Resistance and Gendered Racism: Middle-Class Black Women's Experiences Navigating Reproductive Health Care Systems

Historical Perspectives on Reproductive Injustices and Gendered Racism

For years, Black reproductive health scholars and clinicians have sounded the alarm that racism, not race, is the underlying factor of reproductive health inequities (e.g., Boyd et al., 2020; see also Scott & Davis, 2021). However, public health officials were reluctant to declare racism as a public health issue until 2020 (Center for Disease Control, n.d.). The Center for Disease Control's declaration of racism as a public health issue was monumental and yet fails to provide a historical context of how the Black reproductive body was conceptualized during slavery, the violence inflicted on Black reproductive bodies in the name of scientific progress, and its contemporary connection to gendered racism. Gendered racism in reproductive care has a long history with resounding echoes today, carried in individual women's bodies and affecting our collective well-being.

The progression of medical science and the development of reproductive medicine coincided with Congress’ banning the importation of African-born enslaved people in the early 1800s (Owens, 2017; Owens & Fett, 2019; Washington, 2008). Enslavers became invested in maintaining and growing enslaved Black bodies through medical intervention because the United States economy and profitability as a nation increasingly depended on the labor of enslaved people. Therefore, enslavers’ need for Black women to (re)produce a healthy enslaved nation created a reproductive medical system that disciplined and subjugated bodies to uphold the United States’ racial capitalistic profits from slavery (Ahmed, 2002). Thus, a complex and complicated relationship was born between enslavers, reproductive medicine, and the racialized Black reproductive body.

In the antebellum South, medical schools and doctors often partnered with enslavers to attend to the reproductive health of enslaved Black women. Being granted access to Black women's reproductive bodies transformed the field of modern American gynecology in the 19th century through non-consensual experimental sexual reproductive surgeries (Owens, 2017). The experimentation and exploitation of the Black body produced an ethnocentric bias towards European Americans, racialized as white, that became embedded into medical and scientific knowledge (Washington, 2008). The historical legacy of exploiting Black women's bodies for gaining gynecological knowledge, far too extensive to adequately review here, offers a window into how gendered racism is deeply embedded in the current infrastructure of reproductive healthcare systems. The present study, relying upon the construct of gendered racism, seeks to trace how this history haunts the bodies of Black women, even middle-class Black women, today.

Gendered Racism

Gendered racism is a compounding form of oppression structured around racist perceptions of gender roles (Essed, 1991). Research suggests that gendered racism and gendered racial microaggressions are pervasive forms of psychological distress that Black women experience (Thomas et al., 2008) and are related to traumatic stress, endorsements of depressive symptoms and can be considered a source of adverse mental health among Black women (Jones et al., 2022; see also, Lewis et al., 2017; Moody & Lewis, 2019). Further, gendered racism is grounded in societal expectations of negative depictions of Black womanhood rooted in racist and sexist stereotypes, such as the Jezebel and Mammy (Collins, 2000). For example, empirical evidence suggests that Black women experience pregnancy-related stress caused by gendered racism in the form of stigmatizing stereotypes of Black motherhood, such as assumptions of being single, having multiple children, or being a recipient of government assistance (Mehra et al., 2020; Rosenthal & Lobel, 2020). Even though prior research has established the psychological and physical consequences of gendered racism, none of the literature cited above meaningfully included social or economic class in their analyses.

Gendered Racism and Social Class

Many studies on Black women's reproductive health treat race as a proxy for class when attempting to explain racialized maternal health inequities among Black women (Davis, 2019a; Kawachi et al., 2005). Since studies on the Black maternal health crisis tend to focus on Black women most impacted by systemic oppression (e.g., lower socioeconomic status; see Howell, 2018), there is an assumption that Black women's class status fully protects them from the impact of gendered racism in reproductive health care settings; however, this is not the case. Middle-to-upper-class Black people are less likely to experience positive health benefits than their white counterparts despite having access to material resources and social capital (Assari, 2018). Moreover, according to Bridges (2020), “middle and upper-middle-class black women die from pregnancy-related causes at rates that are higher than middle and upper-middle-class white women” (pp. 1257–1258). Intersectional research focusing on class differences is needed to understand how class influences differential maternal health outcomes among Black women.

The above studies suggest that class does not fully protect middle-and-upper-class Black women from racism's impact on reproductive and maternal health inequities in comparison to white women's outcomes. However, Black women of lower socioeconomic status do not have access to the few class protections that middle-and-upper class Black women may have. For instance, middle-and-upper class Black women may have access to certain protective factors (e.g., insurance, stable employment, paid sick and family leave) that buffer against mechanisms such as “stressors and chronic strains associated with [the] environment, housing, [economic], and social service delivery…directly affects[ing] women's health and well-being” (Mullings & Wali, 2001, p. 162). Put differently, middle-and-upper-class Black women are less likely to experience the same chronic daily stressors than Black women of lower socioeconomic status because they are more likely to have stable employment, comprehensive health insurance, and earn higher wages. The consequences of gendered racism on Black women's maternal and reproductive health outcomes, regardless of class, remains relentless. Nevertheless, the psychological consequences of middle-to-upper-middle-class Black women's experiences of gendered racism in reproductive health care remain an underexplored area of research.

Black Feminism and Hauntings of Gendered Racism

Gendered racism, understood as historic and contemporary, provides a framework for theorizing how healthcare professionals’ racialized and gendered biases and discriminatory practices may contribute to reproductive health inequities among Black people (Treder et al., 2022). Black feminism has theorized gendered racism as an intersectional issue that acknowledges the unique form of oppression that Black women experience, embodying multiple identities that intersect at micro and macro, structural and social levels, through dynamics of gender, race, and class (Andersen & Collins, 2004; Bowleg, 2012; Crenshaw, 1991). Black women's everyday lives involve experiencing both racism and sexism, which compound racial inequities in maternal mortality (Patterson et al., 2022). Put differently, racism, sexism, and classism (as well as heterosexism and cisgenderism) contribute to reproductive health inequities among Black people. However, here I introduce an intersectional framework of gendered racism to analyze how these historical and structural dynamics live in bodies and medical interactions. Drawing from writer Sharpe (2014), Black women's experiences of gendered racism can be understood through the theoretical framework of living “in the wake”—a concept and analytic framework used to describe the duality of Black people's consciousness and awareness of slavery's legacy of Black subjection, as well as Black people's current modes of resistance against living in the aftermath of slavery. As a consequence of being “in the wake,” there is “the persistence of the [gynecological] trauma of slavery into the present,” which “haunts” Black women's experiences in reproductive health care (Weinbaum, 2019, p. 64).

Black Women's Coping and Resistance Responses to Gendered Racism

Understanding the oppressive impacts of gendered racism is, however, incomplete without lifting Black women's creative and dynamic forms of coping and resistance. Substantial research has identified gendered racism as a psychological stressor. When Black women experience gendered racism, they employ coping strategies to mitigate the physical and mental consequences of stress caused by racism (Spates et al., 2020). Research suggests that Black women use the coping strategy of cognitive-emotional debriefing (e.g., attempts to forget or passively avoid thoughts about discrimination and racism) to manage emotional distress associated with gendered racism (Thomas et al., 2008). Black women who experienced gendered racial microaggressions more frequently used disengagement coping methods, such as self-blaming, substance use, denial, or behaviors that facilitate disengagement (Lewis et al., 2017). Similarly, a handful of studies underscore Black women's use of avoidant coping to either eliminate the possibility of experiencing race and gender-based discrimination or to minimize any resulting stress (Everett et al., 2010; Shorter-Gooden, 2004; Spates et al., 2020). Other coping strategies that Black women used to combat gendered racism are faith-based and spiritual practices (e.g., praying, mindfulness, and their belief/faith in God) and relying on social support networks (e.g., talking to friends and seeking comfort from family; Shorter-Gooden, 2004; Spates et al., 2020). Thus, while previous research identifies Black women's coping mechanisms against gendered racism, the strategies middle-class Black women employ in reproductive healthcare remain unexplored.

The Current Study

As outlined above, previous research has established a strong historical relationship between chattel slavery in the United States and the Black reproductive body, describing how this history influences the psychological dynamics of gendered racism and exploring how Black women have developed culturally rooted coping strategies in response to experiencing gendered racism as a psychological element of their everyday lives. However, a dearth of research explores the impact of Black women's class status on their experiences of and resistance to gendered racism in reproductive health systems in the aftermath of slavery.

This study moves beyond the previously established psychological research on the coping strategies that Black women employ to alleviate the distress and psychological impact of gendered racism by contextualizing these dynamics for middle-class Black women in psychology's underexplored area of gynecology and obstetrics. My goal for this study was to transcend the numerical dependence on adverse reproductive health outcomes among Black women and to shift the focus to the subtle and devastating psychological dimension of gendered racism by situating middle-class Black women currently navigating reproductive health care systems in the historical context of slavery. Specifically, I explored the following research questions:

How do Black middle-class women experience and navigate reproductive health care systems?

Participants

Participants self-identified as Black or African American (83%) or self-identified as Black during the interview but chose bi/multiracial (17%) on the demographic survey. Participants ranged in age from 20 to 60 years old (M = 30, SD = 10.70). Most participants self-identified as middle class (92%), held private insurance (75%) and saw an OBGYN for their reproductive health needs (92%), and attended graduate school (58%). Although class position is often contested within the social sciences and changes depending on sociopolitical contexts, a single measure of income was not used to determine participants’ class status (Renwick & Short, 2014; Sacks, 2018). Instead, class was conceptualized through multiple criteria of (a) income (e.g., current household income or parental income for un-and-under-employed students of $50,000 or more); (b) education (e.g., currently pursuing a bachelor's or degree or beyond); and (c) occupation (e.g., employment at institutions that are considered to have high social and capital, such as being an artist, the potential to earn higher wages, and provides access to material resources and prestige).

Recruitment and Sampling

The study protocol and materials were reviewed and approved by the Institutional Review Board at the City University of New York. Between 2017 and 2018, as part of a larger project focusing on Black women's attitudes toward cultural competence in reproductive healthcare, I used purposive sampling (Charmaz, 2014) to identify individuals who self-identify as Black. I posted recruitment flyers advertising an interview-based research study on race, culture, and reproductive health care on the campus of a private university in New York City. A PDF copy of the recruitment flier was disseminated via email to various student union email listservs and Black women's community groups’ email listservs. Snowball techniques were employed during recruitment (Woodley & Lockard, 2016). After prospective participants reached out to me, showing their interest in the study, they were screened for eligibility.

Eligible participants needed to identify as Black or African American, a woman, 18 years of age or older, and willing to discuss their experiences seeking and receiving reproductive health care. I selected participants who received reproductive health care within the past 12 months so that their experiences were easier to recall. After conducting three interviews, however, I realized that people were quickly able to vividly narrate their experiences and stories navigating reproductive healthcare systems that occurred more than a year before our interview date. In other words, while interviewing and listening to these narratives, I realized 05wthat Black women's experiences navigating reproductive health care systems stick and become part of their life stories. Therefore, after recruiting and interviewing three participants, I determined that receiving care within the past 12 months was no longer relevant to the screening process. Nine out of 12 participants were recruited without these criteria. There were no exclusion criteria other than being able to speak English. Recruitment was completed when theoretical saturation was reached and no new information or insights emerged from participant narratives (Charmaz, 2014; Esposito & Evans-Winters, 2021; Morse, 2007). Recruitment efforts yielded a total of 12 participants in the sample. See Table 1 for demographic information for each person in the sample.

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Table 1.

Participant Sociodemographic Characteristics.

Pseudonym	Age	Race/Ethnicity	Education	Insurance	Sexual Orientation	Occupation	Income
Donna	31	Black	MA	Private	Heterosexual	Stay-at-Home Mom	$100,000+
Ayana	19	Black	Pursuing BA	Private	Heterosexual	Undergraduate Student	≤$10,000
Kia	33	Black/Multiracial	MA	Private	Heterosexual	Teacher	$100,000+
Joy	19	Black	Pursuing BA	Private	Heterosexual	Undergraduate Student	≤$10,000
Maxine	23	Black	Pursuing MA	Private	Heterosexual	Graduate Student and Retail Worker	$30,000–$49,999
Whitley	24	Black	Pursuing BA	Private	Heterosexual	Undergraduate Student and Retail Worker	≤$10,000
Simone	29	Black	Pursuing MA	Private	Queer	Graduate Student and Sex Health Educator	$30,000–$49,999
Antonia	31	Black	MA	Private	Heterosexual	Social Worker	$75,000–$99,999
Ashley	29	Black	BA	Private	Heterosexual	Project Coordinator in Non-Profit	$50,000–$74,999
Kendra	34	Black/Multiracial	MA	Medicaid	Queer	Artist and Adjunct	$10,000–$14,999
Lisa	60	African American	MA	Private	Heterosexual	Architect and Professor	$75,000–$99,999
Ericka	28	Black/ Latina	AA and Pursuing BA	Private	Heterosexual	Undergraduate Student	≤$10,000

Note. AA = Associate Degree; BA = Bachelor of Arts Degree; MA = Master of Arts Degree.

Interviews

I conducted interviews between 2017 and 2018 as part of a grounded theory study focused on Black women's attitudes toward cultural competency in reproductive health care that I carried out in the context of completing an independent research project while a master's student in psychology at the time of data collection (Howell, 2018, March 8-11). I developed an in-depth, semi-structured, open-ended interview protocol broken into four domains based on my interest in learning about Black women's attitudes toward cultural competency. The interview protocol was updated and revised depending on the conversation's trajectory (Cohen & Crabtree, 2006). Interview questions fell under four topic domains: (a) influence of race and gender on seeking and receiving reproductive health care; (b) descriptions of reproductive encounters that stood out—both good and bad (e.g., Can you tell me about the last reproductive treatment visit that stands out to you the most); (c) microaggressions and explicit racism (e.g., Have you ever experienced microaggressions while receiving care? Can you tell me about that experience); and (d) positive and negative qualities of reproductive healthcare providers (e.g., What qualities does a good provider have? What does good care look like to you?).

I conducted interviews in a private space, either in person or over teleconference platforms like Skype and Google Hangouts. Before starting the interview, I discussed the goals and purpose of the study, participants completed an informed consent form and a demographic survey, and allowed participants to raise concerns or ask me any questions. Interviews lasted approximately 45–75 min, with most interviews averaging approximately 60 min. The participants’ responses were audio-recorded and transcribed using trint, an AI transcription software. Once an interview was transcribed, I checked the transcription against the audio recordings for accuracy. Recruitment, conducting interviews, and transcribing audio interview recordings co-occurred. Audio recordings were destroyed once transcription was completed.

Epistemological and Methodological Frameworks

This study is dedicated to amplifying and centering the lived experiences of middle-class Black women through an analytic lens that recognizes that gendered and racialized biases and violence in reproductive health are too often easily dismissed as poor care at the hands of a few bad actors (Davis, 2019b). Additionally, an epistemological framework of critical bifocality guided the analysis and interpretation of participants’ narratives to animate how psychology can develop a thicker understanding of the interactions of class, gender, and race while also illuminating how the historic sociopolitical formation of power structure Black women's reproductive lives (Weis & Fine, 2012).

Data analysis was guided by a constructivist grounded theory approach (Charmaz, 2014, 2017) because it acknowledges that there is no single objective reality and that the researcher's subjectivity and social reality are embedded in the research process. Utilizing Black feminism in qualitative inquiry (Evans-Winters, 2019) allowed me to make meaning of Black women and femmes’ nuanced experiences of gendered racism in medical settings and analyze their narratives with a critical lens to how treatment and care in medical encounters are situated in a historical context even when the participants do not necessarily make these connections themselves.

Statement of Positionality in Relation to Epistemology and Methodology

According to Evans-Winters (2019), a Black feminist qualitative approach allowed me to attend to nuances of my lived experiences as a researcher and Black woman who is part of the community being researched to be centered during the research and analysis process. Additionally, a Black feminist approach to qualitative inquiry is rooted in the ancestral knowledge that my participants and I have enabled me to pose an alternative to how knowledge is produced by challenging hegemonic discourses (rooted in white supremacy) and methods within psychology and social sciences more broadly (Esposito & Evans-Winters, 2021; Evans-Winters, 2019). My political commitments as a Black feminist informed my epistemological and methodological approach; therefore, I must offer my positionality as a researcher. I am a middle-class Black American (of African and Jamaican descent) cisgender woman, who is heterosexual, and have been educated in predominantly white institutions. Trained in qualitative and quantitative methods and analytic strategies, committed to relational ethics in social inquiry, and dedicated to lifting and complicating Black people's experiences across the reproductive health care spectrum, my experiences and upbringing inform my methodological approach and the knowledge that is produced through this project. Further, my social position allows me to acknowledge how the different aspects of who I am (as a person, a researcher in a position of power, and my political commitments to Black feminisms) influenced how I saw and interpreted the data during the process of analysis.

Data Analysis

The present study is aimed at understanding the extent to which and how these participants address experiencing gendered racism in their reproductive medical encounters. First, I immersed myself in the data by conducting multiple transcript readings. During this initial data immersion, I engaged in the Black feminist practice of reflective memo-taking (Davis & Craven, 2022). Reflective memo-taking involves writing interpretive notes on possible patterns or potential codes, as well as writing down any emotional reactions and any personal reflections that come to mind while doing an initial reading of the transcribed interviews. This practice of reflective memo-taking occurred after every reading of the data throughout the analysis process.

Next, I reviewed the transcripts to select narratives related to the research question. In this step, I focused on finding narratives that captured participants’ experiences of (a) gendered racism and microaggressions, (b) resistance practices and coping strategies against gendered racism, and (c) conceptualizations of the quality of care received—both good and bad. After immersing myself in the data through multiple readings, I undertook the first phase of coding. Line-by-line coding was conducted, followed by reducing similar codes to create initial codes concerning my research question and the experiences captured in each chosen narrative domain. Then, I reviewed the initial codes against the interview data to ensure that they were reflected in the data (Charmaz, 2014). Once I reviewed the initial codes and interviews, I began the process of focused coding. The process of focused coding consisted of reducing initial codes by selecting the most salient, significant, and frequently used codes by comparing initial codes against the data (Charmaz, 2014). Focused coding helped me to organize, categorize, and make analytic sense of my initial codes. This step allowed me to see what patterns in the participants’ narratives were emerging while staying close to the data and identifying and taking note of any outliers when they appeared (Charmaz, 2014). After I engaged in focused coding, I checked the focused codes against the transcripts to ensure that they stuck close to the interview data (Charmaz, 2014). Subsequently, I created a codebook consisting of the final set of focused codes, as well as their definitions organized according to the three domains (gendered racism, quality of care, and refusal, resistance, and coping strategies) related to my research questions.

In the second phase of coding, following focused coding, I entered the data into MAXQDA 2020 and labeled all excerpted narratives with the focused codes. I synthesized categories across the data during this process, reducing overlapping codes. Next, as shown in Figure 1, I looked for relational patterns and made connections across codes that were defined during the focused coding process by using mapping features (i.e., creating a visual representation of the interconnections between codes in each domain) in MAXQDA 2020. The coding map created in MAXQDA allowed me to see how codes overlapped, intersected, and connected. Seeing this visual representation helped me reassess focused codes based on interconnections and co-concurrences. I then reviewed the focused codes across interviews and placed them into categories related to domains of interest. Finally, the interview data were reviewed for patterns and relationships to support, identify, and define each category (see Figure 2). The interview guide, codebook, and initial and focused coding audit trail are available upon email request to the author.

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Figure 1.

Coding Map of Codes in Gendered Racism Domain.

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Figure 2.

Model of Interconnections Between Domains of Interest, Codes, and Themes.

Trustworthiness and Methodological Integrity

Throughout the recruitment, data collection, and analysis process, multiple checks and procedures took place to ensure methodological integrity and scientific rigor. As noted above, I maintained a practice of reflective memo-taking. This practice of reflective memo-taking allowed me to attune to the differences between my perspectives and the participants’ experiences (Williams & Morrow, 2009). I also engaged in analytic journaling through the data analysis process by noting notes and memos consisting of initial thoughts and interpretations of participant narratives that later became part of the larger data corpus (Morrow, 2005). In addition to reflective memo-taking and analytic journaling, I built quality checks into the data analysis process by conducting multiple readings of the interview data to support trustworthiness (Charmaz & Thornberg, 2021; Morrow, 2005).

Additionally, there was a prolonged engagement with the data during analysis through multiple comparisons of the data (interview transcripts) against the data (codes) initial and focused coding (Charmaz, 2014; Morrow, 2005; Williams & Morrow, 2009). Lastly, I used peer debriefing (Esposito & Evans-Winters, 2021; Morrow, 2005; Williams & Morrow, 2009). The process of peer debriefing consisted of my engaging in conversations with trusted peer qualitative researchers and experts of reproductive (in)justice and maternal health inequities. Peer debriefing allowed me to share my interpretations of my research process and receive valuable feedback on how I analyzed and interpreted the data (Esposito & Evans-Winters, 2021).

Hauntings: Speculations of Gendered Racism as Historical Gynecological Trauma

Black women in gynecological care know, in their minds and their bodies, the brutal history of Black women and reproduction. Multiple participants referenced the current Black maternal health crisis, and the historical subjugation of the Black reproductive body influenced their attitudes towards gynecology and obstetrics. These participants also speculated that this fraught historical relation underscored their off-putting feelings while visiting the gynecologist. As Simone, a 29-year-old graduate student and sexual health educator, plainly stated:

I think there is a lot of inherited generational trauma around sexual, sexualization, and things like that. The history of [and] even the practice of gynecology and obstetrics being steeped in violence towards the bodies of Black women. That was something that I was aware of later. I learned about that stuff later, but I always knew the idea of like sitting in stirrups was disgusting to me. It was all of these that were like {makes squeamish sound} not right.

Kia, a 34-year-old teacher, further expanded on how the historical trauma of gynecology has influenced the anticipation and experience of gendered racism. During our interview, Kia mentioned that she was “desperately looking for a new doctor.” I followed up on this comment and asked her why she did not want to return to her current gynecologist and if race had anything to do with it. Kia responded:

Oh definitely. I refuse to have her silence me or make me feel crazy. African American women have the highest mortality rates when it comes to reproductive issues, childbirth, which is why I’m looking for a new doctor. I refuse to have her deliver my baby. They don’t see me. Black women need different care. There's a history of white doctors treating Black people with substandard care. That history and trauma has not been undone. When a doctor is treating a patient, they need to be aware of all the stuff they carry into the room. That may not be clear, what I mean is that doctors should be aware of Black Americans and how the medical community has treated them. They should be more gentle and have a different approach.

Furthermore, participants acknowledged how the history of slavery influences Black people's interactions with medicine more broadly. For instance, Ashley, a 29-year-old project coordinator, stated:

You know the Tuskegee experiment back to slavery, it's just one of those, like that's part of it. I would love more, like, more providers to understand what the history of medicine was like for Black people. And then, getting like the modern view of it, how our modern, like culturally Black people like interacting with medicine.

These middle-class Black women were intimately aware of how the relation between the past and present influences their gynecologists’ perception and treatment and how they enter the exam room and interact with medical practitioners more broadly. Like Ashley, this study's participants had historical knowledge on the reproductive injustices experienced by enslaved Africans that was most likely acquired through the education that their class afforded them. It is possible that, participants’ class and social position provided them with the specific Black feminist rhetoric to clearly name the haunting of racism in their reproductive experiences.

Embodied Experiences in the Present: Dismissals and Violations

When describing their experiences navigating reproductive healthcare systems, most participants reported they often felt, at best, dismissed and violated during their interactions with healthcare workers. This category captures the specificities of healthcare workers’ words and actions, or inaction, that create an environment where the legacy of gynecology's racism materialized in the patient–provider relationship.

Participants’ experiences of gendered racism can be categorized as both vicarious and catastrophic instances of being dismissed (not seen nor heard) and violated (objectified and fetishized). Kia:

[My gynecologist] does not treat me with respect or empathy. Our meetings are very short. The last time I went to see her, I timed my visit with her, it was less than 10 min, and this was the visit where I was getting my IUD removed so that I can try to get pregnant. She's gruff, opens my robe without even asking, doesn’t ask if I have questions or if anything is concerning me, doesn’t seem to take my questions seriously. When I went to her a year ago to get my IUD in, it was incredibly painful. The last time I had it done, five years ago, the doctor gave me some pain meds. My current doctor gave me none and didn’t seem to care at all that I was in a lot of pain.

“In the wake,” (Black people's consciousness of and resistance to living in the aftermath of slavery), and yet more than a century away, these participants carried memories, stories, effects, and bits of how Black enslaved women were denied subjectivity in the name of sexual and reproductive exploitation (Hartman, 1997). Participants reported feeling fetishized, objectified, and denied bodily autonomy by their OBGYNS. When describing one of her first visits to the gynecologist as a teenager, Ayana, a 20-year-old undergraduate student, recalled her parents being upset when learning that a nurse told her to strip naked for a routine wellness check. Ayana recalled:

I remember, well, this is with the non-Black doctor, there was like an issue where my parents got upset because I was young and they [were] not supposed to ask you to fully strip until you’re older. I was maybe 15, and I think you have to be like, it's either 16 or 18 that they’re supposed to do it, and like it's just like some liability thing, and [my parents asked why] and [the gynecologists’ office said] “in case you’re pregnant or something we need to check.” When I told my parents ‘cause that was the first time that I ever had to take my clothes off, they were like “they should not have done that” and they talked to someone [at the office about] this assumption that [I was] pregnant because [I’m] 14 or 15, and [my parents said] “she's not pregnant.” That [conversation] was with some nurse, she wasn’t Black, I don’t remember specifically what race she was but that was an issue that struck me as weird. I was young and probably too young to have that assumption put on me if I had been like white.

Some participants reported similar experiences of objectification by their gynecologists. Kendra, a 34-year-old biracial artist, describes feeling “exotified” during a pelvic exam. Kendra disclosed:

I had Medicaid, so I was just assigned a gynecologist, and she was maybe newly gay. She found out that I dated women, and she just started talking about her sex life and talking about dating Black women. She's white, and she's talking about dating a cop the whole while she's inside of me. The whole thing, just obviously like, ah. I just felt like she was exotifying my body as this part of her own sexual exploration as she's examining me. Like how is that appropriate? It's not.

Strategies of Protection and Resistance Against Gendered Racism

Across all interviews, participants discussed the distinct ways they would enter the exam room with “armor,” prepared to protect themselves from poor care and uncomfortable experiences (Bell et al., 1998). Participants anticipated harm at the hands of their gynecologist and other reproductive healthcare workers, and these coping mechanisms and strategies of resistance assisted them in protecting themselves from said harm. They described the different mechanisms of coping and resistance that assisted them with mentally processing the anticipation and experiences of gendered racism. Performing for doctors took on two forms: Roleflexing Class Status and Slipping into Moments of “It's Cool.”

Limitations and Future Research Directions

Despite the contributions of this study to understanding middle-class Black women's experiences of gendered racism in the context of reproductive health, this study has limitations. First, the interviews were conducted between 2017 and 2018 and were used in the present study to address new questions related to gendered racism in reproductive health encounters. Although the interviews yielded rich data, and there are several advantages to secondary analyses, they have their limitations. For example, the socio-cultural-political context under which the interview data was analyzed for the current study differs from the contexts in which the interviews were conducted. In other words, psychology's understanding of how race, class, gender, and other social identities impact peoples’ lived experiences has become more nuanced. Conversations and scholarship with an intersectional analysis and framework have deepened since 2018. For example, intersectionality is being used to critically examine how psychological scholarship is used to address systemic oppression and social change (e.g., Bowleg, 2021; McCormick-Huhn et al., 2019; Sabik et al., 2021). Second, most of the sample (75%) was based in New York City. Most participants were based in one of the largest cities in the United States and were more likely to have access to Black gynecologists, as well as a large and diverse pool of gynecologists more broadly. Access to Black gynecologists and flexibility in choosing providers and private insurance are privileges that other Black women in rural and suburban areas may not have. Future research should expand the scope of their sampling to rural, suburban, and urban settings and focus on the influence of insurance's limitations of “choice” and “flexibility” in choosing a gynecologist and its impact on the patient-provider relationship.

Third, the psychological implications of gendered racism discussed in the paper are conceptualized and understood outside of a psychological and psychiatric medical model (e.g., the Diagnostic and Statistical Manual and American Psychological Association guidelines). Nonetheless, the psychological dynamics of gendered racism discussed in the present study are also a strength because it exists outside of the medical model historically rooted in the same eurocentric bias and systemic racism as the field of obstetrics and gynecology. For example, drapetomania was a psychiatric diagnosis of “insanity” given to enslaved peoples who wanted freedom or attempted to escape bondage (Willoughby, 2018).

Fourth, most of our sample reported being heterosexual (84%). This study attempted to recruit a heterogeneous sample of Black participants; however, only 2 of the 12 participants reported being queer (16%). Research focusing on examining social determinants of health treats data on sexual orientation as additive demographic information rather than purposefully integrating sexuality and gender identity into analyses of the social impact that the intersections of these different identities have on health inequities (Bowleg, 2008). Future studies should expand to transgender, non-binary, gender expansive, and queer communities whose experiences with gendered racism in the reproductive context have not yet been fully captured by research.

In addition to the above-suggested research directions, future research should explore the differences in experiencing gendered racism across Black women's life course. The age range of participants in this study demonstrates that gendered racism happens across the lifespan. Black girls are often viewed as more adult than their white counterparts (Epstein et al., 2017), and the adultification of Black girls impacts their physical health outcomes (Koch & Kozhumam, 2022). Future research should explore Black girls’ first gynecological visits and experiences of gendered racism. Additionally, future research should explore gendered racism in healthcare encounters of Black perimenopausal and menopausal women.

Practice Implications

By centering the powerful narratives of middle-class Black women seeking reproductive care, this study contributes to the empirical evidence that race and particularly racism dilute the protections that even Black women's middle-class status may confer. First, my findings stress the importance of integrating institutional changes in obstetrics and gynecology (while acknowledging the field's past relation with slavery by implementing and updating anti-racism educational and training practices and guidelines). Second, clinics, hospitals, and other settings that provide reproductive health care can implement patient-reported measures of racism and quality improvement, such as the PREM-OB Scale (White VanGompel et al., 2022), and incorporate anti-racism training for all clinicians and other healthcare workers that includes how to recognize when patients use strategies of protection and coping. Third, the participants’ narratives have implications for clinical psychologists, especially feminist psychologists, helping middle-class Black women dispel anxieties and ease psychological burdens, tensions, and consequences. Clinical psychologists and therapists can affirm their patients’ experiences of gendered racism and help them manage and cope with racism-related stress.

Lastly, the strategies of protection employed by the participants of this study may not be limited to medical exam rooms but may also extend to a range of medical, physical health, and mental health settings, including the therapy room. Psychological training programs and doctoral education guidelines should be updated and targeted to train therapists to recognize when strategies of protection and coping mechanisms such as roleflexing are being employed within the therapeutic relationship so that the therapist can confront and repair instances of gendered racism and help guide their clients towards healing and overcoming racialized and gendered trauma. However, I caution against employing clinical interventions and practices rooted in white-Eurocentric frameworks that lack cultural relevance, as this may cause further harm. Instead, clinical training should focus on implementing a critical consciousness of anti-Black racism model to educate clinicians on recognizing, processing, and challenging gendered anti-Black racism (Mosley et al., 2021). By adapting models to confront gendered racism and anti-Blackness in clinical settings, therapists will be better equipped to treat their gendered and racialized trauma as a result of experiencing systemic gendered racism.

Conclusion

This study contributes to the larger bodies of literature concerning gendered racism, coping strategies, and reproductive health by underscoring the role that the class, race, and gender intersection plays in Black women's interactions with their gynecologists and their interpretation of and response to gendered racism. Race and gender were compounded by the participants’ middle-class status and relegated to the veiled racist and sexist remarks made by their gynecologists, unaware of their gendered racism. Through this study, I offer a historical understanding of gendered racism as a set of interpersonal and psychological dynamics that animates how, for Black women, gendered racism is as mundane as it is insidious. Put differently, Black women's narratives illuminate that having to think about whether the words, behaviors, and actions (or inactions) of the gynecologists and reproductive health care providers were because of their race and gender, which in turn influences how Black women enter and navigate reproductive health care systems. Despite psychology's contributions to advancing our understanding of social injustices and oppression, mainstream psychological research tends to lack a critical intersectional analysis and reduces race and gender into a singular social identity (Bowleg, 2017).

This study uses a critical feminist psychological framework, offers new insights into the psychological dynamics of gendered racism, and brings forth a thicker understanding of how class, race, and gender intersect and reveal structural oppression through individual and interpersonal experiences. Black women are ready to talk about the hauntings, address the dismissals and violations, and prefer to feel safe and vulnerable—even as they enter a space where they anticipate gendered racism. This paper opens meaningful conversations for researchers of reproductive justice and clinicians working with Black women and femmes, as well as medical personnel, in understanding the histories of gendered racism already in the room, even before the “exam” begins. Knowing, naming, addressing, and soothing these dynamics is far more important than ignoring or acting as if they were not present.

I hope that the findings from this study move the field of psychology forward in its conceptualizations of how race, gender, and class intersect with reproductive (in)justice in communities of substantial and also minimal racial diversity and are used by feminist and critical psychologists alike to continue to push for social justice within our beloved discipline.