Case Study: Understanding how intersectional disparities in sexual orientation and ethnicity had unexpected impact on the use of Papanicolaou (Pap) tests in the US

Agénor, M., Krieger, N., Austin, S.B., Haneuse, S. and Gottlieb, B. R. 2014. At the intersection of sexual orientation, race/ethnicity, and cervical cancer screening: assessing Pap test use disparities by sex of sexual partners among black, Latina, and white US women. Social Science & Medicine, 116:110 – 118.

Main text

The work of Magina Agénor illustrates the importance of integrating intersecting dimensions of inequalities in research questions. It also shows options for exploring structural drivers of unequal experiences when relevant data are not available in secondary data sources.

Madina Agénor is a social epidemiologist based in the USA specialising in sexual and reproductive health. Using secondary quantitative data from a large national survey, Agénor and her colleagues observed lower uptake of cervical cancer screening among black lesbian, bisexual and queer (LBQ) women relative to black heterosexual women. However, they were unable to identify the potential structural drivers of the lower uptake of screening in this group using the quantitative data available to them.

To explore potential explanations Agénor and her colleagues conducted four focus group interviews with black lesbian, bisexual and queer women. They found that patient-provider communication was key in understanding the low uptake. The most salient themes that emerged from the analysis of the qualitative focus group data were:

(1) health care provider communication style and demeanour – women preferred “friendly,” “supportive,” “caring,” and “helpful” providers who had experience and felt comfortable serving LBQ patients, and took the time to build a relationship with them;

(2) ‘heteronormative’ assumptions (i.e. based on the belief that heterosexuality is the only normal and natural expression of sexuality) amongst health care providers were not appropriate to, and could have negative impacts on, LBQ women’s lived and health care need;

(3) a lack of diversity amongst health care providers including in their socio-demographic background resulted in complex discriminatory attitudes racism, classism and heteronormative prejudices;

By applying an intersectional lens to the analyses of quantitative secondary data source and collecting primary qualitative data from focus group interviews to explain the quantitative findings, Agénor and her colleagues were able to illuminate fine grained inequalities in the health care experiences of women of colour in non-heterosexual relationship (i.e. Black lesbian, bisexual, and queer women) and identify some of the root causes of these. As a result they were also able to make policy recommendations that had greater potential to increase screening uptake in this group focused on training for and recruitment of health care providers. These are described in this case study.