Introduction

Despite public health efforts, there has been a persistent rise in the prevalence of sexually transmitted diseases (STDs) worldwide (World Health Organization (WHO), 2022). Globally, more than one million individuals get infected with STDs every day, most of which are asymptomatic (WHO, 2022). Approximately 374 million STDs are reported yearly, including chlamydia, syphilis, gonorrhea, human immunodeficiency virus (HIV), and trichomoniasis (WHO, 2022). In the USA, 1 in 5 individuals reported having an STD in 2018, with almost 50% of new STD infections reported among young individuals ages 15–24 years, who also have the highest prevalence and incidence rates of human papillomavirus (HPV) infection (Centers for Disease Control and Prevention (CDC), 2021). STDs have also been associated with poor health outcomes, especially among females, including infertility, pelvic inflammatory disease (PID), congenital infections, and cervical cancer (NIH, 2022). Furthermore, the direct medical expenses associated with STDs exceeded $16 billion in 2018 (Adzrago et al., 2021; CDC, 2021). The rising prevalence of STDs and its cost to the medical system merit research investigating predictors of STD incidence, particularly in vulnerable subgroups in the USA, such as racial–ethnic minorities.

Previous studies indicated that Black/African American populations in the USA have been disproportionately affected by STDs due to health disparities and other sociodemographic factors, including gender, age, education, income, geographic location, and social status (Adzrago et al., 2021; CDC, 2020, 2021; Chittamuru et al., 2018). These correlates, as mentioned above, have also increased the risks of STD prevalence and incidence rates among Black/African American adults due to systemic barriers, societal stigma, and lack of access to proper treatment (Adzrago et al., 2021; Feaster et al., 2016). In 2018, the CDC STD surveillance also reported that chlamydia and gonorrhea rates were 5–8 times higher among Black/African American females and males than among their White female and male counterparts (CDC, 2020). There was also a more disproportionate burden of HIV among Black/African American men (31%) than among Black/African American females (11%) (CDC, 2020). It should also be noted that most HIV infections domestically have been reported among Black/African American men who have sex with men (MSM) compared to other racial/ethnic and sexual identity subgroups (Kelly et al., 2020). Conversely, HIV diagnoses (92%) among Black/African American females have been attributed to heterosexual contact (CDC, 2020). In addition to the physical health consequences (e.g., PID, congenital infections, and cervical cancer) of STDs, Black/African American individuals have reported experiencing co-occurring mental health and substance use disorders, including depression, anxiety, and bipolar disorder, due to the struggles and stigma related to sexual health and STDs in this population (Adzrago et al., 2021; Hotton et al., 2020; Rein et al., 2004; Thames et al., 2018). Consequently, young adults with depression have been noted to have an increased risk for STDs, with these increased odds being higher in males than in females in the general population (Jenkins & Botchway, 2016).

The long-established negative stereotypes (e.g., insatiable sexual desires, sexual promiscuity, lack of morality) associated with Black/African Americans regarding their race and sexuality, both in research studies and in the real world, have led to unresolved repercussions of poor sexual and physical health outcomes (Boutrin & Williams, 2021). These negative stereotypes and social stigma contributed to the rise in social inequality, including educational, economic, social class, and healthcare access opportunities (Boutrin & Williams, 2021). Also, there is a lack of provision of adequate healthcare and treatment for Black/African Americans as a result of pronounced disparities, racism, and marginalization (Boutrin & Williams, 2021). Previous studies that have examined gender and sexual disparities regarding the prevalence of STDs among Black/African Americans are outdated, lacked a larger sample size, and had low generalizability, with a predilection on assessing STD prevalence among Black/African American sexual minority females and adolescents residing in urban areas over the inclusion of Black/African American males to improve generalizability (Chambliss et al., 2021; Hampton & Gillum, 2020; MacCarthy et al., 2015; Muzny et al., 2011; Pérez et al., 2020; Wu et al., 2009). Consequently, these above-mentioned research gaps and issues stemming from structural racial barriers, societal dysfunction, psychosocial determinants, and poor interpersonal relationships have perpetuated sexual health disparities among Black/African Americans (Banks et al., 2020).

Even though studies have been conducted focusing on assessing issues related to STDs among Black/African Americans, the literature is still scant regarding understanding the gender and sexual identity-based disparities in STD prevalence among Black/African Americans. To address this gap, we conducted a study using a nationally representative sample of Black/African American adults in the USA to assess (1) the trend of STDs over 3 years (2017, 2018, and 2019) based on sex; (2) estimate the prevalence of STDs based on sex by mental health and substance use disorders and sociodemographic characteristics; (3) examine the association between STDs and the mental health and substance use disorders, adjusting for sociodemographic characteristics and sexual identity based on sex; and (4) whether mental health or substance use disorders moderate the association between STD diagnosis and sexual identity based on sex while adjusting for the sociodemographic characteristics. The stratification by sex helps, for instance, to examine the intersection of sex and sexual identity to identify, for example, individuals whose sex at birth was male but identified their current sexual orientation as lesbian. The results from this study will help inform efforts to develop strategic public health interventions to combat the socio-cultural and structural issues to provide better access, knowledge, treatment, and care regarding STDs and co-occurring diseases for Black/African Americans, especially their most at-risk groups.

Methods

Study Design

We analyzed secondary data using the 2017–2019 de-identified public-use data from the National Survey on Drug Use and Health (NSDUH), an annual cross-sectional survey. NSDUH assesses sexual health behaviors, mental health, and substance use among a nationally representative sample of the US civilian, noninstitutionalized population in each of the 50 states and the District of Columbia (Center for Behavioral Health Statistics and Quality, (CBHSQ), 2020; Substance Abuse and Mental Health Services Administration (SAMHSA), 2020). SAMHSA sponsors the survey, CBHSQ plans and manages the survey, while Research Triangle Institute is contracted to execute the data collection and analysis. NSDUH uses a complex, multistage area probability to select individuals aged 12 years and older. The combined datasets from 2017 to 2019 include 168,725 samples. Our analysis was limited for this study to focus on the 15,924 respondents with complete data on sexually transmitted diseases among those who self-reported to be non-Hispanic Black/African Americans.

Measures

Dependent Variable

The dependent variable is a self-reported sexually transmitted disease (STD) diagnosis status. This variable was measured by asking the participants, “During the past 12 months, did you have a sexually transmitted disease such as chlamydia, gonorrhea, herpes or syphilis?” with a yes or no response option (CBHSQ, 2020; SAMHSA, 2020).

Independent Variables

Self-reported sex (male or female) and sexual identity (heterosexual, lesbian/gay, bisexual, or other) were analyzed as the main independent variables. Other independent variables included past-year major depressive episodes (MDEs) and dependence on alcohol use and illicit drugs other than marijuana, opioids, and marijuana.

Past-year symptoms of MDE were measured based on the Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-5) in the NSDUH. The DSM-5 has nine self-reported criteria to determine lifetime MDE (American Psychiatric Association, 2013; CBHSQ, 2020; Harvard School of Medicine, 2005). Participants were classified as experiencing lifetime MDE if they met at least five of the criteria. Participants were further classified as experiencing MDE in the past year if they had lifetime MDE and reported also experiencing depression lasting for at least 2 weeks and still experiencing some of the lifetime MDE symptoms. Those not meeting these past-year criteria were classified as not experiencing past-year MDE symptoms (CBHSQ, 2020).

Past-year alcohol use dependence (AUD) was measured based on seven DSM-4 criteria (Fauman, 2002; SAMHSA, 2020). Participants who met at least three of the criteria were categorized as experiencing past-year AUD. Those with less than three of the criteria were considered not experiencing past-year AUD. The criteria are described in detail in SAMHSA (2020).

Past-year illicit drug use dependence other than marijuana use was determined if the participants were dependent on at least one illicit substance except for marijuana in the past year (SAMHSA, 2020). These illicit substances, except marijuana, include hallucinogens, inhalants, methamphetamine, cocaine, heroin, prescription pain relievers, prescription sedatives, prescription stimulants, or prescription tranquilizers (SAMHSA, 2020). They were classified as not dependent on illicit drug use dependence other than marijuana use if they did not experience any dependence on any of the illicit substances.

Past-year marijuana use dependence was determined with six criteria from the DSM-4 (American Psychiatric Association, 1994; SAMHSA, 2020). Those who met at least three of the six criteria were considered as experiencing marijuana use dependence in the past year. In contrast, those who met less than three of the criteria were not classified with marijuana use dependence in the past year.

Past-year opioid use dependence was determined if the participants had either a heroin use dependence or pain reliever dependence or dependence on both heroin use and pain reliever use (CBHSQ, 2020; SAMHSA, 2020). Otherwise, the participants were classified as non-dependent on opioid use in the past year.

Covariates

We analyzed the sociodemographic variables as covariates based on their potential associations with STDs in previous studies (Adzrago et al., 2021). These variables include age (18–25, 26–34, 35–49, 50–64, and 65 or older), level of education completed (less than high school, high school graduate, some college/associate degree, or college degree), marital status (never been married, divorced/separated/widowed, or married), total family income (less than $20,000, $20,000 to $49,999, $50,000 to $74,999, or $75,000 or more), and employment status (unemployed, employed part-time, employed full-time, or not in the labor force (retired, disabled, keeping housing, or caring for children full-time, in school/training).

Statistical Analysis

We used STATA/SE version 16 (StataCorp, 2019) to obtain design-based (weighted) point estimates for STDs. We estimated the weighted prevalence of STDs by sex (males vs. females) among Black/African American adults over 3 years (2017, 2018, and 2019). Stratified by sex, we computed unweighted frequencies with their weighted percentages for all variables by self-reported STD diagnosis status. Next, we conducted a weighted bivariate analysis using Rao–Scott χ2 tests (Rao & Scott, 1981) to determine differences in the self-reported STD diagnosis status by the sociodemographic, mental health, and substance use disorder factors stratified by sex. Group differences at the bivariate analysis level were detected at a statistical significance level of ≤ 0.0005 to reduce uncertainty in the significance of the group differences.

Furthermore, we examined the association between STD diagnosis status and the independent variables, adjusting for the covariates based on sex among the Black/African American adults. We used weighted logistic regression models to examine the associations, and the Wald chi-squared (χ2) test at an alpha level of 0.05 was used to assess the statistical significance of the odds ratio estimates. The logistic regression models estimated adjusted odds ratios (AORs) with 95% confidence intervals (CIs). Finally, moderation analyses were performed to examine whether mental health or substance use disorders moderate the association between sexual identity and STD diagnosis, adjusting for the covariates based on sex.

Results

Visual Trends in the Prevalence of STDs by Sex

Figure 1 displays the prevalence of STDs by sex among Black/African American adults over 3 years (2017, 2018, and 2019). The prevalence of STDs showed curvilinear or convex trends among males and females over the three years. Females had a higher prevalence in 2017 and 2019 than males, while males slightly had a higher prevalence in 2018 than females. As shown in Table 1, the overall prevalence was higher among females (3.01%) compared to males (2.61%).

Fig. 1
figure 1

Visual trends in the prevalence of STDs by sex among Black/African American adults over 3 years (2017, 2018, and 2019)

Full size image
Table 1 Descriptive and bivariate analyses of STD prevalence by sociodemographic, mental health, and substance use disorder factors (N = 15,924)
Full size table

Descriptive Statistics of the Population Characteristics Stratified by Sex

Table 1 presents the weighted proportions of the study population. Most of the study population was female (54.75%). Among males, individuals aged 35–49 (25.37%), self-identified as heterosexual (94.04%), with a high school education (34.06%), never been married (45.89%), with a total family income of $20,000 to $49,999 (33.70%), or employed full-time (51.08%) formed the largest subset of the sampled male population. About 4.16%, 3.81%, 1.25%, 2.15%, and 0.80% of the males experienced past-year MDE, alcohol use dependence, illicit drugs other than marijuana use disorder, marijuana use dependence, and opioid use dependence, respectively.

The female population was mostly aged 35–49 (25.36%) or 50–64 years (25.08%), heterosexual (90.54%), had some college/associate degree (34.82%), was never married (44.09%), had total family income of $20,000 to $49,999 (36.12%), and was employed full-time (45.00%). A proportion of them also experienced MDE (7.15%), alcohol use dependence (2.01%), illicit drugs other than marijuana use disorder (0.78%), marijuana use dependence (1.09%), and opioid use dependence (0.49%).

Subgroup Differences in STD Diagnosis Status Based on Sex

We observed differences in STD diagnosis between subgroups among males and females. The majority of the males who had STD were aged 18–25 (3.82%) or 26–34 (3.96%) years, lesbian or gay (11.40%), never married (3.48%), and unemployed (4.70%), or employed part-time (4.24%). The STD prevalence was also highest among males who experienced MDE (6.91%), alcohol use dependence (6.24%), or marijuana use dependence (9.69%). The majority of the females who had STD were aged 18–25 years (6.95%), bisexual (10.22%), never married (4.60%), had less than $20,000 total family income (3.94%), and was unemployed (4.44%). A high prevalence was also observed among the females who experienced MDE (5.97%), alcohol use dependence (9.11%), illicit drug other than marijuana use disorder (13.64%), marijuana use dependence (17.92%), and opioid use dependence (14.26%).

STD Diagnosis Status and Its Associated Factors Based on Sex

As shown in Table 2, males who identified as gay (AOR = 4.51; 95% CI: 2.60, 7.81) or bisexual (AOR = 3.92; 95% CI: 1.90, 8.12) were more likely than heterosexual individuals to have STDs. Those not in the labor force (retired, disabled, keeping housing, or caring for children full-time, in school/training) had lower odds of STDs (AOR = 0.33; 95% CI: 0.16, 0.68) than their unemployed counterparts. Marijuana use dependence was associated with higher odds of having STDs (AOR = 2.29; 95% CI: 1.31, 4.02).

Among females, those 35 years or older had lower odds of STDs (AORs = 0.21–0.43) than their younger counterparts aged 18–25 (see Table 2). Compared to heterosexual individuals, bisexual individuals were more likely to have STDs (AOR = 2.11; 95% CI: 1.36, 3.27). Having a total family income of $20,000 to $49,999, compared to having less than $20,000, was associated with lower odds of being diagnosed with STDs (AOR = 0.63; 95% CI: 0.43, 0.91). Those who experienced marijuana use dependence were more likely than their counterparts to be diagnosed with STDs (AOR = 3.11; 95% CI: 1.99, 4.85).

Moderation Analysis: Between and Within Group Differences

The results of the moderation analyses are presented in Figs. 2, 3, 4, 5, and 6 using a marginsplot. The results determined whether MDE and dependence on alcohol, illicit drugs other than marijuana, opioids, or marijuana moderate the association between STD diagnosis and sexual identity based on sex, adjusting for the sociodemographic characteristics.

Fig. 2
figure 2

Differences in STD diagnosis between and within sexual identity and MDE based on sex

Full size image
Fig. 3
figure 3

Differences in STD diagnosis between and within sexual identity and alcohol use dependence based on sex

Full size image
Fig. 4
figure 4

Differences in STD diagnosis between and within sexual identity and illicit drugs other than marijuana use dependence based on sex

Full size image
Fig. 5
figure 5

Differences in STD diagnosis between and within sexual identity and marijuana use dependence based on sex

Full size image
Fig. 6
figure 6

Differences in STD diagnosis between and within sexual identity and opioid use dependence based on sex

Full size image

Figure 2 shows the moderation effects of MDE and sex on the association between STD diagnosis and sexual identity. The association was significantly moderated by MDE and sex (p < 0.001). Bisexual females who experienced MDE had the highest probability of being diagnosed with STDs, whereas the lowest probabilities were observed for heterosexual males and females with no MDE. Heterosexual females with MDE, lesbian/gay males with MDE, and bisexual females with MDE had the highest probabilities in their respective sexual identity subgroups.

Moderation of the association between STD diagnosis and sexual identity by alcohol use dependence and sex is presented in Fig. 3. Alcohol use dependence and sex moderated the association between STD diagnosis and sexual identity (p < 0.001). Sexual minority males with no alcohol use dependence had the highest probability of being diagnosed with STDs, while heterosexual males with no alcohol use dependence had the lowest probability. High probabilities were observed in each sexual identity group for the following subgroups: heterosexual females with alcohol use dependence, lesbian/gay males with no alcohol use dependence, and bisexual males with no alcohol use dependence.

We found significant moderation of the association by illicit drugs other than marijuana use dependence and sex (p = 0.001). Figure 4 shows the moderation analysis results of how illicit drugs other than marijuana use dependence and sex moderate the association between STD diagnosis and sexual identity. While lesbian or gay males with no illicit drugs other than marijuana use dependence had the highest probability of being diagnosed with STDs, heterosexual males and females without illicit drugs other than marijuana use dependence had the lowest probabilities. In each sexual identity subgroup, the highest probability was found for heterosexual females with no illicit drugs other than marijuana use dependence and lesbian/gay and bisexual males without illicit drugs other than marijuana use dependence.

As shown in Fig. 5, marijuana use dependence and sex significantly moderated the association between STD diagnosis and sexual identity (p < 0.001). Bisexual females with marijuana use dependence had the highest probability of being diagnosed with STDs, whereas heterosexual males and females with no marijuana use dependence had the lowest probabilities. Among heterosexuals, females with marijuana use dependence had the highest probability; bisexual females with marijuana use dependence had a significant likelihood, which was also revealed among lesbian/gay males with no marijuana use dependence.

Figure 6 displays the significant moderation of opioid use dependence and sex on the association between STD diagnosis and sexual identity (p = 0.001). Lesbian or gay males with no opioid use dependence had the highest probability of being diagnosed with STDs. However, the lowest probabilities were found among heterosexual males and females with no opioid use dependence. Among heterosexuals, females without opioid use dependence had the highest probability; lesbian or gay males and bisexual males without opioid use dependence had the highest probabilities in their respective subgroups.

Discussion

Overall, our study found that certain subgroups faced higher odds of STDs among Black/African Americans. The prevalence of STDs was higher among Black/African American females than males across all years of analysis, with high prevalence seen among females and males with MDE and substance use disorders (AUD, cannabis use disorder, OUD, and illicit drug use disorder). Notably, Black/African American sexual and gender minorities, including gay and bisexual males and bisexual females, had the highest odds of STDs. Accordingly, the highest prevalence of STDs was seen in gay and bisexual males with MDE, bisexual females with MDE and cannabis use disorder, and bisexual males with cannabis use disorder.

Table 2 Weighted logistic regression analysis of STD diagnosis and its associated sociodemographic, mental health, and substance use disorder factors
Full size table

The rationale behind the higher rates of STDs in Black/African Americans has been theorized to be multifactorial, a reflection of systemic, institutionalized, and structural racism, in addition to interpersonal racism facing Black/African Americans (Noah et al., 2018; Prather et al., 2018). These factors culminate in Black/African Americans, particularly disproportionately residing in socioeconomically disadvantaged neighborhoods, having high risks of STD diagnoses (Noah et al., 2018; Prather et al., 2018). The risks are also due to a lack of positive social and economic outlets leading to an increased propensity for behaviors across varied domains of substance use to sexual behaviors, which are strong risk factors for STDs (Noah et al., 2018; Prather et al., 2018). Additionally, early sexual initiation and exposure to adverse childhood experiences (ACEs) disproportionately impact the Black/African American female population, contributing to a higher prevalence of STDs in this population (Tsuyuki et al., 2019). Moreover, the increased prevalence of STDs seen among people with substance use disorders, including cannabis and alcohol use disorders in this study, might be tied to ACEs predisposing individuals to engage in behaviors related to substance use and sexual behaviors (Tsukuyi et al., 2019). Furthermore, Black/African American females, compared to White females, are noted to have more prevalent risky sexual behaviors such as being in a high-risk sexual social network and engaging in assortative partner selection patterns, including increased odds of having concurrent opposite-sex sexual partnerships and perceived nonmonogamous sexual partners (Aholou et al., 2017; Mena et al., 2017). Again, many of the behavioral discrepancies are rooted in multifactorial systemic and interpersonal racism, which denies the equitable allocation of resources and opportunities for Black/African Americans, including in the domains of health and education (Aholou et al., 2017; Dretler et al., 2020; Mena et al., 2017; Prather et al., 2018).

In our study, we noted the accentuated prevalence of STDs in Black/African American sexual minorities. Apart from the physical health consequences (e.g., infertility, pelvic inflammatory disease, and cervical cancer) of STDs, Black/African American sexual minorities have been reported to suffer inexplicably from poor mental health outcomes and substance misuse disorders (Hotton et al., 2020). There is a pronounced interpersonal stigma that Black/African American sexual minorities face regarding their STDs, which culminates in adverse mental health outcomes, including depression, and can form barriers to seeking medical care (Vyavaharkar et al., 2010; Wohl et al., 2013). Black/African American women who have sex with both women and men (WSWM) were more likely to report prior STD infections, including chlamydia and gonorrhea, compared to Black/African American women who have sex with women only (WSW) and had higher risks of STDs (Muzny et al., 2011). Black/African American sexual minority women were also more likely to have multiple sexual partners and substance misuse disorder and had greater odds of transactional sex than heterosexual women (MacCarthy et al., 2015). A national study among university students found that both previous-year and lifetime STDs were significantly higher in Black/African American women, and marijuana users reported higher risks of STDs compared to non-marijuana users (Wu et al., 2009).

Furthermore, our study found an increased prevalence of STDs among Black/African Americans with MDE, where Black/African American males with MDE had higher odds of STDs that approached statistical significance, whereas there was no trend among Black/African American females. The rationale behind this association could be tied to the complex interplay between poor mental health and risky sexual behaviors. Indeed, depression can lead to indiscretion and the lack of desire to care for one’s health, thus increasing the propensity for engaging in risky behaviors from substance use to sexual behaviors, while a diagnosis of an STD can instigate and exacerbate depressive symptoms (Jenkins & Botchway, 2016). Future efforts are needed to improve mental health screening and treatment, particularly for Black/African American young adults who lack adequate access to and provisioning of mental health services and, even when being able to access services, are not diagnosed at the same rate as and given similar treatment regimen as White individuals (Lemonius et al., 2022; Plowden et al., 2016).

There should be intentional efforts that can harness the unique neighborhood assets in Black/African American communities to develop targeted interventions in subgroups of the Black/African American community who have a disproportionate burden of STDs, including enhancing the education on safe sex practices and augmenting access to efficient medical diagnosis and care of STDs and other sexual diseases. One such intervention can focus on strengthening intra-familial sexual education messaging domestically in Black/African American households. A program that focused on enhancing maternal–son discussions of safe sexual practices led to an increased awareness of safe sex practices among male adolescents Black/African Americans (Zhang et al., 2018), while the Shape Up community-based participatory research-focused program harnesses the relationship between neighborhood barbers and young men to promote condom usage and risk mitigation in young Black/African American men (Jemmott et al., 2017). Accordingly, targeted interventions from a community-based participatory research approach, where community members are empowered collaborators rather than passive recipients, should be considered for the Black/African American sexual and gender minority (SGM) subpopulations that disproportionately face the highest prevalence of STDs. Moreover, the intersectionality of sexual identity and mental illness was apparent in our analysis. Our analysis identifies that the subgroup most at risk for STDs appears to be Black/African American SGM with depression. Targeted interventions should be implemented for this subpopulation, given their high risks. Resources not just for safe sex practices but also targeting the poor mental health in the Black/African American SGM population stemming from internalized stigma and externalized discrimination should be considered (Jennings et al., 2019).

From a healthcare perspective, there is concern that Black/African Americans have higher rates of STDs, particularly females, yet, they often do not receive proper treatment for STDs in an urgent care setting (Dretler et al., 2020). Our study identified Black/African American subgroups with higher rates of STDs, who at the institutional level face inequitable treatment of STDs in the clinical setting, a population health problem that also must be rectified from a health equity perspective. In particular, Black/African American females were noted to be more likely to be undertreated for STDs which can relate to systemic issues of racism, inadequate access to high-quality healthcare in poorer areas, and because of the more subtle and non-specific symptoms at presentation for STDs compared to men (Dretler et al., 2020). Additionally, the complex intersectionality of various identities comes into factor, as being Black/African American and being an SGM provide two salient identities whose healthcare needs and need for inclusion healthcare providers often fail to meet (Salerno et al., 2020). Indeed, there is a significant need and desire for continuous enhancement of provider sensitivity training to augment their level of cultural competency in dealing with ethnic, sexual, and gender minorities (Salerno et al., 2020).

Limitations

This study had a few limitations that should be considered. First, this study sought to restrict its analysis to Black/African Americans, but it should be noted that this categorization—based on the operationalization of the survey, which had individuals self-identify their racial and ethnic identity in mutually exclusive categories—is broad and can obscure nuanced cultural and linguistic differences. For example, respondents whose origins lie in the Caribbean or Latin America may be primarily of African ancestral descent and may, based on phenotypic features, be treated by society as Black/African American with all of the discrimination and systemic barriers this entails, but this population would not be included in our analysis as they may not self-identify as Black/African Americans. Our analysis, based on the limited operationalization of race and ethnicity of the national survey, does take a simplified analysis of race and ethnicity that does not fully account for the complex intersectionality of ethnic identity, genetic ancestry, and phenotypic characteristics. Furthermore, STD prevalence was not confirmed via laboratory testing but was self-reported by participants, which also can be underestimated in this survey due to social desirability bias. The data also only included sex, not gender identity, which is a simplified analysis that omits transgender/gender nonconforming individuals and subsequent risk factors for this subpopulation that could skew findings.

Moreover, the data utilized in this analysis stemmed from a national-level cross-sectional survey. Accordingly, no causation can be implied from this analysis. We were unable to deduce a temporal trend or causal analysis of the interplay of the various domains of variables we analyzed, for example, whether mental health outcomes preceded the development of STDs. The survey also uses self-reported data, subject to recall and social desirability biases. This can cause respondents to not faithfully report STD diagnosis, consequently mitigating the associations measured in this study. In addition to the social desirability bias, some folks who took the survey might not have known their status due to limited testing, a lack of symptoms, or both. However, the national survey data across several years, including the early pandemic, provides important contextual information for STD researchers regarding the status of STD prevalence in the Black/African American population. The survey data are nationally representative and, therefore, provide good external validity to make inferences about the general Black/African American population and its varied sociodemographic subgroups, as measured in this study, at the national level. Discrepancies between subgroups were accordingly identified and can be used to guide future prevention and risk mitigation efforts to reduce the disproportionate burden of STDs in subgroups of the Black/African American population, including females, SGM, and those with MDE. Lastly, our analysis did not consider the tremendous ramifications the current COVID-19 pandemic has had on every domain of life. The impact of pandemic-induced social isolation would likely alter the trajectory of the STD prevalence trends identified in this study; this aspect should be further assessed in future epidemiological analytical studies to update the narrative regarding the current status of STD incidence and prevalence in the Black/African American population and among all racial and ethnic subgroups in the USA. Such studies will be instrumental in guiding prevention efforts in a post-pandemic world.

Conclusions

Disparities in prevalence and odds of a disease, such as STDs, suggest a fundamental failure in the healthcare system to deliver equity in healthcare access and outcomes. Identifying and exploring the causes of such disparities serve as the onus for public health practice. STDs are common diseases that are easily preventable and treated, yet, a well-established disparity has been that the general Black/African American adult population has the highest STD prevalence out of all racial and ethnic groups. Accordingly, our analysis based on the intersection of sex and sexual identity, age, disorders of mental health, and substance use in a cross-sectional study identified subgroups within the Black/African American adult population who face a disproportionately higher prevalence and odds of STDs from 2017–2019. Of note, the highest risk subgroups within the Black/African American adult population are individuals whose lives are shaped by the intersectionality or confluence of identities that historically had issues with accessing and receiving equitable treatment and results from the healthcare system. Specifically, Black/African American SGM adults and Black/African American adults with various mental health conditions such as depression and substance use disorder are noted to have a particularly accentuated prevalence and odds of STDs in our analysis.

These findings highlight the need for longitudinal studies to analyze the risk of these factors for STD diagnosis among Black/African American adults, while interventions are tailored for high-risk subgroups in this population. Researchers should have the prerogative to use community-based participatory research and community asset mapping approaches to form empowering, effective, and sustainable interventions. Such interventions should harness neighborhood environmental assets in the Black/African American community to overcome intra- and interpersonal barriers, such as stigma that can influence behaviors related to developing and treating STDs, to ensure equity in healthcare access and outcomes for this population. The use of formal educational institutions, such as the school system, as a channel for improving sex education in areas with a high Black/African American population would be a useful strategy for reducing STDs in this population. For providers, cultural competency in approaching individuals with one or multiple historically disadvantaged identities will be key to rectifying the observed disparities in this analysis. Culturally competent education and training may also improve the skills and experiences of sexual health education providers in educating teens and young adults. Hopefully, this exploratory analysis provides an impetus for future epidemiological analysis in this and other racial and ethnic subgroups regarding sexual health and STD prevalence, particularly with post-COVID pandemic data, which can guide future health promotion efforts.