The Invisibility of Black and Latina Women in Sexual Health Care: Shifting from Biological Individualism to Intersectionality

Abstract

Black and Latinx women have long endured racist healthcare practices and policies that influence their sexual health outcomes. Despite having increased health care access, Black and Latina women continue to have higher rates of sexually transmitted infections compared to their white counterparts. We utilised Critical Race Theory to examine the myriad ways in which Black and Latina women and their unmet needs may be invisible to healthcare providers and to better understand the compounding factors that may affect Black and Latina women’s engagement with sexual health services. Eighteen individual semi-structured interviews were conducted with healthcare providers, administrators and policy advocates working to address sexual health needs of Black and Latina women in California. Interviews were recorded and transcribed verbatim. Qualitative data were analysed using an inductive thematic approach. Two primary themes and subthemes were developed from our analysis. Within the healthcare system there is a lack of recognition of 1) intersectional identities of Black and Latina women, including intersectional oppressions and systemic vulnerabilities; and 2) structural barriers that mediate their sexual health treatment engagement. Recognition of intersectional identities and addressing structural barriers can potentially improve the sexual health of Black and Latina women and support efforts to address disparities in sexual health care.

Introduction

Previous studies have outlined the injustice, cruelty and inhumane treatment of Black and Latina women at the hands of healthcare professionals throughout US history (Ford and Airhihenbuwa 2010; Jones 2000). From the medical experimentation conducted on Black women without consent or anaesthesia in the 1600s to the coerced sterilisation of Latinas/Chicanas in California during the 1970s, Black and Latina women have endured institutionally sanctioned and overtly racist policies and practices influencing contemporary sexual health outcomes in this population (Feagin and Bennefield 2014; Manian 2018; Prather et al. 2016, 2018). Multiple, intersecting mechanisms are attributable to these outcomes, including generational poverty, mass incarceration, racialised stereotypes, unemployment and lowered access to quality education and healthcare (Prather et al. 2016, 2018). Among the sexual health outcomes of increasing concern are the rising rates of sexually transmitted infections among Black and Latina women. In California, where this study is situated, Black and Latina women have a higher incidence of Chlamydia and gonorrhoea compared to the population more generally (California Department of Health 2019).

Using a Critical Race Theoretical Lens

This study adopted Critical Race Theory, a legal framework developed to counteract initiatives that would roll back Civil Rights legislation in the USA in the late 1960s (Bell 1995; Delgado 1995). Considered among the pioneers of Critical Race Theory, Bell (1995) articulated his racial realism thesis which deemed racism and white supremacy as permanent fixtures in society. Critical Race Theory later found a new audience in the late 1980s as young law scholars of colour, including Kimberlé Crenshaw (2010), detailed how laws applied as “race-blind” or “race-neutral” perpetuate systemic oppression and racism. Critical Race Theory has since been used outside of the legal framework to examine systems of equity in disciplines such as public health, education and social work.

Through a Critical Race Theory lens, scholars and practitioners can question systems of power embedded in racial hierarchies. This lens allows scholars to recognise how racism is built into US systems and structures and how current US values perpetuate racial subordination (Matsuda et al. 2018). Key tenets of Critical Race Theory utilised in the present work are the concepts of racial realism and intersectionality. Racial realism deems racism in the USA as inherently ordinary, not the exception, and embedded into systems (Delgado 1995). Intersectionality recognises that people possess multiple components of identity (e.g. race, class, gender, sexual orientation) from which marginalisation can be experienced. These marginalising encounters compound and result in experiences of inequality (Crenshaw 1989). The legacy of enslavement, imprisonment, and sexual violence against Black and Latina women in the USA falls within the frame of our study’s examination (Prather et al. 2016, 2018). The invisibility of Black and Latina women and their unmet needs as it relates to sexual health are directly connected to their invisibility under the law (Crenshaw 1989).

Critical Race Theory and Biological Individualism

The application of Critical Race Theory works to counter a widely used practice in medicine that scholars termed “biological individualism” – whereby practitioners evaluate patients based on their individual behaviours and dissociate the patient from their social context and environment (Lane et al. 2004). In the study of HIV, social factors such as stigmatisation, lack of transport, poverty, and housing insecurity play a role in the progression of HIV in any given community (Singer et al. 2017). Healthcare providers, however, may overlook social and structural factors that are tied to disease transmission, since they are often expected to make decisions in a short time frame (Farmer et al. 2006).

Using Critical Race Theory’s tenets of racial realism and intersectionality, we query the degree to which health providers are focused on patients’ individual risk behaviours in relation to sexual health issues in contrast to their intersectional identities and structural barriers that may influence their vulnerability to disease (Lane et al. 2004; Rosenthal and Lobel 2020). For example, exposure to poverty and neighbourhood crowding are linked to higher rates of sexually transmitted infections (Krieger et al. 2003). Additionally, financial difficulties may impact Black and Latina women’s healthcare service engagement. Notably, among those with medical debt, more than half (51.7%) of Black and nearly one third (27.8%) of Latina women report being unable to pay for basic needs because of medical bills (UCLA Center for Health Policy Research 2019).

Gendered Racism and Medical Mistrust

The application of Critical Race Theory’s tenets of racial realism and intersectionality counter the gendered racism and medical mistrust experienced by Black and Latina women. Medical mistrust is defined as a lack of confidence in the medical system (Tekeste et al. 2019). The sexual and reproductive subjugation, imprisonment and maltreatment of Black and Latina women throughout US history, often within its healthcare system, has built generational medical mistrust in these communities. A lack of understanding of Black and Latina women’s experiences of everyday racism and acknowledgement of their intersectional identities may perpetuate their gendered and racialised stereotypes of being overly promiscuous (Rosenthal and Lobel 2016, 2020). In fact, concerns about being stereotyped are high for Black and Latina women, as 45.1% of Black and 10% of Latina women indicate they have been treated unfairly in their lives when accessing medical care (Rosenthal and Lobel 2020; UCLA Center for Health Policy Research 2017). Accordingly, interactions, largely between white providers and patients of colour, have been fraught with medical mistrust. Despite having more sexual health visits and a willingness to discuss their sexual health with a provider (Townes et al. 2020), Black women also have high medical mistrust (Cuevas, Kerth, and Somnath, 2016; Tekeste et al. 2019).

Purpose of Current Study

While current evidence demonstrates the sexual healthcare needs of Black and Latina women, less is known about the specific healthcare-related barriers Black and Latina women experience, particularly as they relate to their intersecting marginalised identities. The present study addresses this gap by obtaining narratives from providers, healthcare administrators and policy advocates who are working on the ground directly with Black and Latina women who seek sexual health services.

Methods

Our study was part of a larger investigation, entitled Organizing Women Centered Approaches to Trauma Related, HIV/STI and Reproductive Health Risk Reduction for Women of Color Study (WC4WC), aimed at examining the factors affecting Black and Latina Women’s sexual health service engagement. Individual semi-structured qualitative interviews were conducted with healthcare providers (e.g. social workers, case managers and outreach workers), administrators, and state-and federal-level policy advocates (all of whom hereafter are named “healthcare practitioners”) working to improve Black and Latina women’s sexual health outcomes in California.

Participant Recruitment

WC4WC study staff identified and recruited interview participants in May 2019, primarily through state-wide organisational partners involved in the California Wellness Foundation’s Women of Color Health Initiatives (California Wellness Foundation 2022). Additional recruitment efforts focused on achieving a diverse sample, factoring in individual characteristics of the participants’ roles (e.g. as direct service providers, direct service administrators, policy advocates), the size of their respective organisation/agency (i.e., eight to 800,000 employees), and geographic service area (i.e., National; Northern, Central, and Southern California). Recruitment occurred via email and phone to organisational representatives (n=43) from 29 distinct entities including public health departments, healthcare organisations, community-based organisations and coalitions.

Eligibility

Inclusion criteria included: (1) being ≥ 18 years old; (2) serving Black and Latina women in California; (3) working to address sexual health in California (including policy advocacy); (4) familiar with sexual health services; and (5) a direct service provider, administrator or policy advocate. Eighteen (N=18) participants were screened via email or by telephone. All were deemed eligible and completed the interview. Respondents provided oral consent and were offered a $50 e-gift card as compensation for their time. Participants’ names have been changed to pseudonyms throughout the manuscript to protect confidentiality.

Data Collection

The semi-structured interview guide was developed by the WC4WC research team, with input from California Wellness members who had experience conducting research and delivering sexual health services for Black and Latina women. The virtual interviews were approximately 30 minutes to an hour and a half, with an average length of 44 minutes. Interviews were audio-recorded and transcribed verbatim.

Data Analyses

Data analysis occurred in three stages, with the team adapting a rapid qualitative analytic approach (Hamilton 2013; Hamilton and Finley 2019). Rapid qualitative analysis is often team-based and involves data reduction techniques to complete preliminary analysis. With interview data, it begins with identifying neutral (i.e. neither good nor bad) conceptual domains of interest corresponding to interview questions. Each data collection episode may be summarised according to a template of predetermined domains. The data contained in summaries are further reduced to a matrix that allows data to be compared, and trends and points of emphasis to be identified (Averill 2002).

At the initial stage of analysis, at least two (n=2) members of the study team (LS, AMO, CL, KG) reviewed each transcript and summarised the data according to the following domains of interest: service delivery, organisational capacity, best practices, and social and structural barriers to care. The second stage of the analysis involved biweekly meetings among research team members over three months. We used inductive thematic analysis to identify themes relating to barriers Black and Latina women face in accessing equitable, culturally appropriate sexual healthcare services. Summary data were then combined into a single, comprehensive matrix for analysis. Through an iterative process, initial codes and potential themes derived from codes were identified from the matrix data; matrix data were checked against transcripts and additional data were drawn from them, including representative direct quotes. After identifying potential themes, the team split into two groups, the first exploring themes related to intersectionality (LS, RB), and the second looking at barriers to care (AMO, LC).

Research Team and Reflexivity

The study team was composed of racially and ethnically diverse womxn from varied professional backgrounds in social welfare, health policy and public health. While we are academic and public health policy researchers (LS, RB, LC, CL, AMO), two of our co-authors also provide mental health services (LS, CL). We shared a perspective that systemic racism contributes to embedded biases in healthcare delivery. We practised reflexivity by holding extensive meetings and debriefing sessions during data analysis (Mauthner and Doucet 2003). While we intentionally did not note the racial and ethnic identities of our participants for this study, we attempted to gain trustworthiness and establish “insider status” with our interview participants through our shared professional and personal interests in improving the sexual health of Black and Latina women in California (Lincoln and Guba 1986).

Ethical approval

This study was reviewed by the UCLA Institutional Review Board and was determined as exempt as it posed minimal risk to participants.

Results

Two primary themes with corresponding subthemes were developed from our analyses: (1) Black and Latina women’s intersectional identities influence their sexual health care experiences; and (2) structural barriers impede Black and Latina women’s sexual health treatment engagement.

Intersectional identities of Black and Latina women influence their sexual health care experiences

Black and Latina women’s multiple intersecting identities impact their ability to access sexual healthcare. Although these identities (e.g. race, gender, religion, sexuality, education, socioeconomic status) can be difficult for providers to ascertain during a sexual health visit, Nancy, a policy advocate, explained the importance of considering identities in relation to HIV transmission:

[O]ften times we’re just looking as if HIV is transmitted through heterosexual sex, but we’re not looking at domestic violence, financial insecurities, all these other things that are wrapped into the larger issue of transmission. So, if we can get to a place where we can make a woman whole…then we’re decreasing the risk of transmission … I would also like for us to start…engaging practitioners to look at other things aside from that you’re doing your annual exam. But what else is happening?

Particular aspects of women’s intersectional identities often cited by participants included cultural identity, religion, socioeconomic status and membership of a special population.

Cultural Identity

Participants detailed that as providers, they often served Black and Latina women who were part of a culture that stigmatised sex and sexual health. This cultural identity and corresponding taboo made it difficult for women to seek sexual health services in the first place. Adriana, a direct service administrator, elaborated:

“Because of the…area that you’re providing the services in, and what a taboo issue it is, and how hard it is for folks to walk in the door, that you genuinely have to go out of your way to say thank you for taking care of your [sexual] health.”

Participants also explained that cultural identities and the culture of service users’ communities need to be considered, especially with respect to shame and stigma surrounding sexual health. Maya, a policy advocate, detailed this as follows:

[There needs to be] a culture change in terms of how people talk about sexuality, how people relate to being sexual, what that looks like, in terms of prevention and treatment, all of that. You know, who’s doing the services…even though you might not be a crisis clinic, in terms of being abstinence only, or abortion or anti-abortion. If you still can’t talk about sexuality well, without shaming and stigmatising and all of that, then who’s going to talk about it?

In sum, providers, regardless of their own cultural background, should be able to discuss sexual health in a supportive and non-stigmatising way. This was especially important for Black and Latina women with cultures that may shame issues related to sexual health.

Religion

Providers who do not consider the religious backgrounds of their patients or acknowledge how patients’ religious views may differ from their own may impede the care that Black and Latina women receive. Yetty, a direct service provider, relayed a story of a young woman who had previously sought sexual health services from another local clinic:

I work with young people, who are [from] majority immigrant Catholic households, so they never receive any type of information regarding sexual health testing, pregnancy prevention, pregnancy options…In this rural town, [a patient] went to go get tested from one of the local [sexual health] clinics. And then they just started grilling her with a lot of questions of why? Why does she even need to get tested? What makes her think she has an STI? Then she tried to explain herself, she’s had multiple partners and hasn’t been using protection. They asked her if she’s ever been pregnant or has children. She mentioned she had an abortion. Then they started to question her about that, early on about her history with that as well. So that was a big turnoff for her to seek services there.

A provider’s religious beliefs or the influence of religion on medical service provision can influence women’s access to important sexual health services and perpetuate the institutional oppression experienced by Black and Latina women in medical clinics. Shandra, a policy advocate, stated:

“We know that, for example, one out of six hospital beds in the nation are in a Catholic, religiously affiliated hospital. And they deny care based on their…ethical and religious directives. So, for example, to trans folks, and they simply just don’t provide certain kinds of reproductive health care, sterilisation among them, birth control, and abortion being the other ones.”

Socioeconomic Status

Participants also described the experiences of low-income women who had difficulty managing their sexual health care while simultaneously navigating the stressors of poverty. Yvonne, a policy advocate, explained:

“I think a lot of the barriers [that] exist…range from folks living in poverty, folks not being able to access the healthcare they needed …all of those structural barriers, impact women of colour… women are often the main person that’s taking care of the other people around them. And then they think about themselves last when it comes to health care, when it comes to the doctor’s appointments that they need to make. And so really making sure that we…take in to account the full picture and full breadth of a person and the realities in which they navigate those experiences.”

Navigating the difficulty of providing for families with low-wage work was a stress for women. Yetty, a direct service provider, described the clients she serves:

“People [earn] not even minimum wage, because the majority of people, like farm workers, are working in the packing house and get paid far less than minimum wage, and having to sustain a whole family on that.”

Socioeconomic status is also an important identity to consider for Black and Latina women because it is often associated with health insurance coverage. When women work part-time or in positions paid in cash with no way to trace payments, they often experience being uninsured or underinsured, impeding their ability to manage their sexual health care. Nancy, a policy advocate, provided context for this barrier:

“All of these other barriers or challenges affect some of the choices that women make. So… what else can we do? Can we do some employment training? Particularly for transgender women. They’re underemployed, underinsured the whole nine [yards]. So, we can do some skills based training with them to help them become employed, then they’re less likely to do sex work or something like that? So looking at the issue, what can we do to address this issue? And then, overall, have a better health outcome.”

Special Populations

Another subtheme pointed to the intersection of Black and Latina women and their membership of other vulnerable groups (e.g., immigration status, age, incarceration). The ways in which these vulnerabilities intersect for Black and Latina women can pose challenges to accessing sexual health services. Jessica, a direct service provider, described the outcomes for Black and Latina women who are not legally admitted to the USA:

“And they’re not coming for their STD check-ups. Even if they’re having symptoms. If they’re afraid they’re going to get deported, if they’re afraid to leave their house. So we have a large population of immigrants of varying documentation statuses and a huge Latino community, majority of our population, especially in the younger age ranges, that are undoubtedly affected by the federal policies and ICE being in our communities.”

Black and Latina women who are undocumented face unique difficulties at the intersections of race, gender and legal status. When US federal immigration policies contribute to fear among communities, Black and Latina women who are undocumented may be reluctant to engage with the systems that can provide appropriate sexual healthcare.

Young Black and Latina women represent another group that may experience unique difficulties in accessing sexual health services. Yetty explained:

“We work with a lot of youth and young people and young adults. So when it comes to young women getting access, we’ve had incidents where they get biases…from doctors. So being denied either birth control or testing due to [their] age range. So that’s also a big barrier as well.”

When service providers act upon biases related to age, younger Black and Latina women may be unable to receive appropriate sexual health services.

Black and Latina women who are incarcerated also experience difficulties accessing appropriate sexual health care. Shandra, a policy advocate, noted that these women often have fewer services:

“For folks who are in prisons or jails, [we need to consider] their access to [reproductive and sexual] healthcare…For example, making sure that county jails have to follow the same laws around ensuring that the people in their care have access to [sexual health services] …but it continues to be something that people just don’t think about. And [this is important] because the incarceration rates are significantly higher for women of colour.”

Structural barriers impede Black and Latina women’s sexual health treatment engagement

A second theme that emerged focused on the structural barriers that Black and Latina women experience as they navigate sexual health services. We defined structural barriers as obstacles that disproportionally affect an entire group and lead to the maintenance of disparities in outcomes. Barriers evident in the data included organisational level barriers, sexual health care accessibility and sexual health education.

Organisational Level Barriers

Providers described organisational structures and policies that affected how the clinic operated and impacted how providers implement sexual health services. For example, providers explained that clinic scheduling policies permitted providers to have short appointments with each patient. Leticia, a direct service provider, explained:

“I think that sometimes in terms of barriers, I think that time is probably the number one thing, that patients have very limited time with their doctors. And so to have a thorough conversation with patients is difficult when you have a 15-minute appointment scheduled.”

Another organisational level barrier was a lack of appropriate assessment tools. Specifically, participants spoke about the lack of tools to assess a patient’s level of disease risk that may require a more nuanced approach. Lisa, a direct service provider, explained:

“You don’t want to stigmatise a race by saying, ‘If you’re this race, you should be tested for STDs because you inherently are going to have, [or are] more likely [to] have STDs.’ I also think with STDs in general, that when you’re talking to a person and the risk of getting an STD, it’s not just about that person and their risk factors. But it’s also about their partner or partners and the risk factors of their partner’s partners.”

Due to disparities in STI rates, an ‘even’ approach that treats all women equally can create problems that burden Black and Latina women. Jessica, a direct service provider, explained,

“But even though we’ve had guidelines for years that all women under 25 should be screened annually…[t]hey’re still not used consistently. So I think women of colour are more impacted by that, because they have much higher rates of STDs due to historic discrimination and sexual and social networks and access to care historically and now. So when providers don’t follow evidence-based guidelines…that is a gap for women of colour. It’s a problem for all women. But like many things, the more vulnerable get hit the hardest.

In sum, the structure, policies and tools within these organisations can act as barriers to fully actualising sexual healthcare among Black and Latina women.

Sexual Health Care Accessibility

Lack of accessibility of sexual healthcare and clinics at the community level posed another barrier to Black and Latina women. Yetty explained what she would like to see:

“[M]ore reliable transportation, whether it be more funds for transportation, like for bus passes, but also having more… routes throughout the area. Having more times available for that as well.”

She went on to explain that even when clinics and agencies provide transport to clients, difficulties remain in using the services:

Being able to get to a clinic has been also hard. One of the main ones, [agency name omitted] does provide transportation. But if you want to get it, you have to book it weeks in advance. Because they have a long process or long waitlist.”

Another barrier to service accessibility was the wait time that women experienced once arriving to the clinic. Edwin, a direct service provider, said:

“The average wait time is a long time because [the clinic] make[s] all appointments in the morning at the same time or in the afternoon at the same time. So…everybody gets a 1:30 appointment. Mondays, everybody gets a 10am appointment. Obviously, we can’t see everybody at 10am. So, sometimes the wait can be really long.”

Other barriers to sexual health services for Black and Latina women include clinic schedules and the lack of childcare provision. Scheduling options are not always supportive of the needs of Black and Latina women who may juggle jobs and caregiving responsibilities. Edwin explained:

“I think we need to offer evening and weekend services.... extending the hours and the days to make it easier for the patient instead of for the providers. We need to offer on-site childcare.”

Sexual Health Education

Participants described the lack of attention on sexual health education for Black and Latina women. Yetty explained that even though comprehensive sexual health education was now mandated in schools by the California Health Youth Act, many young women still did not receive that education:

“The California Healthy Youth Act…should be implemented in our district [name omitted]. [The district has] been resistant towards us…[For example] I want to do a condom demo…And I get a lot of pushback. They’re like “nope”… So that’s the biggest one, comprehensive sex ed is not truly [there], it’s there, on paper. But the districts are not actually implementing what it encompasses.”

In addition to the lack of comprehensive sexual health education, participants described a gap in healthcare literacy. Yvonne, a policy advocate, stated:

“I think there’s a huge gap when it comes to education about… just basic stuff, like how to set up an appointment for themselves. How to find an appropriate doctor that speaks their language and just really basic literacy around their healthcare.”

Even for women who were able to attend their sexual health appointments, many were not informed about their rights as patients. This included the right to choose a provider and the frequency of their sexual health screening. Edwin, a direct service provider, elaborated:

“Not all the women…feel comfortable talking to their male provider about any issue they may have…Women need to really know what the standard of care is…How often you are supposed to get your Pap smear? How often [are you] supposed to get a mammogram? …What’s appropriate, what isn’t?”

It is the responsibility of the healthcare system to uphold a consistent standard of care and provide women with the information they need about sexual health. If women are not provided with sexual health education or informed of the standard of care, this acts as another barrier to the receipt of sexual health services.

Discussion

Through qualitative interviews, we explored the perspectives of healthcare providers, administrators and policy advocates and sought to understand how respondents, as individuals and as part of the organisations they represent, helped improve access and facilitate the delivery of culturally appropriate sexual health services. Findings add to previous research examining the healthcare experiences of people of colour including Black and Latina women (Vardeman-Winter 2017). Our study is one of few that consider sexual health services from the perspectives of service providers. Findings have implications for strategies to improve service provision, including changes to the healthcare system and shifts in law, policy and practice.

Two main themes from the study underscore challenges Black and Latina women face. First, interviews revealed that providers experience difficulties in understanding the intersectional identities of Black and Latina women. Some participants recognised how intersecting identities related to poverty, unemployment, immigration and healthcare insurance status have consequences for Black and Latina women’s sexual healthcare. One participant detailed how among women without legal residency, federal immigration policies that incite fear can lead to disengagement from sexual healthcare. Also, religious beliefs and affiliations of both Black and Latina women and service providers may influence sexual health. Issues can arise when religious organisations refuse to treat certain populations or offer only certain sexual health services (Guiahi, Sheeder, and Teal, 2014). Recognising the intersectional identities of Black and Latina women is just the first step to enhancing sexual health service provision.

Critical Race Theory shows how race-conscious approaches and an intersectional lens should inform institutional policies and practices to facilitate adequate and appropriate sexual healthcare. Providers could benefit from better tools, training and policy to not only recognise, but validate, intersectional identities in the delivery of sexual health services. Our findings support previous research calling for culturally-informed training for sexual health practitioners working with Black women (Townes et al. 2022). Training can help providers have more intentional conversations to understand the nuances of what may be influencing patient behaviours in ways that standard questions may leave unexplored. Future practice parameters should be designed in ways that are race-conscious without violating various local, state, and federal anti-discrimination statutes.

The second theme pointed to structural barriers that mitigate Black and Latina women’s access to sexual health services. Findings echo those in previous research showing that structural racism and barriers persist in institutionalised healthcare practices that may not align with the interests of people of colour (Freeman et al. 2017). For example, participants noted how short clinic visits and inadequate assessment tools impede opportunities to learn about Black and Latina women’s intersectional identities and factors that influence their sexual health decisions. Additionally, participants described the conflicting nature of policies that determine how women’s sexual health needs are identified, screened for, tested and treated. Policies that present as “race neutral,” do not necessarily translate to equitable conditions. This link between organisational policies and individual health outcomes reveals the importance of prioritising structural changes to better support the nuanced needs of Black and Latina women.

Implications

At a structural level, healthcare institutions often function based on values, principles and foundations that are not inclusive of Black and Latina women. The practices of health facilities that follow the traditions and needs of dominant cultures (Graham et al. 2011) can make it harder for Black and Latina women to successfully navigate these systems. Colour-blind approaches fail to consider the importance of women’s intersectional identities, as well as the structural and systemic barriers they face in accessing care.

To begin addressing these barriers, institutions should review their policies and practices that prevent access to care. A review of the screening tools used by providers can help broaden the scope of considerations related to Black and Latina women and their sexual health needs (e.g. poverty, interpersonal violence, transport). It is important to consider what providers can do in addition to following the usual screening guidelines to be more attuned to circumstances facing Black and Latina women without resorting to pernicious stereotypes.

Healthcare institutions seeking to improve sexual health outcomes among Black and Latina women may need to advocate for incorporating new and innovative tools in their clinical workflow. Among these potentially useful implements are health-related social needs screenings. Some healthcare initiatives to assess, within a clinical setting, a patient’s vulnerability to social factors (e.g., housing instability, food insecurity and health insurance status) in conjunction with patients’ intersectional identities are already underway (Chen, Tan, and Padman 2020; Gruß et al. 2021; O’Gurek and Henke 2018). Select community healthcare centres across the US were among the first to pilot a screening process for patients. The Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences is a 4-item screening tool designed to coordinate patient care and increase patient engagement with their care team (Gruß et al. 2021). However, barriers in implementing screening tools persist and include the lack of time to conduct screening, lack of training to administer the screening tool, and lack of connection to resources once a patient’s social needs are identified (Billioux et al. 2017). Yet, evidence suggests healthcare systems that have incorporated these screening tools experience an increase in referrals to social services, patient adherence to medication and lowered risk for 30-day readmission (Chen, Tan, and Padman 2020).

Shifts in law, policy and practice may benefit providers of Black and Latina women in sexual healthcare. Enforcing anti-discrimination statutes on the basis of race/ethnicity, gender and religion will require clinics and institutions to create ongoing opportunities for provider and staff trainings to minimise stigma, microaggressions and overt discrimination. Collaborating with selected faith-based organisations could create opportunities to engage with community members and combat stigma surrounding the sexual health needs of Black and Latina women. Institutions should also consider partnering with community-based agencies to design strategies, projects and campaigns to improve the patient-provider relationship. Expanding free and low-cost sexual health services including online, at-home options through federal and state funding mechanisms (e.g. Title X, FamilyPact) could also mitigate some of the identified barriers for Black and Latina women. Lastly, community sexual health education could be expanded and delivered in culturally appropriate ways in order to meet the needs of Black and Latina women.

Limitations

This study has several limitations. First, the researchers acknowledge that a key tenet of Critical Race Theory is to listen to and amplify narratives directly from people of colour. The research team did not speak directly with Black and Latina women but elicited the perspectives of those who serve Black and Latina women. Secondly, we were unable to conduct research activities that would increase our study’s credibility (Guba and Lincoln 1994) such as prolonged engagement and observation with participants in their social environment, as we conducted hour-long interviews with participants. Finally, we were unable to triangulate our data with sources that included conducting clinic observations or direct patient interviews. Our results are not necessarily generalisable to all providers.

Conclusion

Recognising the intersectional identities of Black and Latina women will help future service providers identify areas of risk and opportunity for prevention and intervention. Black and Latina women encounter structural barriers that can increase sexual health risks and contribute to sexual health disparities. Providers and healthcare organisations must recognise and work to change the structures and contexts in which sexual health services are provided in order to more appropriately serve these women. Findings from this study reveal that recognition of women’s intersectional identities and an emphasis on organisational and community-level structural accessibility can help address the sexual health inequities that exist for Black and Latina women.

Table 1.

Characteristics of study participants

Participant	Pseudonym	Participant Rolea	Type of Organisationb	Size of Organisationc	Regiond	Interview Length (minutes)
1	Nancy	Policy Advocate	Health Services	Small	National	31
2	Flor	Direct Service Provider	Health Services	Medium	Southern California	42
3	Christopher	Direct Service Provider	Health Services	Large	Southern California	35
4	Yvonne	Policy Advocate	Advocacy	Small	National	49
5	Lucas	Direct Service Administrator	Health Services	Large	Southern California	58
6	Yetty	Direct Service Provider	Health Services	Small	Central California	45
7	Shandra	Policy Advocate	Health Services	Medium	Central California	49
8	Adriana	Direct Service Administrator	Health Services	Large	Central California	79
9	Maya	Policy Advocate	Advocacy	Small	Southern California	48
10	Rhonda	Policy Advocate	Advocacy	Small	National	44
11	Lisa	Direct Service Provider	Health Services	Large	Northern California	50
12	James	Direct Service Provider	Health Services	Small	Southern California	24
13	Leticia	Direct Service Provider	Health Services	Small	Northern California	33
14	Edwin	Direct Service Provider	Health Services	Small	Southern California	53
15	Jessica	Direct Service Provider	Health Services	Large	Southern California	48
16	Rachel	Direct Service Administrator	Health Services	Medium	Southern California	32
17	Janaya	Direct Service Administrator	Health Services	Medium	Southern California	30
18	Kristen	Direct Service Administrator	Health Services	Small	Northern California	51

^aDirect service provider: a clinician or other healthcare provider delivering HIV, STI and/or reproductive health services. Direct service administrator: a person who administratively oversees the delivery of HIV, STI and/or reproductive health services. Policy advocate: an individual who engages in policy discussion addressing unmet HIV, STI, and/or reproductive health needs.

^bHealth Services organisation: a body that delivers services including clinical care to address HIV, STIs, and reproductive health needs. Advocacy organisations provide other support to communities affected by HIV, STIs and unmet reproductive health needs.

^cSmall (25 > staff ); Medium (> 25 staff, < 100 staff); Large (multiple sites; > 100 staff)

^dNational: includes states outside of California; Northern California: includes San Francisco Bay Area and north of that area; Central California: includes Fresno, Central Valley and Central Coast; Southern California: Includes primarily areas within Los Angeles County