Understanding HIV Prevention With College-Going Black Women: An NIMH-Funded Pilot Study

SAMPLING AND RECRUITMENT

Fifty-one participants were recruited from a public university in New York City. Eligibility for the study included being between the ages of 18 and 29, self-identifying as female, and being currently sexually active or active within the past 12 months.

Consenting study participants first completed validated objective survey measures. Five participants who agreed to be contacted for an interview consented again and were interviewed for the study. Participants were compensated $15 for each part of the study.

PARTICIPANTS

Each participant self-reported her race as Black/African descent; one participant reported her ethnicity as African American, three reported their ethnicity as both Caribbean American and African American, and one emigrated to the United States from Ghana. Participants’ average age was 20.2 years. Four participants self-reported having sex with men, and one self-reported having sex only with women in the past 12 months. Each participant was raised in a two-parent household in New York City, with the exception of one who lived in West Africa until she was 9 years old. One participant had a child, and none were living with a partner nor married.

INSTRUMENTS

The interviewer explored questions about socialization related to race, gender, sex, and dating (e.g., “Who were the primary influences for your gender socialization?” “What did they teach you about being a girl/woman?” “What messages did you receive about being a member of your racial group that were connected to dating or sex?”). All interviews were conducted by the first author at the college where the students and first author were affiliated. Participants had no relationship with the interviewer (i.e., were not enrolled or previously enrolled in any of her courses). See the Appendix for the interview protocol.

RESEARCHERS

The first author, a Black professor and licensed psychologist, designed the study. The second author, a multiethnic South and Southeast Asian American professor and dually licensed creative arts therapist and professional counselor, joined the study after data were collected.

DATA ANALYSIS

All interviews were audiotaped and transcribed by a professional transcriber. Data were then independently analyzed using content analysis that grouped key ideas, words, and phrases together based on their relation to the purpose of the study (Morgan, 1996). We systematically analyzed the material, beginning by immersing ourselves in the written transcriptions and then using open coding to identify broad themes related to race and gender socialization. Following this independent work, together we identified themes related to the outcome variable of sexual risk-taking behaviors and the independent variables of race, gender, and socialization. We attended to both the presence and the absence of topics.

IDENTIFYING AS A BLACK WOMAN

Participants had difficulty teasing apart whether social messages from their parents were related to gender, race, or both. Cindy (all names are pseudonyms) noted that she was not taught explicit messages from her parents about being Black or being a woman, yet she had developed a strong intersectional identity as a Black woman from her mother. These findings support those of researchers who found that exploring gendered racial identity development was more salient for Black high school– and college-going young women than was looking at race and gender as separate factors (Thomas et al., 2011).

All participants reported that being a woman was a source of pride that influenced their attitudes and behaviors in general and romantic relationships in particular. They reported receiving clear messages, and in some cases, a complex set of messages, from their parents about appropriate gender roles. On the one hand, many were socialized to adopt a traditional “feminine” role that emphasized physical appearance; on the other, all were taught to be independent and manage multiple roles and responsibilities, supporting the “Strong Black Woman” schema (Thomas et al., 2011, p. 532), also referred to as the Black “Superwoman Schema” (Woods-Giscombé, 2010, p. 668). The Black women in this study were also socialized to emphasize a “feminine” appearance, which may be influenced by current and historical questions about who has access to femininity.

The image of what a woman was to look and act like was based on messages from family, peers, and society at large. All participants reported receiving messages about the importance of behaviors often categorized as feminine, with an emphasis on appearance, such as particular styles of clothing and behavior. Alyssa said, “I was taught that girls wear dresses even though I was a tomboy.” Kyra reinforced the importance of behavior by messages given by family members, “That’s not ladylike; cross your legs.” Some participants connected these earlier messages to their current gender expressions as stereotypically feminine. Kyra further explained that she felt best about herself as a woman when she wears “heels … tight short dress … [and is] dancing some type of feminine way,” whereas Angelina recalled being told not to wear short skirts. Being socialized to don traditional feminine clothes and behavior may be related to the historical and ongoing debate about who has access to womanhood in North America. White women have been recognized as the standard for what it means to be a woman and Black women have faced resistance when trying to gain access.

MAINTAINING MULTIPLE ROLES

Complicating these messages on femininity was a second set of messages about independence and self-reliance. All study participants reported being socialized to be strong and independent in spite of their relationship status. Participants had strong female role models, mostly their mothers, who were “smarter,” worked “harder,” and were more educated than their fathers. Participants reported observing their own mothers holding multiple roles as a signal about how they were expected to behave. Angelina said, “She cooks, she cleans, and you know, like the man works, but my mom also, my mom actually works more than my dad.” Thomas et al. (2011) highlighted that African American young women are taught “to appear strong, tough, resilient, and self-sufficient through socialization and their mothers” (p. 532).

However, some participants reported that these aspects of strength should be downplayed when in romantic or sexual situations with men. Although most participants seemed to embrace being self-reliant, three also struggled with the duality of being strong and independent while simultaneously protecting their male companion’s self-esteem and role as a provider. The balancing act was illustrated by Cindy, who said,

All participants shared that they took responsibility for safer sex practices in the bedroom and outside. Some noted that they had to “remind” their partner about condom use. The majority of participants also indicated that they either initiated HIV testing in the relationship or went to the clinic together with their partner. Cindy described her process as, “Well, I’m usually the one that goes to get tested. I have to make him go every now and then.”

TRUST AS A PRIORITIZING FACTOR

Participants indicated that trust is demonstrated by practicing unsafe sex, which may explain why they minimized their perceptions of risk for HIV. This concept was noted by three of the five participants as a reason for a lack of consistent safer sex practices and minimal discussions about condom or barrier use with a romantic partner. Pricilla explained that not using protection “makes me feel like it’s a monogamous relationship. It’s just you and I,” even if the relationship was not necessarily exclusive. She continued, “To have sex with somebody and to a certain degree not using a condom in a way kind of convinces me that this is my—you know, because he has to trust me if he’s not using a condom.” Pricilla mentioned trust the most and also has a complicated sexual history that includes sexual abuse. However, trust was noted by Kyra and Angelina as well.

Some participants in our study also noted a decline in condom use over time in relationships. This may suggest that perceptions of risk decline over time as an expectation of trust increases.

LIMITED DISCUSSIONS ABOUT SEX

Participants reported that they had not received clear messages about sex from parents or peers. Two categories emerged: avoidance of the topic and religious or other value-based messages (i.e., abstinence, no sex until marriage, and monogamy). Alissa explained that discussions with her father never occurred and the messages from her mother were simply blanket statements that were not meaningful, such as “No dating whatsoever.” Others received messages of monogamy and no sex until marriage through the home and church. Only Cindy noted receiving explicit instructions from her mother about how to put on a condom for pregnancy-prevention purposes. Pricilla indicated that although her mother was very open in sex talk and behaviors, safer sex practices were not discussed.

Participants also reported minimal sex education from peers or in school—a finding that was amplified for those who believed there were racial differences in sex talk with peers. Pricilla believed that her White friends had more open and informative discussions in regard to sex in general, condom use, and preferences. In contrast, she reported that her Black friends never had such discussions with one another, which gave the impression that sex is something secretive. She felt that open discussions contributed to positive feelings about sex and a possibility of sharing information about safer sex practices, such as condom and dental dam use and how to negotiate with a partner. She wondered aloud,

Pricilla found that a White male partner was more open to discussing condom use than her partners of other racial backgrounds. We return to the topic of sex education in the Participant and Researcher Recommendations section.

PERCEPTIONS OF RISK: PREGNANCY OVER STIs

Possibly related to the lack of discussion surrounding sex are participants’ perceptions of risk; this may also be a defensive strategy to avoid the possibility of resistance from their sexual partners. All of the women reported accurate knowledge about contracting an STI or HIV infection, but they minimized their own risks for various reasons. None reported having personal interactions with people they believed to be HIV positive (as noted by the absence of mention); however, some participants disclosed interactions with peers who have been pregnant or have had children. Participants may indeed know people who are HIV positive but do not know their status given that secrecy is prevalent because of stigma, whereas it is more difficult to hide a pregnancy or a child. Their reported lack of direct exposure to HIV made it less “real” of an issue, and therefore the perception of risk was minimized. Pregnancy, on the other hand, was top of mind and perceived as a risk that must be actively managed. Alyssa highlighted this phenomenon, noting that she becomes more aware of the need for safer sex practices when a peer contracts an STI. Despite this, she identified pregnancy prevention as her and her peers’ main concern. Whereas some participants noted that they were given clear messages by parents, such as “You better not end up pregnant,” others were given more tacit messages, such as Angelina’s father talking in a disparaging tone about “babies having babies.” No participants reported receiving similar messages about HIV.

The participant who was in a same-sex relationship reported an absence of personal safer sex practices (i.e., barrier protection) due to lack of pregnancy concerns. However, she noted routine sexual health care, such as regular testing and gynecological exams with her partner.

INTERSECTIONAL CONSIDERATIONS: GENDER, RACE, AND STRENGTH

Research on gender roles has found that traditional feminine roles, which often include passivity and nurturance, are associated with less power in advocating for safer sex practices (Wingood & DiClemente, 2000) than more instrumental or masculine gender roles. Although all five participants reported that their parents were explicit about expectations related to being a girl/woman, they also (except for one who was not raised by her biological mother) described their mothers as being strong, being independent, and holding multiple roles, characteristics often labeled as “masculine.” The modeling and messages translated into feeling empowered to assume some level of control related to sexual practices. In fact, many reported assuming responsibility for dimensions of their sexual relationships, including recommending HIV testing to their partners and following safer sex practices such as condom use, but their requests were not always honored by their sexual partners.

Three of the five women reported a second set of messages that placed them in a bind. Their parents emphasized that they should be strong and independent, while also suggesting the need to be proficient with household duties to be a suitable candidate for marriage. Although participants said these messages were outdated, some were unable to fully disregard them. These findings are consistent with other research that has found that Black women often struggle with having to balance and hold multiple roles while simultaneously allowing their Black male partner to maintain a traditional role in which he feels empowered and necessary (Boyd-Franklin, 2003). Furthermore, previous studies have found that young Black women are socialized to be strong (Thomas et al., 2011) while also being subject to sexual double standards (Fasula, Carry, & Miller, 2014).

Research has found that persons with a positive racial identity are less likely to engage in risky behaviors, such as drug and alcohol use and unsafe sexual behaviors (Beadnell et al., 2003; Brook & Pahl, 2005; Caldwell, Sellers, Bernat, & Zimmerman, 2004; Oparanozie et al., 2011; Wills et al., 2007). In our study, most women recalled receiving negative messages about being African American and positive messages about being of Caribbean descent, which may have been confusing, making it difficult to have access to the benefits of a positive racial identity that can reduce sexually risky behaviors.

Two other findings related to racial identity were notable. Although most participants reported that being Black was not salient to them, they described being a “Black woman” as a source of pride and strength and had difficulty teasing apart these two dimensions of their identity. This finding is consistent with a growing body of research that argues social identity groups may intersect and exert both independent and simultaneous influences on experiences (Cole, 2009) and with research that found gendered racial identity is more meaningful than looking at race and gender as separate constructs for Black adolescent girls (Thomas et al., 2011). Second, several participants identified a pattern of communication related to sex that they believed was informed by race. They reported limited conversations about sex with other Black people, even among friends with whom they had long-term and intimate relationships, which they contrasted with their peers from other racial groups who they believed had more open dialogue about sex that could ultimately increase safer sex practices. This pattern of communication is consistent with research that has found that sex talk indeed varies between cultures (Guzmán et al., 2003).

LACK OF COMMUNICATION AND TRUST

Most participants described limited communication with their parents about sex, dating, or contracting STIs or HIV infection, a finding that is consistent with other research with racially diverse samples that has found similar patterns—that parents were not engaging in dialogue with their daughters; rather they were providing rules and instructions (Krauss, 1997; Roye, Silverman, & Krauss, 2007). Yet, parents have a vital role to play in the provision of HIV/AIDS education to their children, particularly their daughters (Krauss & Miller, 2012).

Our participants verbalized tacit reminders from parents to avoid pregnancy at all costs and avoidance in discussing matters pertaining to HIV infection. O’Sullivan et al. (2010) noted that 78% of the young adults they interviewed used condoms for pregnancy prevention and less than half used condoms for STI prevention. In our study, when the interviewer noted the discrepancy in participants’ practices, such as having knowledge about the need for condoms and choosing not to use them, a few seemed confused by their own behavior. They deduced that their lackadaisical behavior was due to several factors: familiarity with a partner that gave them a false sense of security, a desire to minimize the possibility of tension by asking a partner to use a condom, and a desire to believe that the relationship was monogamous.

Our findings related to trust were consistent with other research. In a study of male and female students in Australia, concerns about “violating trust” were common when discussing safer sex practices with a potential partner (Gavin, 2000, p. 117). Worries about trust can complicate advocating for safer sex practices because it implies that young people do not trust their partner and they worry about how that can have an impact on a partner’s desire to be monogamous (Gavin, 2000). This conflict put our participants in positions in which they had to assume responsibility for several aspects of romantic relationships, including negotiating condom use, maintaining their own sexual health, encouraging the STI and HIV testing of their partners, and upholding feelings of trust.

LIMITATIONS

Participants attended an urban college in the Northeast, and results may not be applicable to women attending college in other areas (e.g., rural southern areas in the United States that are not considered epicenters of the HIV epidemic). Additionally, given the sensitive and complex nature of this topic, it may have been helpful to have a two-part interview. Some work has found that for retrospective recall of racial memories, a second interview was helpful in triggering those memories (Buckley & Carter, 2005). Finally, participants may have overreported prosocial behavior because of the semistructured interview format. However, the interviewer is a licensed psychologist and was careful to provide a safe and nonjudgmental space for participants to be honest.

PARTICIPANT AND RESEARCHER RECOMMENDATIONS

Participants in this study directed their safer sex practices toward what they perceived to be more immediate risks (e.g., pregnancy) rather than what they perceived as more distal risks (e.g., HIV). Their behavior was aligned with how they had been socialized by their parents, who also focused on pregnancy prevention rather than STI infection. When we asked the participants for recommendations that may help other young women with respect to HIV-prevention strategies, they overwhelmingly stated the importance of using “real” persons as part of the education and skill-building process. Roye and Hudson (2003) came to similar conclusions, that young women “believe they need to see HIV infected people, like themselves … to increase their motivation to engage in preventative behaviors” (p. 149). It is notable that none of the participants discussed the availability of antiretrovirals used to treat HIV, which is an example of how the virus is managed.

There is research demonstrating that innovative ways of delivering safer sex messages (e.g., showing a video featuring young people similar to the target audience), coupled with sexual health education, is effective in the short term for Black and Latina young women (Roye et al., 2007). Whereas Angelina suggested nonpunitive messages as more helpful, fear appeal messages have been found to be effective when coupled with an in-person action message (Roye et al., 2007) to increase self-efficacy. Our participants also recommended text messaging and in-person, peer health education, such as outreach efforts including free and open-access sexual health services targeted specifically toward young people. Even brief, personalized sexual health and HIV-prevention messages have been effective in multicultural communities (Krauss et al., 2000), particularly when presented in a way that eroticizes sex (Scott-Sheldon & Johnson, 2006). In addition, our participants also recommended interventions such as holding “talking circles” in which women gather to engage in casual conversation about sex and dating. Customizing interventions may be a useful way to approach safer sex practices rather than a generic, one-size-fits-all methodology. Furthermore, trust was an aspect of relationships mentioned across participants and should be discussed and possibly challenged in developing interventions and public health education. The participants described trust as something that develops over time (i.e., the longer I am with you/you are with me) and includes aspects of being able to be vulnerable or taking risks with another (i.e., not using a condom).

Our recommendations for practice and policy come from the suggestions made by participants as well as from our collective research and clinical practices. To start, we recommend that counselors approach the work from a standpoint grounded in cultural humility (Fisher-Borne, Cain, & Martin, 2015; Hook, Davis, Owen, Worthington, & Utsey, 2013). Counselors should keep in mind that all individuals are socialized differently, regardless of whether they come from the same or different ethnic, racial, or cultural background. Additionally, counselors will benefit from understanding the historical context in which their clients are situated. In the case of Black women, bodies have been sexualized as a result of the historical context of slavery (Watson, Robinson, Dispenza, & Nazari, 2012). Black women may not be as open to discussing matters surrounding HIV, STIs, or sex because of their need to protect themselves from being seen as a sexualized body. Finally, as counselors, we should not only focus on the behaviors of our clients but also work with the ways in which our clients have been socialized—in other words, understand the why. Using an intersectional approach can assist counselors in better understanding that the individuals we treat are complex and are not defined only by race or only by gender. Another promising model to use is the counselor–advocate–scholar model (Ratts & Greenleaf, 2018), which requires therapists to determine the nature of the client’s problems (i.e., biological, psychological, and/or sociological), not just the presenting problem or behavior itself.

The participants provided useful ideas regarding HIV prevention for policy makers. Similar to our practice recommendations, the focus should be on socialization and not only on behaviors. For example, HIV prevention, testing, and treatment options should target all individuals at risk, not only certain populations. In New York City, this has been seen in the way pre-exposure prophylaxis (PrEP) has been promoted. When PrEP was first introduced, the target audience was clearly young Black and Latinx males as seen in the visual advertising. Recently, the NYC Health Department noted that women were not using PrEP at the same rates as men (personal communication, March 5, 2018). Since then, advertising including women has subsequently increased.

Semistructured Interview: HIV Prevention Among College-Going Women