Reproductive coercion, medical mistrust, and Black women’s health from the antebellum period to the 21^st century

Abstract

This analytical essay examines the history of reproductive coercion and medical mistrust among Black women in the United States. Using historical and interdisciplinary literature, the essay presents evidence of racialized and gendered violence, colonial medicine, and structural inequities that have shaped the medical experiences of Black women. It contextualizes medical mistrust as a rational and protective response to generations of medical exploitation, including forced breeding, involuntary sterilization, and unethical experimentation. The essay also highlights how controlling images have normalized systemic injustices and perpetuated barriers to equitable care. Contemporary disparities in pain management, reproductive autonomy, and maternal mortality are also situated within this legacy of racialized medical abuse. The paper concludes by emphasizing the need to address health inequities and to foster trustworthy healthcare systems for marginalized populations.

Introduction

This essay examines the historical roots and enduring impact of reproductive coercion and medical mistrust among Black women in the United States. Framing mistrust within the context of historical and structural violence, it challenges pathologizing narratives and instead positions mistrust as a rational and informed response to ongoing systemic injustice.

Historical and structural dimensions of medical mistrust

Medical mistrust is not merely the absence of trust but the belief that the trusted party may act against the trustee’s best interests [1, 2]. Trust is fundamentally characterized by an asymmetry of power, wherein the trusting party is typically situated in a position of lesser power relative to the institution or individual upon whom they depend [3, 4]. Mistrust is an accrued attitude, shaped by cultural transmission, where distrust is passed down through collective experiences or developed as a protective response to discrimination, racism, and injustice within healthcare systems [1, 5]. It is a dynamic, transactional response, shaped by lived experiences [1, 6]. As a social determinant of health, medical mistrust amplifies health inequities, particularly among marginalized groups [1, 5, 7]. Historical and contemporary forces, including slavery, medical racism, structural violence, and internalized stereotypes, have entrenched suspicion toward healthcare institutions and actors [1, 3, 8–10]. Consequently, medical mistrust is especially prevalent among populations living with chronic illness, disabilities, or low socio-economic status, as well as ethnic and sexual minorities [1, 2, 5].

Constructing Black womanhood through colonial narratives

Understanding the origins of medical mistrust necessitates examining colonial narratives that dehumanized Black individuals, particularly women, establishing enduring frameworks of racialized violence and systemic inequity. The 15th-century memoirs of white men travelling from Europe to sub-Saharan Africa often dehumanized Black women, comparing them to apes and defeminizing their bodies [11]. Such narratives laid the groundwork for the perpetual violation of Black women and justified the transatlantic slave trade. English writers promoted the “ignoble savage” imagery to defend slavery [12]. In 1647, Richard Ligon, an English writer and colonist in Barbados, described Black women: “their breast hang down below their navels, so that when they stoop at their common work of weeding, they hang almost to the ground, that at a distance, you would think they had six legs” [11]. Similarly, William Bosman’s New and Accurate Description of the Coast of Guinea (1705) and John Barbot’s 1732 account depicted Africans as depraved and hypersexualized; Barbot wrote North Guinean women had “tempers hot and lascivious, making no scruple to prostitute themselves … for very slender profit, so great is their inclination to white men …” [11]. Between 1500 and 1770, racial ideology became increasingly gendered, with Black womanhood central to narratives of savagery and inferiority [11]. These distorted images of femininity, sexuality, and civilization justified assumptions of cultural inferiority and underpinned race-based slavery [11].

The dehumanization of Black women persisted with the story of Sarah Baartman, a Khoekhoe woman from South Africa who was transported to London in 1810 by her Dutch owner, Cezar, and displayed for public entertainment at 225 Piccadilly Circus. Images of Baartman, circulated in both medical and scientific contexts, emphasized her body as evidence for racial difference and became central to the construction of scientific racism [13]. As Gordon-Chipembere [14] notes, “upon Sarah Baartman’s body a superstructure of scientific racism was built which supported the continued enslavement of Africans in the Americas and the ‘civilizing’ mission in Africa” [14]. Eurocentric narratives portrayed Baartman as a prostitute, victim, and drunk, identities that have been historically and contemporarily imposed on Black womanhood. Images emphasizing her enlarged buttocks and labia reinforced notions of savagery and barbarism associated with Africa [13]. As such,

Baartman was used as a yardstick by which to judge the stages of Western evolution, by which to discern identity, difference, and progress… [She was] relegated to the terrain of primitive -the lowest exemplum of the human species- while the European…always…assume[d] the pinnacle of human development….

As Sander Gilman has shown [14], representations of Sarah Baartman became central to the cultural and scientific construction of Black womanhood as deviant and pathological. Gilman demonstrates how Baartman’s body was repeatedly deployed in medical and popular discourses to naturalize racial and gender hierarchies, making her an enduring symbol of the intersection of science, spectacle, and racism [15].

Black women endured extreme dehumanization through branding at West African “doors of no return,” rape during the Middle Passage, and sexual, physical, and emotional violence on plantations [11]. The first women’s hospital in the United States was located on a slave farm in Alabama, likely built and maintained by enslaved women [16]. Jean Comaroff demonstrates that colonial medicine and the rise of modern biomedicine were inseparable projects, each dependent on racialized constructions of the Black body [17]. She argues that scientific racism was not incidental but central to the colonial enterprise, providing the medical and moral justification for domination. This framework helps explain how the dehumanization of Black women in colonial narratives translated into the systematic medical exploitation of their bodies in slavery [17].

Enslavement and the medical exploitation of Black bodies

Structural violence in medicine was expressed not only through the neglect of Black patients but also through the exploitation of their bodies in experimentation, training, and research. The medical industrial complex fostered conditions for medical mistrust long before the notorious Tuskegee syphilis study. From the Middle Passage, where European ship surgeons, typically trained in naval or military medicine, were employed to preserve enslaved people as human cargo, to the inspection and certification of enslaved bodies at slave markets, the medical industry systematically oppressed Black bodies [18, 19]. Enslaved women were abused for reproductive purposes, and both living and deceased Black individuals were subjected to medical experimentation. Harriet Washington’s Medical Apartheid details how Black people were denied medical care and subjected to racist beliefs that regarded “blackness” not only as skin color but as a biological classification, a view termed the “immutability of blackness” [16, 20]. Owens [16] identifies this as part of the 19th-century racial formation theories. Physicians experimented on enslaved individuals without consent and later used formerly enslaved and deceased Black bodies for medical research, often stealing them from graves [16, 20].

While the medical establishment exploited and experimented on enslaved Black women’s bodies, it simultaneously disregarded the medical knowledge they generated and preserved within their communities. Enslaved women carried extensive botanical and healing expertise that sustained daily survival, safeguarded reproductive health, and resisted the dehumanizing conditions of slavery. Black midwives, later known as “granny midwives”, played indispensable roles in childbirth and maternal care, passing down intergenerational practices that provided continuity and safety outside of formal medical systems [21]. By asserting authority in reproductive care, granny midwives not only preserved intergenerational knowledge but also actively resisted the medical system that sought to marginalize them. Their expertise created trusted networks of care that allowed Black women to avoid mistreatment in segregated hospitals. Highlighting their agency is important because it disrupts narratives of victimhood and shows that Black women’s resilience and innovation have always been central to survival and community health [22]. These embodied forms of expertise were essential to community resilience, yet they were consistently devalued, criminalized, or appropriated by dominant medical institutions [23, 24]. This dual process of exploitation and erasure not only advanced Western medicine but also reinforced the structural conditions that fuel enduring mistrust [16, 20, 23, 24].

Gynecological experimentation and the construction of scientific racism

Structural violence, rooted in colonial and imperialist legacies, is embedded within institutions and perpetuates harm against marginalized populations [25]. As Paul Farmer (2004) explains, structural violence refers to the social arrangements that systematically disadvantage certain groups by constraining their agency, limiting access to resources, and producing avoidable suffering [26]. Black people have long been excluded from equitable access to medical facilities and education [8, 27]. Before the 1808 ban on slave importation, enslaved Black women were exploited as both patients and surgical assistants for white male gynecological surgeons [16]. After the ban, their reproductive abilities became even more valuable, leading to coercive practices such as forced breeding, medical experimentation, and incentives like freedom for bearing multiple children [28]. Black women’s worth on plantations was closely tied to their childbearing capacities [11]. As Wallace-Sanders (2006) notes, “it was the exploitation of Black woman’s body—her vagina, her uterus, her breasts, and also her muscle—that set her apart from white women and that was also the mark of her vulnerability” (p. 30) [11]. This exploitation, she argues, defined the contrasting experiences of womanhood for Black and White women [11].

Owens (2017) introduced the term “medical super-bodies” to describe how enslaved Black women, through coerced and unrecognized participation in invasive gynecological experiments, became foundational to modern gynecology [16]. Enslaved women such as Anarcha, Betsey, and Lucy, who suffered from conditions like vesicovaginal fistula, were repeatedly subjected to experimental surgeries performed by J. Marion Sims without anesthesia, or were overdosed with morphine to suppress their screams [16, 28]. This is a phenomenon referred to as racial reification, which falsely attributes diseases and behaviors to women of African descent, legitimizing racialized medicine. Enslaved Black women were used as “guinea pigs” for gynecological research [28]. Roberts (1995) outlines how biology was weaponized to justify Black inferiority and control reproduction [29]. This process exemplifies what Owens [16], drawing on Fields and Fields’ concept of racecraft, describes as the transformation of racism into race - a practice that naturalizes inequality and shifts blame onto the oppressed [29, 30].

Blakely and Harrington (1997), in Bones in the Basement, detail how post-mortem racism pervaded 19th-century medical training. Institutions like the Medical College of Georgia selectively used the bodies of low-income individuals and African Americans for dissection, while excluding Euro-American corpses. Although deemed “inferior” in life, Black corpses were sought after in death [31]. Between 1898 and 1904, two-thirds of the cadavers dissected at Johns Hopkins University were African Americans, many procured by grave robbers. Findings from these dissections perpetuated racialized medical theories, reinforcing beliefs in anatomical differences that justified slavery and the labor exploitation of Black bodies. Other sources of cadavers included enticing free Blacks with subsidized medical care and donations of deceased slaves by their owners [31]. Despite systemic exclusion from most medical institutions, Black physicians and nurses built professional associations, opened practices, and offered dignified care within their communities. Their work demonstrated resistance in the very heart of the medical profession, where they challenged racism not only by healing but also by establishing spaces of advocacy and expertise. Emphasizing this agency underscores that mistrust in medicine coexists with traditions of self-determination, making clear that Black communities have long worked to define and claim their own standards of care [32].

Although these examples are rooted in the nineteenth and early twentieth centuries, the institutions implicated in these practices, including medical colleges, elite hospitals, and research universities, remain powerful actors in healthcare delivery and biomedical research today. For many Black women, seeking care still involves entering spaces that were historically sites of exploitation or interacting with professionals trained in institutions that once benefited from such practices. This continuity underscores that mistrust is not only inherited from past harms but is also sustained by the enduring presence of institutions whose authority was built through systemic violence and the extraction of Black bodies [8, 10, 20].

Reproductive coercion refers to practices that limit or control an individual’s reproductive autonomy through force, deception, or structural constraint. Grace and Anderson describe it as behaviors that interfere with contraception use or decision-making, often in connection with intimate partner violence [33]. At the same time, reproductive coercion extends beyond interpersonal relationships and reflects broader systems of power. Morgan and Roberts use the concept of reproductive governance to show how states, religious authorities, and medical institutions regulate fertility and family life [34]. Roberts further shows how U.S. policies and medical practices have historically sought to control Black women’s reproduction, linking coercive interventions to the denial of reproductive liberty [29]. Building on this, Bridges demonstrates how pregnancy itself can operate as a site of racialization, where clinical practices reproduce inequality and surveillance of Black women’s bodies [35]. Dána-Ain Davis identifies obstetric racism as the neglect, dismissal, and coercion experienced by Black women in maternity care, practices that reproduce racial inequities in reproductive health [36]. Garcia similarly analyzes obstetric violence as systemic mistreatment during pregnancy and childbirth, ranging from verbal abuse to unnecessary interventions and the denial of informed consent [37]. These perspectives underscore that reproductive coercion is not only an individual experience but also an institutional and structural phenomenon that continues to undermine Black women’s reproductive freedom and deepen mistrust of healthcare systems.

In 1907, Indiana became the first state to pass a sterilization law in the U.S. [38] Between 1913 to 1917, eugenics laws protected physicians from facing legal consequences for performing sterilizations. Over the course of the twentieth century, more than 60,000 people were sterilized in 32 states [39]. Sterilization was promoted as a public health measure aimed at preventing those labeled “unfit” or “feeble-minded” from having children; these labels were heavily influenced by racial biases that prioritized Anglo-Saxon and Nordic groups [39, 40]. Those targeted included people with disabilities, immigrants, poor whites, and Black and Indigenous populations [39].

Between 1960 and 1970, Medicaid began funding sterilizations, raising concerns about whether women fully understood the informed consent process, particularly given literacy barriers [40, 41]. During this period, revelations emerged about the nonconsensual sterilization of Native American, African American, Mexican, and Puerto Rican women [42]. In 1973, the involuntary sterilization of 12- and 14-year-old Minnie Lee and Mary Alice Relf in Montgomery, Alabama, brought national scrutiny to coercive practices in federally funded family planning programs. The case resulted in a class action lawsuit, Relf v. Weinberger, which revealed that thousands of poor Black, Indigenous, and Latina women had been sterilized without proper consent. The lawsuit led to new federal guidelines on informed consent, yet it also underscored how reproductive coercion remained embedded in medical practice and policy well into the twentieth century [42, 43]. In the South, forced hysterectomies targeted low-income Black women as a means to reduce welfare rolls, a practice later found in cities like Boston and New York [28].

These practices were not isolated to Black women in the United States but reflected a broader racialized pattern of reproductive experimentation on women of color. For instance, the 1950s and 1960s contraceptive pill trials in Puerto Rico enrolled poor women without adequate consent or disclosure of risks, illustrating how colonial and racial hierarchies shaped reproductive science across contexts [44].

HeLa cells and the ethical reckoning in biospecimen research

The story of Henrietta Lacks, source of the immortal HeLa cell lines, exemplifies the structural violence faced by Black women in U.S. healthcare [45]. In 1951, Lacks, a Southern African American tobacco farmer, visited her doctor about a “knot” in her womb [45]. After testing negative for syphilis, she was referred to Johns Hopkins Hospital, the only institution in a twenty-mile radius treating Black patients, though under strict segregation [45]. A month after childbirth, she tested positive for gonorrhea but missed her follow-up appointment, likely due to limited medical literacy, and later presented with late-stage cervical cancer [45].

Despite Lacks’ complaints, Dr. Howard Jones noted, “I do not quite know what she means by this, unless she actually palpated this area” and observed that “no note [was] made…that there is any abnormality of the cervix” during her previous visits (p.17) [45]. In an era when public hospitals freely experimented on patients without consent, Jones remarked that “Hopkins, with its large indigent black population, had no dearth of clinical material” (p.30) [45]. Without her knowledge, Lacks’ cells were harvested, becoming the first immortal human cell line. She was also unknowingly rendered infertile by radium treatments; records suggest she would have refused had she been informed [45].

Black patients like Lacks were typically treated later, given less pain management, and had higher mortality rates than White patients [45]. After her death, further tissue samples were taken under false promises to her husband that the research would help their children [45]. The family remained unaware of the use of HeLa cells for years. Lacks’ case has since raised enduring ethical questions in biospecimen research [46]. Similarly, the Tuskegee Syphilis Study (1932–1972) stands as a major marker of medical mistrust. In this study, Black men were deliberately denied penicillin to observe the natural progression of syphilis [2, 47].

Controlling images and the pathologization of black womanhood

Early descriptions of Black women by white male travelers and pro-slavery intellectuals created stereotypes that persist today [48]. Black women’s resistance to systemic oppression has been met with negative, controlling images that normalize inequities and reinforce otherization [49–51]. Common stereotypes include the “mammy,” “matriarch,” “welfare mother,” and “jezebel” [48, 51]. The “mammy” image, situated at the intersection of race, class, gender, and sexuality, portrays Black women as subservient caregivers to white families [49, 51]. During slavery, Black women were harshly treated during childbirth, “strapped down, refused comfort,” and subjected to “unimaginable indignities,” which they could not resist [11]. This image endures in expectations that Black women defer to Whites [49, 51].

The “matriarch” image, a conflicting extension of “mammy,” casts Black women as masculine and unfeminine [51], reinforcing stereotypes about family instability rooted in slavery’s dismantling of Black patriarchy and fostering the view that Black culture is inferior for defying dominant norms [52] English writers further depicted Black women as “unrepresentable and a significant threat to patriarchy” (p.38) [51].

The “welfare mother” updates the “breeder woman” stereotype from slavery, now portraying Black women as “lazy” and incapable of caring for their children [50, 52]. This controlling image polices Black women’s fertility and operates at the intersection of race, gender, and class oppression [52]. During slavery, Black women endured reproductive domination through breeding practices, as controlling reproduction was seen as necessary since race is passed through lineage [29]. In the 1970s, the “welfare mother” image reemerged as the infamous “welfare queen,” a racialized trope popularized in Ronald Reagan’s presidential campaigns to demonize poor Black women and justify the retrenchment of welfare programs. Ange-Marie Hancock [53] demonstrates how this narrative fostered public disgust toward Black mothers and legitimized punitive welfare reform, while Julilly Kohler-Hausmann [54] situates it within broader efforts to link poverty governance to carceral expansion. Wahneema Lubiano [55] further argues that the “welfare queen” served as an ideological tool, deploying narrative means to stigmatize Black women as the embodiment of deviance and irresponsibility. These constructions illustrate how cultural stereotypes and political rhetoric combined to undermine public support for social safety nets while reinforcing structural inequities.

The “jezebel” image portrays Black women as sexually aggressive and uncouth [50, 52], aligning with Barbot’s portrayal of Native African women: “even the great punishment inflicted here on women for adultery … is not sufficient to restrain their lust” (p.174) [12]. This image brands Black women as the “bearers of incurable immorality” (p.8) [29].

These controlling images sustain a matrix of domination at the intersections of race, class, gender, and sexuality [49, 50], creating interlocking systems of oppression that limit access to services for Black women [56]. For example, only about 5–6% of U.S. physicians are Black or African American, compared to approximately 12–13% of the population. [57, 58] Similarly, among registered nurses, Black professionals make up between 11 and 14%, with lower representation in advanced practice and leadership positions [59, 60]. Licensed practical/vocational nursing shows somewhat higher proportions (around 26%), but these are largely in less specialized roles, indicating that representation drops off in higher tiers of healthcare professional hierarchies [59].

Today, Black women report higher rates of discrimination in healthcare than their racial/ethnic counterparts [28]. They are more likely to undergo cesarean sections even for low-risk pregnancies, despite cesareans carrying a death rate three times higher than vaginal births [28]. The pain of Black women is often ignored, rooted in stereotypes and the historical denial of anesthesia during nonconsensual surgeries [28, 61–63].

Contemporary medical education reinforces these assumptions, as curricular materials and clinical examinations often present race as biological rather than social. As Dorothy Roberts argues, this naturalizes racial difference, reproduces stereotypes about Black bodies, and legitimizes unequal treatment [64].

The historical construction of controlling images and the pathologization of Black womanhood institutionalized racialized biases within healthcare. These enduring narratives continue to shape the treatment of Black women and other marginalized groups. Contemporary analyses underscore that addressing current health inequities requires a structural lens, linking persistent disparities to the historical continuum of racism and systemic oppression that fuels medical mistrust today.

Agency and resistance were also evident in community-based initiatives. The Black Panther Party’s health programs in the late 1960s and 1970s, including free clinics and health education projects, combined direct care with systemic critique. As Nelson shows, these programs reframed health as a political right rather than a privilege, confronting medical racism through both lived practice and structural analysis. Highlighting this history of agency is important because it demonstrates that Black communities have long developed their own strategies for health equity. These strategies remain instructive for dismantling systemic racism in healthcare today [65].

From historical injustice to contemporary medical mistrust

Minoritized populations continue to face significant discrimination, prejudice, stigma, and racism in accessing healthcare. [2] These experiences are not isolated but rooted in a historical continuum of injustice and oppression that continues to shape health outcomes today. Health inequities can be understood through a framework informed by both historical and contemporary inequities, which identifies systemic inequities and institutional and cultural racism as basic causes of health disparities [66]. These basic causes create social statuses, including socio-economic and marginalized racial status, that are shaped by systemic oppression [1, 66].

Social status, in turn, influences exposure to discrimination, stigma, stress, socio-economic opportunities, and access to resources and knowledge. These exposures impact behavioral, psychological, physiological, collective, and individual health outcomes [1, 66]. The framework illustrates how basic causes lead to disparities in morbidity, mortality, and disability and underscores that historical and contemporary racism cannot be separated from current health inequities. [1] These historical antecedents have built a foundation of medical mistrust, continually reinforced by ongoing injustices and unequal outcomes.

Racism manifests through prejudices, stereotypes, and preferential treatment favoring dominant groups, contributing to lower-quality healthcare and poorer outcomes for marginalized populations, who face higher rates of chronic disease, disability, and mortality [66]. However, quantifying racism today has become increasingly difficult due to the prevalence of aversive racism and implicit bias, wherein individuals engage in “an effortless evaluative process to make decisions based on information already available in their memory” [66]. Delivering equitable care requires providers to act “without bias or arational evaluations” [67].

Further compounding these disparities, racial inequities persist in healthcare education, where Black clinical educators, providers, and care managers remain underrepresented [68, 69]. Healthcare professionals also exhibit the same levels of implicit bias as the general population [67]. Black patients often feel they are not properly centered in care, that providers lack contextual knowledge, and that patient-provider communication is inadequate [70, 71]. Moreover, psychosocial outcomes for both Black and white populations are negatively affected by provider biases [71]. Racial bias is embedded in contemporary medical standards, including pain assessment, treatment recommendations, and racialized perceptions of biological differences [63]. These cumulative biases continue to widen health disparities and reinforce the deep mistrust marginalized groups have toward the healthcare system.

Implications for public health

Understanding the historical roots of reproductive coercion and medical mistrust among Black women is critical for addressing contemporary health disparities. Medical mistrust is not a transient attitude but a rational response to a legacy of systemic violence, exploitation, and discrimination embedded within healthcare institutions. Efforts to reduce disparities in reproductive health outcomes must therefore move beyond individualized interventions and address the structural factors that sustain distrust. Equity in healthcare refers to the absence of systematic disparities in health or in the major social determinants of health between groups with differing levels of social advantage [72]. Public health initiatives should prioritize rebuilding trust by ensuring transparency, accountability, and meaningful engagement with Black women and their communities. This includes expanding community-led models of care, diversifying the healthcare workforce, and implementing structural competency training that directly confronts the historical and contemporary realities of racism in healthcare. Research shows that community health worker and patient navigation programs have improved cancer screening, chronic disease management, and treatment adherence in marginalized populations by creating trusted points of contact between communities and healthcare institutions. Research shows that these programs improve access, enhance patient experience, and reduce reliance on acute care among marginalized populations, thereby addressing mistrust by helping individuals navigate complex and often unwelcoming systems [73–76].

In maternal health, culturally responsive initiatives that integrate Black midwives and doulas have reduced disparities in outcomes while affirming dignity and autonomy in reproductive care. These interventions directly counter obstetric racism and help rebuild trust in healthcare by centering patient voice and agency [77]. Similarly, structural competency training equips clinicians to recognize how systemic inequities shape health and to respond in ways that demonstrate respect and accountability. By addressing the structural roots of bias, such training works to reduce patient mistrust of providers [78, 79]. At the institutional level, reforms that increase transparency, establish accountability mechanisms, and involve communities in decision-making further strengthen trust. These practices demonstrate institutional trustworthiness, signaling to historically marginalized groups that systems are changing in response to past and present harms [1]. Moreover, policies must be informed by an intersectional framework that acknowledges the compounded impact of race, gender, and socio-economic status on health [80]. Trustworthiness, not just trust, must become the central goal of public health institutions. Historical reckoning, institutional reform, and community empowerment are essential steps toward dismantling the structures that perpetuate reproductive health inequities and restoring faith in the healthcare system among marginalized populations [61, 81].

Black women themselves have consistently articulated how history shapes their present mistrust of healthcare systems. In interviews, women describe how the legacies of forced sterilization, experimentation, and obstetric racism resonate in their experiences of neglect, dismissal, and coercion in contemporary clinical encounters [36]. Prather et al. note that Black women explicitly connect reproductive oppression across generations to their hesitancy toward medical institutions today [81]. In addition to describing mistrust, Black women also articulate pathways toward more equitable care. They emphasize the importance of respectful communication, culturally responsive maternal health services, and accountability to the communities most harmed by systemic racism [82]. Community-led models, such as Black midwives, doulas, and reproductive health organizations, are highlighted as trusted spaces where care affirms dignity and autonomy [83]. Incorporating these perspectives demonstrates that Black women are not only subjects of medical mistrust but also experts whose insights are essential for building institutional trustworthiness.

Conclusion: toward trustworthy and equitable healthcare

There is a critical need to build trustworthy institutions capable of effectively serving underserved and historically marginalized populations. As this review demonstrates, trust profoundly influences health decision-making among Black women, particularly in accessing preventive reproductive health services. Medical violence, deeply embedded in the historical and contemporary experiences of racism and discrimination, has been detrimental to Black women’s health outcomes. These enduring experiences of prejudice and systemic inequity continue to shape Black women’s perceptions of the healthcare system’s trustworthiness and their willingness to seek care. Addressing these inequities requires not only confronting individual biases but also dismantling the structural forces that sustain medical mistrust. A historically grounded understanding of medical mistrust directly informs clinical practice, health policy, and medical research. In clinical settings, acknowledging this history underscores the need for structural competency and culturally responsive models of care that validate patient experiences and rebuild trust through transparency and accountability [1, 78]. For health policy, it highlights why reforms must address structural barriers such as workforce diversity, insurance coverage, and equitable access to reproductive and maternal health services [61, 81]. In medical research, it calls for community-based participatory approaches that engage historically marginalized populations not merely as subjects but as partners, ensuring that research agendas reflect community priorities and generate interventions that are both effective and trusted [84]. By explicitly connecting the history of medical racism to current inequities, these strategies move beyond abstract calls for trust and toward concrete practices of institutional trustworthiness.

Author contributions

TEA engaged in the entire spectrum of research.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethical approval

This study was approved by the University of Louisville Institutional Review Board (IRB #22.1004).

Competing interests

The authors declare no competing interests.