I review the astrophysical insights arising from high-precision astrometric observations of X-ray binary systems, focussing primarily (but not exclusively) on recent results with very long baseline interferometry. Accurate, model-independent distances from geometric parallax measurements can help determine physical parameters of the host binary system and constrain black hole spins via broadband X-ray spectral modelling. Long-term proper motion studies, combined with binary evolution calculations, can provide observational constraints on the formation mechanism of black holes. Finally, the astrometric residuals from parallax and proper motion fits can provide information on orbital sizes and jet physics. I end by discussing prospects for future progress in this field.
