Title: Being Fast or Cautious? Sociocultural Conditions Influencing the Sexual Pathways of
Black Females in the United States
Version: 1 Date: 07 Oct 2021
Reviewer's report:
The authors are to be congratulated on an interesting, novel, and worthwhile study, which seems
to be well-conducted and has been written up fairly well. I have a number of comments which
I hope will help the authors to improve the manuscript further, prior to publication. Several
of these relate to making the paper more suitable to BMC Women’s Health’s international
readership. All comments are intended to be constructive – the paper was really thought-
provoking, and may make a significant contribution to the field.
MAJOR POINTS/REVISIONS
1. Authors should state in both the title and abstract of the paper that the paper concerns
Black American (United States) females. (Authors have provided a clear and reasonably
comprehensive introduction to why their study population faces ‘unique sociocultural
conditions’ that impact on sexual health and sexual development, but these sociocultural
conditions are only partly shared with Black people in other countries in the world (e.g.
being an ethnic minority group, history of slavery, starkly different rates of incarceration
ethnicity).) Similarly the title ‘Sociocultural Conditions influencing Black Female Sexuality’
could helpfully end ‘in the United States’.
2. It should be clearer whether the statistics and literature cited in the Background and
Discussion, and implications from the research in the Discussion, refer to Black girls and Black
women in the US, North America, or whole world, etc. (If all stats/background research cited
is from the US perhaps this could be stated once, early on in the first paragraph). Please also
state whether the same definition of Black is being used here as used by the researchers (p8,
paragraph 2 under the heading ‘Procedure’). P29, Limitations and Conclusion – the points about
transferability to Black heterosexual females should be qualified ‘in the United States’.
3. Abstract, Results section could more clearly state which pathway is considered to entail greater
STI risk.
4. Individual/group/population level –
a. Concurrency not only increases STI risk for individuals; population groups with higher rates
of concurrent sexual partnerships experience greater rates of STI transmission.
5. Onset of puberty: there could be greater clarity of meaning in the first sentence of p5 paragraph
2. Is it supposed to mean (a) Black females experience puberty younger than females of other
ethnicities* and this is associated with early sexual activity and increased STI risk; or (b) early
onset of puberty is associated with early sexual activity and increased STI risk when it occurs in
Black females (i.e. more so than among other females, irrespective of any ethnic differences in
age at puberty). (*If there is a difference, how much younger, how much overlap is there, and
is this the case in the US or globally? I doubt the latter, because in the poorest countries in sub-
Saharan African menarche takes place at an older average age than in Europe, influenced by
girls’ nutritional status. The study cited later in the paper p26 [59] uses US data and references as
evidence for racial differences in age at menarche two other studies which also rely only on US
data; additionally the differences presented in the US data [reference 59] are quite modest, less
than a year difference in average age). Also, please consider the evidence supporting the point
that ‘The onset of puberty comes with increased sexual curiosity and desire, which can lead to
early sexual activity’ (p5) (I think the authors may intend to state that puberty can lead to early
sexual activity *when puberty occurs at an early age*). At a minimum, please provide a reference
for this statement, if it is true, and consider explaining why it might be the case (e.g. biological
reasons, or how the girl/young woman is perceived and treated by others). In the Discussion p26,
‘Previous studies have found that girls who mature early are more likely to engage in sexual
intercourse’ [at an early age?] please reference these previous studies, and consider whether this
could be due to puberty giving them ‘increased sexual curiosity and desire’ as claimed earlier in
the paper, and/or whether it might be because other people treat them differently (as the study
found).
6. P7, Background. Please clarify whether the ‘Fast’ and ‘Cautious’ pathways were identified a
priori, or through the research. If the two pathways were identified through the research, then I
think they should be mentioned in the Results/Findings and not in the Background (though the
earlier description of “fast or fast-tailed girl” should stay, as it is important to define the term).
Similarly, in the Background, the phases Girl, Grown and Woman are presented as coming from
an earlier study (reference [12]) and applied a priori, but then on p9 these categories seem to be
presented as if they are emergent from the data. Which is it?
7. Where inclusion criteria are presented, in Methods, it is essential to include mention of the
initial inclusion criterion of STI diagnosis. This goes some way to explaining why 15 of 20
participants reported a history of STI, as authors note in the Limitations. Please also state why
this inclusion criterion was used, and why and at what stage during the study it was removed.
Please also state clearly in the Methods section how the study was described to participants (this
is currently only referred to at the end of the paper, p26, limitations, and authors identify it as
potentially influencing the data).
8. P8 second paragraph: This is confusing as it refers to an inclusion criterion where participants
had to self-identify as Black, and then it mentions the researchers’ own definition of Black.
Please describe how this worked in practice. Were potential participants presented with the
researchers’ definition of Black and then asked whether they identified with this definition? Or
did they self-define as Black using their own definitions, which were then checked with (or used
to develop) researchers’ definitions of Black?
9. Please describe the characteristics of the interviewer(s), and whether all interviews were
conducted by the same person. This is best practice in many qualitative research reporting
guidelines. The statement in the Data Analysis section (end of p9) ‘As researchers, it is important
to acknowledge our social location and positionality in relation to our participants’ (and the
next few sentences describing the researchers) should be moved to the previous section, since
the point made applies to both the data collection and the analysis. (Authors may wish to
reference the literature on interviewing across ethnicity – if this is considered relevant. –
e.g. Carter 2003 https://doi.org/10.1080/1364557032000094560;  Gunaratman 2003 https://
dx.doi.org/10.4135/9780857024626.d6 ; there may be advantages to using same- and different-
ethnicity interviewers).
10. The Results and Discussion sections would benefit from more clarity about what chronology
and causation: what might cause or give rise to what, based on the analysis that has been
undertaken. Terms such as ‘associated with’ (used several times in the manuscript) are more
typically used when presenting results from quantitative studies, and authors could consider
using alternative, more informative phrases. For example, the beginning of p13 provides a list
of conditions ‘associated with’ the fast pathway – if these are precursors, i.e. conditions which
can lead to the fast pathway, or make it harder to move from the fast to the cautious pathway,
this should be stated. If they are instead/also consequences of the fast pathway, this should be
stated. Another example: p15 – could ‘tension between’ be replaced with phrasing that makes
it clear what occurred first – the traumatic event or the early sex. Also, comparing Kadijah’s
quote (p12) with the second paragraph on p15, it seem that early sex is both a characteristic
and a consequence of the fast pathway. I wondered whether this logic is circular, or whether
there should be more nuance about the developmental stages. E.g. if a girl is on the fast pathway
during the ‘girl phase', she may go on to have an early sexual debut; whereas ‘grown’ girls may
be identified as being on the fast pathway by various behaviours including having already started
having sex at an early age. P24, line 8, should ‘contributes to the Fast pathway’ be replaced with
something like ‘can make joining the Fast pathway more likely, and leaving it more difficult’.
11. The Background and Discussion could benefit from a more critical engagement with the
literature. Phrases such as ‘Research has shown’ and ‘Previous studies found’ give no indication
of the methodology, size, setting or quality of the studies referenced. In the Background and
Discussion there could be greater engagement with research and interventions from outside the
US (e.g. Gerressu et al 2009 https://sti.bmj.com/content/85/4/283.short ) alongside consideration
of applicability to US Black women and girls.
12. The Implications section of the Discussion needs considerable work. What is presented is
‘five windows of opportunity for future research’ and yet the implications of the study seem to
extend – quite rightly – beyond informing research (e.g. implications for practice in healthcare,
education, society). The implications section contains very many statements about what ‘we’
should do, without clarifying whether this refers to researchers, the legal system, teachers and
educators, healthcare workers, policy-makers, etc. It is fine to comment on some general changes
that are needed in US (and wider) society, but I think it would really strengthen the paper if
some of the recommendations are assigned to specific groups of people, and where possible it is
explained how the changes might look in practice. Some of the implications are very vague – for
instance, ‘We should make protectors more available to young Black girls’ ‘We can help young
girls to learn how to make more agentic decisions about their sexuality...’ – at a minimum, the
authors could provide some concrete examples of how these goals could be achieved, by whose
actions, and based on what (if any) additional evidence.
13. In the Discussion, from a feminist perspective, it would be helpful to critique the role of
‘protectors’ of young Black women and girls (and particularly men/fathers of any ethnicity as
‘protectors’ of female sexuality). Were there any examples in the data of ‘protectors’ having
an ambivalent or negative/controlling role over young women’s sexuality? Aside from the very
valid point about social policies that prevent Black men from fulfilling roles as fathers and
protectors, what interventions might optimise the role of protectors (of any gender) in young
women’s lives?
14. In the Discussion it is not completely clear whether the goal is to prevent girls/women from
being on the Fast pathway, or to ensure those who adopt behaviours characteristic of the Fast
pathway are able to do so relatively safely (in terms of STI risk, etc.) – and therefore whether
the Fast pathway is being judged for any reason other than health risk.
15. Authors found that participants did not discuss pleasure as much as they discussed social
relationships (mentioned in the Limitations). This seems to be a Result – can it be mentioned
in the first paragraph of the Results? It seems an afterthought if it is not mentioned until the
Discussion.
MINOR POINTS
16. Consider whether the final sentence of the Abstract’s Background should be rephrased as
the objective of the study. (Check with editor).
17. Repetition in Methods would be reduced if the Methods were restructured to start with ‘Study
population, participants and sampling’. Currently, a description of participants’ demographics
is provided (p7, start of Methods section) before the sampling criteria are presented (p8, under
the heading Procedure). This doesn’t quite make sense because participants are described as
Black before the study’s definition of Black has been provided to the reader. Sampling methods/
strategy/criteria logically should be presented first, in the Methods, and then after that, the final
sample achieved should be described (often the sample is described at the start of the Results
section – check with the editor).
18. Please add a definition of misogynoir on page 4 – it would be helpful for other researchers
to add this concept to our lexicon.
19. Please provide a footnote to the Figure describing ‘grown’ (as a US English term). (The
closest British English term is ‘grown up’ which equates to adult, and so it can be confusing for
international readers). It is a little confusing how the grown phase is described as 11-18 years
(p7) but then on p12, 11 years is presented as an early time to start the ‘grown’ phase. Could
greater clarity be provided in the Background – i.e. that the grown phase *may* start as early as
11 but often at an older age? To what extent did the study agree/disagree or expand upon the idea
of three developmental phases identified in the previous study [12]? Can this be discussed in the
Discussion? Some of the findings presented suggest that it is not only during the Grown phase
of 11-18yrs that participants are ‘figuring out their sexual identities’ – i.e. this process does not
necessarily stop at age 18 and/or with motherhood (as demonstrated by movement between the
pathways at older ages.) Understanding sexual development across the lifecourse may rely on
a theoretical approach which does not stop at adulthood (and this could be a limitation of the
study).
20. In the Background p5, authors could consider explaining that in the US, choice of sexual
partners is highly assortative by race/ethnicity. It is not necessarily obvious to readers that
people of a particular ethnicity will mostly have sexual partners of the same ethnicity. Making
this point will help explain why it is relevant to discuss the ‘availability’ of Black male
sexual partners. (The literature on sexual ‘mixing’ uses terms ‘assortative’/’disassortative’
and ‘concordant’/’discordant’ – this reviewer prefers the former pair because of the negative
connotations of ‘discord’).
21. Mention of infant mortality (p5) – please state if mortality is greater among Black boy babies
than girl babies in the US – this would make the point clearer.
22. P6, line 16 reference [38] – the cited study is not a content analysis of sex positive research.
It is a content analysis of sexuality research in general (and it makes the point that little of the
sexuality research conducted with people of colour is sex-positive). Please correct.
23. P8. What does GED stand for and what is a GED diploma? Please provide a definition
and please state whether this is compulsory or post-compulsory education. Completed at what
(typical) age? P15 line 13 add a footnote or explanation about what age people are in 7th, 8th
grade and ‘senior year’. For readers that don’t know the US education system, it’s not clear
whether Anika is referring to a three-year or longer timeframe. Please defined ‘freshman’ (p23
line 8 – it seems this term refers to women as well as men?).
24. Please check with the Editor and/or Information for Authors what information is required for
ethical approval. Often a reference number, date and the name of the ‘mid-western university’
would be required (the university is named on p31). It may not be necessary to present this on
p8 and p31.
25. P8 Presumably the interviews were conducted face-to-face / in-person? With the move to
remote data collection methods in the covid-19 pandemic (after the study) it would be important
to say so.
26. Member checking, p10 paragraph 3 – please explain whether this involved checking
interpretation with interviewees after their interviews were complete, or checking the draft/
evolving analysis with subsequent interviewees?
27. The first sentence of the Results could be moved to the Discussion; the second sentence
of the Results which defines sexual pathways should be moved to the Background since it is
necessary to understand the whole study.
28. Reference to ‘high-risk sexual behaviors’, and ‘protecting themselves’ (p19  line 10). It
would be helpful to clarify what risks (e.g. STI, violence and abuse, unplanned pregnancy,
emotional harm, or all of these).
29. In the Discussion the authors might consider critiquing participants’ conceptualisation
of pathways as ‘choices’ (described in the first paragraph of Results, p11). Given the data
and background information presented, is calling it a ‘choice’ way of retrospectively taking
responsibility and ownership (and blame?) for what, at the time, might have been highly
constrained choices or might not have seemed like choices at all? This could be discussed on
page 28 where the authors discuss healthy sexual choices and developing a greater understanding
of what prevents some Black girls and women from changing their (unhealthy) behaviours.
30. In the Results or Discussion authors could consider critiquing participants’ expressed view
that ‘fast’ was about how a person looked (and not just about how they acted) - p12; is this
stigma harmful?
31. References to the ‘majority’ of participants, e.g. p13; and ‘all participants’ e.g. p14; ‘most’
‘many’ etc. Is the majority/all on a particular pathway, or the majority/all of the entire sample?
Please take care to avoid pseudoquantification given the sample is purposive and not statistically
representative of all Black (US) women. P20 line 15, would it be better to say ‘the most
commonly discussed event that caused such a shift’ (given the limitation discussed on p29 –
participants knew they were taking part in a study concerning STI risk).
32. P13 line 2: Should ‘lacking protection’ be changed to ‘lacking protectors’? (see also p15
line 17, p16 lines 19 and 23). Protectors is the term used elsewhere – and ‘protection’ can be
confused with ‘condoms’, in this field. (Also p21, line 14, to avoid confusion should this line read
‘prioritizing the child’s care over their own sexual needs or desires’ (unless this is specifically
about being a protector in the way described elsewhere in the paper)).
33. P15. Please clarify why the two consequences identified are considered the ‘most
prominent’ (i.e. Are these universally/near-universally described by interview participants who
discussed the fast pathway? Are they the most salient within interviewees’ accounts? (and could
this be affected by the way the study was presented to them, as discussed in limitations?) Are
they the consequences that the authors identified as the most serious?)
34. P15 line 15, should ‘developmental age’ read ‘actual age’ – if this point is about girls who
develop early being treated as if they are older than they are (and capable of consenting to sex).
P15, line 18 should ‘because of their bodies’ be ‘because of the way their bodies looked’ (the
point is made more clearly on p26 paragraph 2). (This finding/result is more clearly presented
in the Discussion, P26 paragraph 2, line 2).
35. Given the cautious pathway ‘occurred at all three developmental phases’, does this contradict
with the idea that the cautious pathway is a period of ‘slowing down’ (p16, line 12)? Should
a period of slowing down instead refer to movement from the fast pathway onto the cautious
pathway? (Similarly later on (p23), in Ada’s quote, I wonder if ‘fast’ is a temporary phase or
a right of passage for some people – perhaps those who’ve been over-protected when younger,
and for whom the freedom of college is a big contrast to home life?)
36. If girls on the cautious pathway do not necessarily have protectors available after the girl
phase (p17), what does this mean for the age when we should deliver sexual health interventions?
37. P18, line 21. If the social condition described is common to all US Black women, and the
point made is about those who gained a greater awareness of it, then please replace ‘The social
condition motivated many to assert greater agency in their healthcare’ with ‘Awareness of their
social condition...’ (or similar wording)
38. P19,line 13, please comment on the significance of ‘age 16’ (is this the age of consent
in the US? This varies between countries). P26, paragraph 2, is the age of consent for sex 18
years? Please preface this with ‘In the US...’( because the legal situation is different in different
countries).
39. P20, Conditions Influencing Movement from the Fast to Cautious Pathway. Here and
elsewhere, could it be clearer whether participants were discussing their own experiences
and/or those of their peers and others? The phrase ‘All participants described bidirectional
movement between the Fast and Cautious pathways’ can be read as: all participants moved from
one pathway to the other and back again, or: all participants acknowledged that bidirectional
movement happens (to some people, not necessarily themselves). The implications are quite
different.
40. Given the text at the end of p20 and p28 line4-6, does the Figure need to make it clearer
that STI diagnosis is not always (or not for everyone) a wake-up call/teachable moment that
moves people from Fast to Cautious? In the data, is there a role of vicarious experiences in
movement between pathways – e.g. finding out the consequences of other people’s behaviours,
and deciding to change your own?
41. P22 third paragraph and p23. Given the examples provided, should ‘peer pressure’ include
pressure from partners too? (As partners are not always peers – they are often older and male).
Authors could change it to ‘peer and partner pressure’ or specifically define peer pressure as
including pressure from partners.
42. The final sentence of the Results seems disjointed from the rest of the text, and because it
is in a section on movement from Cautious to Fast, it seems to suggest that the access to health
information to keep them safe from STI would encourage them to move towards greater sexual
risk behaviour. Is this the intended meaning?
43. P24 ‘key to the Cautious pathway’ – what does this mean? Important in helping girls/women
be on, and stay on, the cautious pathway, perhaps?
44. P27, lines 13-15. Whilst it is true that internalising oppressive language may negatively
affect Black women and girls’ mental health, self-esteem etc., use of this language (especially
when describing oneself) could also be an indicator of low self-esteem.
45. P28 please check the phrase ‘...it was inevitable that father absences often led Black girls
to choose risky behavior’. The word ‘inevitable’ is at odds with ‘often’ (i.e. not always so it’s
not inevitable) – and so the point is unclear.
Minor discretionary edits –
P6 ‘it is important to understand the behaviours that occur during various developmental stages’.
Could add ‘and how events and experiences may affect later stages’
P10 line 3 should ‘constant comparisons’ be singular (‘constant comparison’) and line 8 ‘under
what consequences’ be ‘under what circumstances’?
p11 line 14 delete ‘which’
P14 line 4 – ‘as’ should be ‘was’
Scare tactics ‘aiming to promote abstinence’ (since we know that these programmes are not
effective in ‘enforcing’ abstinence).
P26 ‘filling a void’ (or ‘fulfilling a need’) in place of ‘fulfilling a void’
P28 line 2 ‘facilitate barriers to protecting’ could be changed to ‘prevent protection of’
P29 ‘most of who participated’ could be shortened to ‘most participants’