Mandy J. Hill- University of Texas Health Science Center at Houston, Houston, TX, United States
Existing HIV-related literature affirms that Black women in the US have a low perceived risk of HIV. Yet, Black women consistently experience higher HIV incidence than other women. The ability of HIV risk perception to influence HIV prevention behaviors remains unclear. Lack of knowledge is often described as the primary driver of a low perceived risk of contracting HIV. What if the primary driver is not lack of knowledge? Instead, it is possible and even likely, that cognitive dissonance became a commonly used coping strategy for survival among Black women whose social standing hinges, in part, on the independent ability to maintain romantic partnerships while doubling in purpose as a primary driver for low perceived risk of HIV. The three key points of this commentary are that underpinnings of low perceived risk of HIV among Black women exist, cognitive dissonance is a likely byproduct of reconciling cultural norms with self-identity, and there is a permanence in disconnect between actual and perceived risk of HIV among Black women. To achieve sexual health equity, researchers must enhance awareness into the nuanced reasons that low perceived risk of HIV persist.
Introduction
Over the last 35 years, low perceived risk of HIV has been discussed as a prevalent qualitative finding among Black women across the sexual health literature (Younge et al., 2010; Amaro, and Love, sex, and power, 1995; Chapin, 2001; Chapin, 2000; Ellen et al., 2002; Ellen et al., 1996; Ferguson et al., 2006; Ford et al., 2006; Kalichman and Cain, 2005; Mays and Cochran, 1988; Nydegger et al., 2020; Budge et al., 2023). This finding has been linked to condomless sex (Calabrese et al., 2019; Gilbert et al., 2021; Hill et al., 2022; Hill et al., 2023; Patel et al., 2019; Pratt et al., 2022), multiple sexual partners (Calabrese et al., 2019; Adimora et al., 2002; Gerend and Magloire, 2008; Grimley and Hook, 2009; Ho et al., 1998; Khan et al., 2009; Nydegger et al., 2020; Sewell and Blankenship, 2019; Sly et al., 1997; Tillerson, 2008; Wagstaff et al., 1995), and most recently low PrEP initiation rates (Hill et al., 2022; Cheek et al., 2022; Flash et al., 2018; Nydegger et al., 2020; Pyra et al., 2022; Willie et al., 2021). Literary findings illustrate that having low perceptions of HIV vulnerability is often identified among Black women who report personal sexual behaviors that place most individuals at significant risk for HIV. Researchers and interventionists have yet to discover fundamental drivers for reports of low perceptions of risk. In fact, the literature has largely attributed this common factor to a lack of knowledge (Kiviniemi et al., 2018). This commentary aims to challenge the notion that a lack of knowledge is the sole reason for the prevalence of a low perceived risk of HIV vulnerability among diverse groups of Black women in the US. The literature has failed to distinguish differences in perceptions of HIV risk by demographic profiles of Black women by education, income, insurance coverage, social support systems, and/or family dynamics. The proposal here is that an undiscovered aspect of the low perceived HIV risk among Black women in the US relates to cultural factors that may extend beyond demographic considerations.
Investigating the underpinnings of low perceived risk of HIV among Black women
Black women have been indoctrinated in a culture that embodies different practices, values, and behaviors. Some of those complex factors esteem partnership as an extension of personal value (Henry, 2013). Henry (2013) described the emphasis of researchers who have studied identity development among women, leading to her concluding remarks where ‘it could be surmised that the dating decisions of Black women are influenced in part by their experiences at particular stages of racial and gender identity formation’ (Henry, 2008). For Black women in the US, race and gender identity relegates this segment of the population as least valuable on the societal hierarchical scale of human life. (Rodriguez, 2018). Vulnerability to health risks, which include HIV vulnerability, are a consequence of this social stratification, whereby being relegated as less valuable in society hinders access to education, employment, healthcare, while driving stigma, poverty, cultural norms, and social beliefs (Thapa et al., 2021). Of the nine studies assessed through the systematic review referenced in the prior sentence, one of those study’s ‘asserts that disadvantaged women have a higher chance of severe illness and without any improvement in caste and class barriers, improved health resources and outcomes are almost impossible.’ Rosenthal and Lobel (2016) said that ‘the assumptions people make about Black women have a wide range of implications for the ways that Black women are treated in our society’.
The lingering by product of societal norms whereby a racial and gender identified group is deemed to be of low human value is countered by familial norms where those same group members are esteemed highly within family units with purposeful intention to insulate and preserve the value of each individual member. This approach offers each individual member a level of protection, simply by being a part of the whole. It also afforded Black people freedom, self-determination, autonomy, and agency (Smith et al., 2019; Waterman, 1981). Findings of empirical studies of cultural values with African American and Black adolescent girls ‘found that collectivistic values operationalized as collective work and responsibility, cooperative economics, and self-determination, were associated with higher levels of self esteem, perceived social support, and life satisfaction’ (Henry, 2013). These viewpoints have been passed down from one generation to the next with African American and Black people here in the United States (Smith et al., 2019; Constantine et al., 2006).
When women become of the age in society to become partnered, there is a communal expectation reinforced by the matriarchs, including mothers, grandmothers, aunts, family friends, church members, etc. to motivate the ‘coming of age’ woman to prioritize being selected as a partner (Salisu and Dacus, 2021). Salisu and Dacus (2021) state that ‘Black women have strived to survive in a society that created and has perpetuated an unequal system of social and economic deprivation of their Black husbands, in heterosexual relationships.’ The qualities of the partner are general and have traditionally hyper-focused on the partner’s ability to provide support and stability. Qualities such as fidelity and trust are rarely mentioned. Cultural conditioning of partner selection in some cases is reinforced by the teachings of women in the female lineage of Black women who are indoctrinated to ‘accept the role of the strong Black woman’ and ‘embrace this role and frequently make sacrifices because their life choices were affected by those of their families’ (Smith et al., 2019). When indoctrinated within this culture, Black women are often met with the need to identify strategies to cope with the pressure while adjusting to a new found independence in determining one’s life course (Salisu and Dacus, 2021). This is where cognitive dissonance has the optimal opportunity to make an appearance and establish a permanent foundation.
Cognitive dissonance as the unintended byproduct of reconciling cultural norms with self-identity
Cognitive dissonance is the ‘mental discomfort that results from holding two conflicting beliefs, values, or attitudes’, especially as relating to behavioral decisions and attitude change (Cherry, 2022). Feelings associated with cognitive dissonance can morph into feelings of low self-esteem and low self-worth. Cognitive dissonance can be a powerful internal influence on behaviors and actions of an individual. Conversely, Black matriarchs can be a powerful external influence on behaviors and actions of Black people in the US, especially Black women who are coming of age. Through the power of influence through relational interactions, Black matriarchs often build social network power that solidify their centralized roles in families and their communities (Salisu and Dacus, 2021).
When cognitive dissonance arrives, Black women may have to grapple with the feelings of low self-esteem while placating the demands of the matriarchs to be partnered. Salisu and Dacus (2021) described the experience of some Black women who live in a paradox where they struggle with trying ‘to balance the expectations of their roles they occupied in society with their own identity as a sexual being’. When prioritizing the needs of others, which in this case are elders and respected women in the community (Rosenthal and Lobel, 2016), a coping strategy to please themselves may result in adopting a low perceived risk of HIV in order to garner the coveted personal value bestowed upon an individual who is a part of a complex culture in society that in part, values when a Black woman is ‘chosen’ by a male partner. The stigma of not being ‘chosen’ in society can be accompanied by a negative stereotype (e.g., a harmful belief or disparaging opinion about a group of people that falsely associates negative characteristics to them), which ‘have important consequences in many realms of life’; ‘stereotypes have a connection to decision-making’ (Constantine et al., 2006). The mental exercise of showcasing oneself as ‘desirable’ can become a survival strategy in an effort to stave off judgment and ridicule while ascertaining and preserving social standing in a multifaceted culture with components that values partnership, with no metric of quality assurance.
Sewell and Blankenship (2019) identified a complex interplay between risk perception, risk behaviors, and stigma related to HIV among a female cohort comprised of individuals who were mostly Black (93.0%) and impoverished (87.7%). For the past 20 years, the degree of influence that HIV risk perception has had on decisions to change patterns of engagement in behaviors that are linked to reasons for contracting HIV remains unclear and inconsistent (Sewell and Blankenship, 2019; Prata et al., 2006). Scientists aim to seek clarity in the known associations. Women poverty (p = 0.010), employment (p = 0.012), insurance (p = 0.024) and homelessness status (p < 0.001) were all significantly associated with their level of HIV risk perception (low, medium, or high) (Sewell and Blankenship, 2019). Most of the participants lived in poverty, were unemployed, and had health insurance. Specifically, women who experienced homelessness in the last 12 months were most likely to have a high perceived risk of HIV versus low risk (68.1% vs. 35.8%, p < 0.001). Knowledge of a male sex partner’s HIV status at last intercourse was low among women with low HIV risk perception (68.7%, p = 0.007) and most of them reported condomless anal or vaginal sex within the last year (86.7%, p = 0.025). HIV stigma and discrimination did not significantly influence HIV risk perception among a sample of mostly Black women in Detroit, MI within the United States (Sewell and Blankenship, 2019). Sewell and Blankenship (2019) described how Black women who engaged in sexual behaviors that included reasons for HIV vulnerability were more likely to experience stigma. As a result, those women were likely to perceive those experiences as ‘negative’ in association with HIV risk. Some researchers hypothesize that when women have negative experiences in relationships, these experiences are accompanied by an understanding and acceptance of HIV vulnerability, which may influence Black women to disassociate themselves with HIV risk (Sewell and Blankenship, 2019). Sewell and Blankenship (2019) found that ‘many women with low HIV risk perception still engaged in high-risk behaviors’ (Sewell and Blankenship, 2019). By linking the HIV risk to the negative experience, the women unlink themselves from the HIV risk when they unlink themselves from the negative experience or from the partner who they perceive as causing the negative experience. Pharr et al. (2015) found that ‘HIV risk perception may not ultimately lead to reductions in high-risk behaviors, as socioeconomic, sociocultural and structural constraints represent an external locus of control that high-risk populations face, but cannot necessarily overcome’ (Pharr et al., 2015). The translation of using this temporary fleeting strategy into a permanent dissociation of risk removes the responsibility and accountability to the woman’s personal sexual health. This likely leads to a permanence of low perceived risk of HIV. This allows for a permanence in vulnerability to HIV and subsequently, an abandonment of self-protection.
The permanence in disconnect between actual and perceived risk of HIV among Black women
Human beings tend to shy away from or avoid feelings of discomfort (Connelly, 2009). One of the ways in which we minimize discomfort is to manifest and make our ideals, fantasies, and figments of our imaginations seemingly real. This helps us to avoid facing inconsistencies between beliefs and behavior. Over time, when the avoidance becomes the default behavior, the distinction between knowing whether what was imagined versus what was real becomes unclear and what was once seemingly real becomes real. When what was once seemingly real becomes the default perception, it becomes misconstrued as what is actual. This misconstrued information between perception and actual risk has likely become a permanent disconnect between actual and perceived risk of HIV among Black women. The strength of this disconnect, or cognitive dissonance, can be influenced by factors that can include the importance one attaches to a belief and/or the quantity of dissonant beliefs (Cherry, 2022).
Discussion
Consideration of such psychologically rooted complex models highlighting multifactorial influences from societal and social constructs that mediate or moderate risk perceptions among HIV-negative Black women in the US who engage in heterosexual sex are necessary to fully understand correlations that may appear illogical on the surface.
Precursors for women’s HIV risk perceptions must be identified in order to effectively bridge the gap between eligibility for HIV prevention services, particularly pre-exposure prophylaxis (PrEP), and access to and uptake of those services among Black women. Even among 112 Black women who are using PrEP, the decision to continue PrEP treatment was based on their perceived HIV risk, resulting in only 18% who were identified as persistent PrEP users (Pyra et al., 2022).
The lack of congruence between behaviors that are aligned with HIV transmission routes, HIV risk perception, and expectations of negative experiences linked to an HIV status suggests that more research is needed to better understand these pathways among Black women in the United States (Sewell and Blankenship, 2019). If cognitive dissonance is indeed one of the determinants of low perceived HIV risk among Black women, overcoming this communal dissociation is required if we are to realize ending the HIV epidemic. Advancing sexual health equity for all, especially for Black women in the US, will require us to look beneath the surface to seek and understand the reason for the decision that leads to the behavior (i.e., taking PrEP or not taking PrEP). Once we have sought and understood the reason, we must honor and respect it, then heal it before we set forth to rectify it and change it. Reversing the trend in the uptake of effective sexual health services among Black women will require consistency, commitment, and a continuous investment in actualizing sexual health equity among a group of women who have likely had to collectively dissociate to survive generations of marginal access to full humanity.
Data availability statement
The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.
Author contributions
MH: Conceptualization, Formal analysis, Investigation, Methodology, Project administration, Resources, Writing – original draft, Writing – review & editing.
Funding
The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article.
Conflict of interest
The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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Keywords: sexual health, cognitive dissonance, Black women, culture, perceived risk and normative influences, coping strategies, human immunodeficiency virus
Citation: Hill MJ (2025) Cognitive dissonance as a reason for low perceived HIV risk among Black women. Front. Sociol. 9:1498383. doi: 10.3389/fsoc.2024.1498383
Edited by:
Sibille Merz, Alice Salomon University, GermanyReviewed by:
Latrice C. Pichon, University of Memphis, United StatesRhoda Aduah, The University of Memphis School of Public Health Division of Social and Behavioral Sciences, United States, contributed to the review of LP
Copyright © 2025 Hill. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Mandy J. Hill, bWFuZHkuai5oaWxsQHV0aC50bWMuZWR1