Intersectionality and Women’s Health: Sexual Orientation, Race/Ethnicity, and Cervical Cancer Screening with Madina Agénor

Over the last few years, there has been a significant increase in public health literature that employs an intersectional approach. Intersectionality is an analytical tool that allows us to more accurately describe how human experience is shaped by multiple forms of social inequality that act in diverse and mutually reinforcing ways. This week’s WAPPP seminar featured Madina Agénor, Assistant Professor of Social and Behavioral Sciences at the Harvard T.H. Chan School of Public Health. Professor Agénor presented her research on how sexual orientation and race/ethnicity simultaneously affect disparities in cervical cancer screening among U.S. women.

Professor Agénor presented the results of three studies to demonstrate how intersectionality matters for population health and health equity. The first study examines how sexual orientation affects cervical cancer screenings without using an intersectional approach, and the second does the same for race/ethnicity. The third study employs an intersectional approach to illuminate how sexual orientation and race/ethnicity interact to produce discrepancies in cervical cancer screening.

Sexual orientation and cervical cancer screenings 
Lesbian and bisexual women (collectively referred to here as “sexual minority women”) are less likely to receive cervical cancer screenings and routine gynecological care than heterosexual women. Women with female sexual partners may also be more susceptible to cervical cancer because of higher rates of smoking and HPV. In addition, sexual minority women face a number of barriers to healthcare, including lower average income, lack of access to regular care and health insurance, and discrimination in society and in the healthcare system.

However, sexual minority women’s health is an understudied area, and there are significant gaps in research, including overreliance on convenience samples of mostly white, college-educated women; problems with measurement of sexual orientation (some studies conflate sexual orientation identity with sexual behavior); lack of appropriate comparison groups; and limited attention to potential drivers of sexual orientation disparities in pap testing.

Professor Agénor’s research uses a national probability sample of U.S. women, operationalizes sexual attraction, sexual orientation identity, and sexual behavior as different components of sexual orientation, uses appropriate comparison groups for each component of sexual orientation, and assesses whether healthcare factors (including access to insurance, receiving contraception, and STI services use) contribute to sexual orientation disparities in pap testing.

Lesbian-identified women exhibited significantly lower pap test use compared to heterosexual women (43% versus 69%), as did women with only female sexual partners compared to women with only male sexual partners (46% versus 71%). These disparities persisted even after controlling for age, household income, and other similar factors. Interestingly, differences in healthcare factors – access to health insurance, contraception, and STI services use – completely attenuated this disparity. According to the results of this study, focusing on only sexual orientation without an intersectional lens, healthcare factors may explain the discrepancy in cervical cancer screening among sexual minority women.

Race/Ethnicity and cervical cancer
In 2012, incidence of cervical cancer was highest among black and Latinx women, and cervical cancer mortality was three times higher among black women than white women. However, there has only been one subnational population-based study on sexual orientation, race/ethnicity, and pap test use, and this study also lacked appropriate comparison groups and didn’t seek out the drivers of disparities. Again using a national probability sample, Professor Agénor examined sexuality, race/ethnicity, and healthcare factors across racial and ethnic groups within sexual minority groups.

Professor Agénor found a lower prevalence of pap test use among women with only female sexual partners for black and white women, with the greatest disparity in pap test use between white women with only female partners and white women with only male partners. There was no difference in pap test use among Latinx women, regardless of whether they had male or female sexual partners. Importantly, the results of this study indicate that healthcare factors completely attenuated the disparity between women with female sexual partners and women with male sexual partners for white women only.

The magnitude and mechanisms of sexual orientation disparities in pap testing vary by race, which we wouldn’t have known without employing an intersectional approach. The crucial implications of this study are that addressing healthcare access barriers may mitigate disparities for some but not all women, and that we should be wary of “one-size-fits-all” interventions.

Qualitative Intersectional Study 
In order to better understand the mechanism of these effects on black sexual minority women, Professor Agénor held focus group discussions that centered around four key themes: healthcare provider communication style, heteronormative healthcare provider assumptions, heterosexism, racism, and classism, and healthcare provider background.

• Participants preferred healthcare providers who took time to build relationships, were knowledgeable about sexual minority women’s health, and provided them with relevant sexual health information. 
• Many participants reported that their healthcare providers assumed heterosexuality, and therefore provided patients with limited relevant sexual health information. Similarly, many participants reported both a fear of disclosing their sexual orientation to healthcare providers and negative experiences when they did so. 
• Many participants reported that their healthcare providers made social class assumptions based on their race/ethnicity. Some healthcare providers made further assumptions based on perceived social class about their patients’ ability to understand health information, which affected both how they communicated with them and how they involved them in decision making. 
• Participants reported negative experiences with OB/GYNs and expressed a preference for nurses and physician assistants, who provided more individualized attention. Finally, respondents reported a preference for healthcare providers with similar lived experiences, particularly for black sexual minority women healthcare providers. 

The results of this study indicate that patient-provider communication may be an important contributor to sexual orientation disparities in pap test use among black women. Sexual orientation and race influence black sexual minority women’s pap testing experiences and outcomes by shaping their exposure to multiple forms of discrimination and their access to and rapport with healthcare providers. Interventions designed for black sexual minority women should address multiple forms of discrimination and will have to look different than interventions designed for white sexual minority women.

Whether or not we employ an intersectional approach can be critical for designing appropriate interventions to promote health. Intersectionality matters for population health and health equity.

Bargaining Power within Households: Can it Prevent HIV?

Over the last few months, we’ve been looking at how gender imparity has affected equity and efficiency in some very high-power spaces: politics, the corporate board, academia, and the STEM fields. But what about those more banal, day-to-day issues of gender imparity---those that most people don’t even see? Namely, how couples relate to one another. As commonplace as it might seem, relationship dynamics can have wide and profound consequences for society.

In the WAPPP seminar this week on “Intra-household bargaining power and HIV prevention,” WAPPP Fellow and PhD Candidate at the University of St. Gallen in Switzerland, Berit Gerritzen, looked at how married couples in rural Malawi approach issues of sexual health. Approximately 14.3 percent of the adult population of Malawi were living with HIV/AIDS in 2005, demonstrating the need for better information on its transmission.

And because many HIV infections throughout Sub-Saharan Africa take place during heterosexual intercourse between persons in stable couple relationships, the way that each of those partners approaches the other---and the issue itself---can be most telling for the diffusion of the virus.

Through data from the Malawi Diffusion and Ideational Change Project, Gerritzen looked at questions of (a) whether partners spoke about HIV risk, (b) accepted condom usage within marriage, (c) self-reported infidelity, among other issues including, of course, (d) HIV infection itself. Gerritzen cross-referenced those answers with indicators of household bargaining power, namely a spouse’s personal economic status, the number of wives in the family, local political participation, and other demographic data.

While conceding that there are a number of additional variables at play, Gerritzen concludes that factors associated with gains in female bargaining power---such as a wife’s own earnings and education, fewer co-wives, and political participation---are in fact generally related to increases in spousal discussions of sexual health, greater acceptance of condom use within marriage, and other HIV risk-reduction efforts.

When women demand the processes and outcomes that they know to be best for themselves, the household’s own welfare improves. And behaviors within the house are often what influence societal health outcomes, further strengthening the case that empowering women and increasing agency has benefits far beyond equality.



Photo Source

Global Health Diplomacy

The Man: Scott Ratzan, MD Vice President, Global Health, Government Affairs & Policy for Johnson & Johnson

The Talk: Working Together on Health Literacy, Diplomacy and Innovative Health Communication to Advance Women’s Health

The Question: Health affairs as foreign affairs: how can we create a healthier world for women and girls? 

After hearing Dr. Ratzan at Davos, Harvard Kennedy School Academic Dean, Iris Bohnet, invited him to speak on campus -- I can see why. Ratzan spoke on achieving the MDG goals, using evidence to increase universal access to healthcare, incorporating technology into health education, and using health as a tool for foreign affairs. Not bad for a 60 minute presentation. 

Health as a common currency

Dr. Ratzan specifically focused on women and girls. He believes -- along with many others -- that if women and girls are given access to basic healthcare services, coupled with girls’ education, we can change the fabric of global inequalities. His position? Because health permeates all levels of society, altering this part of the equation affects all other variables. “Health is the common currency if what we’re trying to pursue is happiness,” says Dr. Ratzan. 

Much of what Dr. Ratzan discussed focused on achieving the MDG goals three and five: (3) Reducing child mortality, and (5) Improving maternal health. The highest rates of infant and maternal mortality are regional, but mainly clustered in six countries: India, Nigeria, Pakistan, Ethiopia, the Democratic Republic of Congo, and China. While some progress has been made in decreasing the under five mortality rate, attaining universal access to reproductive health would dramatically impact our ability to achieve these goals. “Short-term campaigns really don’t make the difference; you really need policy change. You need to have the advocacy for women and women in public policy to solve these problems.”

The catch-22, Dr. Ratzan says, is that, “Governments and people don’t want to invest unless they have evidence; but how do you have evidence unless you have investment?” He cited a well-known statistic that between 30 to 50 percent of Asia’s economic growth from 1965 to 1990 can be attributed to maternity and reproductive health programs; yet, we still find reasons to limit investment. 

Global health diplomacy: what is it? 

The WHO defines global health diplomacy as diplomacy that, “…brings together the disciplines of public health, international affairs, management, law and economics and focuses on negotiations that shape and manage the global policy environment for health. The relationship between health, foreign policy and trade is at the cutting edge of global health diplomacy.” 

Ratzan says it’s embedded in everything; from the U.S. Department of State to the Gates Foundation to the ivory towers of academia to the private sector, global health diplomacy engages all areas. While setting a global goal is important, getting there is much different. To bring these goals from ideas to practice, we need innovation. 

Mobile Technology

In April of this year, the New York Times ran a story about a woman in Nigeria who gave birth in an area without running water or electricity. What made this story so unusual? Cell phones lit the birth. In places where clean water is almost inaccessible, cell phone have deeper penetration. Dr. Ratzan called this the potential of mobile health. He then discussed a program called “Text4Baby” in a country with the following statistics:

• Annually, 500,000 babies are born prematurely
• Each year 28,000 die before their first birthday
• 89% of women between the ages of 18 - 49 have a mobile phone

What country is this? The United States of America. 

Text4Baby, founded by Johnson and Johnson, became a direct texting service out of this information. Although many factors influence these numbers -- access to health care, low income, poor health behaviors -- their research found that increasing knowledge around health, coupled with simple text reminders, could help mothers and children stay healthier. The program partnered with state and local government, along with cell phone carriers, to reach the lowest income mothers based on zip code. They plan to bring a service similar to this to Bangladesh and South Africa shortly. 

In closing

Personally, my favorite part of Ratzan’s presentation was the passion and conviction with which he spoke. Often cynicism and failure undermine our energies and ambitions, but Dr. Ratzan had a compassionate charisma that left the room feeling empowered. In essence, he brought it back to simple ways to achieve global health by utilizing existing technologies and innovative approaches. And all of this in the name of happiness.  

Melissa Sandgren is a MPP1 at the Harvard Kennedy School and a participant in WAPPP's From Harvard Square to the Oval Office program.

*Photo courtesy of http://globalhealth.illinois.edu/