Research Facts and Findings, September 2020
A publication of Act for Youth
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by Vanessa Amankwaa
Vanessa Amankwaa, formerly a research aide with ACT for Youth, is currently entering the Health Equity, Social Justice, and Human Rights Master of Public Health program at the Gilling School of Global Public Health at the University of North Carolina, Chapel Hill. Betty Lam, Mary Maley, and Karen Schantz also contributed to the literature review.
Rates of sexually transmitted infections (STIs) are climbing among young people even as adolescent pregnancy rates fall. To better understand this counterintuitive trend, ACT for Youth wanted to know what young people themselves have to say about it. We conducted an extensive review of recent survey, interview, and focus group literature on the question of norms, attitudes, perceptions, and beliefs that impact young people's risk of STIs. Our full report (Schantz, Amankwaa, & Lam, 2020) and a forthcoming Research fACTs and Findings brief centering young men who have sex with men are published separately. In this article I focus on how heterosexual Black American youth, who are disproportionately affected by STIs, describe the factors that influence their sexual health. (Note that while we sought to be inclusive of different races and ethnicities that are coping with STI disparities, our review came up short on qualitative studies involving Latinx and American Indian youth. Academic research engaging these youth in terms of the attitudes and norms they hold regarding risky sexual behavior is severely lacking.)
Our review gives us a small insight into how some Black youth think. These studies could never offer a complete representation of the attitudes, norms, and beliefs of all Black youth, but the voices of youth can begin a dialogue and spark more research, as well as illuminate possible underlying causes of sexual risk taking. This article will briefly delve into each of the themes that emerged throughout the literature for Black youth: prioritization of risk, barriers to and facilitators of healthy practices, and relationship dynamics.
For youth and emerging adults, risk may be prioritized in terms of what has the greatest perceived harm or danger. Edwards and colleagues (2017) describe young people's ranking of risks as fundamental in examining health behavior among young adults. In focus groups and interviews, some young people indicated that when they are overwhelmed by threats in their environment, sexual risks seem less important. Likewise, when certain risks (such as the risk of pregnancy) could have enormous consequences for one's life or relationships, they take priority over more manageable threats (such as the risk of STIs).
In their study of primarily Black and heterosexual college students and young adults, Edwards and colleagues found that youths' environments played a large role in how they prioritized perceived risks. Black youth placed a high priority on their risks of police interactions and community violence: among their peers, interaction with the police can be fatal. Police interactions and violent environments can also threaten a young person's physical and mental health, leaving them feeling distressed, hopeless, and dehumanized. Worrying about STIs may seem trivial to youth who may face interactions that cause them violent bodily harm.
"My priority every day is to make it back home, the way I left out. I don't want any trouble with the police."
- Young adult (Edwards et al., 2017)
"You never know when you may catch a bullet, fist, stick, or knife. This shit is crazy, and I am supposed to worry about an STD or HIV?"
- College student (Edwards et al., 2017)
Living in this state of constant fear can also result in a sense of hopelessness and consequently very little reason to delay immediate gratification through sex.
"I have the desire for immediate gratification and to get what I can right now!!! I don't care about anything except what I want. I know that sounds selfish! It's dope when you can live life the way you want while you're here. I know too many friends that are gone. They are dead!! Almost every week, every day, somebody gets killed or hurt real bad in a fight or something. I need to get mine now!! Sex helps you get through the day and deal with stress. If I have a condom, I may or may not use it. It really depends but if I am high, I might forget to practice safe sex."
- Young adult (Edwards et al., 2017)
Living life in the moment and on a day-to-day basis is the sole means of survival for many youth and emerging adults when survival is not a certainty.
When youth prioritize their risks regarding their sexual health there are two major categories that are considered: STIs and unintended pregnancy. Throughout our literature review we found a theme that generally stayed constant for young women: pregnancy was consistently perceived to be the bigger threat (Schantz et al., 2020).
Black college women made it clear that their concern over risk for STIs was outweighed by concern over the risk for pregnancy (Craft-Blacksheare et al., 2014; McLaurin-Jones et al., 2017). Similarly, some younger Black females (ages 15-19) considered most STIs to be less severe than pregnancy because of their impermanence (Craft-Blacksheare et al., 2014). In focus groups with heterosexual Black college women, McLaurin-Jones and colleagues found that these students felt the importance of prioritizing themselves and their future goals. Participants explained that having a baby would derail the plans they have for life regarding school, a career, financial stability, etc. They also described pregnancy as bringing shame and guilt onto themselves and their families.
"Worrying about pregnancy is so much bigger than the worrying about STDs."
- Black college woman (McLaurin-Jones et al., 2017)
"I think for me personally, I am terrified of being pregnant."
- Black college woman (McLaurin-Jones et al., 2017)
"So I just don't think there's an excuse, if you're having sex, why not to get on birth control, because pregnancy is the biggest - I mean, we're afraid of STDs, AIDS, and all that that, too, but pregnancies, like you said, abortions are expensive. You don't want to go through that. You don't want to go through the emotional stress."
- Black college woman (McLaurin-Jones et al., 2017)
Black college women described casual attitudes about STIs as a norm (Chandler et al., 2016). However, HIV was always discussed as the STI that Black youth, men and women alike, feared the most.
"...It's like they're laughing. 'Oh, I just got chlamydia. Man, that was like a crazy weekend.' It's like it's nothing. If it's not AIDS, it's nothing."
- Black college woman (Chandler et al., 2016)
In contrast to young women, one small focus group study exploring condom attitudes among Black high school males found that use of condoms by these young men was driven by the fear of STIs (Woodhams et al., 2017). Pregnancy prevention was largely seen as women's responsibility in casual relationships, though some believed both parties were equally responsible in committed relationships. (See larger discussion of relationship dynamics below).
"I personally feel like it's more of the woman's fault if she gets pregnant irresponsibly...So if they [women] choose to have sex and then they end up being impregnated I feel like that's on them...it's y'all's body!"
- Black male teen (Woodhams et al., 2017)
"Like, if you put yourself in a situation, knowing you could get pregnant, it's like when it does happen, you have no one else to blame but yourself."
- Black college woman (Chandler et al., 2016)
"You still use a condom. I don't know what [STIs] she's got. No matter what. Like, a girl could be on birth control all her life. She could be on the best birth control. I'm still not gonna go in raw."
- Black male teen (Woodhams et al., 2017)
Miseducation and lack of education can also play an unhealthy role in young people's personal risk assessment of STIs, creating a false sense of security that can result in high sexual risk-taking behaviors like condomless sex, sex with multiple partners, and drug and/or alcohol use during sex. Fear and stigma can also keep youth from accessing sexual health services. However, many young people do prioritize their health and adopt effective strategies for themselves and their partners.
A common misconception held by both young men and young women was that they could tell by physical appearance if a potential partner had an STI. In three different studies, participants said:
"If a person doesn't look right, I won't have sex with them unless I am smoking weed or maybe high."
- Young adult (Edwards et al., 2017)
"I always thought I was careful, and the guys I was with were clean and didn't have anything like that."
- Young Black woman (Craft-Blacksheare et al., 2014)
"I start [to] notice how this girl, she's walking, I'm like, she didn't use to walk like that...She's getting skinnier and skinner...I think she got that clap, right now. So, I'm not gonna talk to her."
- Black male teen (Woodhams et al., 2018)
Misperceptions like these distort one's sense of risk, with clear implications for health and health care.
In a clinic-based study that sought to understand why young Black women were not using condoms even after they had been diagnosed and treated for chlamydia, Craft-Blacksheare and colleagues (2014) observed how miseducation can lead to low perceived risk. One of the study participants, for example, believed that once she was treated for chlamydia it would work as an immunization.
"I thought when I first had that [chlamydia], since I got the medicine, it would work for a long time...I didn't know it would stop working and you could get it again; I thought it would work for a long time."
- Black female teen (Craft-Blacksheare et al., 2014)
If youth feel that they're at low risk for STIs, or fear what they might experience from testing and treatment, they might choose to forgo necessary STI services. Some young men say they wait until there are physical symptoms while others simply hope the symptoms resolve by themselves (Marcell et al., 2017).
"I just don't see myself at risk for HIV. I know how the virus is transmitted and how to protect myself even when I don't use a condom. Although I often have unprotected sex occasionally with a few partners, I just don't see myself at risk and neither do they.... There's no need to be tested. I am satisfied not being tested and not knowing. The results from a test could mess things up and I don't want to deal with whatever that is."
- Young adult (Edwards et al., 2017)
"If I get gonorrhea, I'm just going to wait until the symptoms arrive because I'm not getting that test no more. I'll take the HIV test. the blood test. But that rod thing, no. You've got to find a better way."
- Black male teen (Marcell et al., 2017)
"...If you know you got an STI but you don't want to hear you got one, you just hoping it's something else."
- Black male teen (Marcell et al., 2017)
Stigma was also discussed as a deterrent to seeking STI services (Chandler et al., 2016; Marcell et al., 2017). Young Black women described feeling uncomfortable accessing on-campus sexual health services because of stigma, as well as being embarrassed to be seen purchasing contraception or pregnancy tests (Chandler et al., 2016).
"I understand that it's a horrible disease, but we [African American community] make it so that we don't want to tell anybody that we're at risk. We don't want to go to the clinic and be like 'I need to get tested,' because of the way we are taught about it - we are taught that it's so bad. And we are taught that when you do get it, it's almost like you're a leper if you will."
- Black college woman (Chander, et al., 2016)
Despite these barriers to understanding personal STI risk and utilizing services, some young adults also discussed ways they and others could reduce risk and take proactive measures to support their sexual health (McLaurin-Jones et al., 2017; Pass et al., 2016).
"Your health is your own health; you protect yourself first and foremost. Like when I ask somebody to use a condom you, um, yeah, I mean of course I care about your health if I'm sleeping with you I must care about you. But it's 100 percent about myself, my health, my future that I'm worried about."
- Black college woman (McLaurin-Jones et al. 2017)
"...I'm going to use condoms like every time. Like I'm always stressing --I don't care, like male, female, to me everyone has HIV."
- Black college man (Pass et al., 2016)
In discussing making one's own health a priority, some young women also spoke about the importance of utilizing campus health services, as well as limiting sexual partners or promoting abstinence. Even with individual self-efficacy, some young women felt that increased support from health clinics in terms of free condoms and educational information would enable them to protect themselves from STI infections (Craft-Blacksheare et al., 2014).
"If you're having sex, you're going to be susceptible to infections and diseases. But I really feel like you need to make sure you're getting checked, because I get checked every three, four months. They do it for free at school. You go to the health center, Wednesdays, this time. So, I mean, it's here for us. Because if we're having sex, even with condoms, because there's still diseases that you can catch through the skin to skin contact that condoms won't help you. So you just need to be on your health, period, but especially when it comes to STDs and STIs. Just go get checked."
- Black college woman (McLaurin-Jones et al. 2017)
Some young people cautioned against the use of drugs and alcohol because of its thought-altering potential and ability to make unplanned casual sex more likely, while others felt they remained in control even when intoxicated.
"Again, I make it a rule, like if you drunk, like we going to save that [sex] for the next day."
- Black college man (Pass et al., 2016)
"I do have my moments where I feel like yeah I'm going to go ahead and have sex today or tonight, you know, so I'd rather play it the safe way, you know, regardless if I'm under the influence or not, it doesn't make a difference to me."
- Black college man (Pass et al., 2016)
Comfort, timing, and trust are just some of the factors that youth think about when it comes to sex in their relationships. The different types of relationships discussed throughout the literature included casual and monogamous relationships. In McLaurin-Jones and colleagues' 2017 study, young Black college women stated that casual sex could mean multiple partners, making condom use more important as protection against HIV and STIs. This generally held true for most youth with casual relationships.
"I'm not scared to tell an individual to use condoms, like I'm very like - some people say it's aggressive but like if I let's say we're in the moment and I'm not okay with something I don't care who you are - [Name] is going to tell you no, or what's going to happen. That's just me as an individual and I'm never scared to tell anybody, 'Oh, pull out a condom or we will stop and you will go to CVS, Kroger...or whatever to find a condom.'"
- Black college woman (McLaurin-Jones et al., 2017)
"If I'm outside of my girlfriend, I use [condoms] all the time ... She's the only girl I've ever not used a condom with, and it was only a couple of times."
- Black college man (Pass et al., 2016)
While in monogamous relationships, young women whose partners' status was known at one point in time were more likely to engage in unprotected sex because they assumed low risk (McLaurin-Jones et al., 2017). Similarly, throughout the literature for young men and women across populations, an assumed monogamous relationship ultimately led to a decline in condom usage (Schantz et al., 2020). Even as trust developed and grew throughout relationships, some young people still held reservations about whether to use condoms but, in the end, trust led them to feel there was no need (Chandler et al., 2016; Woodhams et al., 2018). McLaurin-Jones and colleagues describe trust in relationships as a factor that allows women to exude confidence in the expectation of faithfulness in their relationships.
"I think it was in the beginning when we first started having sex. I was very big on condom use. But, I think getting comfortable with him kind of like has made me shy away from it. So, I don't really care as much as I did before. But, it's just because now I'm very comfortable."
- Black college woman (McLaurin-Jones et al., 2017)
Young people who weren't using condoms due to their monogamous relationship status were typically only concerned about preventing pregnancy. In order to prevent pregnancy, women mentioned using other contraceptive methods like regular birth control or Plan B, while women who did not want to use hormonal contraception but were in relationships did use condoms for pregnancy prevention (Longmire-Avital & Oberle, 2015; McLaurin-Jones et al., 2017).
Relationship dynamics and gender norms within them can influence risky behavior. Young Black women participating in the Craft-Blacksheare et al. 2014 study dealt with chlamydia and, after being re-infected, stressed that their exposure increased the active role they took in condom negotiation.
"He can get mad, but there is nothing you can really do. Either put the condom on, or you're not getting any [sex], so you better put the condom on."
- Black female teen (Craft-Blacksheare et al., 2014)
Unfortunately, this isn't such a straightforward task for every young woman. One study (Zhao, Kim, & Peltzer, 2017) found gender differences for young Black men and women regarding condom usage: men were using condoms during sexual intercourse while women were not. The authors cite gendered power dynamics in relationships as one reason for this discrepancy, noting that "female adolescents often have less power in their sexual relationships; therefore, they may not be able to decline their partner's decision to have condomless sex." In a committed relationship, a woman's insistence on condom use with a partner can be seen as an insulting sign of mistrust (Bell et al., 2018).
In summary, it is important to mention again that the environment youth live in plays a large role in their perceived risk priorities. For some Black youth, male and female alike, the fear of fatal police interactions and violence in the community leaves youth prioritizing their right to live. For some college students, pregnancy prevention is at the forefront as graduating and creating financial success are their top priorities. There are also Black youth who feel stigmatized when making the effort to attain the sexual health services they need. Lack of perceived risk and misinformation (perhaps due to lack of sexual health education) are factors that left Black youth throughout our research susceptible to potential infection and, in one case, re-infection of STIs like chlamydia.
As best said by Edwards and colleagues, in order to create effective and useful prevention interventions for youth, one must recognize and address the risk priorities youth have. For individuals risk priorities may differ, but for the collective we see similar themes that can assist us in addressing misinformation and stigma, increasing the breadth of sexual-health knowledge, and empowering youth with the tools they need to keep themselves safe.