A Black Feminist Analysis of Patient Provider Concordance in Sexual Health Care

Abstract

Racial disparities in gynecological health have persisted over time. Interestingly, there is a dearth of research that centers Black women’s experiences with gynecologists and even less research that uses Black feminist theory and methods. We use semi-structured interviews (N = 39) to understand the sexual health care related experiences of Black women at a Predominately White Institution (PWI) and a Historically Black College or University (HBCU). We found that the following themes captured Black women’s experiences: (1) Feeling Ignored, (2) Having Their Intelligence Insulted, (3) Receiving Proper Help and Education, (4) Benefits of Concordance across Race and Sex Categories, (5) Discomfort Due to Sexual Taboos, (6) Perceived Medical Racism, (7) Impact of other Intersectional Identities, and (8) No Impact. Implications for enhancing experiences with sexual health care appointments and improving patient provider relationships are discussed.

Keywords

medical racism sexual health care qualitative research Black feminist theory gynecology patient provider interactions

According to the Centers for Disease Control and Prevention (CDC 2021) maternal and infant mortality are the most serious concerns in terms of reproductive health. Specifically, the rate of maternal death is 2.5x higher now than it was in 1987, and racial disparities persist as Black women have a rate that is three times that of their White American counterparts. Reproductive health is often a product of sexual health, which is also a major concern for Black women and young women. According to the CDC (2021) individuals (ages 15–24) account for more than half of the 26 million new sexually transmitted infection (STI) diagnoses each year, and young Black women are overrepresented in many STI diagnoses including chlamydia and gonorrhea. This is both a personal and public concern as, (1) gonorrhea, for instance, has been tied to chronic pain, ectopic pregnancy, and infertility if left untreated, and (2) sexual health care costs the US $16 billion in direct medical expenses each year. Because biological distinctions across race groups are negligible and do not explain these disparate outcomes, it is imperative to research and understand their social basis. According to Lisa Bowleg (2012), individuals who have multiple marginalized identities (ex: Black and woman) should be centered in health research. This means scholars should avoid situating Black women as a comparison group (to White women, for example) and situate them as the point of interest (Puar 2012). Also, rather than using race-neutral methods and approaches to social research, an approach should be taken that allows for a critical analysis of social factors that influence disparate outcomes among young Black women.

Regular, proper gynecological care is an established social determinant of sexual health. The CDC (2021) defines regular care as every other year prior to one’s sexual debut, annually from one’s sexual debut to 30, and every other year thereafter. To ensure Black women receive proper care, it is vital to understand and learn from, both, the challenging and favorable experiences they have at sexual health care appointments. The goal of this paper is to allow Black women to create the narrative around their sexual health by engaging them in a qualitative exploration of their experiences with gynecological care. Our hope is that by challenging Black women to process their own perceptions of the medical field, we can empower them to be autonomous agents of their own sexual health moving forward.

According to the National Partnership for Women and Families (2017) factors like financial disparities, institutional concerns, and disparate access to transportation create barriers to gynecological health care. Another major concern is the shortage of Black women in health care research (Frederick et al. 2021). The result is that, in many cases, gynecological interventions and practices do not consider or address the needs and concerns of Black women. A final concern is medical racism. Medical racism broadly refers to interaction, environment, and society level policies and practices that create disparate health-related outcomes and are shaped by social aspects of race (Bronson 2020). According to Patricia Homan, Tyson H. Brown, and Brittany King (2021) Black women reported lower self-rated health under the condition of state-level structural racism, sexism, and income inequality.

Given the intersectional nature of our investigation, we will use gendered racism to connote the medical racism Black women experience. Gendered racism speaks to racially biased treatment that is also gender specific. In a study examining maternal mortality rates from 2015 to 2019, Evelyn J. Patterson, Andréa Becker, and Darwin A. Baluran (2022) found that when compared to white women, Black women were 2-3x more likely to have pregnancy complications and that Black women with higher levels of income experienced higher mortality rates than white women with lower levels of income (Patterson et al. 2022). These findings serve as an indicator of the complexity of structural gendered racism in the United States.

In this article, we present findings from our Black feminist analysis of patient provider interactions in a sample of Black female college students. The goal of this study was to understand the role patient provider interactions play in reproducing disparities in sexual health care. Black feminist theory and methods are useful here because they make it possible to use a gendered approach to this study of racialized outcomes and medical racism. A Black feminist approach allows for the analysis of racism, sexism, and the intersection of the two in medical research. The use of this approach separates our work from studies focusing on sex and race alone, or cultural practices adopted by Black Americans, to explain this public health crisis. The following sections outline existing literature on the ways race and gender differences (discordance) and similarities (concordance) impact patient provider interactions.

Background

Patient Provider Interactions

The quality of patient provider interactions has a major impact on health care. Research has demonstrated that establishing trust encourages medical compliance (Altice, Mostashari, and Friedland 2001) and that being open and honest is especially important when treating Black women (Thom, Bloch, and Segal 1999). Research has also demonstrated a racial mismatch whereby Black Americans seek high-quality care and perceive white doctors are seeking a high quantity of care. Specifically, Irena Stepanikova and colleagues (2007) found that individuals from minoritized race groups are less likely to trust their physicians when trust is measured in terms of (1) referrals to specialists, (2) being influenced by insurance providers, and (3) receiving unnecessary tests. Furthermore, according to findings from Christina Nicolaidis and colleagues (2010) Black women perceived white doctors as driven by economic gain and catering to insurance companies, not by spending time and establishing rapport with individual patients.

Patient Provider Concordance

Concordance across race and gender categories, is useful in terms of building trust and making both simple and meaningful connections in patient provider interactions. Richard L. Street and colleagues (2008) analyzed post-visit provider ratings and found that patients felt more connected with their provider when they shared personal beliefs, values, and styles of communication. Additionally, Salimah H. Meghani and colleagues (2009) asserted that racial concordance makes it easier to develop trust and rapport in medical settings. Racial concordance, which often connotes cultural understanding, has been shown to promote optimal care (LaVeist and Carroll 2002), greater levels of empathy conveyed by the provider (Williams, Mullan, and Fletcher 2007), and shorter wait times and greater satisfaction with treatment (Jetty and colleagues 2021). Finally, Alyson Ma, Alison Sanchez, and Mindy Ma (2019) found that racial concordance significantly increased the likelihood of visiting the doctor and seeking preventive care for Latinx, Black, and Asian American patients. So, not only has racial concordance been shown to improve health care in general, it has also been shown to improve health care for Black Americans in particular.

Sex (biological traits associated with being male, female, or intersex) and gender (sociocultural traits associated with being masculine, feminine, or queer, for example) can also impact patient care. Similarity across sex categories has been shown to promote greater levels of trust (Bonds et al. 2004) and more intimate quality care (Franks and Bertakis 2003). Additionally, Klea D. Bertakis, Peter Franks, and Ronald M. Epstein (2009) found that female providers demonstrated a greater focus on partnership building, information sharing, discussion of psychosocial topics, and encouragement of patients in their own care, while male providers devoted more time to technical practice behaviors, which tend to be less patient centered. So, for Black women who value trust and honesty, the relationship centered approach used by female doctors would better meet their needs.

Age Concordance

It is also important to consider age concordance in patient provider interactions. Rachel L. Thornton and colleagues (2011) studied the impact of concordance across several psychosocial characteristics and found that race, gender, education, and age all impact the quality of patient provider communication and the care that is received. Andrea J. Hoopes and colleagues (2017) interviewed adolescents to examine their perceptions of patient provider interactions. Their sample reported experiences of judgment, a lack of trust and confidentiality, and a lack of adaptation to their maturity level. Specifically, gynecologists spoke to Black youth about topics like contraception options before it was developmentally appropriate, and prior to their sexual debut. Jennifer E. DeVoe, Lorraine S. Wallace, and George E. Fryer (2009) found younger patients received lower quality health care as well. Their study showed that as age increased, so did high ratings for quality of care and satisfaction. Currently, there is a lack of research on the topic of age-concordance and its impact on patient provider interactions, prompting the need for further research that accounts for social concordance more broadly.

Patient Provider Discordance

The negative implications of patient provider discordance are often shaped by racial stereotypes. Racial stereotypes are pervasive in our society and manifest as implicit bias even among well intended practitioners. Kelly M. Hoffman and colleagues (2016) studied a sample of medical students to understand their perceptions of race and health and found that the students believed that Black Americans have smaller brains, greater fertility, and stronger immune systems than their white American counterparts. These preconceived notions undoubtedly impact the treatment patients receive which is often to the detriment of Black women. According to Bani Saluja and Zenobia Bryant (2021) implicit bias exists at the subconscious level, and is shaped by constant exposure to stereotypical behavior, that results from seeing individuals navigate structural racism. Michael J. Hall and colleagues (2015) reported that that implicit bias had a significant impact on patient provider interactions which in turn impacted treatment decisions, adherence to care, and patient health outcomes.

The medical cost of racial biases is clear in health research. For one, David R. Williams and Ronald Wyatt (2015) noted that a patient’s race impacts access to care and quality/intensity of care. For two, Jennifer Malat and Michelle van Ryn (2005) found that Black Americans’ preference for racial concordance with their providers was shaped by personal instances of discrimination, not the influence of historical medical racism, and recommended future research on race and health that centers firsthand experiences. And for three, Jennifer Malat and Mary Ann Hamilton (2006) reported that 57.4 percent of their Black respondents believed they were discriminated against “somewhat often” or “very often” when they received treatment from non-Black medical professionals.

Theoretical Framework: Black Feminist Theory

Rodney D. Coates, Abby L. Ferber, and David L. Brunsma (2022) describe the social construction of race as a process by which groups are created based on differences like skin color, hair texture, and eye shape. These groups are then placed in a hierarchy whereby certain races receive societal privileges and others are held accountable and minoritized. They also describe healthcare as one such institution where Black Americans have been systematically excluded and denied access to care. This is problematic considering that the impact of racism on health is the most understudied area of medical sociology (Williams and Sternthal 2010).

According to Black feminist scholars like Angela Davis (1983), Bell Hooks (2000), and Patricia Hill Collins (2002), Black women experience multilayered oppression as members of two marginalized populations. This means race-neutral feminist theories, or critical race theories that fail to account for sexism, cannot fully contextualize outcomes for them. L. Lindsay-Dennis (2015) added that empirical findings tend to be deficit centric when they fail to capture the multidimensional nature of structural gendered racism. As advice for future scholars, Lindsay-Dennis (2015) argued that Black women should be investigated with attention to every socio-ecological factor impacting their development and socialization. This recommendation reflects what Collins (2002) refers to as the matrix of domination. Collins’ theory is that a matrix of domination is in place that shapes the social realities of Black women in America. The term matrix is used to connote how interconnected factors like Black women’s history, health status, and popular or media depictions tend to be. Additionally, Black feminist anthropologist, Dána-Ain Davis, created (2019) and expanded (2020) a framework on obstetric racism based on 8 years of ethnographic work. The key assumptions of her framework are that Black women face diagnosis lapses, neglect/disrespect, intentional pain, coercion, ceremonies of degradation, medical abuse, and racial reconnaissance when receiving obstetric services. This means both medical sociologists and scholars of race and ethnicity need to consider social aspects of gender and its impact on individuals’ lived experiences.

Black feminist medical sociology is an emerging approach that works to challenge existing schemas around race, gender, and healthcare. Contextualizing trends in Black women’s sexual health requires the level of nuance previously outlined by Black feminist scholars. According to Gilbert C. Gee and Chandra L. Ford (2012) historical trauma can have an intergenerational impact on population health. In the case of Black women, examples of such trauma include (1) the Alabama Fistula Study, where enslaved women were forced into Cesarean section trials; (2) the Tuskegee Study of Untreated Syphilis in the Negro Male, where the life course of syphilis was examined, in a sample of uninformed Black men, which resulted in the infection of two generations of Black women and children; and (3) forceful sterilization where in North Carolina, for example, over 7,600 impoverished Black women were forced to choose between social assistance and their own fertility (Carmon 2014; Gamble 1997). This sordid history and resulting distrust are almost impossible for health care workers to overcome as Black women of today are also plagued by headlines such as, “Childbirth is killing Black women in the United States, and Here’s Why” and “Black newborns more likely to die when looked after by White doctors” (Howard 2017; Picheta 2020). Black women were also confronted with their own mortality when they had to grapple with the fact that racism transcends class status after wealthy tennis legend, Serena Williams, went public about the medical racism she experienced during labor and delivery (CNN.com 2018). Schenita D. Randolph and Colleagues (2020) provided evidence of this distrust in their qualitative study of HIV care. Women in their study reported that previous experiences with medical racism made it challenging to trust medical advice, systems, and structures work against Black women (e.g., sanctions for welfare and hurdles in place to acquire insurance), and providers lacked effective communication skills. The combination of historical and modern-day gendered racism in health care settings leaves Black women cautious and non-Black doctors unsure how to resolve tensions and properly treat them.

The utility of Black feminism in the examination of racialized health outcomes can be understood through the following contributions to the literature. Roberts (1993) examined the relationship between racism and patriarchy, and how they both contribute to the societal understanding of motherhood. She described how motherhood is different for Black women for a variety of reasons, including the difficulties they have parenting children who are often targeted by police and the sexism they experience from Black men. Her use of a Black feminist framework allowed for a historical narrative that considered the ways in which intergeneration oppression shapes how we see Black mothers today. Tina K. Sacks (2018) explored “stereotyping, bias and the use of cultural health capital as a strategy to mitigate them” (p. 59). She noted that middle-class Black women are rarely the focus of studies and that failing to consider class-related capital misses the opportunity to understand intra-racial class variation. Kamesha Spates and colleagues (2020) examined the ways in which Black women cope with gendered racism. They noted that prayer is a common theme in the literature on Black women and stress reduction, but less is known about non-Christian Black women. Again, this Black feminist perspective highlights the need to understand intra-racial experiences and how the impact of stressors differs for diverse Black women. Christy L. Erving, Evelyn J. Patterson, and Jacqueline Boone (2021) created a “transdisciplinary model of Black women’s mental health” useful in capturing the heterogenous experiences of Black women. Specifically, at level 1, they considered stressors that impact all Black women, namely racism and sexism, at level 2, they considered stressors that impact Black women in divergent ways, namely those tied to social class, sexuality, age, and so on, and at level 3 they considered social institutions and how they reproduce racism and sexism. In sum, Black feminist approaches have done the important work of dismantling the idea that racialized experiences around health and wellbeing can be understood without consideration for history and gendered experiences.

Guided by the Black feminist theoretical framework, and the historical exclusion of Black women’s stories around sex and sexual health, we designed a study that centers Black women and calls for them to create their own narratives. This qualitative study uses results from in-depth interviews to understand how Black female college students experience gynecological care and what role, if any, their race, and sex plays in shaping patient provider interactions?

Data and Methods

Data for this project came from a larger study, “An Exploratory Study of Barriers to Black Women’s Involvement in Gynecological Research and Health Care.” Participants who identified as Black female college students, heterosexual, sexually active within the past 24 months, and had seen a sexual health care provider in their lifetime were invited to participate in the study. The research team conducted 39, 40- to 60-minute interviews with Black female college students ages 18 to 25, who attended a large Predominantly White Institution (PWI, n = 15) and a large Historically Black College and University (HBCU, n = 24) in the Southeast, between September and December 2020. We recruited by circulating a flier via social media and large campus emails targeting Black women. Each participant received a $25 gift card for their participation. The study was approved by the Institutional Review Board at both Universities.

Our inclusion criteria were impacted by several factors. For one, we chose to focus on heterosexual women to concentrate on race-, sex-, and gender-related barriers. Black women who are not heterosexual face a unique set of barriers related to homophobia, which were beyond the scope of our study. For two, our sample is limited to college women to limit the impact of class differences. Black women ages 18 to 25 who have low or no income, or those who are financially secure, experience classism or some level of class-based privilege, which is also beyond the scope of our study. For three, we chose to limit our sample to this age group because developmentally, it is considered emerging adulthood and higher risk in sexual and reproductive health and health care (Arnett 2000). And for four, our larger study examined sexual socialization processes, so we chose to conduct a cross campus analysis. This allowed us to understand how Black women establish their sexual selves in predominately Black settings where their culture is celebrated (Johnson 2017), versus predominately white settings where their culture is less welcome and often policed (Robertson and Dundes 2017; Wilkins 2012). Demographic information is presented in Table 1 below.

Table 1.

Demographic Variables of Participants—Full Sample (N = 39).

	HBCU	PWI
Age
19	4	3
20	3	3
21	8	6
22	2	1
23	2	1
24	NA	NA
25	NA	1
Major
Psychology	11	2
Human Development and Family Studies	1	2
Sociology	2	2
Exercise and Sports Science	NA	2
Biology/bioengineering	1	2
Nursing	4	NA
Other	4	5

Note. HBCU = Historically Black College or University; PWI = Predominately White Institution.

Four HBCU respondents did not provide demographic information via follow up emails.

The study used Black feminist methodological approaches to center Black women and their experiences with sexual health care appointments. According to Collins (2002:35) “Black women intellectuals are central to Black feminist thought for several reasons” including the empathy that results from shared experiences. In response to the need to engage in culturally relevant research that centers the needs of Black women, we used a Black female student advisory board to help develop and vet the interview questions and recruitment strategies. The five advisory board members reviewed the questions and made suggestions for improving the interview guide. The study also included an all, Black female research team composed of three scholars, two graduate students, and one undergraduate research assistant. This allowed us to create race and gender concordance during data collection and analysis. Our conceptual model for using BFT to inform this study of gynecological experiences is illustrated in Figure 1 below.

Figure 1.

Conceptual model: Using Black feminist theory and methods to examine gynecological care.Note. BFTM = Black Feminist Theory and Methods.

We interviewed participants through Zoom following IRB data collection protocols. Participants completed informed consent forms through Qualtrics survey software. The three primary investigators used the same interview guide (with open-ended questions) for all participants and used probes when appropriate to solicit more in-depth responses. At the end of the interviews, the audio files from the Zoom interviews were professionally transcribed and de-identified by one investigator and two trained graduate student assistants.

For the current study, we analyzed data related to women’s experiences with receiving gynecological services from health care providers. To begin, interviewees were asked about their experiences with sexual health care appointments broadly. Next, the members of the research team asked the women if their race and/or sex categories created an issue at the hospital or clinic. The first step in data analysis involved the development of a codebook from eight randomly selected interviews. What followed next was a thematic assessment described by Virginia Braun and Victoria Clarke (2006) conducted by three team members (two investigators and a graduate student) who independently reviewed and analyzed the remaining transcripts and through an iterative process identified relevant themes. During coding meetings, discrepancies between codes were reconciled and coding reports generated for each code.

To maintain anonymity, but distinguish respondents by campus, results are labeled as PWI and HBCU along with a pseudonym. We also note that the staff and providers at the campus health clinic at the HBCU were predominantly Black and the staff and providers at the campus health clinic at the PWI were predominately white with only had two Black health care providers listed on their website. Our results show delineations across campus (PWI vs HBCU) and provider type (on campus vs off campus). Given the lack of access to racial concordance at the PWI campus, we noticed a theme of better care off campus for those students and better care on campus for the HBCU students.

Statement of Reflexivity

Evidence from prior research and Black feminist scholarship points to the usefulness of this approach (Collins 2002) and Black female respondents have indicated that having minority researchers served as a motivator for participation in health-related research (Y. R. Smith et al. 2007). Additionally, Ashley Townes and Debby Herbenick (2020) highlighted the value of using Black feminist thought to guide research on Black women because it allows them to relate to each other and develop ideas that will be beneficial to the larger community of Black women. Members of our research team openly discussed the potential biases they bring to the study and focused on using a script to ensure that participants responded to the same prompts. We also acknowledged the value of having Black women conduct a study related to Black women’s sexual health as each of us was committed to promoting health equity and able to authentically connect with our interviewees.

Research has also demonstrated that the researcher’s positionality, identity, and values can have a positive impact on the qualitative research process. It is helpful with recruitment, inside knowledge, and creating a safe and comfortable setting for the interview (Berger 2015). Thus, having a team of Black women allowed for a richer data collection process. Qualitative researchers also emphasized the need for trustworthiness at every phase of the research process, including recruitment, data collection, and reporting of results (Lincoln and Guba 1985). Our use of an advisory board, student research collaborators, a consistent interview protocol, and independent and joint coding processes were in line with recommendations made by qualitative scholars.

Results

Our analysis of Black women’s experiences with sexual health care generated eight main themes: (1) Feeling Ignored, (2) Having Their Intelligence Insulted, (3) Receiving Proper Help and Education, (4) Benefits of Concordance across Race and Sex Categories, (5) Discomfort Due to Sexual Taboos, (6) Perceived Medical Racism, (7) Impact of other Intersectional Identities, and (8) No Impact. Major codes and themes are presented in Table 2 below. Details on each theme and contextual factors that may promote them are outlined in the following section.

Table 2.

Gynecological Experiences Codes and Frequency Distributions.

Question	Codes	Frequency
Describe your experiences with gynecological care and the ways race and gender impact them	Feeling Ignored	8
	Having Their Intelligence Insulted	5
	Receiving Proper Help and Education	5
	Benefits of Concordance across Race and Sex Categories	14
	Discomfort Due to Sexual Taboos	3
	Perceived Medical Racism	14
	Impact of other Intersectional Identities	4
	No Impact	4

Feeling Ignored

The first theme that emerged was feeling ignored. This finding aligns with Kendra L. Smith and colleagues’ (2022) work on Black women and preterm birth. The women in their study noted feeling invisible and relying on self-advocacy to navigate health care settings. Many of our interviewees expressed a sense of feeling ignored during their sexual health care appointments. They indicated that the providers seemed anxious to move on to the next appointment. This problem was most prevalent in racially discordant patient provider dyads:

PWI Campus Health Provider

I know what I’m going to get with campus health, it’s just them having students in and out, it’s not going to be super personable. Like, “Do this, do this, do this, do this, on the table, bye.” “Bye!” (PWI Darlene)

Off Campus Provider

It made me feel, not to question her too much, not ask too many questions or hold her back from her next appointment. So, I was kind of, let me just wait for my results, see if anything is wrong and then I’ll contact her to have a personal conversation. I felt like now it was more of, okay, let’s just get this together, so I can go so she can go. (HBCU Barbara)

Intelligence Insulted

The second theme that emerged was feeling like their intelligence was being insulted. Previous work has shown that physicians see Black patients as less intelligent and educated even after controlling for patient socioeconomic status (van Ryn and Burke 2000). While some students we spoke to reported feeling ignored, a passive act, others reported feeling like their intelligence was being insulted, an aggressive act. These women felt like they were talked down to and not treated with the respect they deserved as patients:

PWI Campus Health Provider

I feel like I’m still being talked down to as if I’m the eight-year-old complaining of chest pain. (PWI Claudette

Off Campus Provider)

I think that when I go, there’s an assumption that I’m here to talk about my options per se. I feel like they assume I’m pregnant because they rarely see, Black women in my clinic because it is in a predominantly White area. So, I feel like when they see me walk in, if I don’t have on my college sweatshirts, they just automatically assume I’m here because I was young, dumb, and got pregnant. (HBCU Stephanie)

Help/Education Provided

The third theme was reports of receiving help and education from their provider. Students who mentioned receiving help and education categorized their experiences as pleasant. Receiving help and education makes a young woman feel welcome and secure at the doctor’s office. This practice should take place during all gynecological visits. This result reflects a vastly dissimilar experience to those who felt they were being ignored or that their intelligence was being insulted:

She would . . . she’d explain, “Well, because you’re in this age range, this is normal until this point. When you get to this point, if it’s still happening then come back.” Which made me feel better because it’s like she wanted to follow up. (HBCU Alicia)

And what I liked is that they didn’t make me feel dumb. I had a lot of questions; they didn’t make me feel dumb. (HBCU Marie)

Concordance/Discordance across Race and Sex Categories

The fourth theme was feeling the benefits of concordance across race and sex categories. As members of two marginalized groups, Black women are subjected to negative stereotypes and often treated in a way that stems from subscribing to stereotypical depictions of them. It is well established in Black feminist literature that Black women are best suited to engage with other Black women as individuals with shared lived experiences (Collins 2002). Students with Black female physicians spoke highly about the value of having a shared culture and how it enhanced their time at the clinic:

They were thoughtful and everything that I had to say, they cared about what I had to say. I think I was comfortable being there, but again, it would just feel more comfortable having a Black gynecologist. (PWI Darlene)

Women from both universities claimed that their Blackness did not negatively impact their gynecological appointments when a fellow Black woman was treating them. This shows the value of a practitioner’s ability to treat patients as individuals, not members of a particular group defined by stereotypes:

I felt that she understood the sense of, as a Black patient, I always will have that concern in the back of my head and her being super reassuring and being understanding like, “Okay. Yeah.” This is a concern to have. And your concern is very, very valid. Is what I feel like I lacked in *hometown* (PWI Ingrid)

Just as several respondents described concordance across race and sex categories as a protective factor, several others described the costs of discordance. The quote below comes from a student who outlined the disgust she feels when professionals are unaware of how diverse Black women are.

This is very personal, but since I have naturally red hair, it’s naturally red down there as well. And so, I always get a million questions when I go to a gynecologist . . . I don’t think they’ve ever seen it on a Black person before. So, I’ve found that finding . . . Black doctors to go to, they don’t ask that many questions. They ask, but it’s not like (looking shocked) ‘It’s red and blonde’. (HBCU Stephanie)

Students talked about how providers who do not understand Black bodies or culture foster a less than ideal experience. The intimate nature of gynecological appointments calls for a genuine commitment to inclusive practices. The quotes below convey how a lack of understanding can create tension and discomfort in an already uncomfortable setting:

I feel like they don’t understand that Black bodies and White bodies are different, but I feel like they don’t understand . . . There’s just not enough of us in these offices. You just don’t feel heard enough because you’re being treated by somebody who doesn’t even look like you, can’t even relate on some type of level to what you’re going through and why you’re there in the first place. (PWI Jeanine)

Sex Related Discomfort/Taboo

The fifth theme that emerged was sex-related discomfort and taboos. Natasha Crooks and colleagues (2019) examined Black women’s sexual development and reported that it occurred in three stages girl, grown, and woman. Our respondents were at the tail end of the “grown” stage and progressing toward the “woman” stage. The grown stage, much like emerging adulthood, involves coming into one’s own, feeling unsure, and lacking confidence around sex and sexuality. Some respondents reported feeling uncomfortable for reasons beyond the patient provider dynamic. They felt uncomfortable due to the sexual nature of the visit, sometimes because of religious beliefs and other times because their parents were present. As emerging adults who are transitioning from parental monitoring to self-governing, discussing topics that were off limits to their nuclear family remains challenging for some young women. Providers should take heed of this concern and work to demystify the topic of human sexuality during appointments. Examples are highlighted in the quotes below:

Religiosity

I don’t know, being a Christian, and being raised in a Christian household, and a single father household, my dad didn’t talk about anything regarding to sex at all. I don’t talk about any of that with my dad. My dad would freak out. (HBCU Stephanie)

Parent presence

It was just uncomfortable because my mom was there, and I was going because I had gotten pregnant, and that was the first time she ever heard of me doing anything sexual. And, well we were mostly going to just see if I was okay and kind of talk about like abortion methods. (HBCU Erica)

Medical Racism

A sixth theme was Medical Racism. Some participants made references to the ways racism negatively impacted their encounters with physicians. Medical racism can be experienced both personally and vicariously. The quotes below show how medical racism can manifest as (1) average care for Black women versus superior care for White women, or (2) profiling, whereby Black women are perceived as oversexed and treated accordingly. Again, this narrative is rooted in a subscription to racialized sexual stereotypes:

Average Care

I was still talking to a couple of the Caucasian girls I went to high school with, and they were telling me about their experience when they went to the gynecologist. And they were like, they were so sweet to them. They were talking to them like they were a baby, explaining everything they’re about to do. And with me, she explained it a little bit. She was like, “So this is the forceps. It’s going to be very cold, but that was the only explanation I got. (HBCU Stacey)

Racial Profiling

So, I’m going to say yes, it could affect it because they just don’t care enough. They’re like, “She’s probably just here, I don’t know, for a plan B or something like that, wasn’t a real appointment.” But I think, it had, my race influenced it. (HBCU Lara)

Additionally, students from both campuses discussed vicarious medical racism. The quotes below illustrate how patient perceptions can be driven by (1) anxiety from historical instances of medical racism or by (2) vicarious racism whereby the racism experienced by others impacts their own approach to sexual health and health care:

Historical Instances of Medical Racism

I don’t really trust it all that much because I’ve done a lot of eugenics studies and I don’t trust birth control. -HBCU Veronica

Vicarious Racism

My sister had a very long season where she was in and out of the hospital. It was very hard for the family, and I just know that in all our experiences none of us personally received the care that we were supposed to. But none of us would’ve received the care that we were supposed to if it wasn’t for the presence of my mother and her having to say that she’s a doctor. She doesn’t really like to pull that card because it’s like, “I shouldn’t have to.” (PWI Darlene)

Other Intersectional Identities

The seventh theme was other intersectional identities. According to Patricia Hill Collins (2015), intersectional identities encompass all the biopsychosocial markers that directly impact our life chances. In our study, some respondents did not believe their race or sex and gender created an issue at the doctor’s office. They did, however, cite other aspects of their identity—in this case age- as a point of concern. Respondents felt their status as young adults or adolescents shaped the treatment they received. The women below described how her status as a teenager came with higher quality care since her physician perceived how stressful gynecological appointments could be. Her experience was notable because youth report provider judgment, power differentials, and a lack of confidentiality as barriers to sexual healthcare (Hoopes et al. 2017) as well as a desire for a safe space to express their emotional concerns (Rose 2008):

Age

I feel like they were taking extra care of me because they knew I was still a teenager, and I was emotional and stuff. (HBCU Marie)

The quote below comes from a student who felt profiled and haunted by the typology that Black women are naturally heavier than their White American counterparts. According to Black feminist thought, Black femininity involves portraying a social construction of gender that strives for the white ideal, but is “unsuccessful,” as a means of perpetuating the us/them divide among Black and white women. This external construction leaves Black women tied to typologies that are detrimental to their health and wellbeing. For example, Black women are depicted as the promiscuous Jezebel (curvy), the asexual Mammy (fat), or large and strong (fat) (Beauboeuf-Lafontant 2003; Kulkarni 2007):

Weight

I am a heavy girl, but I noticed that my doctor does not mention that a lot. She doesn’t mention much of that BMI kind of scale because it’s not as applicable to women of color. (PWI Adrienne)

No Impact

The final theme that emerged was no impact reported. Not all respondents had memorable, race-specific encounters with their sexual health care providers. There were students who had neither positive nor negative recollections from their gynecological visits. These women did not celebrate concordance or report any medical racism or misunderstandings:

Not to a severe extent, no. But I feel in ways that I don’t understand because I have never really had any situations where I’ve had to go to the hospital because something was terribly wrong with me. (PWI Barbara)

Discussion

This qualitative study uncovered universal understandings and distinct differences in the sexual health care experiences of Black women from PWIs and HBCUs. Historically power dynamics between the patient and provider have exploited Black women’s vulnerability in health care, resulting in Black women’s voices being discounted by the medical community. Our study intentionally provided narratives from Black female college students to add their voice to the sociological literature around race and ethnicity.

For many women, the conversation of sex was seen as taboo. Religious institutions and/or caretaker discomfort influenced discussions involving sex. The fact that sex was seen as taboo created a barrier for some to talk with their providers about sexual health. Notably, HBCU students expressed feelings of being ignored and reluctant to ask questions regarding their health from private providers. This could be evidence of the difference between a predominantly Black clinic (at all levels) compared to a Black practitioner (in an otherwise diverse clinic). In other instances, women felt judged during their medical visits. When sharing medical concerns and questions, some women from both institutions felt the provider was dismissive and stifled women’s voices. Thus, women were uncomfortable, or reluctant to openly communicate with the provider. This finding is supported by results from Lakshmi Goparaju and colleagues (2017), who reported patient provider communication was a barrier to sexual health. In their study, Black women presented with sexual health concerns reported feeling judged when they took action to prevent HIV infection, via pre-exposure prophylaxis (PrEP) medication.

Students at 4-year colleges expect to receive quality sexual health care provisions on campus. Both colleges in our study had sexual health care resources for students. However, there are limits to the services available on campus and some participants sought care away from the campus setting. It is not entirely clear why the choice was made to use one setting over the other. Marla E. Eisenberg and Colleagues (2012) noted that simply having resources on campus is not enough to provide sexual health care. They found inequities in access to these resources. For example, some students have greater awareness of the resources than others and some are more comfortable accessing the resources. We call on college campuses to make sexual health care resources more widely accessible, user friendly, and available.

Culturally informed, non-judgmental sexual health providers can improve the health outcomes of Black women (Townes and Herbenick 2020) and promote positive patient provider interactions. It is important for Black women in emerging adulthood to understand their bodies and to have their health concerns addressed without feeling ignored or devalued. Medical mistreatment, including dismissive attitudes and action toward the sexual health experience of Black women contributes to a level of distrust with medical providers. Research posits that Black women who can be comfortable, open, and honest with their provider have better provider-patient interactions (Thom et al. 1999) and foster a trusting relationship. Providers’ ability to foster transparency, open communication and unbiased responses can improve women’s experiences with their providers. This level of interaction allows for opportunities for women to engage in conversation regarding their healthcare concerns, and most importantly, ask questions to better understand their bodies and medical procedures.

Women in our study expressed that concordance across race and sex provided more positive encounters with medical providers. Women experienced feelings of trust, openness, comfort, and genuine care by Black female providers. Student participants perceived Black female providers as able to understand their lived experiences, women’s health, and Black culture. Research has shown that patient provider racial concordance promoted greater satisfaction, medication adherence, and shared decision making (Jetty et al. 2021; Laveist and Nuru-Jeter 2002). Our results mimic those of previous scholars. As we advocate for more Black health care professionals, we must remember that they must navigate a racist medical system, driven by racist health related research, which can limit their ability to deliver optimal care. Since the turn of the 20th century Black doctors have called for more inclusive medical research and care (Gamble 1997). This call remains relevant today as the National Institute on Minority Health and Health Disparities made a similar statement in 2018 (Pérez-Stable 2018).

Limitations

Findings from the study have several notable limitations. For one, the recruitment of students and data collection deviated from our plan of face-to-face contact to online via Zoom due to COVID19 and stay-at home-orders. It is unknown whether face-to-face contact would impact the interviews compared to using the Zoom platform. We asked participants if the change in platform impacted the interviewing process and received an equal mix of “in person is preferred,” and “Zoom is better” because it allowed them to discuss sexuality in a controlled environment. For three, some students were reluctant to participate in the study due to not knowing the racial identity of the researchers. We adjusted to this challenge by updating our marketing flyers with our photos on them, as well as creating a website with details of our study and research team. For two, our sample and thus findings are limited to Black women in college and cannot be generalized to all Black women in emerging adulthood. More research is needed with community-based samples of young women who represent a greater degree of socioeconomic diversity.

Future Directions and Practical Applications

Our study adds to the literature on race and ethnicity by providing further evidence in support of intersectional analyses. Black feminist scholars have conveyed the need to use an ecological, approach to the study of Black women’s social life (Collins 2002; D.-A. Davis 2019; Lindsay-Dennis 2015). It is not useful to assume universal best practices will generalize to Black women in healthcare settings. We must consider their lived experiences, family processes, stereotypical depictions that are reproduced through social interactions, and how to create safe spaces that mitigate the impact of historical and modern-day medical racism. Our findings demonstrated how women’s experiences with sexual health care are racialized and differential based on age and weight. Our recommendation is for future studies of sexual and gynecological care to engage Black women across class, age, and geographical regions to expand our college-specific findings. We have also provided evidence that processes around sexual and medical socialization vary by race, as the women in our study described vicarious racism and how it shaped their approach to provider selection.

Findings from the study have practical applications for the field of gynecology as well. For one, it increases awareness of the contextual factors that create racial disparities in health outcomes. We believe more medical schools should train physicians in patient-centered approaches with a focus on cultural differences, inclusive practices, and health disparities. Although there are ethics boards and customary practices around interpersonal communication in place, both were created with the reproduction of whiteness at the center. This means an overtly anti-Black (and other racial and ethnic minorities) and anti-woman (and other sex and gender minorities) approach is embedded in the structure of medicine- and health-related scholarship. For example, the institutional review boards we know today were in development from 1965 to 1981 (Grady 2015). This is relevant here in three ways, it makes a clear case about how long widespread change takes time to disseminate, how relatively new fully ethical medical research is, and for Black Americans, there is a clear overlapping between these dates and the horrors of Tuskegee, 1932–1972.

Additionally, despite adding the Psychological, Social, and Biological Foundations of Behavior (PSBB) section to the Medical College Admission Test (MCAT) (Warshaw 2017), students only need to complete an introductory course on Sociology and Psychology to successfully pass it. This limited exposure to social scientific research creates structural barriers to effective cross-racial communication in health care. Jeannette M. Wade, Anderson Bean, and Stephanie Teixeira-Poit (2019) argued that social justice should be a topic highlighted in all courses, discipline aside, to unpack biases, train equity-oriented students, and decrease inequalities in society. Jennifer Tsai (2021) implemented and outlined several teaching strategies medical schools can employ to promote health equity using tenets of critical race theory in courses on health and society. Qualitative feedback from her course evaluations showed the efficacy of this approach as students reported (1) increased efficacy around advocacy and activism, (2) a newfound ability to reflect on their own privileges in patient provider interactions, and (3) increased empathy for patients from minoritized populations. We also recommend training medical providers to create patient friendly judgment free zones that prioritize quality over quantity. This too comes from changing the culture of medical school. If students’ success were tied to quality care, the way it is tied to effective care, they would prioritize developing those skills.

Finally, and perhaps most importantly, we call for mentoring, recruiting, and training Black girls and women to pursue careers in medicine and public health. Our findings showed somewhat of a consensus that concordance across race and sex categories are vital to quality care. As a Black feminist analysis, we must highlight several structural barriers that work to limit Black women’s participation in these fields that must be considered as we attempt to diversify them. Two examples include (1) inequitable funding for k-12 schools, as predominantly white districts earn an average of $2,226 more per student than their nonwhite counterparts (Edbuild.org 2019) and (2) increased representation for Black women in STEM who have historically been coined “hidden figures” for their highly utilized, but under celebrated contributions to science (Ireland et al. 2018).

Our greatest contribution, however, may be the understanding that concordance across race and sex categories is beneficial not just among key providers (as in doctors), but entire clinics (i.e., billing professionals, technicians, assistants). This means policy change (for funding) and academic program creation (for training) need to go toward developing a diverse workforce to provide quality medical care to Black women in the United States. One of the greatest barriers to funding inclusive research is the lack of diversity among scientific reviewers. Much like many institutions in America, the NIH Center for Scientific Review committed to “Advancing Equity, Diversity and Inclusion in Peer Review” in response to the Black Lives Matter protests of 2020 (Byrnes 2021). Only time will tell if these commitments are honored, but that important change could mean saving the lives of Black women and children.

Footnotes

Acknowledgements

We would like to thank the members of the student advisory committee (Darian, Tiana, Ayana, Sandrika, and Que) for their assistance with the development of the semi-structured interview guide and guidance on the recruitment of student participants.

Funding

The author(s) disclosed receipt of the following financial support for research, authorship, and/or publication of this article: This research was funded by North Carolina Translational and Clinical Sciences (NC TraCS) Institute, National Institutes of Health, through Grant Award Number UL1TR002489

ORCID iD

Jeannette Wade

Author Biographies

Jeannette Wade is an assistant professor of sociology at NC A&T SU. Her teaching and research interests include black feminist theory and social psychological determinants of health.

Helyne Frederick is currently a clinical associate professor at the University of North Carolina NC Chapel Hill. She directs the undergraduate program in Human Development and Family Science (HDFS) in the School of Education.

Sharon Parker is the executive director of The Health Equity Research and Innovation Lab (the HERILab). The HERILab focuses on improving the health outcomes for Black and Latinx communities through the elimination of health inequities.

Briana Wiley is a graduate of the joint MSW program at NC A&T and UNC-G. She is now employed as a clinical social worker.

Hannah Dillon is a student in the joint MSW program at NC A&T and UNC-G. Her plan after graduating is to pursue a PhD in Sociology.

Dorrian Wilson is a graduate of the Master of Education, Innovation, Technology, and Entrepreneurship program at UNC-CH. She is also passionate about addressing medical racism and making healthcare equitable for all.

Kwani Taylor is a graduate of the Bachelor of Psychology program at North Carolina A&T State University. She is currently pursuing a MA in Psychology at Appalachian State U.

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