Affordability, Negative Experiences, Perceived Racism, and Healthcare System Distrust
Experiences of racism and heterosexism in medical settings are social and systemic barriers to timely sexual and reproductive health care for women who hold both racial and sexual minority identities. This mixed‑methods study examines how affordability constraints, prior negative clinical encounters, and two distinct but related forms of group‑based medical mistrust—racial and heterosexist—shape the timing of sexual and reproductive health visits among Black sexual minority women. Drawing on an online survey of 320 participants and in‑depth interviews with a purposive subsample, we use ordinal logistic regression to estimate independent and interaction effects of the two mistrust constructs on self‑reported time since last visit, and we contextualize statistical patterns with qualitative narratives about anticipatory stigma, identity erasure, and coping strategies. Results reveal a significant interaction between racial and heterosexist mistrust, with heterosexist mistrust showing the strongest association with delayed care under particular configurations of racial mistrust and economic constraint. The study underscores the need for intersectional clinical training, affordability interventions, and community‑centered approaches to rebuild trust and improve timely access to care.
Introduction
Black sexual minority women experience intersecting forms of marginalization that shape access to sexual and reproductive health services. Medical mistrust rooted in historical and contemporary racism and heterosexism can deter preventive care and timely treatment. This paper applies an intersectional lens to quantify how racial and heterosexist mistrust interact with affordability and prior negative experiences to influence timing of care, and it uses qualitative narratives to illuminate lived strategies for navigating health systems.
Methods
We conducted an online survey of 320 Black sexual minority women aged 18–35 recruited via targeted social media and community panels. The primary outcome was time since last SRH visit (ordinal). Key predictors included validated scales for racial and heterosexist medical mistrust, a composite affordability index, and a binary indicator for prior negative clinical experiences. Ordinal logistic regression models included interaction terms and controlled for demographics and insurance status. We supplemented quantitative analysis with 24 in‑depth interviews to contextualize mechanisms and coping strategies.
Results
Heterosexist mistrust was a robust predictor of delayed SRH care; racial mistrust moderated this association such that the effect of heterosexist mistrust was strongest at particular levels of racial mistrust. Affordability concerns and prior negative experiences independently increased the likelihood of delayed care. Qualitative interviews described anticipatory stigma, identity erasure in clinical encounters, and reliance on community clinics or peer networks as adaptive strategies that shaped care timing.
Discussion
Findings indicate that interventions must be intersectional: clinician training should address both anti‑Black bias and heterosexist assumptions, affordability supports must be expanded, and community‑centered outreach and accountability mechanisms are needed to rebuild trust. Future research should evaluate interventions that combine identity‑affirming care with structural affordability measures.
References
- Gray A, Fisher CB. Affordability, negative experiences, perceived racism, and healthcare system distrust: Intersectional effects on sexual and reproductive healthcare visits among Black sexual minority women in the United States. Culture, Health & Sexuality. 2024.
- Agénor M, et al. Sexual orientation and cervical cancer screening among Black women. Preventive Medicine. 2016.
- Fisher CB, et al. The LGBTQ Health Equity Scale: Measuring group‑based medical mistrust. Journal of Health Psychology. 2018.
- Bowleg L. The problem with the phrase “women and minorities.” Am J Public Health. 2012.
- Earnshaw VA, et al. Stigma and health outcomes among sexual minority women. Social Science & Medicine. 2015.