STDs adversely affect the health of many women, particularly women of color. Although national studies suggest racial disparities are not accounted for by individual level factors, such as sexual risk behaviors,14–16
these studies used combined samples of men and women and do not report on racial disparities in sexual risk behaviors and their associations with STDs specifically among women. Furthermore, because drug-using women are at higher risk for engaging in sexual risk behaviors than women in national studies or even drug-using men, research focusing on this population is particularly salient. Results from the 214 recent heroin, crack, or cocaine-using women studied reveal no racial differences in the prevalence of sexual risk behaviors examined. However, there were significant racial differences in the sexual risk behaviors associated with STDs. After controlling for other sexual risk behaviors and participants' age, the only significant sexual risk behavior correlate of having a lifetime STD for black women was ever having a casual sex partner, whereas the only significant sexual risk behavior correlate of having a lifetime STD for white women was ever trading sex for money. These findings extend previous studies pertaining to correlates of STDs among drug-using women19,26
by further elucidating patterns that may be unique to black and white women who have recently used heroin or cocaine.
What is particularly striking about the pattern of findings concerns the threshold of risk behavior associated with STD status across the two racial groups studied, which may provide important insights into relationships between differential STD risk levels characterizing social networks of black and white female drug users. Namely, the findings suggest that a relatively high prevalence risk behavior, such as casual sex, may place black female drug users but not white female drug users at elevated STD risk. Conversely, the findings also suggest that a comparatively low prevalence but high risk behavior, such as sex trade, places white female drug users but not black female drug users at elevated STD risk. Each of these findings is both simultaneously sensible and curiously noteworthy. One possible explanation may have to do with variations in STD prevalence across the social networks of the black and white women in this study. To the extent that white drug users tend to access casual sex partners in social networks that are generally not characterized by high levels of STDs, casual sex, though risky, still might not be a potent predictor of STD status. However, when white female drug users engage in sex trade, they expose themselves to a social network with much higher levels of STDs, thus helping to explain the significance of sex trade status among this subgroup of women. The findings may also suggest that the prevalence of STDs is higher among social networks in which black women find sex partners, and to this end, casual sex operates as a potent predictor of STD status. Further, if already high rates of STD among casual sex networks of black drug-using women explain the STD risk associated with casual sex in this group, it may also help explain why the additional risk engendered by sex trade status does not achieve significance. This pattern of findings is consistent with extant studies suggesting differing rates of STDs among social networks across racial/ethnic lines, with considerable pertinence to the focus of targeted prevention efforts.
STDs were common in this sample of recent heroin-using or cocaine-using women, with 40.7% of women reporting that a health professional had told them they had an STD, including gonorrhea, syphilis, chlamydia, genital herpes, genital warts, or trichomoniasis. More black women (49.6%) than white women (27.6%) reported a lifetime history of one of these six STDs. The higher rates of STDs found among our sample of black women are consistent with the broader literature suggesting racial disparities in the prevalence of STDs.8–10,14,15
Sex trade for money was more common and showed a larger association with STDs in terms of the size of the ORs and significance levels than sex trade for drugs. These findings suggest that there may be differential patterns of associations between types of sex trade and STD risk that warrant further investigation. To date, these two types of sex trade are typically combined in studies,27,28
but future studies looking into potential unique relationships with these variables and health outcomes may elucidate specific patterns that may inform infectious disease prevention interventions. Future studies are also needed to repeat these analyses while controlling for other potential covariates, including women's histories of violence, which have also been associated with women's risk for contracting STDs.29
These findings suggest that although targeted STD/HIV interventions may assist with reducing STD/HIV risk among white recent heroin-using and cocaine-using women, these individual level interventions are necessary but not sufficient to address the racial STD disparities that exist among black recent heroin-using and cocaine-using women. In fact, multiple studies suggest that high rates of STDs among black women are attributed to networks and other structural level factors, such as the high rates of incarceration among black men, that impact black women. Therefore, to truly reduce the rates of STDs among high-risk black women, such as those who use heroin or cocaine, reducing safe sex alone, including promoting women's methods (e.g., female condom, microbicides), may not be enough to substantially reduce STD rates in this high-risk population. Other structural interventions for reducing STDs among black recent heroin-using or cocaine-using women, including those that address poverty, discrimination, racism,30–32
and the impact of incarceration,33
are also needed, in addition to individual level interventions, to reduce risk for STDs in this population of women.
Important study limitations should be noted. This study relied on participant self-reports of STDs, which may be less accurate than serological data.34
However, self-reports of STDs have been found to be valid in comparison to other assessment methods, including medical record reviews and state health department reports.35
The span of some CIs also suggests some instability in the models. Also, this study is cross-sectional so conclusions about the temporal relationship of variables examined cannot be drawn. Although partner, peer, social, cultural, and structural level variables also play a role in the transmission of STDs,31,32,36
such data were not available for this study. Future research should examine these factors in order to better understand how these mechanisms may influence racial STD disparities in this population of women. Nevertheless, individual level information, such as that reported here, is essential for informing individual behavioral interventions.