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Abstract

This study explores the intersection of race, class, and gender on substance abuse treatment and human immunodeficiency virus risk among 12 incarcerated black women by integrating the Health Belief Model with Black Feminist Theory. The findings suggest that the culture and context of substance abuse not only influenced the women’s perception of susceptibility of risk and severity of risk but, perhaps more importantly, the perceived benefit of the intervention on their life circumstances. These findings have implications for the conceptualization, implementation, and evaluation of substance abuse treatment, HIV prevention education, and prison reentry programs targeting Black women.

Keywords

Black Feminist Theory/Womanism Health Belief Model HIV Intersectionality micro research categories social work history social work practice social work/social welfare history and philosophy substance abuse

The combination of drug-related crimes and prostitution arrests is increasing among Black low-income women (Swavola, Riley, & Subramanian, 2016). The intersection of drug use and prostitution places this population at increased risk for contracting human immunodeficiency virus (HIV). While some correctional facilities offer substance abuse and HIV prevention education to inmates, the theoretical underpinnings of such interventions are typically rooted in public health models and lack cultural sensitivity with regard to the impact of gender, race, class, and health on inmates.

The purpose of this study was to investigate the utility of integrating a traditional public health model with a nontraditional cultural framework. Thus, this research sought to infuse Black Feminist Theory (BFT) with the Health Belief Model (HBM) to better understand cultural issues that can affect HIV risk among incarcerated substance abusing Black women.

Background

In 2014, Blacks accounted for 44% of estimated new HIV diagnoses in the United States (Centers for Disease Control and Prevention [CDC], 2016). Regarding women, incidence rates reveal that there were 1,350 Hispanic/Latino women and 1,483 White women diagnosed with HIV in comparison to 5,128 Black women in this time period (CDC, 2016). Further, there are several factors that contribute to the increase of HIV susceptibility in Black women when compared to other races/ethnicities. Specifically, personal characteristics such as childhood sexual abuse, post-traumatic stress disorder (PTSD), and substance abuse, in addition to relationship dynamics and intimate partner violence, contribute to greater susceptibility of HIV among Black women (El-Bassel, Caldeira, Ruglass, & Gilbert, 2009). Other factors and root causes that increase HIV susceptibility among Black women include structural barriers such as poverty and access to HIV preventive services as well as cultural values and belief systems that relate to gender roles and social norms regarding safe sex practices (El-Bassel et al., 2009).

Women and Substance Abuse Treatment

Many researchers agree that women are less likely than men to seek out treatment for substance abuse (Schober & Annis, 1996; Walitzer & Connors, 1997). Research shows that women who do enter treatment are less likely to be married (Wechsberg, Craddock, & Hubbard, 1998) and more likely to report experiencing other abuses (Pettinati, Rukstalis, Luck, Volpicelli, & O’Brien, 2000), use alcohol and/or cocaine (Pettinatti et al., 2000), and have more family responsibilities (i.e., child and parent–related issues). Black women were least likely to complete substance abuse treatment, especially if they were in semiskilled positions such as housekeeping/cleaning or restaurant services such as a waitstaff (Mertens & Weisner, 2000).

Substance Abuse Treatment Disparities

In addition, in an article by Le Cook and Alegria, the authors conducted a meta-analytic review of various studies examining the disparities that exist within substance abuse treatment. The reported reasons were the relationships between race–ethnicity and substance abuse treatment by income, previous involvement with criminal justice system, access and eligibility to treatment services, and the severity of the disorder. The authors concluded that future studies must address the intersection of race–ethnicity, socioeconomic status, and criminal history when understanding the disparities that exist within substance abuse treatment.

The literature suggests there are many gender differences in the substance abuse treatment experiences of men and women. Additionally, women who receive substance abuse treatment while incarcerated are more likely to have more severe abuse issues and experience greater barriers upon release (Opsal & Foley, 2013). However, the extant literature is virtually silent on the substance abuse experiences of incarcerated Black women. Gilfus (2002) reported that incarcerated Black women are often exposed to structural affects such as poverty, racism, and violence as a result of childhood abuse and victimization. Consequently, factors such as the onset of substance abuse, self-harm, depression, suicidal ideation, relationship disturbances, and running away from home and entry into prostitution were found as frequent negative consequences the abuse. Further, Olphen, Eliason, Freudenberg, and Barnes (2009) also found that the substance abuse experiences of Black women who have been incarcerated are tied to structural affects such as histories of abuse, low education, and poverty. As a result, this population also faces stigma upon release and experiences challenges reintegrating to their communities. There is a gap in the literature regarding the interrogation of substance abuse treatment and HIV prevention for incarcerated substance using Black women from a cultural lens. While this population stands to benefit greatly from HIV prevention programs during incarceration, very little is known about their experiences and how best to meet their unique needs in a culturally relevant manner.

Theoretical Frameworks

The Health Belief Model

The Health Belief Model is a cognitive learning theory that focuses on health-related perspectives and motivations and utilizes a cost–benefit perspective in explaining preventive health behaviors (Mantell, DiVittis, & Auerbach, 1997). The original model is rooted in psychology and was developed by Rosenstock (1974) for the purposes of promoting the work of social psychologists. This model was based on four constructs designed to predict the social response to a behaviorally based treatment or intervention. These four constructs include perceived susceptibility, perceived severity, perceived barriers, and perceived benefits (Janz & Becker, 1984; Rosenstock, 1974). In essence, the HBM assumes that individuals will make a change in negative health behaviors, such as substance abuse and risky sexual encounters, if they believe this practice will decrease their chances of acquiring HIV.

There have been revisions made to the HBM that included the addition of two constructs, cues to action and self-efficacy. For the purposes of this study, the author used the original model of the theory which focused on the four constructs that specifically addressed susceptibility of risk, severity, barriers, and the benefits of changing behaviors in regard to health for the target population of incarcerated substance using Black women who were at risk for HIV.

Black Feminist Theory

Black Feminist Theory explores how race, class, and gender intersect to produce an incorporated examination of power and oppression (Burnham, 2001; Crenshaw, 1989). A distinguishing characteristic of BFT is its insistence that both the changed perception of individuals and the social transformation of political and economic institutions constitute true essential components for social change. According to Collins (1991), Black feminism endorses four basic principles:

Racism, sexism, and classism are interlocking systems of oppression.

We must maintain a humanist vision that will not accept any amount of human oppression.

We must define ourselves and give voice to the everyday Black woman and everyday experiences.

We must operate from the standpoint that Black women are unique and our experiences are unique.

Collins posits that offering subordinate groups new, rediscovered, knowledge about their own experiences can be empowering. In sum, revealing new ways of knowing allows these oppressed groups the opportunity to redefine their own reality which has larger implications.

Few (2007) provides the notion that when conducting research that will sufficiently focus on the lived experiences of Black women in the United States, social scientists must first examine and understand how Black women view themselves in the context of their relational and familial relationships as well as carefully consider how research methodologies, data interpretation, and utility may impact how the information is translated. She further wrote that the essence of Black feminism provides a safe space where Black women can “legitimately” stand in two or more realities—the perceptions of being “Black” and a “woman” at the same time (Martin, 1993). Bell-Scott (1995) highlighted the notion that Black feminism acknowledges the shared struggles of oppression faced by Black women and men that result from racism, classism, and in some forms, sexism. From a methodological perspective, Black feminists and Womanists use a variety of traditional research methods such as interviews, surveys, and so on, as well as nontraditional tools such as music, art, and spoken word in examining the lives of Black women and their families. This provides a sense of empowerment for Black women to articulate and share their lived experiences in any creative manner they select when engaging in research studies.

Black Feminist Theory has been applied in HIV prevention research targeting low-income Black women. Gentry, Elifson, and Sterk (2005) used BFT to interpret how 45 low-income Black women in Atlanta, GA, negotiate their social conditions and interpret their high- and low-risk behavior in regard to contracting HIV. The study identified five themes unique to Black women struggling with substance abuse and HIV risk: (1) Self-definition and self-evaluation are critical to understanding risk perception and motivation of behavior; (2) an interconnectedness between race, class, and gender; (3) Black women have unique experiences in America; (4) controlling social images distracts poor Black women; and (5) agency can play an important role is social change. Ultimately, the study results challenge the traditional practice of using behavioral theories as a singular framework by which human behavior is interpreted.

The Use of BFT and HBM as a Treatment Model

In using BFT, the focus is simultaneously placed on the individual, in this case, the incarcerated substance abusing Black woman, as well as on the community in which she lives and the structures, institutions, and policies which dictate her trajectory (Constantine, Gainor, Ahluwalia, & Berkel, 2003). The individual versus communal perspective is a critical point of divergence between behavior-focused public health theories and cultural theories. While the HBM focuses only on the individual as the source of the problem/issue and the site of agency, BFT acknowledges the interdependence of the Black woman, community, and history. The lens of BFT and the HBM allows us to see how Black female stereotypes emerge to codify into law the inhumane treatment of already victimized Black women. Consequently, the integration of the HBM with BFT broadens the research question to capture contextual issues that inform perception of risk and benefit of action.

Method

Sample

Institutional Review Board (IRB) approval for this study was obtained from the Office of Sponsored Research. The researchers employed a mixed methods phenomenological research design. Women were eligible to participate in the study if they were 18 years of age, identified as Black, had been arrested for a drug offense or reported having drug problems at the time of their arrest, had engaged in sexual intercourse (vaginal, oral, or anal) with a man at least once in life, and had a negative HIV serostatus at the time of the study. Moreover, a number of women had participated in the Women for Women (W4W) Program (a group-level program/intervention) at least 2 times and for some, failure to complete the mandated program resulted in a prison sentence for their offense(s). The benefits of this program included sobriety, the termination of pending penal cases, and newfound, lifelong supportive relationships (D. Rasouliyan, personal communication, February 2009). To ensure anonymity, study participants selected pseudonyms; their government names/identities were not provided.

The W4W Program

The W4W Program is an in-custody addiction treatment program for women in a small-sized medium security detention center in an urban city. This program does not operate from a specific therapeutic model. The curriculum consisted of alcohol and drug education, group therapy and community meetings, career and vocational training, parenting skills education, domestic violence education, self-esteem education, individual therapy/case management, and transition to aftercare services. Participants engaged in this program for a minimum of 9 months and were automatically transferred to an aftercare program at a local substance abuse treatment center.

Data Collection

In addressing this topic, there were three data collection approaches that were utilized in answering the research questions. These included the use of a survey, individual interviews, and two focus groups. The following are the research questions that guided this study:

Research Question 1: What are the inequities that exist in substance abuse treatment, whereby the oppressive issues such as race, class, and gender are barriers to substance abuse treatment for Black women that should be addressed?

Research Question 2: How does forced recovery (incarceration) influence a women’s perception of their substance abuse?

Research Question 3: What is the perceived susceptibility of risk for HIV among Black women in recovery?

Research Question 4: Are women who do not successfully complete substance abuse treatment at greater risk for HIV infection?

A semistructured interview guide was designed by the first author to obtain information regarding the constructs of the original HBM (Research Question 4) and the perception of risk for HIV and influence of substance abusing behaviors. The following are a sample of questions that were included in the semistructured interviews and focus group in order to draw comparisons among the two methodologies: Do you consider yourself at risk for HIV? Why do you think Black women are at risk for HIV? Tell me about ways you earn money and how does your use of drugs impact your ways to earn money? Do you consider your arrests for prostitution severe to your health? What are some factors that cause you to have sex for money? Interview items were developed based on the constructs of the HBM and BFT. The author utilized the same open-ended research questions for both interviews and focus groups.

Based on eligibility criteria, individual interviews were conducted with 12 women who reported being HIV negative at the time of the interview. Voluntary HIV testing was done on sight at the jail. As the study focused on perceived risk for disease acquisition, there were two members who were excluded from the study as they reported being “HIV positive” and “having AIDS.” Based upon preliminary qualitative data analysis, the findings revealed certain results according to age (older participants vs. younger participants). Subsequently, further focus groups were stratified according to age for the purposes of deeper analysis. Stratified sampling was used to select participants from each age cohort to yield a total of four for each group. When using this method of sampling, the population is divided into groups called strata. This technique is most useful when stratifying variables are simple to work with and closely relate to the research topic (Kalsbeek, 2008).

Regarding perceived susceptibility of HIV, the study participants were asked, “Why do you think Black women are at risk for HIV.” Interestingly, the older participants in the study (ages 35–54 years) identified that Black women were collectively at risk for HIV infection but did not identify their own individual risk. On the contrary, younger participants (ages 19–34 years) acknowledged their own individual risk for infection as well as the collective risk among Black women.

Prior to the administration of any data collection tools (survey, interview, and focus group), the researcher read the informed consent aloud to each participant, insured they understood their volition for participation, and obtained their signatures on each of the informed consent forms (survey and interview informed consent were combined and the focus group informed consent). Each individual interview was conducted in a small cell in the jail. Two chairs were placed in the cell and a pod officer, an employee of the jail who provides supervision and monitoring over the inmates, instructed the researcher to sit nearest to the door for safety precautions. The focus groups were conducted in the larger group meeting room with a pod officer present.

The interview and focus group guides were semistructured with a prepared list of topics and questions related to perception of their substance abuse history, perception of HIV risk, perception of susceptibility to HIV due to substance abuse, barriers to HIV risk and substance abuse efficacy, and perceived benefits of intervention. Prior to each interview, the study participants completed a brief 12-item survey that focused on their demographic characteristics (i.e., age, ethnicity, arrest record, drug history, and substance abuse treatment history).

Data Analysis

We utilized the constant comparative method developed by Glaser and Strauss (1967) in analyzing the data in this study. This method of analysis, simply put, involves the researcher “constantly comparing” the data as they are collected. The use of this method provided an opportunity to organize the data analysis process in order to increase the traceability and substantiation of the analyses (Boeiji, 2002). Further, reflexivity was used to ensure reliability in this study. The lead author developed a statement detailing her personal biases and also conducted member check-in and interrater reliability with other members of the research team (Johnson, 1997; Stenbacka, 2001). In addition, another researcher listened to each audio recording, read each transcript, and coded each set of interviews. This also assisted in addressing any bias that existed by the lead author and satisfied interrater reliability for this study. The lead author and researcher then compared their data coding to observe similarities and differences.

Results

Characteristics of Participants

The sample included Black women, averaging 35 years of age, ranging between 19 and 53. For the purposes of anonymity, study participants selected pseudonyms which were used for the duration of the study. Most of the women possessed a ninth grade level education, were heterosexual (57%), and preferred crack as their drug of choice (57%). Only eight participants had previously attempted substance abuse treatment prior to the study; however, all had relapsed. The length of addiction ranged from 3 to 40 years, with the substance abuse beginning in adolescence and typically as the result of a trauma (i.e., death of a parent, sexual abuse, or violent assault). A majority of the women were unskilled with only one possessing a professional cosmetology license. Over half (57%) of the women had never worked and engaged in prostitution or theft as their primary source of income. Those who had worked previously held jobs as janitors, landscapers, and grocery store clerks. While 6 of the 12 women reported having children, only 2 women primarily raised their children. The children of the remaining women were raised either in the foster care system or by relatives.

Further, there was a clear intersection between race, class, and gender in the sample, as it pertains to their perception of HIV risk. Perceptions of HIV risk based on substance abuse are discussed below.

Perceived Susceptibility

Perceived susceptibility refers to how a person assesses their risk for acquiring a disease, and the majority of the women in the sample agreed that Black women as a whole were more susceptible to contracting HIV due to their substance abuse. Perceptions of susceptibility were attributed to four primary factors: (1) more money for engaging in unprotected vaginal and oral sex, (2) an innate belief about the promiscuity of Black women, (3) Black men who have sex with men and women, and (4) age.

In addition, several women noted an increasing number of Black women and young girls who were engaging in prostitution and substance abuse in their communities. One participant who strongly attributed increased HIV to ethnicity said, “A lot of Black women play around in the street.” This was her rationale and why she believed Black women were more promiscuous than any other race. Another participant admitted that a desire for more money and feeling lonely were her triggers for engaging in unprotected sex. She shared, “I got a real bad sex drive…I mean…I want it when I want it,” and chuckled as she made this statement. Further, this statement is related to both men and women, as she disclosed being “bisexual.” Money was considered a trigger, as she stated the following, “I could git whatever I want once I got it…so if I got money, I can git drugs…if I git drugs I can git sex…,” relating the triggers together. In addition, regarding Black men who had sex with men and women, a participant stated, “most Black men like to have sex ‘raw’ or without a condom…they are the same nasty motherfuckers who have sex with other boys.”

Interestingly, the perception of risk differed by age, with older women in the sample seeing themselves less at risk for contracting HIV. Most of the older women in the sample felt less at risk of HIV transmission because they tended to have the same sexual partners for years, always used condoms, and didn’t become sexually active with men who were infected. One older participant stated, “I don’t feel my substance abuse increases my risk because I don’t bother with anyone that got HIV…I try to stay away from those people.” Even when she admitted to not using condoms during a period of heavy drug use several years ago, she still didn’t think she was at risk because she never had anal sex. Specifically, she stated, “oh hell naw, you aint finna do dat, I ain’t havin’ that…I don’t do back doors…in yo’ asshole…anal sex…I can’t do dat one.”

Perceived Severity

The constructs of class and gender intersect uniquely to inform how incarcerated substance abusing Black women view the “severity” of their abuse and by default their risk of contracting HIV. Perceived severity refers the assessment of consequences as a result of engaging in risky behaviors. According to eligibility self-reports, the sample of 12 women totaled 105 arrests with an average number of 40 arrests for substance abuse and 65 arrests for prostitution. In individual interviews, however, the women did not interpret their arrest record as an indicator of the severity of their substance abuse but rather a reality of their lack of job skills. The participants indicated that their lack of job skills translated to the use of sex as a means of income and served as a motivation for the risk behavior. One participant who completed the seventh grade and worked as a landscaper reported that she “never had a job.” She shared, “it’s easier for me to sell pussy…plus, I can always count on someone taking care of me.” Another participant reported that she “turned tricks” for US$60–US$70 and as her drug habit got worse, she had engaged in risky sexual behaviors for as little as US$3 as her focus was on acquiring more crack. As such, perceived severity of risk for HIV was nonexistent because the participants justified their behaviors of having risky sex for money due to their lack of job skills. Other ways in which the women obtained money included cleaning homes, shoplifting, selling drugs, and setting up drug deals for the police. One respondent said it best by saying, “You gotta suck and fuck for money” and “freakin’ in the streets gets my children fed and bills paid.”

Consequently, it is impossible to view perceived severity and perceived barrier as separate entities in the context of BFT. Many of the women in the sample spoke to the need to have a “hustle” to make money to live and care for their children. They understood the severity of their actions yet confounded the barriers as a result of meeting their needs.

The lens of BFT allows us to see that in the context of substance abuse and HIV risk, perceived severity to contracting HIV and barriers are enmeshed and measured against the importance of other realities in the lives of these Black women.

Perceived Barriers

Issues related to employment status, children, partners, and community ties presented a unique mixture of supports and barriers for the study participants. Perceived barriers in the context of the HBM refer to how one assesses the drivers that promote/discourage engaging in risky behaviors. The average education level of sample was ninth grade with little to no vocational skill training and prostitution the primary trade of the sample. Consequently, breaking the cycle of addiction for this sample is intimately interwoven with their ability to earn a livable wage upon release from jail.

Another barrier for the women was the perception that substance abuse treatment was an untenable option as evidenced by the fact that a majority (57%) of the women in the sample never sought treatment for their addition for myriad reasons, including access to resources, lack of family support, fear of losing children to foster care, and simply not wanting to leave their communities. Overwhelmingly, the women who had children agreed that their children were a source of inspiration for their recovery. However, many women were single parents with multiple children and no family or father who could maintain custody during their absence.

Perceived Benefits

Perceived benefits refer to how a person conceptualizes the positive results of avoiding risky behaviors. Many women struggled to articulate the value of substance treatment and HIV prevention education for themselves. There seemed to be a greater sense of fatalism about their inability to transcend substance abuse and HIV risk. One participant who had relapsed 15 times attributed her lack of success to being scared of success. She said she was “afraid of the unknown” and felt “unworthy” because she had done things in her life that caused her shame and regret. Another participant shared the following,

I have sold pussy for crack and fucked without rubbers for money…and the truth is, I may be clean when I leave here but I’ll probably go back to my lifestyle because I will still be broke.

Moreover, an older participant felt the experience was very beneficial saying,

By bein’ in here I don’t think I have any chance of getting it (HIV) and when I get outta here I’m through with this…I’m not goin’ to jail…this is it for me…I’m goin’ home.

In most cases, the women felt HIV and substance abuse prevention should be focused on young Black girls because of the risky behavior they observed on the streets. One participant said,

Classes on protectin’ yo’ self from AIDS needs to be in drug treatment and young Black girls need to know what to do to protect themselves, especially with Black men ‘cause they have a lot of risky sex…they fast!

Discussion

A central revelation in the women’s narratives about perceived susceptibility revolved around the intersectionality of Black femaleness regardless of age. Younger Black women felt at increased risk because they believed that Black women were innately more promiscuous. Older women, and some younger women, contended that they were less at risk because White prostitutes were perceived to be more sexually adventurous (i.e., engaging in anal and group sex) and thus more likely to be exposed to HIV. Being Black and female was simultaneously a protective and risk factor. Their notions of Black femaleness appear to have roots in mainstream media stereotypes about Black women.

Moreover, a perceived barrier that the participants shared was the enforced philosophy of substance abuse treatment wherein intimate relationships are prohibited. Several of the women in the sample expressed how supportive and instrumental their partners were in their seeking treatment. In some cases, expressing that their partners disdain of their addiction being the impetus of their decision to enter treatment. Women with children explained their children influenced their decision to not seek treatment, stay in treatment, or end treatment. This information calls into question the common wisdom of substance abuse treatment programs that typically have hard-and-fast policies against participants being involved in intimate relationships during recovery. Cultural theorists support the notion that Black people live in a duality where identity always supersedes position, gender, and role (Akbar, 1984; Jarama, Belgrave, Bradford, Young, & Honnold, 2007; Nobles, 1978, 1985). The fact that Black women in this sample often found solace, motivation, and encouragement in their relationships with family and community give further support to greater cultural grounding in substance abuse treatment to improve the treatment outcomes of Black women.

Most disturbing perhaps is the perceived benefits of substance abuse treatment and HIV education among the sample. There was overwhelming sense of being unworthy of recovery and restoration. These feelings were not necessarily expressed in the context of substance abuse and ethnicity. One respondent shared the following reflection, “I’ve done some fucked up things in my life…it’s like…sometimes, I feel like I don’t deserve a clean start.” When probed about the feelings of unworthiness as it related to success and recovery, another participant shared the following,

I’ve had 14 relationships in my 33 years of living…none of them worked and all failed relationships because the men just left…used me up and left….so at times I don’t think this (recovery) will work.

Other respondents commented about the innate promiscuity of Black women, which suggests internalized racism. Further, this sense of fatalism and unworthiness existed among the majority of the study participants. The hope of substance abuse treatment is that one can separate themselves from addiction and learn to value their inherent worth. However, if some Black women see themselves as inherently unworthy because of their ethnicity where can restoration be found?

The implications of these findings for social work practice and substance abuse treatment are critical in that the individual—as the source and site of problem and recovery—is antithetical and possibly detrimental to substance-abusing Black women. Historical antecedents and contemporary educational, economic, and penal structural barriers that have defined and continue to shape the trajectory of Black women must become an integral part of substance abuse treatment and HIV prevention education. Success in treating substance abuse and educating women on HIV prevention is tied to notions of worth and value. It is less relevant to begin the conversation at the juncture of self-esteem, gender, and ethnicity for white women; however, for Black women who often times internalize societal notions that defeminize and dehumanize them, it is requisite. Notions of worth are not tied so much to their substance abuse, but rather their ethnicity, and ethnicity is unchanging. Based upon the study populations’ long history of substance abuse, poor recovery history, and perhaps most importantly, the absence of cultural relevance in the substance abuse intervention, we hold out little hope for overwhelming success for this group. Based upon the study findings, we conclude it to be true for this sample that continued substance abuse treatment that fails to consider the individual and collective historical antecedents that have systematically contributed to their economic marginalization, social victimization, and patriarchal oppression, offer little hope of sustained recovery.

This study has several limitations. This was a convenience sample of women, who may differ from the general population of substance abusing incarcerated Black women in another metropolitan area. In addition, the small sample size did not allow comparisons in perspectives on substance abuse patterns and HIV risk by sexual orientation or other personal characteristics. Furthermore, both individual interviews and focus groups were conducted in the presence of a pod officer. This is a limitation because it challenges participants’ ability to feel safe in sharing their lived experiences. Finally, alcohol usage among this population is unknown and this presents a limitation in fully understanding the extent of participant substance abuse.

In conclusion, the purpose of this study was to explore the integration of a traditional public health model and nontraditional cultural framework in addressing HIV prevention and incarcerated substance abusing Black women. The intersection of race, class, gender, and health in the context of substance abuse and HIV risk represents a very different cultural experience for White and Black women. Until culture and context become a central component in substance abuse and HIV treatment, design, implementation, and evaluation, Black women will continue to be marginalized and enslaved by oppressive racist stereotypes from without and within.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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