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Epidemiological research increasingly recognises that health disparities are driven by complex interplay among factors including housing, education and employment.1 Intersectionality—‘the relationships among multiple dimensions and modalities of social relations and subject formations’—offers a theoretical approach for expanding our understanding of health disparities beyond independent systems of privilege and oppression (eg, racism and sexism).2 Intersectionality theory was developed more than 30 years ago to better understand how various identities interact and produce cumulative impacts across the life course. Still, traditional public health approaches of examining a single exposure and health outcome continue to limit our understanding of how health disparities are experienced across varying classes, races, ethnicities, genders and sexualities.3 Intersectionality theory in health research is often relegated to social science literature, highlighting a missed opportunity for epidemiological research to consider how larger structural inequities shape health.
Kimberlé Crenshaw, a leader in Black feminist legal theory, introduced the term intersectionality in her 1989 work, Demarginalizing the Intersection of Race and Sex: A Black Feminist Critique of Antidiscrimination Doctrine. Crenshaw illustrated how Black women’s lives are shaped by racism and sexism in ways that separate examinations of gender or race cannot adequately capture. In other words, gender and race do not exist in parallel, but are intertwined and produce compounding effects among marginalised groups.4 In the context of public health, intersectionality theory can provide a framework for considering how disease trajectories are experienced and how inequities may manifest in different populations. For example, the high rate of US Black women’s mortality during childbirth and postpartum may be understood through a framework that highlights the oppression Black women face from both the sexism and racism deeply embedded in our healthcare system.5 6 Intersectionality interrogates intersecting systems of power and oppression (including, but not limited to, capitalism, structural racism, heterosexism, ableism) rather than attributing health outcomes solely to individual-level factors.1
The limited integration of an intersectional theoretical framework in epidemiological research is partly due to methodological challenges. Intersectionality theory was not predicated on the ability to test health outcomes related to validated constructs; there are no central variables of intersectionality that can be tested empirically.7 Common approaches to public health research consider social categories as immutable, mutually exclusive analytical groupings (eg, race) devoid of historical and social context.8 For example, limiting ‘culture’ to an individual-level variable risks homogenising immigrant groups, rather than taking into account various dimensions such as immigrant status and gender influence health.9 To address this issue, social psychologist Lisa Bowleg advocates for an ‘an intersectionality-informed stance’ that explores the intersections of social inequalities at the microlevel (eg, racism, classism) and macrolevel, and considers how people can simultaneously occupy positions of privilege and oppression (eg, white homosexual men).7 Researchers using this approach would consider historical and socioeconomic contexts of populations, which may involve using multiple, perhaps untraditional, public health methodologies (eg, historical materials and social theories).7 For example, we might consider how ambiguous racial categories may classify Arab immigrants as white but not afford them the privileges of this category, or how immigration policies lead to the conflation of immigrant status and race/ethnicity.9 An intersectionality-informed approach helps produce research that moves the needle forward on health equity by highlighting how power dynamics at various levels (eg, individual, institutional) have produced structural inequities in marginalised communities.10 This approach can have real-world policy implications. For example, situating HIV prevention interventions within the Black population (ie, targeting messages to men who have sex with men rather than individuals who identify as gay or bisexual), as opposed to a white middle-class population, led to a change in HIV/AIDS surveillance guidelines in 2011.7
Intersectionality theory has the potential to enhance our understanding of health disparities by recognising not only that identities intersect (ie, people inhabit and express various identities) but also that systems of privilege and oppression result in health disparities that are perpetuated by social inequalities intersecting at a structural level.1 Intersectionality theory can play a critical role in advancing health equity by expanding our understanding of health disparities beyond the single structural forces shaping them.
Footnotes
Contributors This article was written entirely by the primary author.
Funding The author has not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; internally peer reviewed.