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The Impact of Racism on the Sexual and Reproductive Health of African American Women

Cynthia Prather, PhD1, Taleria R. Fuller, PhD2, Khiya J. Marshall, DrPH3, and William L. Jeffries IV, PhD, MPH, MA1

1Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia.

2Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.

3Division of Violence Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia.

Abstract

African American women are disproportionately affected by multiple sexual and reproductive

health conditions compared with women of other races/ethnicities. Research suggests that social

determinants of health, including poverty, unemployment, and limited education, contribute to

health disparities. However, racism is a probable underlying determinant of these social

conditions. This article uses a socioecological model to describe racism and its impact on African

American women’s sexual and reproductive health. Although similar models have been used for

specific infectious and chronic diseases, they have not described how the historical underpinnings

of racism affect current sexual and reproductive health outcomes among African American

women. We propose a socioecological model that demonstrates how social determinants grounded

in racism affect individual behaviors and interpersonal relationships, which may contribute to

sexual and reproductive health outcomes. This model provides a perspective to understand how

these unique contextual experiences are intertwined with the daily lived experiences of African

American women and how they are potentially linked to poor sexual and reproductive health

outcomes. The model also presents an opportunity to increase dialog and research among public

health practitioners and encourages them to consider the role of these contextual experiences and

supportive data when developing prevention interventions. Considerations address the provision of

opportunities to promote health equity by reducing the effects of racism and improving African

American women’s sexual and reproductive health.

Address correspondence to: Cynthia Prather, PhD, Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, National Center for HIV, Hepatitis, STD & TB Prevention, 1600 Clifton Road, MS E-37, Atlanta, GA 30333, [email protected].

Disclaimer The findings and conclusions of this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Author Disclosure Statement No competing financial interests exist.

HHS Public Access Author manuscript J Womens Health (Larchmt). Author manuscript; available in PMC 2016 August 01.

Published in final edited form as: J Womens Health (Larchmt). 2016 July ; 25(7): 664–671. doi:10.1089/jwh.2015.5637.

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Introduction

ALTHOUGH PUBLIC HEALTH efforts have made considerable progress in promoting health equity

in the United States, studies suggest that African American women are disproportionately

affected by multiple sexual and reproductive health conditions compared with women of

other races/ethnicities.1,2 HIV and pregnancy-related complications remain within the top 10

leading causes of death for African American women aged 20–54 and 15–34 years,

respectively.3 African American women accounted for 60% of the estimated new HIV

infections that occurred among all women in 20144 and are 2.8–3.7 times more likely to die

from pregnancy-related complications compared with women of all other races/ethnicities.5

To improve the sexual and reproductive health of African American women, several

evidence-based prevention interventions have been developed and implemented.6 Although

these interventions have been found to be efficacious in public health practice settings,

research models are needed to address the underlying social determinants that directly and

indirectly influence sexual and reproductive health disparities. We argue that racism, in both

historical and contemporary contexts, is one condition that warrants more attention in

models seeking to understand the sexual and reproductive health outcomes of African

American women.

There is currently a dearth of research models that actually highlight the role of racism in

sexual and reproductive health, with many studies focused on the reproductive (i.e., perinatal) health of African American women.7,8 Thus, we offer a socioecological model to

provide a contextual understanding of the role of racism on the sexual and reproductive

health outcomes of African American women and provide public health considerations that

promote health equity. Socioecological models allow a better understanding of how social

determinants such as racism influence health at individual, interpersonal, community, and

societal levels.9,10 This article considers the context of race-specific experiences of African

American women. A thorough understanding of how racism has facilitated disparate sexual

and reproductive health outcomes may provide a foundation to appropriately address sexual

and reproductive health issues within this population.

Levels of Racism and African American Women’s Sexual and Reproductive Health

Racism is an institutionalized system of oppression that designates value to persons based on

race/ethnicity.11 Jones delineates three levels of racism that contribute to health disparities.

Institutional racism is characterized by large organizations or governments that impose practices that negatively affect access to health services, resulting in differences in the

quality of healthcare for racial/ethnic minority groups. Personally mediated racism occurs when healthcare providers’ preconceived notions about racial groups result in the provision

of substandard healthcare to racial/ethnic minorities. Last, internalized racism involves the embodiment and acceptance of stigmatizing messages from society by racially oppressed

groups.11

We suggest that the three levels of racism play a key role in the trajectory of sexual and

reproductive health experiences and outcomes of African American women. Many studies

suggest that African American women are more likely than white women to experience

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discrimination,12 receive sub-standard medical care,13 and undergo unnecessary surgeries

such as hysterectomies.2 These inequities are independent of socioeconomic status14 and

access to quality medical care.13 Furthermore, at equal levels of socioeconomic status,

insurance coverage, and healthcare access, African Americans receive lower quality medical

care than white Americans.15 This suggests that race-based mistreatment may underlie racial

disparities in sexual and reproductive health. Therefore, to address the effects of racism on

sexual and reproductive health outcomes, it is important to understand how racism

influences other social determinants of health.

Applying the Socioecological Model to Understand the Influence of Racism on African American Women’s Sexual and Reproductive Health

Socioecological models describe how individual, interpersonal, community, and societal

factors shape population health.9 An underlying premise of this framework is that

understanding these multiple levels of influence is necessary to avert health problems

experienced by oppressed groups.16 We propose a multilevel model that describes the social

determinants of health and important prevention opportunities (Fig. 1). Additionally, our

model provides a framework to guide intervention planning, development, and

implementation related to reducing risk factors and increasing protective factors related to

sexual and reproductive health.

The five-level socioecological framework presented is adapted from Bronfenbrenner’s

ecological model for human development.9 The individual level, same as Bronfenbrenner’s,

represents characteristics of the individual, including knowledge, attitudes, behaviors, and

history. The family/interpersonal support level, parallel to Bronfenbrenner’s microsystem,

describes familial and social networks of individuals, which may influence behavior and

contribute to a range of experiences. Aligned with Bronfenbrenner’s mesosystem, the

neighborhood/community level accounts for the environments in which individuals live.

Last, the societal level considers factors such as institutionalized racism. In slight contrast to

Bronfenbrenner’s macrosystem level (which describes the culture in which individuals live),

and similar to the Alio et al. model devoted to infant mortality,7 the outer tier denotes the overall historical context of racism experienced by African American women, with the three

levels of racism integrated across the model.

Individual level—African American women comprise the individual level of the proposed model. HIV and other sexually transmitted infections (STIs), pregnancy-related

morbidity and mortality, stress, and internalized racism may be influenced by racism-related

determinants (e.g., unemployment) that potentially increase risk.

HIV/STIs: Limited education, unemployment, lack of quality care, distrust of physicians, and negative perceptions of the healthcare system serve as barriers to HIV/STI prevention,

treatment, and care. In 2014, African American women had an HIV diagnosis rate that was

18 times greater than white women.17 Furthermore, in 2012, African American women were

more likely than white women to be diagnosed with having primary or secondary syphilis,

gonorrhea, or chlamydia (16.3, 13.8, and 6.2 times, respectively).18 They are also twice as

likely to be diagnosed with bacterial vaginosis, a correlate of poor pregnancy outcomes (e.g.,

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low birth weight).19 For some African American women, racism continues to hinder optimal

educational access, such that limited education is associated with poor HIV treatment

adherence20 as well as unemployment, whereby some women may engage in sexual risk-

taking behaviors to attain basic needs.21 Racism also affects women’s interactions with

healthcare providers. For example, African American women living with HIV have

expressed mistrust toward healthcare professionals.22 This may stem from knowledge about

both historical experiences of African Americans interfacing with the healthcare system23

and current discriminatory practices from providers.24 Importantly, increased HIV risk

among African American women has also been associated with the historical and

contemporary role of mass incarceration of African American men.25

Pregnancy-related morbidity and mortality: Racism is a chronic stressor that not only contributes to HIV/STIs but can also directly affect the health of pregnant women and their

children.26 African American women are also more likely than women of other races to

experience pregnancy-related death.5,27,28 The black–white pregnancy-related mortality

ratio ranged from 3.4 to 4 during 1998–2005.5 Additionally, infant mortality is more than

twice as likely to occur among African Americans than whites.26,29 Racism-related factors

associated with pregnancy-related mortality include economic vulnerability,30 stress,31,32

and experiences of discrimination.12,32,26

Stress: The relationship between stress and health outcomes has been well documented.33

Because racism is a form of stress, it may contribute to adverse health outcomes. Stress is

associated with HIV-related discrimination, negative birth outcomes, and depression among

African American women.24,34–36 Racism also fosters poverty, unemployment, and other

social factors that increase the likelihood of experiencing stress.37 Furthermore, chronic

stressors such as discrimination and poverty that occur over time may worsen health

disparities because they can be experienced across generations38 and negatively affect social

relationships that are known to be health protective.33

Internalized racism: Internalized racism can impact sexual and reproductive health by promoting psychological distress, substance use, and physical health conditions (e.g., glucose intolerance) that contribute to pregnancy-related complications39,40 as well as

negatively affect behavioral decisions that may contribute to HIV/STI risk. For African

American women, internalized racism may manifest in low self-worth, low self-confidence,

and depression. These experiences may, in turn, foster behaviors that compromise the health

of African American women.41 In addition, negative societal stereotypes targeting African

American women can unfavorably affect their sexual health.42,43 The relationship between

self-esteem and engaging in risky sexual behaviors44 may be evident among some African

American women who internalize negative stereotypes.45 For example, a recent study

suggested that young African American women who perceive negative sexual stereotypes in

the media are more likely than others to have multiple sex partners.46

Family and interpersonal level—Family and interpersonal level factors associated with sexual and reproductive health outcomes include domestic and sexual violence, mass

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incarceration, and cultural mistrust. These factors may be influenced by historical racism

and related experiences.

Domestic and sexual violence: Some researchers suggest that racism underlies much of the domestic violence that African American women experience because historically slavery

promoted devaluation of African American women, strained African American male–female

relationships, and provided little to no protection from sexual assault.47,48 More recently, it

has been proposed that the intersection of domestic violence and HIV should be explored

through the lens of historical racism due to a legacy of sexual stereotypes and negative

images.43 When compared with white women, African American women have a

significantly higher lifetime prevalence of rape, physical violence, and stalking by an

intimate partner (34.6% among white women and 43.7% among African American

women).49 These experiences have been associated with HIV acquisition among women50,51

and more frequent and more severe forms of domestic violence among women living with

HIV.52 Additionally, domestic violence affects women’s decision-making pertaining to

sexual behavior50,51,53,54 and is associated with psychological trauma,55 which can increase

the likelihood that women experience sexual health problems (e.g., sexual dysfunction).56,57

These findings suggest that although domestic violence might be one determinant of HIV

acquisition for African American women, it may be necessary to intervene from a

sociocultural context that considers how historical factors related to domestic and sexual

violence affect present-day sexual and reproductive health outcomes.

Mass incarceration: Racism has contributed to the extensive history of mass incarceration of African Americans following slavery. This continuum of incarceration has

affected the familial structure, including access to education, housing and employment, and

ultimately disparate health outcomes.25 Fullilove highlights the relationship between

incarceration of African Americans and disproportionate rates of HIV.25 Thus, policy

changes that affect disparate sentencing laws, encourage successful reentry into society, and

address social determinants are needed.

Cultural mistrust: Cultural mistrust refers to African Americans’ tendencies to mistrust whites.58,59 Cultural mistrust has been associated with low self-esteem,60 dissatisfaction

with healthcare,61,62 and delayed medical treatment.63 The legacy of medical mistreatment,

scientific and medical experimentation, and sexualized violence against African American

women likely continues to shape their mistrust of the medical profession. Indeed, one study

found that cultural mistrust was linked to African American patients’ lack of satisfaction

with their providers,64 while another study found patient dissatisfaction as one predictor of

low antiretroviral therapy adherence among persons living with HIV.23

Neighborhood and community level—Neighborhood and community level factors influenced by racism affect the settings where African American women reside.

Neighborhood characteristics (i.e., concentrated unemployment), unequal healthcare access, and personally mediated racism affect the health of women and their communities.65

Neighborhood characteristics: Neighborhood and community settings have historically been related to racism and potentially increase adverse health risks. These factors include,

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but are not limited to, concentrated unemployment, poverty, and under-resourced education.

Throughout the past six decades, the unemployment rate for African Americans has

remained approximately twice the rate experienced by whites.66 Health consequences

associated with unemployment or insufficient income may include engaging in risky sexual

behaviors in exchange for food or money for living expenses (i.e., rent).21,67 These behaviors place many African American women at risk for HIV/STIs.68,69 Additionally,

poor health outcomes have been attributed to living in impoverished communities that are

residentially segregated by race.70,71 Overall, limited education is associated with poor HIV

treatment adherence, preterm births and infant mortality, living in poverty, and

violence.20,29,67

Unequal healthcare access: Although healthcare segregation continued through the mid-1960s, the passage of the Civil Rights Act of 1964 was one attempt to grant African

Americans with healthcare equal to that of whites. However, African Americans are more

likely to be uninsured than whites and receive poorer quality medical care.13 Disparate

access to and quality of care are underlying determinants of African American women’s

disproportionately high HIV/STI burdens72 and poor perinatal outcomes.29

Personally mediated racism: Physicians’ unconscious attitudes and stereotypes have been associated with disparities in treatment recommendations for African American

patients.73 Personally mediated racism has been experienced by African American women

in their interaction with providers who project stereotypes of sexual promiscuity toward

them and provide inferior service.73 Although it may be unconscious, this type of

discrimination is associated with delayed reproductive health screenings, such as HIV

treatment adherence, Pap smears, and mammograms.74,75

Societal level: Factors that facilitate racial and gender gaps at the societal level and impede healthy outcomes include cultural competence and institutional racism.

Cultural competence: Cultural competence encompasses behaviors, attitudes, and policies that allow medical establishments and providers to effectively serve clients of

diverse racial/ethnic backgrounds.76 Patient-centered approaches that account for the process

and delivery of healthcare are pertinent to culturally competent care and treatment. Medical

providers’ lack of cultural competence has the potential to negatively affect the sexual and

reproductive health of African American women because it can result in stigmatizing

patient–provider interactions. Stigmatizing experiences may result in African Americans not

being willing to be tested for HIV or receive medical services to prevent HIV acquisition

and transmission.77

Institutional racism: Institutional racism reinforces personally mediated and internalized racism by promoting attitudes, practices, beliefs, and policies that give an advantage to

whites and disadvantage to other racial groups.78 Although policies may be instrumental in

creating societal change conducive to health equity, institutional racism is a root cause of

racial disparities in health outcomes.13 Racially discriminatory policies affected healthcare

access, treatment, and delivery of quality care, as well as housing, employment, and

educational opportunities, and disparate sentencing laws toward African Americans.

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Historical and systemic healthcare barriers include accessibility and delivery of quality care

by providers who are culturally and linguistically competent. Currently, the Affordable Care

Act will allow individuals who were underinsured or uninsured to have access to quality

care.79 While the long-term impact in healthcare settings is yet to be seen, early findings

indicate the benefit of making health insurance available to many. Moreover, it has the

potential to impact sexual and reproductive health outcomes by providing access to

preventive care, including contraception, prenatal screenings, mammography, HIV/STI

testing, and other sexual and reproductive health services.80,81 Additionally, policies that

support equal access to quality education and employment will provide further opportunities

to those who may not otherwise have access to adequate healthcare.82 Ultimately, structural

changes that involve policy adjustments may ensure all members of society have

opportunities that contribute to long-term health improvements.83

Historical context—Understanding the historical underpinnings of racism’s impact on the sexual and reproductive health of African American women provides context to current

health outcomes. The historical and contemporary health and healthcare experiences of

African American women provide a perspective that may be considered by healthcare

providers and others who offer services and implement programs for African American

women. Across the socioecological model, the historical context provides a framework to

understand the relationship between health outcomes, social determinants, and experiences

of racism within the lives of African American women. For example, at the societal level,

experiences of sexual violence, including reproductive exploitation,48,84 medical

experimentation,85 and policies targeting African American women, originated during

slavery and were a form of institutional racism.7 Before the Civil Rights Act of 1964, legal

segregation in healthcare as well as federally funded reproductive health procedures (i.e., coerced sterilizations) were commonly practiced.86 At the neighborhood and community

level, experiences of poverty, concentrated unemployment, and residential segregation,

which also had roots in slavery, are exacerbated by contemporary institutional and

personally mediated racism. Although stereotypes regarding African American women as

sexually promiscuous began during slavery, some women have internalized these images.

Thus, it is important to ensure that the historical context is taken into consideration,

particularly since these historical experiences have been shaped by sexual violence, medical

mistreatment, and social injustice.84–86 Although healthcare has greatly improved since this

time, African American women still experience varying levels of racism and discrimination

that ultimately impact their current health and well-being.87

Conclusion

In this article, we offer a socioecological model that can be used to understand how racism

underlies the social determinants of health and affects the sexual and reproductive health of

African American women. In both historical and contemporary contexts, race-based

mistreatment has been shown to place African American women at increased risk for HIV/

STIs, pregnancy-related complications, and early mortality. Moreover, widespread health

implications of racism are evident and exist at the individual, interpersonal, community, and

societal levels. In this regard, African American women appear to be situated in contexts in

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which racism is rarely avoidable. A socioecological model that considers the historical

influences of racism may improve understanding of the present-day sexual and reproductive

health outcomes of African American women. In addition, such a model can strengthen

reproductive justice efforts that acknowledge the historical context of sexual and

reproductive mistreatment and promote social justice.

Although the purpose of our model was not focused on public health practice, per se, it does offer considerations that provide opportunities to promote health equity by reducing the

effects of racism and improving African American women’s sexual and reproductive health.

Because racism is present at multiple levels within the social environment, strategies across

the socioecological model are necessary to address its broad impact and may prove to be

more efficient and effective. In this study, we propose examples of public health

considerations to help improve the sexual and reproductive health outcomes of African

American women. It should be noted that these considerations are not exhaustive, yet

provide key strategies that could be implemented. For example, individual-level

interventions that seek to decrease African American women’s risk for HIV/STIs might also

promote self-esteem in one-on-one or group-based interventions.88 This may work in

conjunction with community-level interventions that provide quality educational and

employment opportunities to inner-city residents.89 Economic incentives or microenterprise

programs may also be viable options to increase employment opportunities for women.90

Coupling health interventions with employment programs not only addresses individual-

level characteristics such as self-esteem and levels of stress exposure but may also address

community outcomes.91 In addition, some African American women may need

opportunities to increase their own understanding of the historical impact of racism and its

links to contemporary health outcomes. This information might act as an impetus for further

learning and support individual and community advocacy opportunities.

For the interpersonal level, interventions that involve family members can provide

supportive opportunities to enhance the overall well-being of African American women. For

example, interventions that involve partners of pregnant women might help reduce stress

levels while also improving communication and coping skills. As mentioned above, there are

numerous opportunities at the community level to improve health outcomes, specifically by

developing partnerships that may facilitate structural changes. For example, rates of HIV are

highest among African Americans and Hispanic/Latinos in communities where greater than

20% of persons lived below the poverty level and more than 8% did not have a high school

diploma.92 Similar findings on socioeconomic correlates of HIV infection93 provide support

for focusing interventions on social and structural determinants of health. These efforts not

only help individuals but also address the social underpinnings of racism, which play a

critical role in health outcomes and would likely be most effective in counteracting race-

based mistreatment. In addition, efforts that acknowledge the role of mistrust of the

healthcare system are better equipped to understand health-seeking behaviors and

compliance matters.

As discussed by Frieden’s health impact pyramid89 (Fig. 2), interventions that address

societal-level factors have the greatest potential to achieve public health impact across

disease outcomes and need governmental support to be effective. According to Frieden,

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although societal changes may be costly, the main obstacle to addressing these changes is a

lack of political will.89 At a minimum, a systematic review of overarching health, economic,

and education policies that may continue to disenfranchise African American women might

be needed at this level. Since historically many policies were designed to further oppress and

marginalize African American women, it is critical to examine how long-standing and even

some contemporary statutes (i.e., welfare system, access to quality healthcare) ultimately impact the health and well-being of marginalized populations, including African American

women. Provider and staff education and training to improve cultural competence to

heighten sensitivity to the needs of African American women and to better understand the

cultural norms and behaviors is also needed.94 Moreover, research focused on African

American women should prioritize the role of racism and health disparities to sufficiently

address the root causes of inequity. Implementing culturally tailored interventions may

improve African American women’s health outcomes as well.95 Overall, strategies that

support multisectorial partnerships at federal, state, and local levels may maximize the

probability of implementing successful programs.96 Sexual and reproductive health equity,

based on evaluation data of interventions and demonstration projects, can be achieved with a

commitment to effectively address racism and other underlying social determinants that

promote health disparities.

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FIG. 1. Socioecological model of African American women and sexual and reproductive health

influences and outcomes.

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FIG. 2. The health impact pyramid.

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