Our previous post introduced a framework for understanding the levels of the determinants of people’s health and well-being. In this post, we expand on that framework by introducing the concept of intersectionality.
What is intersectionality and why does it matter for health equity?
The concept of intersectionality can be credited to a long line of Black feminist thinkers, from Sojourner Truth in 1851 to Kimberlé Crenshaw, who coined the term in 1989. Intersectionality is a framework to describe how systems of power and oppression (for example, racism, sexism, heterosexism) interlock to shape people’s lived experiences, health, and well-being, based on their multiple identities (for example, their race, gender, and sexual orientation, respectively). Seeing health through an intersectional lens lets us identify patterns, drivers, and intervention points that we would not otherwise see if we were only considering of these systems or identities one at a time. By incorporating intersectionality into each level of our health equity framework, we can illustrate and provide concrete examples of how it manifests to amplify the impacts on equity.
It all starts with the soil. We begin by acknowledging the context surrounding our health equity tree. Cultural determinants such as white supremacy, patriarchy, heterosexism, colonialism, classism, ethnocentrism, and ableism represent the soil in which the tree grows. These pervasive ideologies operate within our collective consciousness to shape perceptions about which members of society are most valued. For example, media representations and beauty standards reinforce ideologies that value white, cisgender, able-bodied, young, and thin people above others. By signaling whose lives are most valuable, the soil affects individual and collective decision making, shaping how our social structures and institutions operate, including the policies passed and infrastructures built.
These structures and institutions are represented by the roots of the health equity tree, or the structural determinants of health. Intersectionality allows us to see how multiple systems of structural oppression—such as structural racism, structural sexism, structural heteropatriarchy, and others—overlap and reinforce each other to concentrate power among the most privileged groups in society and exclude those with multiple marginalized identities from institutionalized resources and opportunities. For example, racial capitalism—or the entanglement of capitalism with racial exploitation in the United States—intersects with sexism to drive persistent inequities in job opportunities, advancements, and earnings at the nexus of race and gender, with Black and Latina women workers earning disproportionately less than their white and male counterparts. Wage gaps are even wider among LGBTQ+ workers of color. Mortgage applicants who are Black and/or in a same-sex partnership face higher rates of home mortgage denials than white and heterosexual buyers, even with the same levels of income. These examples demonstrate how structural racism, sexism, heterosexism, and capitalism intersect across multiple social institutions to deprive marginalized groups of key wealth-building opportunities—and therefore opportunities for optimizing health.
The social determinants of health, represented in the trunk and branches of our health equity tree, describe the conditions of where we live, work, learn, grow, and play. Intersectionality in the soil and the roots of the tree means that health-promoting social factors (for example, quality education, healthy food, and safe housing) accumulate for privileged members of society, while health-harming exposures cluster and compound risk for those with multiple marginalized identities. One key example is how intersectionality manifests in neighborhoods. Neighborhoods that are home to lower-income, racially minoritized, and immigrant communities are often burdened by multiple social and environmental risk factors, including poorer housing quality, over-policing, toxin-producing facilities, and fewer jobs and health services.
As we move up the tree to the leaves—the quality and use of health services available—intersectional forms of discrimination and stigma manifest in the health care experiences of those with different combinations of social identities. For example, Black women experience gendered racism (that is, discrimination based on race and gender) when engaging with health care providers and systems; these experiences multiply to exacerbate health inequities. A vast body of research explores how intersectional forms of stigma can undermine the health care experience and quality of care received among people living with HIV who are also members of a marginalized racial or ethnic group, are part of the LGBTQ+ community, or engage in IV drug use or sex work. Health care policies, systems, and provider training must be attentive to these intersectional factors to deliver high-quality, equitable care to all patients.
Moving further up the tree, intersectionality operating at the cultural, structural, social, and health care levels culminates in the fruits: the level of health and well-being each person experiences. Interlocking systems of racism, sexism, heterosexism, ageism, and other forms of oppression compound and multiply over a lifetime to widen health inequities. One consequence of intersectional oppression experienced over a lifetime is accelerated aging. Groups with multiple marginalized identities, such as women of color, experience illness (including breast cancer diagnosis, hypertension, and cellular aging) as well as death at younger ages and higher rates than those who hold more social privilege. The cumulative stress of gendered racism, which can also be compounded by other forms of marginalization, is a leading culprit. Intersectionality enables us to see and honor the barriers, lived experiences, and unique forms of strength and resilience that each person carries with them. We can bring this awareness and humility into our work with individuals, communities, and policymakers.
Applying an intersectional lens to our health equity work necessitates that, at each level of the determinants of health, our interventions are multi-dimensional. At the structural level, working to dismantle structural racism without addressing its intersections with structural sexism, classism, colonialism, and other systems of power, may be ineffective. At the person level, attending to the discrimination a Black transgender woman faces based on her gender identity, without attending to how this discrimination is compounded by racism, may fail to consider the totality of her experience. No matter the level at which we are seeking to affect change—whether we are working to improve patient-provider interactions, or re-imagine how wealth and resources are distributed in society—attention to intersectionality can help us do our work more equitably and effectively. As we continue to explore intersectionality and health equity, we will refine our framework and share with you how those insights must be used to inform effective solutions to advance well-being for all.