Race, ethnicity, and sexual healthBMJ 1997; 314 doi: https://doi.org/10.1136/bmj.314.7096.1703 (Published 14 June 1997) Cite this as: BMJ 1997;314:1703
Can sexual health programmes be directed without stereotyping
- Kevin Fenton, Lecturera,
- Anne M Johnson, Professor of epidemiologya,
- Angus Nicoll, Consultant epidemiologistb
- a Department of Sexually Transmitted Diseases, UCL Medical School, Mortimer Market Centre, London WC1E 6AU
- b PHLS Communicable Disease Surveillance Centre, London NW9 5EQ
Studying and interpreting the relation between race, ethnicity, and health often invites debate and controversy. Research in this area is rapidly expanding, driven by a desire to explore variations in health and to understand the aetiology of diseases. However, concerns have been raised about the ways in which race and ethnicity are defined and used in epidemiological research. Some have questioned the motives behind research in ethnicity; with hindsight, it is often unclear who, besides the researcher, benefits from the results. Methodological errors in some studies, chief of which is non-adjustment for confounding by socioeconomic variables, have led to erroneous conclusions or to findings of limited generalisability. To this end, guidelines for improving the use of ethnicity in research and mechanisms to avoid common pitfalls have been published.1 2
In this week's BMJ, Raj Bhopal takes a critical look at research in race and ethnicity (p 1751).3 He challenges researchers to “move from repetitive demonstration of disease variations” towards “assessing needs and inequality, and guiding practical action.” Alongside this article are a series of papers that demonstrate or comment on ethnic differences in the incidence of sexually transmitted diseases, including HIV infection and AIDS.4 5 6 7 The studies also highlight the difficulties in carrying out such research. But to what extent has Bhopal's challenge been met by researchers and practitioners in sexual health? How should these findings impact on the provision of services to reduce inequity?
Surveillance data for HIV infection and AIDS and other sexually transmitted diseases show variations in incidence across ethnic groups.8 9 10 In the United States, higher rates of sexually transmitted diseases have been described among some minority racial groups compared with white people. The most recent epidemic of syphilis was located largely among African Americans living in poverty.11 Heterosexually acquired HIV infection in the United States is now increasing in all ethnic groups, with the highest infection rates occurring in young women in ethnic minorities (Rosenberg et al.
(Abstract Tu C572.) XI International conference on AIDS, Vancouver, July 7-12, 1996).In Britain, apart from some data for HIV infection and AIDS, the absence of ethnicity in routine surveillance has limited our ability to explore ethnic differences.12 Descriptive surveys undertaken in sexually transmitted disease clinics, though convenient, can provide only limited information that has limited generalisability. Comparisons between clinics are limited by poor comparability of patient data, diagnostic criteria, and ethnic categories. Where minority populations are more or less likely than white people to make use of sexually transmitted disease clinics (from which surveillance reports are completed), reporting bias may also contribute to differential rates.
Recent studies have looked at the distribution of sexually transmitted infections diagnosed in sexually transmitted disease clinics in relation to the local population. Studies in south east London (p 1719)4 and in Leeds (p 1715)5 suggest that being of a black ethnic group is associated with a higher risk of acquiring gonorrhoea as judged by incidence rates, even after controlling for socioeconomic status. The differences in disease incidence suggested between racial groups are alarming, although the inability to differentiate between some ethnic groups, particularly between black African and black Caribbean, by the authors' own admission, limits the usefulness of the findings in ethnically diverse areas such as London. This highlights the problem emphasised by DeCock and Low (p 1747),6 that without standardised collection of interpretable data on ethnicity, opportunities for surveillance to inform action on public health are lost.
How ethnicity relates to health is unclear
Bhopal chastises the research community for undertaking “black box epidemiology” in which the emphasis is placed on describing associations without due regard to the underlying mechanisms by which they occur.3 How ethnicity relates to sexual health remains unclear. There are no known biological reasons to explain why racial or ethnic factors alone should alter the risk for sexually transmitted diseases. Race and ethnicity may be markers that are associated with fundamental determinants of health such as poverty and seeking health care.12 A person's cultural background can have a strong influence on his or her sexual attitudes and behaviours,13 sexual mixing patterns, and choices of partner. For example, people tend to have partners within their own ethnic group (a form of assortative mixing),14 and, in the presence of raised levels of undetected sexually transmitted diseases, assortative mixing may make ethnicity an important determinant of incidence of sexually transmitted diseases, further disadvantaging some communities. Conversely, other communities may seem to be protected: for example, Asians have lower incidences of AIDS and sexually transmitted diseases.8 10 Variations in the quality, availability, delivery, and use of services proved to be effective in preventing sexually transmitted diseases (such as screening and contact tracing) may also contribute.
Implications for public health
The public health implications are numerous. Sexual health remains a national priority and a major problem.7 Objectives have been set in the government's Health of the Nation strategy to reduce the incidence of HIV infection and other sexually transmitted diseases, with specific targets related to gonorrhoea and teenage conceptions.15 Citing various national data, including the incidence of gonorrhoea in 1995,16 Adler (p 1743) expresses concern at the poor progress in this area over the past five years.7 Suggestions that, within this, some groups may be more severely affected–such as gay men, teenage women, and certain ethnic minorities–are worrying. It is imperative that a balance is created between aiming control strategies at the general population and meeting the needs of those at higher risk.
How might these findings be useful in guiding national policy on sexual health? Both studies suggest that black groups are at higher risk of acquiring gonorrhoea,4 5 and surveillance reports show black Africans to be at high risk of heterosexually acquired AIDS.8 However, it is crucial to consider also the proportion of the total of infections occurring in different groups, the population attributable risk. In south east London, where black groups comprise nearly 20% of the local population,17 63% of people with gonorrhoea were black, while in Leeds the comparable figure was 27%. The only available national gonorrhea dataset with ethnic data, that from the PHLS Gonococcal Reference Unit, indicates that being a black Caribbean confers higher risk but that most gonococcal infections were among white people.10 Given the uneven geographic distribution of ethnic minorities, appropriate policies and initiatives must be tailored to the needs of local communities.
How should the sexual health services respond? What these observational data cannot answer is whether the underlying differences lie predominantly in different lifestyles, in patterns of health seeking behaviour, or in the quality of services provided. Ethnic differences in consulting behaviours have been documented.18 19 If high risk ethnic minority communities have poor access to sexual health services, then infections will persist within these groups, with the burden of the resultant sequelae. Such inequity demands concerted action by public health practitioners, providers of sexual health services, and specialists in health promotion to ensure that their services are sensitive to the needs of their local communities and are able to respond effectively. Not all ethnic minority communities are at high risk, and some are at lower risk than the ethnic majority,8 10 a point seldom given any attention. Nevertheless, many will have specific needs that should be addressed to improve access and acceptability of services.
Involving the most affected communities in the planning and implementation of programmes is essential. As Bhopal advocates,3 this requires establishing partnerships between ethnic minority and ethnic majority scientists and the continued involvement of organisations based in ethnic minority communities. Continued support should be given to these organisations to carry out initiatives promoting sexual health. Culturally sensitive and innovative approaches to preventing disease are critical, and services will need to be targeted effectively without stigmatising affected communities.
Gonorrhoea is curable, and HIV infection is increasingly treatable. Both are preventable. Acknowledging ethnic disparities in rates of HIV infection and other sexually transmitted diseases is one of the first steps in empowering affected communities to organise and focus on this problem. However, openness to ethnic differences should not be a license for stereotyping and exploitation, and, in this regard, the media carry a particular responsibility. Polarised and dogmatic approaches are more likely to exacerbate than alleviate current problems.