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Sexually Transmitted Diseases:
doi: 10.1097/OLQ.0b013e31818d3cc7
Review

Impact of Attitudes and Beliefs Regarding African American Sexual Behavior on STD Prevention and Control in African American Communities: Unintended Consequences

Valentine, Jo A. MSW

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From the Division of STD Prevention, NCHHSTP, Centers for Disease Control and Prevention, Atlanta, Georgia

Correspondence: Jo A. Valentine, MSW, Division of STD Prevention, NCHHSTP, Centers for Disease Control and Prevention, 1600 Clifton Road MS E-02, Atlanta, GA 30333. E-mail: jvalentine@cdc.gov.

Received for publication April 28, 2008, and accepted September 9, 2008.

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Abstract

Compared to whites, blacks experience significant health disparities for sexually transmitted diseases, particularly in the rates of chlamydia, gonorrhea, and syphilis. To develop more effective interventions to control and prevent STDs, public health practitioners should better understand and respond to factors that facilitate sexual risk-taking behaviors and impede access to STD health care and make use of factors that promote sexual health. Legacies of slavery, racism, and economic or class discrimination leave many blacks suspicious of interventions aimed at improving the welfare of their communities. Sexual behavior, in particular, has been used to justify social oppression of blacks in the United States. Although efforts to engage affected black communities in improving STD health care delivery have been undertaken, bias, prejudice, and stereotyping continue to contribute to negative experiences for many blacks across health care settings, including those involving STD care. Implementing more effective interventions to reduce the disparate burden of bacterial STDs in black communities requires accessible and acceptable STD health care. Understanding and addressing the potential impact of both provider and patient attitudes can improve these service delivery outcomes.

“THE POOR RANKING OF America's black population in the indices of good health is a scandal of such long standing that it has lost the power to shock,” wrote D. S. Greenberg in the Lancet in 1990.1 Recent national STD surveillance data illustrate this point.2 In 2005, approximately 68% of gonorrhea cases reported to the Centers for Disease Control and Prevention (CDC) occurred among blacks. Gonorrhea rates among black men were 24 times higher than among white men, whereas the rates among black women were 14 times higher than among white women. Almost 42% of chlamydia infection cases occurred among blacks. The chlamydia infection rate among black males was more than 11 times the rate among white males, and the rate of chlamydia infection among black females in the United States was more than 7 times higher than the rate among white females. Despite notable successes of the United States Syphilis Elimination Campaign in reducing the black:white disparity,3,4 the primary and secondary syphilis rates among blacks increased between 2004 and 2005 by more than 11%. The congenital syphilis rate for blacks in 2005 was almost 20 times (25.9 cases per 100,000 live births) higher than the rate among whites (1.3 cases per 100,000 live births).5 “It is utterly exhausting being black in America,” Marian Wright-Edelman wrote in, The Measure of Our Success,6 and it is evident that STDs have contributed substantially to the burdens to which she alluded.

The disparities in rates of bacterial STDs between blacks and whites lead unavoidably to discussions involving race and sex. To develop more effective interventions to control and prevent STDs, public health practitioners need to better understand and respond to not only individual behavioral factors but also the social factors (e.g., poverty, racism, racial segregation, and incarceration) that facilitate the incidence of sexual risk-taking behaviors and impede access to STD health care and health education.7–10 Practitioners also need to understand and make use of the protective factors at the individual and community level (e.g., family relations, community pride, emotional commitments, personal values) that can promote sexual health.11

The history of race relations in the United States often renders discussions of race and sex intimidating. Race relations in the United States remain complex and controversial, exacerbated by myths, misunderstandings, miscommunications, and mutual distrust especially in matters of human sexuality.12 Legacies of slavery, racism, and social discrimination leave many blacks highly suspicious of initiatives allegedly aimed at improving the welfare of their communities. Sexual behavior, in particular, has been used to justify oppression, resulting in denigration and segregation of blacks in the United States. “As long as black sexuality remains a taboo subject, we cannot acknowledge, examine, or engage these tragic psycho-cultural facts of American life,” wrote Cornel West in his 1993 book, Race Matters.13

The Institute of Medicine report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care concluded that provider bias, prejudice, and stereotyping contribute to disparities in the health care experience.14 The resulting stigma and shame, although related, are distinct concepts; and the impact of stigma as a barrier to STD health care may be more significant than personal shame. Trust is crucial in the health care setting, but patients are not likely to trust health care providers whom they regard as indifferent, judgmental, or hostile, even if those providers look like them. As an example, for many blacks, the implicit and explicit messages about multiple partners can sound like an accusation of promiscuity and sexual irresponsibility that may not accurately reflect either their actual behaviors or their perceptions of their individual sexual experiences.15

Recognizing the significant role religion can play in shaping individual black attitudes about sexual behavior and risk for STDs enhances understanding of the factors associated with STD risk in these communities and can lead to effective interventions to reduce STD morbidity. For many public health programs, it has become standard practice to involve black community leaders and institutions in their community-based efforts,16 and throughout much of American history, black churches have been the primary providers of a variety of vital social services and advocacy when few other resources were available. Yet, less may be understood about the doctrinal differences among black churches that can either facilitate or inhibit STD prevention and control efforts. For a number of black churches, their religious dogma may not be compatible with STD prevention messages and may in fact lead to the same bias and stigma experienced by black persons in secular health care settings and to lead to personal shame or resistance to health care-seeking. Moreover, individual religion-based coping styles can either positively or adversely affect individual STD risk reduction and health care-seeking behavior by empowering individuals to be proactive about protecting their health or permitting them to be passive and resigned to risks and unhealthy outcomes.

This paper will: (1) examine the impact of provider and patient attitudes regarding black sexual behavior on STD prevention and control activities; and (2) discuss the potential influence religion on black attitudes about sexual behavior, STD risk reduction, and STD health care-seeking.

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Barriers to STD Care: Bias, Stigma, and Shame

“They're very good for what they do. They have a mystique about them that lends itself to negativity because of the staff and lack of staff. *** has a reputation so people stay away. Women asking questions. Not discrete. They stigmatize people. Women at the health department are jaded, complacent, not personal. They treat people like they're ignorant. I had to go to several desks to get to the right place. I had to wait a long time.”17

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Bias in the Health Care Setting

In the Institute of Medicine report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, the authors concluded that although many socio-economic and structural factors contribute to health disparities among racial and ethnic minority groups, provider bias, prejudice, and stereotyping also contribute to differences in the health care experience.14 Patients from minority groups perceive higher levels of racial discrimination in health care settings compared to whites.18,19 Moreover, a number of studies have found that the social treatment blacks experience when accessing health care, particularly for STD treatment, impedes their willingness to seek care.20–22

To be prejudiced is to have an unjustified negative attitude about another person on the basis of that person's group membership (e.g., race, ethnicity, social class, or religion). Social science research suggests that many Americans harbor prejudicial attitudes toward members of other groups. “America has a race problem,” Lerone Bennet, Jr. once wrote.23 America also has a sex problem, or at least a problem talking about sex, even in the STD clinic.24 Stereotyping has been defined as the process by which people use social categories (e.g., race, gender) in acquiring, processing, and recalling information about others. The stereotypes and attitudes that people bring to their interactions helps to organize and simplify complex or uncertain situations and give them greater confidence in their ability to understand and respond to a situation efficiently and effectively; so arguably, stereotypes may seem to be useful. However, this usefulness always comes with a risk. Stereotypes tend to be personally biased, they are frequently unreliable, misleading, and offensive14 and particularly unhelpful in the STD treatment or counseling encounter.

For STD clinic patients, the consequences of negative health care provider biases can begin at the reception desk and continue into the patient's encounter with the health care worker. Measuring patient satisfaction only as it relates to treatment issues, convenience, and cost may be inadequate for a full understanding of the health care experiences of STD patients, especially if assessments fail to include experiences that entail making appointments and talking with clinic staff at the reception desk.25 One study found that STD patient respondents complained about front desk staff whose body language or remarks indicated that the clients were unimportant, deviant, curiosities, or even nuisances. In the words of a female STD clinic patient from the study, “I have had trouble with most of the white ladies. One of them said, ‘Well, you must not care about yourself.' She said it in a real sarcastic, domineering voice. The other one was the one that screamed at me.”25 Given these experiences, black STD patients may come to the clinic with their own set of biases and negative expectations. In the book, Black Rage, the authors described this tendency to be suspicious of or distrust institutions or agencies regarded as being “white” as healthy cultural paranoia that blacks have developed over generations in response to racism, oppression, and discrimination.26 In his or her encounter with the health care professional, whether that professional is black or white, a long history of negative experiences associated with race or class discrimination can have unfortunate effects.27,28

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Stigma

“There is a stigma with doing outreach in the black community. They're not wanting to have anything to do with STDs, particularly in the black community.”29

Prejudice and stereotypes can promote social stigmatization and create personal shame. Stigma has been defined as an attribute or label that sets a person apart from others, links the labeled person to undesirable characteristics, and represents socially shared knowledge understood even by the targets of the stigma.22 Stigma can be experienced in 2 ways: (1) enacted stigma—when people who are considered to be morally, socially, racially, or physically tainted are discriminated against by “normal” persons; and (2) felt stigma—the fear or experience of this type of discrimination.20 STD-related stigma can be so pervasive that it can impact STD clinic staff as well.30

In a paper published in the journal, Culture, Health, and Sexuality in 2005, the investigators note: “Stigma has long been associated with sexually transmitted infections in Western Societies. Syphilis, for example, has been stigmatized through attributions of sexual excess, immorality, and social deviance throughout history, and the association of syphilis and other STIs with sexual immorality continued even after antibiotics offered the promise of a cure early in the 20th Century.”31 Although both black men and women encounter stigma when diagnosed with an STD, black women historically have borne more disgrace and even tragic physical consequences when it is believed that their sexually irresponsible behavior caused them to contract an STD.32 Even today some health care providers tend to hold women more accountable than they do men for both having multiple sexual partners and acquiring and transmitting STDs. Some female STD patients have reported being treated as “dirty” or “promiscuous,” or “bisexual” based on the way they were dressed.33 This double-standard application for women is not unique to STD health care settings. It can be experienced in numerous interactions, including in religious settings.

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Shame

“I'm shy to talk to a doctor. Male doctors take stuff as a joke. I don't like male doctors. Things have happened in the past.”17

Related to stigma is the concept of shame, which is defined as a negative emotion elicited when a person experiences failure in relation to personal or social standards, feels responsible for this failure, and believes that the failure reflects self-inadequacy rather than inappropriate behavior.20 Black STD patients have named several types of shame barriers to accessing STD health care: (1) fear of being seen or discovered, (2) reputation damage, and (3) embarrassment (feeling ashamed). For example, in 1 study, a black male respondent said, “Yeah, if you go into the clinic, all the rumors start. People would start to talk. Everyone at school would know (about the clinic visit) and talk about you. They'd be looking at you when you walk in (to school).” For some young men, it may be more threatening to be seen at an STD clinic by girls rather than by their male peers. As another young humans from the same study put it, “We had to go up to the desk in front of all the people. My boy was trying to keep it on the D.L. (down low) and he tried to say quietly ‘Like I got a problem down there.' But you have to tell them out loud. You have to say you want to see a doctor and they ask you why. And there are people listening all around you.”21 Stigma and shame are related but distinct concepts; and the impact of stigma as a barrier to accessing STD health care may be more significant than personal shame. Moreover, the problem of shame may not be easily resolved.34 A substantial body of social psychology research demonstrates a persistent resistance to changing long-held prejudices and social stereotypes, particularly for conditions or behaviors judged as the consequences of irresponsible behavior.20

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Trust

Patients are not likely to trust health care providers whom they may regard as indifferent, judgmental, or even hostile; and trust is an essential element in a therapeutic alliance, which is needed in the STD health care encounter.35,36 A useful definition of trust is an expectancy held by a person or a group that the word, promise, verbal, or written statement of another person or group can be relied upon and reflects an expectation about the future.37 Trust facilitates communication and the exchange of critical information. Unfortunately, there is a long legacy of black distrust of health care providers and government institutions, beginning with the era of slavery when slaves were used for medical experimentation and extending until now in the age of AIDS, when many blacks continue to believe that the AIDS virus is a manmade weapon of racial warfare against them.38 In the development and delivery of STD services for black patients, in particular, it is helpful for providers—at all levels—and patients to set aside attitudes and beliefs that stereotype and stigmatize and thereby hinder the health-care relationship. However, although all parties should strive to accomplish this, it is perhaps more reasonable to expect that providers assume greater responsibility for improving the health-care relationship.39

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Attitudes and Beliefs About African American Sexual Behavior and Risk for STDs

Historical Perceptions of Black Sexuality

During the years of slavery in the United States, blacks were commonly depicted as subhuman. Their sexual behavior was viewed as primitive and instinctual, devoid of much human emotion or attachment.40 Although these attitudes and beliefs contributed to the justification for slavery by dehumanizing blacks; ironically, the institution itself created the very conditions that undermined committed relationships among slaves, disregarding slave marriages and families, and selling them apart for economic gain or punishment. Slavery allowed the raping of black women and the use of them as breeders, and it emasculated black men and reduced them to studs.41 In the book, Intimate Matters: A History of Sexuality in America, the authors write, “In 19th Century thought sexual control helped differentiate the middle class from the working class, and whites from other races.” They note that for white men that there was a moral double-standard that condoned their sexual transgressions, whereas for white middle class women, there was an elaborate ideal of femininity that emphasized their innate sexual purity as a means of controlling male excess. According to the authors women, who did not—or could not—achieve this ideal of purity were considered fallen and if they were poor, they could be arrested for crimes against chastity.42 At this time, not only were blacks poor, but a majority of them were not even considered fully human, entitled to little legal or moral rights. By the beginning of the 20th century, legal slavery had ended and blacks had attained citizenship. Yet some noted physicians were still publishing in scientific journals that black men could not control their sexual behavior, using such terms as furor sexualis for black men, a term comparing black male sexual behavior to the acts of aggressive bulls and elephants; and building on the moral double-standard, these physicians went on to report that black women were morally inferior to black men and that these low or absent moral standards made black women susceptible to STDs. In the words of 1 physician from that time, “The black men love to frolic with the women; and the women love to frolic with the men; so they frolic.”43

In contemporary popular culture, black sexuality began to include depictions of black men as sexual “supermen” and at times harkened back to the past to describe them as sexual predators. For black women, there was still a tone of impugned moral character in descriptions that labeled them as uninhibited “sexual expressionists,” and often worse.44 Now in the age of HIV/AIDS, the black woman is frequently depicted almost as a victim of her black male partner's proclivity for multiple sexual partners or his denial and deceit about his having sex with other men.45,46

As challenging as some of the perceptions of black heterosexuality have been, the challenges associated with black same-sex sexual behavior are usually laden with more controversy and confusion.42,47 In his book Beyond the Down Low, Keith Boykin discussed “the DL” not simply as a matter of black men who engage in same-sex sexual behavior, denying or concealing their sex lives but rather as a consequence of failing to engage in difficult conversations about black sexuality in general. He noted that much of the dialogue in the black community has served only to further an ongoing unhealthy debate between black men and women that “demonizes bisexuality, dis-empowers women, and misdirects public resources and attention.”48 Moreover, overwhelming societal pressure relating to the stigmatization of blacks, compounded by the additional stigma of societal attitudes toward same-sex sexual behavior, contributes to increased sexual risk taking.49,50

What so many of these attitudes and beliefs seem to convey is the common theme that blacks do not have the power to exercise control over their own sex lives; yet at the same time have only themselves to blame for the high rates of STDs in their communities. One early 20th century physician warned, “The gravest problem to be faced in dealing with the black is not his or her industrial future or right to social equality with the white humans or woman. It is the danger to the public of his or her contagiousness and infections from the standpoint of physical and moral disease.”44 A professor from New York also writing at this time asserted, “Hospital records show that practically all male city blacks indulge in promiscuous behavior and carry with them venereal disease.”44 In Norman Mailer's “The White Black” published in 1959, the author seemed to encourage whites to imitate the hip black male and his lack of sexual inhibition, as demonstrated in black music at that time which for Mailer symbolized sexual orgasm. “While Mailer seems to be advocating that other whites imitate this style, giving up the pleasures of the mind and giving into the pleasures of the body, it was only another way of saying black men were not very intelligent.”51 As recently as 1992, in a textbook entitled, Marriage and the Family, the author in referring to a study examining biologic determinants of adolescent sexual behavior, writes, “In the U.S. the sexual activities of white males, and of blacks of both sexes, are a close reflection of the level of testosterone in their bloodstreams for any given period. Thus for these groups, early puberty predicts early sexual involvement. White females, however, are far less responsive to hormone levels and are far more responsive to the societal rules and psychological considerations.”52

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Black Attitudes Regarding Sexual Intimacy and Infidelity

“It means pleasure time. If I had a main squeeze, it would mean something else. It would mean caring. I wouldn't be going through the motions for fun if I had a main partner.”17

For many blacks, the implicit and explicit messages regarding multiple partners and STD risk can sound like a charge of irresponsible promiscuity, one that may not accurately reflect their individual sexual experience, as there are other social factors, such as disease burden in their social networks that also places them at increased risk for STDs.53 In a study aimed at improving understanding of how young black adults select their sex partners, the investigators found that female participants described their partners only as romantic partners, meaning partners who are respectful, honest, kind, and monogamous. The male participants, however, described 2 distinct types of sex partners: romantic partners and sex-only partners. Whereas the young men expected their sex-only partners to have multiple sex partners, they expected their romantic partners to be good girls (e.g., monogamous).54 One young woman from the study reported having sex both for intimacy and emotional support, “Sometimes a woman feels as though if they not getting the care that they need at home, they'll look for it in a humans …. They feel as though just because he had sex with me that made me feel good.”55 According to findings from this same study, young men have sex to feel wanted, and for them, sex provides both physical and emotional benefits. The study also suggests that for some young black men having multiple sexual partners can also be an expression of hyper-masculinity, which serves to compensate for a lack of financial adequacy.55 Although human sexuality theories generally assert that women will seek mates who can provide for them and help them achieve reproductive success, it is also important to note that for both black women and men sexual intercourse can have additional important meaning. In even the most disadvantaged communities, sexual intercourse is often regarded as having vital psycho-social significance and not simply an act of primal entertainment. Failure to understand and appreciate these important aspects of black sexual relationships is likely to lead to interventions that are less effective at reducing STD risk or promoting sexual health.

If they were to contract an STD, blacks, like many Americans, would likely experience the usual reactions such as shame, sadness, and anger. Nevertheless, they, like other Americans, are often willing to risk these reactions in order to experience the physical, emotional, and social benefits of the sexual relationship. Much research on blacks of various ages reveals that they are aware of STD risks, and that they do consider those risks when developing a personal pragmatic approach to sex in their social environment, including the use of condoms. However, it is also important to note that emotional attachment, or a sense of being in a committed relationship, can reduce their use of condoms and other risk-reduction behaviors even when they are aware of the potential for disease transmission.55,56

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The Impact of Partner Availability on STD Risk

Numerous studies have described the absence of black men in black communities due largely to high levels of incarceration and violence in disadvantaged neighborhoods.57 This scarcity of eligible male sex partners can lead women to place fewer demands on their male sex partners for fear of losing them and an increased tolerance for male sexual infidelity.5,58 In a recent study examining the sexual assertiveness of low-income black women, the researcher found that study participants often engaged in sex out of fear of being left, rather than out of desire, and they concluded that these women were less likely to practice risk reduction.59 How likely is it that such a woman in this situation would comply with STD clinician advice and refuse to have sex with her partner until he is treated? Which relationship is likely to be more valuable to her? In another study, researchers found that although a black woman may doubt her partner's sexual fidelity or know he is having sex outside their relationship, she may accept this as long as she maintains main-partner status and is considered the wifey with all of the perceived emotional benefits. Simply put, the benefits of main-partner status outweigh the understood STD risk. As 1 black female participant explained, “Like, as long as I don't see nothing, hear nothing, like that, then that way I'll feel like I'm being respected. You know if he's out doing other things, then as long as I don't know about it, see it, or whatever, then I'll say, ‘Well, he's respectful as far as I know.'” However, the researchers also found that as tolerant and forgiving as the wifey may be of her male partner's sexual activities, she did not regard the women who engaged in sex with him so forgivingly,55 demonstrating once again that the double-standard by which black women, like other women, have often been judged, persists, even among their peers.

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Black Attitudes About STD Risk

“You get it if the person isn't clean.”17

A number of studies suggest that for many blacks, STD risk is associated with being unclean and dirty. Respondents in one study for example, described syphilis as a disease of “filthy” people.60 It is perhaps understandable why blacks might tend to reject the implications of high STD rates in their communities. Would they need to assume that most of the filthy people in America live in black neighborhoods? Believing that their communities are being stigmatized or penalized, or otherwise unfairly blamed for the high rates of bacterial STDs in the United States, many blacks, who already in large part do not trust the veracity of such things as government reports when it comes to how black communities are described, may simply choose to disregard or dispute the threat.61 Perhaps they will convince themselves that it cannot happen to them, believing that it only happens to people who have sex with “everybody and anybody without protecting themselves,” as 1 black community member put it.17

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Role of Religion in Understanding African American Attitudes About Sexual Behavior and Risk for STDs

Religion-Based Coping and STD Risk

Religiosity has been defined as an organized system of beliefs, practices, rituals, and symbols, whereas spirituality generally refers to a transcendent relationship to some form of higher power.62 Religion has had an enduring role in black life. Even blacks who do not regularly attend organized church services often will have a well-developed faith-based framework by which they hold themselves and others accountable.63 This framework of religious beliefs and values provides a worldview for interpreting life's events and experiences, particularly when it involves adjustment to loss, anxiety, pain, or suffering.64

Religiosity and spirituality provide an important coping framework in the lives of many blacks, whether they regularly attend church services. Religion-based coping styles, such as working in accord with a Higher Power, have been associated with positive health outcomes; paradoxically, religion-based styles that encourage passively waiting for divine intervention have been associated with negative health outcomes.65 Both styles could have important implications for STD prevention and control. For example, the collaborative coping style could empower an individual to take a more a proactive approach to protecting his sexual health such as consistently using condoms. In 1 study conducted among black adolescent females, greater religious involvement was found to be a protective factor for STD/HIV risk by increasing (1) self-efficacy to communicate with partners about sex, STDs, HIV, and pregnancy; (2) self-efficacy to refuse unsafe sex; (3) positive attitudes towards condom use; and (4) the delay of sexual debut.66,67 Conversely, a more passive approach for coping that emphasizes accepting fate could discourage individuals from taking responsibility for their health and thereby result in underutilization of available services.68 In a study exploring the interdependence of culture and psychosocial issues as barriers to breast cancer control for black women, the researchers identified the phenomenon that they labeled as the persona of not exploring the unknown69 in other words, the black women in their study believed that what was not addressed would not happen or would eventually disappear, perhaps by divine intervention. The researchers concluded that the art of pretense and denial as illustrated in the concept of not knowing provides various levels of comfort for some black women. Such a coping style could deter or delay health care seeking for an STD infection, especially if a woman risks learning not only that she has an infection but also risks having to openly acknowledge her sex partner's infidelity.

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The Role of Religious Institutions in STD Prevention

For much of American history, black churches have been the primary community advocates and providers of a wide variety of vital social services when few other resources were available. Although a number of studies suggest that organized churches may be less effective at reaching black men, at least for black women, church attendance and religion have been found to have a positive effect on health, including avoidance of alcohol use, lower rates of cancer, and use of Pap smears.62 In a study of substance abuse interventions, the role of religion was important for (1) spiritually-oriented individual counseling; (2) referral or facilitating referral for professional services; (3) serving as advocates for people negotiating with formal institutions; and (4) providing assistance with resolving practical problems related to drug use.63

In keeping with that tradition clearly, black churches can be important partners in efforts to prevent and control STDs in black communities. For many public health programs, it has become standard practice to involve black religious community leaders and institutions in their community-based activities, and this is increasingly true for STD programs also.70 Black churches have long been the primary providers of a wide variety of vital social services and advocacy when few other resources were available. However, it is important to understand and respect the doctrinal differences among black churches that can either facilitate or impede STD prevention and control efforts.

For a number of black churches, their religious dogma may not be compatible with STD prevention messages and may in fact lead to the same bias and stigma experienced by black persons in secular health care settings. Lay health advisors, who come from affected communities, including from local churches, may be accepted as credible STD health information agents; but as with any intervention, these advisors should be carefully recruited and trained to deliver these services.20

Black churches are first moral institutions,71 with many different levels of knowledge, different values and beliefs, and different available resources.28 Different denominations have different social missions; and a number of these religious institutions have taken conservative positions and actions when it comes to human sexuality.42 Although many black churches have been leaders in public health, compassionately embracing drug and alcohol abusers or persons living with HIV/AIDS, other churches in black communities have expelled members for reasons associated with sexual behavior (e.g., out-of-wedlock pregnancy, homosexuality). A recent New York Times article “For Some black Pastors, Accepting Gay Members Means Losing Others,” illustrates this point: “The debate about homosexuality that has roiled predominantly white mainline churches for years has gradually seeped into black congregations, threatening their unity, finances, and in some cases, their existence.”72 In 2006, NC researchers, seeking to understand the role a group of black churches might play in reducing the STD risk among their female members, found a considerable unwillingness of the pastors to participate in the assessment. The researchers concluded that before seeking to involve churches in public health intervention activities for health promotion and disease prevention, it is critical to understand (1) the black women who attend the church, (2) the current clergy messages regarding sexual risk, and (3) the feasibility of using churches to provide STD prevention messages.73

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Implications for STD Prevention and Control

When the latest CDC STD surveillance report highlights the disparate STD rates among blacks compared to whites, what might Americans in general think? Are negative historical images being reinforced? When a health department staff person randomly stops an black citizen on the street and offers him a syphilis test, on the basis of health department surveillance data that identify his community as a high morbidity area or a hot zone, will that citizen regard it as a benevolent act by the health department and accept the service or perceive it as racial profiling74 and refused the test?

Blacks have long resisted negative perceptions of their sexual selves. “Superficial critics, who have had contact only with the lower grades of black women, claim that they are more immoral than other groups of women,” wrote Elsie Johnson McDougald in 1925. Despite protest and substantial evidence to the contrary, these negative perceptions of black sexual behavior have persisted in much the same way as the STD disparities. Through the years, particularly since the Civil Rights movement, perhaps the words have changed; rarely might a public health professional use the term promiscuous in counseling an black STD patient – although a church-based educator might – what is implied by the term casual partners? Is it another way of conveying the same meaning—to frolic as it were?75 Many blacks reject information and interventions at both the community and individual levels that neither effectively relay an understanding of the applicable social history nor incorporate the cultural context. Obviously, these are not the intended outcomes of such efforts as the publication of the national surveillance reports, the implementation of street-based screening, or the conducting of the partner notification interview.

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Conclusions

For most of American history for blacks, the attitudes and beliefs associated with their sexual behavior have proven injurious to their place in American society. Sexual prejudice and stereotyping have led not only to social stigma and shame but also to civil legislation designed to segregate and alienate.76 Blacks know this history and experience its residual consequences even today. In addition to individual risk taking behaviors, social and economic factors such as poverty, unemployment, low levels of education, drug and alcohol use, and commercial media messages have increased the risk77; and long-held myths, prejudices, stereotypes, and misconceptions have misinformed STD intervention development and delivery and have affected how blacks respond to these interventions.78

Yet there are signs of better times. Real partnerships between public health professionals and affected black communities, including religious institutions, are increasing.79 Engaging and involving affected black communities as active partners in designing and delivering STD prevention and control efforts can provide a critical means of facilitating and improving communication between affected communities and STD programs, and in the process begin to restore, build, and maintain trust.80,81 Moreover, as informed and empowered consumers of STD services, black community members can also better hold STD health care and information providers accountable for quality services.82

Implementing more effective strategies for reducing the disparate burden of bacterial STDs in black communities requires not only that STD health care and health information be accessible, but that it also be acceptable. The complex history of race relations in the United States complicates the efforts to effectively intervene with black communities to reduce STDs. In the past and the not-so-recent past, the disparate burden of STDs in black communities and the public health response has mostly been described and designed reflecting perspectives outside the affected communities. Consequently the subjective implications of the objective data and the well-intended programs have often been missed or at least not effectively addressed. Add to that gender, sexual orientation, and social class bias, stigma, and shame, and the task may seem too daunting to undertake, and yet it is too important to disregard. Understanding and addressing the potentially negative consequences that stem from both provider and patient attitudes and beliefs is critical. The health of American citizens depends upon it.

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