Promoting Black Girls’ and Women’s Sexual and Reproductive Health Requires Acknowledging Their History and Experiences

The concept of sexual and reproductive health refers to individuals’ “physical, mental, and social well-being in all matters relating to the reproductive system.” An individual’s understanding and exploration of their sexual and reproductive health should begin early through developmentally appropriate education, socialization, or both; and continue across their life span—in adolescence and adulthood—as they make decisions about contraception, pregnancy, childbirth, family planning, and infant care. These decisions are most beneficial when they are made autonomously and are based on accurate and timely information. Unfortunately, these aspects of decision making have often been denied to Black girls and women, especially those who live in low-resource communities.[1] The results of this denial can be seen in statistics related to Black girls’ and women’s sexual and reproductive health. When compared to other demographic groups, Black girls and women have:

• Lower rates of access to and use of contraceptives
• Higher rates of unintended pregnancies
• Higher rates of preterm births and infant deaths
• Higher rates of maternal mortality

To address such inequities, research, policy, and practice communities must acknowledge, and attend to, the ways in which the social and structural determinants of sexual and reproductive health—i.e., the economic, educational, environmental, and other nonmedical factors that affect the conditions under which people are born, live, work, and grow—have impacted Black girls and women over time. Accordingly, this brief seeks to promote awareness and understanding of Black girls’ and women’s historical lack of reproductive autonomy and their current sexual and reproductive health needs, and to highlight the potentially transformative role of the reproductive justice framework—which emphasizes that individuals’ human rights include 1) the right to have a child, 2) the right not to have a child, and 3) the right to parent the children one has in safe and sustainable communities.

In this brief, we first describe the legacy of reproductive oppression (i.e., unjust regulation and control of individuals’ bodies, sexuality, and reproductive capacities) and coercion (i.e., behaviors that impede individuals’ autonomous sexual and reproductive decision making) experienced by Black girls and women, from the history of enslavement to current restrictions on access to culturally responsive reproductive health care services. Second, we describe the ongoing disadvantages and barriers in sexual and reproductive health that Black girls and women continue to experience today. Then, third and finally, we show how the reproductive justice framework provides a more holistic approach to Black girls’ and women’s wellness and, in turn, the well-being of their children and families.

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Black Girls and Women in the United States Have Experienced Reproductive Oppression and Coercion Throughout History

For over two centuries, enslavement denied Black girls and women ownership of their bodies and mothers’ rights for their children. As far back as 1662, colonial Virginia legislators made Black girls’ and women’s childrearing central to the system of chattel slavery through a law stating that a child’s enslaved or free status would be the same as that of their mother. In other words, as part of a system of forced reproduction to advance slavery, mothers and their children were the property and wealth of slaveowners. The use of Black girls and women in the United States to expand the enslaved population significantly increased after the 1808 Act Prohibiting the Importation of Slaves.

Without legal recognition as human beings with rights to sexual and reproductive privacy and choice, enslaved Black girls’ and women’s bodies were also used to fuel medical advancements to which they were denied access. Before emancipation from slavery, many advances in obstetrics and gynecology resulted from high-risk surgeries performed on enslaved and freed Black women who were viewed as “savages,” unable to feel pain. Between 1845 and 1849, for example, James Marion Sims’ surgical experimentation to treat vesicovaginal fistula was repeatedly performed on enslaved Back girls and women, without their consent or the palliative effects of anesthesia.[2]

Post-slavery, Black girls and women found little relief from coercive control over their reproductive options and choices. Chattel slavery was soon replaced by systems of forced penal labor: convict leasing and chain gangs. The convict leasing system in the post-Civil War United States allowed private industries to exploit the labor of Black children and adults and permitted the state to profit from their exploitation. Like their male counterparts, Black girls and women were at disproportionate risk for arrest and sentencing within this system and through the subsequent practice of chain gangs— state-run operations that used groups of shackled prisoners to build roads and perform other physically demanding tasks. Once sentenced, Black girls and women were often victims of rape and subsequently denied access to their babies, continuing a history and pattern of sexual and reproductive oppression and coercion.

Later, during the 20th century’s eugenics movement in the United States, Black girls and women were frequently among those targeted for forced sterilization and abortions. In North Carolina, for example, Black women were sterilized at more than three times the rate of White women from 1950 to 1966. Into the 1970s, some Black women were prevented from having children by state laws that determined a woman’s “fitness” for reproduction and motherhood. Coerced sterilization has continued into the 21st century, largely targeting incarcerated and detained women of color.

During the 1980s and 1990s, the reproductive choices of Black girls and women in low-income communities were commonly vilified as irresponsible and exploitative: The stereotype of the welfare queen portrayed them as having children solely to receive an increase in social safety net benefits. This stereotype has persisted, placing Black women and mothers—especially those living at or below the poverty threshold—under a uniquely intense level of reproductive surveillance and critique.

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Black Girls and Women Continue to Experience Disadvantages in Their Sexual and Reproductive Health

Today, Black girls and women are still more likely than their counterparts of other races to face sexual and reproductive health inequities. They are less likely to have access, as adolescents, to comprehensive sexual education that includes information about birth control, and more likely to experience “contraception deserts”—both of which limit Black girls’ and women’s access to (and available variety of) contraceptive options. Black girls and women, who are disproportionately insured through Medicaid, are also disproportionately impacted by federal legislation that prohibits the use of Medicaid and other federal funding to pay for abortions. Likewise, the recent Dobbs v. Jackson Women’s Health Organization Supreme Court decision will likely have a disproportionate impact on Black girls and women, given that Black people are concentrated in states with the most restrictive abortion bans and laws.

Black girls and women also face barriers to safely giving birth and raising their children in safe environments. Black women are more likely than women in other racial and ethnic groups to experience infertility. Nevertheless, studies show consistent disparities in access to (and outcomes of) in vitro fertilization treatments between Black girls and women and their non-Black peers. Black girls and women are also at higher risk of infant mortality at every age during their reproductive lifespan. Once born, Black children are less likely than their White and Asian counterparts to live in neighborhoods characterized by resources that benefit children’s development and well-being, such as high-quality early care, safe green spaces, clean air and water, and healthful foods. Additionally, structural inequities within the criminal justice and child welfare systems—along with racially disproportionate contact with these systems—limit Black families’ agency to raise their families in safe and healthy settings.

Despite their grave consequences for Black children and families, the sexual and reproductive health inequities experienced by Black girls and women are rarely included in national discussions about reproductive rights. Indeed, the current national debate has largely reduced discourse over reproductive health policy and practice to the single topic of abortion access, a narrow debate with harmful outcomes for Black girls and women. The reproductive justice framework holds promise for reversing this course and promoting the sexual and reproductive health and autonomy of Black girls and women, as well as other historically marginalized birthing people.

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The Reproductive Justice Framework’s Holistic Approach Can Advance Black Girls’ and Women’s Sexual and Reproductive Health

In the final decade of the 20th century, a group of Black women scholars and activists coined the term reproductive justice—a combination of reproductive rights and social justice—to address the health and quality of life concerns of people of color and other historically marginalized people who were being overlooked. The reproductive justice framework posits that it is a human right to (1) have a child (including controlling one’s birthing options), (2) to not have a child, and (3) to parent the child(ren) one has in a safe and sustainable community. The framework aims to extend these rights to all people by focusing on intersectionality, social and structural determinants of health, gender equity, and culturally responsive practices. These overlapping foci have particular significance for promoting the sexual and reproductive health of Black girls and women across the reproductive lifespan.

The reproductive justice framework’s focus on intersectionality can promote a more in-depth understanding of the diverse experiences and needs of Black girls and women to improve their quality of care. Dimensions of diversity that exist among Black girls and women—such as ethnicity, disability, socioeconomic status, and sexual orientation—defy monolithic approaches to improving their sexual and reproductive health. Intersectional approaches highlight this diversity and challenge oversimplified portrayals and solutions. For example, using the reproductive justice framework, a qualitative study by Brown et al. explored the abortion experiences of Black women in the San Francisco Bay area who differed by age, sexual orientation, and socioeconomic status. This study highlighted how these intersecting dimensions of participants’ identities affected their abortion decisions, access, and treatment. The study underscored the need for practitioners who provide abortion care to acknowledge the complex forces that reduce reproductive choice for Black girls and women and to provide space for trauma-informed support and healing.

The framework’s focus on the social and structural determinants of health can elucidate how systemic racism—racial discrimination embedded in the norms and institutions of society—affects Black girls’ and women’s sexual and reproductive health and help us identify opportunities to promote structural equity. Systemic racism affects every aspect of Black people’s lives, including their access to and quality of employment, housing, early care and education, food, and health care. The reproductive justice framework can shine light on the pervasive effects of systemic racism on Black girls and women and help identify strategies to disrupt systemic inequities. As an illustration, Alson et al. identified quantitative measures across multiple domains—including housing discrimination, police violence, and mass incarceration—that can be used in population-based studies to understand the relationship between systemic racism and adverse reproductive health outcomes among Black girls and women in the United States. Situating their work within the reproductive justice framework, the authors contend that an explicit empirical focus on the “interlocking and compounding” systems of racial oppression that Black people experience is necessary to disrupt these systems and their harmful consequences.

The framework’s focus on gender equity highlights the role of men as key actors in reproductive decision making. The voices and experiences of Black boys and men are often absent in discussions of—and the practices involved in—sexual and reproductive health; this limits our understanding of the diversity of Black men and boys, and of how race, class, gender, and sexual orientation influence their roles as partners and parents. This absence also further limits our collective understanding of Black girls’ and women’s reproductive health, experiences, decisions, and outcomes, which are often influenced by Black boys and men. The reproductive justice framework can encourage exploration of gender as it relates to Black girls’ and women’s sexual and reproductive health, specifically, and to Black parent, child, and family well-being more broadly.

Lastly, the reproductive justice framework highlights culturally responsive practices that can lead to more equitable reproductive health outcomes for Black girls and women. Sexual and reproductive health care practices that respect Black girls’ and women’s preferences and choices can ameliorate the negative experiences they often encounter. For instance, drawing on the reproductive justice framework, Fuerst and George describe ways to advance “person-centered” long-acting reversible contraception (LARC) services among Medicaid patients by ensuring that they have broad access and choice among contraceptives—including the option of no contraception, comprehensive counseling about options, and free LARC removal upon request. Another study by Townes et al. examined the sexual health care experiences and preferences of young Black women and highlighted the importance of racially diverse and culturally competent practitioners to promote these women’s sexual and reproductive health and agency.

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Conclusion

For centuries, policies and practices in the United States have denied reproductive rights to Black girls and women—a series of decisions that are reflected in a wide array of sexual and reproductive health disparities. In this brief, we have described how the reproductive justice framework can help address these disparities. Specifically, the reproductive justice framework can deepen our understanding of the diversity of Black girls’ and women’s sexual, reproductive, and maternal experiences, needs, and agency. Additionally, the framework can contextualize Black girls’ and women’s reproductive and maternal experiences within the systems and institutions that affect their well-being. It can also lead to actionable evidence to advance sexual and reproductive health care policies and practices that prioritize autonomy and honor the realities of reproductive oppression and coercion experienced by Black girls and women over time.