white and Black women.”

Another way to conceptualize this difference is to look at intersectionality as an important piece for Black women’s experience in the United States.

“It’s not just gender, it’s not just race, but an intersection of those things,” Scheidell explains. “For sexual care providers, talking about contraception in that relationship is important. Others have found reduced condom use and increases in risky sexual behavior when individuals are in stress.”

Sexual health providers can discuss specific issues related to stress and STIs. They can educate women about the effects of stress, referring them to counselors to reduce their stress levels.

“If stress is reducing an individual’s ability to engage in condom use, then let’s talk about other forms of contraception like long-acting reversible contraceptives, which might be important if their lives are overwhelming and chaotic,” Scheidell says.

The area of stress and STIs needs more research, she notes. “Our study is cross-sectional,” she says. “Only one study is longitudinal, and that study found two potential pathways”:

  • Stress affects interpersonal and behavioral things, including multiple relationships and condom use;
  • The effects of stress on the body could make an individual more susceptible to infections if the person is exposed.

“We need a lot more work,” she adds. “The need for future research is something I think is really important.”

Stress is a prevalent issue, and it appears to be increasing in the United States — partly due to the COVID-19 pandemic, she notes.

“Understanding stress is very important and worthwhile,” Scheidell says.