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.

Redesigning Work: Findings from the Work, Family, and Health Network and Implications for Gender Inequality

Social welfare policies in the United States are unique in that they are often provided by employers – think of health care, retirement benefits, and particularly work-family policies. How do we formulate effective work-life integration policies that work for employers and for employees?

This week’s WAPPP seminar featured Erin L. Kelly, Professor of Work and Organization Studies at the MIT Sloan School of Management. Professor Kelly’s early work focused on this hybrid social welfare system in the United States, and she has continued to investigate organizational policies that may address work-family and gender issues. In particular, her work focuses on the consequences of workplace policies for employees and organizations.

Work-life conflict, job control, and flexible schedules

Specific work environments affect work-life conflict and strains. As we’ve discussed in past WAPPP seminars, job control can affect a range of health-promoting behaviors. With more control over where and when you do your work, you may have more time to exercise, cook healthy meals, get enough sleep, and reduce stress. Professor Kelly’s research as part of the Work, Family, and Health Network tests promising workplace initiatives with rigorous methods to determine what workplaces can change to improve the health and well-being of employees and their families while maintaining or improving organizations’ key outcomes.

While flexible work arrangements (like telecommuting and flex schedules) are generally considered a good thing, they may have unintended consequences. Generally, flexible schedules are decided through an “accommodation model,” in which individual employees negotiate with their managers directly. However, there are all kinds of possible confounding factors: who is willing to ask for flexible scheduling? Who gets it? Is there a “flex stigma,” such that flexible workers are perceived as less committed or less competent? Are gendered inequalities exacerbated because flexible work schedules are associated with women and families?

STAR: Normalizing flexibility

Professor Kelly’s work tries to sidestep some of these issues by making flexibility the new normal. She presented the Work, Family, and Health Network’s randomized controlled trial of flexible work in an IT division of a Fortune 500 company. Half of the work units were enrolled in STAR, a program in which work groups reconsider when, where, and how work is done. These decisions are collective and broadly framed to focus on all employees, not necessarily family needs or women’s struggles. 

The other half of the work units remained under existing company policy. Official policy allowed employees to work from home with a formal request that went all the way up to the VP. Existing practice, on the other hand, was more informal – some employees were able to work from home or shift hours, but this practice was deliberately under the radar. 

The researchers collected baseline survey and health data, along with daily diaries and spouse and child surveys. They repeated survey and health data collection at 6, 12, and 18 months. One complication arose midway through the study: the company announced that it was being acquired. The merger was implemented partway through the study.

Effects of STAR on work-family outcomes

Participating in STAR was associated with increased control over work time, greater supervisor support for personal and family life, and employees saying they had “enough time” with family. There was no effect on work hours or overall intensity. While some employers may have hoped for increased productivity, the researchers see this  as a positive sign – flexibility shouldn’t turn into pressure to be “always on.” Significantly, there was no difference in work hours with STAR based on gender or parental status. 

In terms of work outcomes, STAR increased job satisfaction at 12 months and reduced turnover intentions at 12 months. STAR also reduced voluntary exits at 3 years (7.6% of STAR participants left the company, compared to 11.3% of control group members). A related paper estimates  that STAR had a positive ROI of 1.6 for the firm. The employer reduced turnover costs and the lost productivity that comes with training new workers. 

Effects of STAR on health outcomes

STAR decreased burnout, stress, and psychological distress at the 12-month follow up for participants who began STAR before the merger was underway. For other employees, anxiety about the merger (and the future of STAR!) may have confounded these effects. Participants in STAR showed modest increases in sleep duration and quality at the 12-month follow up. STAR also increased parents’ time with children over 12 months. 

Interestingly, many of these benefits transferred to STAR participants’ children. Adolescents whose parents were in STAR showed better sleep quality and more consistent sleep duration, along with more positive affect and less emotional reactivity to daily stressors. Professor Kelly believes that this effect is partially due to parents being more available and able to stick to routines that work for their families with flexible schedules. 

The STAR experiment shows the benefits of flexible work schedules on work-family and health outcomes. However, Professor Kelly brought up a number of other questions for future study. How did behaviors actually change under STAR? Did groups differ in their utilization of flex time? We look forward to hearing more from Professor Kelly and the Work, Family, and Health Network!