Residential Racial Segregation and Sexual Risk in the United States

Adolescents and young adults continue to have the highest rates of sexually transmitted infections (STI) in the United States, and blacks bear a disproportionate burden. While most sexual risk research has focused on understanding individual-level risk factors and intervening on individual behaviors, these individual-level differences do not completely explain the racial disparities in sexual risk. Determining the underlying causes of racial disparities in sexually transmitted infections is important to reduce the burden overall and eliminate inequities in health. Residential racial segregation results in very different contexts for individuals, largely stratified by race, and may be an important determinant of sexual risk. This dissertation examined whether residential racial segregation -- as measured using indices obtained from the US Census Bureau -- is associated with sexually transmitted infections and sexual risk behaviors, and whether it could help explain the racial disparities in these health outcomes.;In the first study, which was ecologic in nature, using data on reported cases of gonorrhea provided by special request from the Centers for Disease Control and Prevention (CDC), I demonstrated that certain dimensions of segregation were associated with rates of gonorrhea among blacks in the United States.;In an attempt to determine whether segregation impacted sexual risk by impacting sexual risk behaviors, the remainder of the dissertation examined whether segregation could help explain black-white differences in sexual risk behaviors in a population-based, 11-year prospective study of adolescents in the United States (NLSY97). Specifically, for the second study, we used 2-level hierarchical survival analysis to simultaneously examine whether MSA-level residential racial segregation is associated with age at sexual initiation, after accounting for other area-level covariates, such as area socioeconomic position, and individual-level covariates, such as gender and family income. We determined that segregation was not associated with early age at sexual initiation overall but that it did help to explain the racial disparity in this outcome. In more segregated areas, blacks were at higher risk than whites, whereas no racial disparity existed in less segregated areas.;In the third study, we performed 3-level hierarchical linear regression to examine whether residential racial segregation was associated with a sexual risk index over 11 years of follow up. In this study, we did not find any evidence that segregation was associated with the sex risk index or that it modified the trajectory of the race-sex risk association.;Collectively, the results of this dissertation suggest that residential racial segregation is related to racial disparities in STIs but that the impact may not be due to the impact on differences in sexual behaviors, particularly among sexually experienced individuals. Future research should begin to test the mechanisms linking segregation to disparities in STIs, and examine whether segregation is associated with sexual network patterns, whether it can help explain the racial disparities in sexual network patterns, and whether sexual networks can mediate the relationship between segregation and STIs. Additionally, future studies might examine whether segregation is associated with behaviors that have been more consistently and directly shown to explain disparities in STI risk, including concurrency and sex with casual and high-risk partners. Ultimately, this information can be used to inform the creation of more context-appropriate prevention interventions or structural interventions that aim to change the underlying racialized contexts.