Social Science & Medicine 74 (2012) 1712e 1712 e1720
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Social Science & Medicine j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c om om / l o c a t e / s o c s c im im e d
Women s health, men s health, and gender and health: Implications of intersectionality ’
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Olena Hankivsky Simon Fraser University at Harbour Centre, School of Public Policy and Institute for Intersectionality Research and Policy, 515 West Hastings Street, Suite 3271, Vancouver, British Columbia, V6B 5K3 Canada
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Although intersectionality is now recognized in the context of women s health, men s health, and gender and health, its full implications for research, policy, and practice have not yet been interrogated. This paper investigates, from an intersectionality perspective, the common struggles within each �eld to confront the complex interplay of factors that shape health inequities. Drawing on developments within intersectionality scholarship and various sources of research and policy evidence (including examples from the �eld of HIV/AIDS), the paper demonstrates the methodological feasibility of intersectionality and in particular, the wide-ranging bene �ts of de-centering gender through intersectional analyses. 2012 Elsevier Ltd. All rights reserved.
Article history:
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Available online 25 January 2012 Keywords:
Women s health Men s health Gender and health Intersectionality Review ’
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Introduction
practice practicess within within the �eldsofwomen s,men s, andgenderand health. health. The intent intent is to show, show, from from an inters intersec ectio tional nalit ity y persp perspect ectiv ive, e, how how the treatment and ubiquitous ubiquitous favouring of gender (and sex) as core and primary dimensions dimensions of health undermine efforts to understand the complex complexiti ities es of health health experie experiencesand ncesand outcomes outcomes.. The paper paper seeksto bring bring into sharp sharp relief relief the resulti resulting ng mis-spec mis-specii�cation cationss of thecontent thecontent of anyprivilegedident anyprivilegedidentity/ ity/soci social al locatio location n (includi (including ng butnot limitedto limitedto gender), as well as the masking of health-related experiences of those those whose whose lives lives are are locat located ed at the inters intersec ectio tion n of multip multiple le dimensions of inequity. To illustrate the importance of an intersectionality sectionality framework, the paper offers normative and operational operational guidance for empirical research, examples from emerging intersectionality research, and in particular, evidence from the �eld of HIV/AI HIV/AIDS. DS. This This discu discussi ssion on striv strives es to demon demonstr strate ate the trans trans-formational possibilities possibilities of an intersectional intersectional analysis but also speci�es ongoi ongoing ng gaps gaps and chall challen enges ges relat related ed to appli applicat catio ions ns of intersectionality intersectionality that require require further attention and research development. The paper concludes by considering some of the research, policy policy,, and politica politicall consequ consequence encess of intersec intersection tionali ality ty for the �elds elds of women s health, men s health, and gender and health. ’
Increasi Increasingly ngly,, health health research researchers,policymakers, ers,policymakers, and practiti practitioners oners concerned with sex and gender are acknowledging the importance of race/ethn race/ethnicit icity, y, class, class, income, income, educatio education, n, ability, ability, age, sexual sexual orientation, immigration status, and geography and are grappling with with how to best best concep conceptua tualiz lizee and respon respond d to issues issues of differ differenc ences es among women and men and how these shape lives and health. As workin this area progress progresses, es, intersec intersection tionality ality is being recogniz recognized ed as a valuable normative and research paradigm for furthering understandings of the complexity of heath inequities (Bowleg, ( Bowleg, 2008; Hankivsky, 2011; Iyer, 2007; Iyer, Sen, & Ostlin, 2008; Schulz & Mullings, 2006; Sen, Iyer, & Mukherjee, 2009; Weber, 2006). 2006 ). Intersectionality challenges practices that privilege any speci �c axis of inequ inequali ality ty,, such such as race, race, class, class, or gender gender and emphas emphasize izess the potential of varied and � uid con�gurations of social locations and interacting social processes in the production of inequities. While the � elds of women s health, men s health, and gender and health have started to explicitly acknowledge and engage with the theoretical retical and methodol methodologic ogical al insightsof insightsof intersect intersectiona ionality lity,, the extent extent to which current practices align with the tenets of intersectionality is largely uninvestigated. The purpose of this paper is to explore the implicat implications ions of intersect intersectiona ionality lity in the context context of these �elds elds and and to raise important questions for dialogue and debate. The paper paper begins begins with a brief brief overvi overview ew of interse intersectio ctionali nality ty,, includin including g its relatio relationshi nship p to diversi diversity ty.. It then moves moves to examine examine core core ’
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0277-9536/$ e see front matter 2012 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2011.11.029 doi:10.1016/j.socscimed.2011.11.029
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Intersectionality
Originating in the work of African American feminist scholars (Coll Collins, ins, 1990; Crens Crenshaw haw,, 19 1989; 89; Hook Hooks, s, 19 1990 90), ), intersectionality intersectionality moves beyond single or typically favoured categories of analysis (e.g. sex, gender, race and class) to consider simultaneous interactions between different aspects of social identity .as well as the impact of systems and processes of oppression and domination “
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(Hankivsky & Cormier, 2009, p. 3). Although there are multiple conceptions of intersectionality, there are also a number of identi�able central theoretical tenets including the idea that human lives cannot be reduced to single characteristics; human experiences cannot be accurately understood by prioritizing any one single factor or constellation of factors; social categories such as race/ethnicity, gender, class, sexuality, and ability are socially constructed, �uid, and �exible; and social locations are inseparable and shaped by the interacting and mutually constituting social processes and structures that are in �uenced by both time and place. These tenets are intended to provide the basis for a new avenue of enquiry where no categoryof oppression is automatically considered as the most damaging and where some differences are not continuously highlighted to the exclusion of others. What also distinguishes this approach from others that have attempted to be responsive to diversity is that intersectionality is not an additive approach. It does not estimate the collective impact of gender, race, and classdmeasured as several simple binariesdas the sum of their independent effects (e.g. genderþclassþrace/ ethnicity). This type of additive approach is critiqued for layering several simultaneous oppressions (King, 1988, p. 47) without interrogating their relationships and mutually constructive processes. In comparison, intersectionality focuses on examining how social locations and structural forces interact to shape and in�uence human experiences. It requires, as Andersen and Collins (2001) explain, recognizing and analyzing the hierarchies and systems of domination that permeate society and that systematically exploit and control people (p. 5 e6). In this way, intersectionality seeks to be a multi-level analysis that incorporates attention to power and social processes at both micro and macro levels through which subject formation occurs (Dhamoon & Hankivsky, 2011). It is also important to note that intersectionality is not only applicable to advancing understandings of marginalized or so-called disadvantaged groups in order to promote social justice, but explains how social organization shapes all of our lives (Weldon, 2008). It also leaves open the possibility of simultaneously experiencing the effects of privilege and penalty, thus challenging binary thinking which tends to place certain groups in opposition to one another (e.g. women/men; black/ white; Aboriginal/non-Aboriginal). Literature examining the theoretical and applied potential of intersectionality has grown exponentially over the last decade (Choo & Ferree, 2010; Cole, 20 09; Dhamoon, 2011; Hancock, 2007; McCall, 2005; Warner, 2008; Weber, 2009; Weldon, 2008) driven by the extent to which this framework advances more accurate and sophisticated understandings of the multidimensional reality of human lives. The growing pressure to � nd better ways to account for differences and respond to the various and intersecting factors that in�uence health for both women and men has also led researchers and policy actors to recognize intersectionality as a valuable resource for re-thinking existing research methods, models, practices, and health policies (Broom & Tovey, 2009; Clow, Pederson, Haworth-Brockman, & Bernier, 2009; Hankivsky & Cormier, 2009; Hankivsky et al., 2010; Hurtado & Sinha, 2008; Read & Gorman, 2010; Sen & Östlin, 2007; Varanka, 2008).In the �elds of women s health, men s health, and gender and health, the promise of an intersectionality analysis is that it advances a new order of complexity for understanding how sex and gender intersect with other dimensions of inequality, particularly historic and geographic contexts, to create unique experiences of health. “
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Women s health, men s health, and gender and health ’
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While there are somewhat different approaches that can be identi�ed as women s health, men s health, and gender and health, ’
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especially in the context of political activism and policy, there are many ways in which they overlap and articulate with one another. Importantly, each prioritizes the dimension of sex/gender above all other axes of social identity and power. From an intersectionality perspective, these practices, which are brie�y reviewed below, undermine theoretical and empirical efforts to fully understand and address health inequities. Con �ation of gender with women
In research and policy practices, gender and gender and health are often con�ated with women and women s health (Richardson & Carroll, 2009; Smith & Robertson, 2008; Wilkins & Savoye, 2009 ). Turshen (2007) has correctly observed for example, that studies with gender in the title still too often mistakenly use the word as a synonym for women, or open with a nod to gender and then glide on to women (p. 320). Moreover, because historically women have been the driving force behind the development of gender equality policies, gender mainstreaming, with the exception of the UK and Norway, has been largely shaped in terms of what women can gain from greater gender equality (Hearn, 2006). Gender is often interpreted as synonymous with women and as a result, men s genderspeci�c needs receive insuf �cient attention (Doyal, 2001; Hankivsky, 2007; Varanka, 2008). It is inconsistent with intersectionality, which does not view gender as a �xed category but rather changeable and contingent in nature. ’
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Primal focus on gender (and or sex)
The emphasis placed on gender or sex is often motivated by concerns over the lack of attention to these factors ( Doull et al., 2010; Gochfeld, 2010; Nieuwenhoven & Klinge, 2010) and/or a lack of clarity about sex (aspects of the body) versus gender (personal identities and social roles designated as masculine versus feminine ) and the relationship between sex and gender in health research (Hankivsky, 2007; Klinge, 2008; Krieger, 2003). Using an intersectionality framework, researchers have noted the explanatory limitations of single axis designs centered on sex and gender. Cole (2009) has warned that analyses that focus on gender are problematic because they often implicitly assume a host of other social statuses that usually go unnamed in American culture: middle-class standing, heterosexuality, able-bodiedness and White race (p. 173). Others have explicated similar limitations. For example, studies in the � eld of violence (Bent-Goodley, 2007; Craig-Taylor, 2008; Crenshaw, 1995; Nixon & Humphreys, 2010; Sandelowski, Barroso, & Voils, 2009) show that violence against women is not only a matter of gendered power relationships but is co-constructed with racial and class strati �cation, heterosexism, ageism, and other systems of oppression, some of which may be more salient within such interactions. Research on cardiovascular disease (CVD) (Brister, Hamdulay, Verma, Maganti, & Buchanan, 2007; King, LeBlanc, Carr, & Quan, 2007; King, LeBlanc, Sanguins, & Mather, 2006) shows that focussing on sex and gender often obscures the fact that CVD is disproportionately experienced by racial ethnic and low-income groups whose lives are shaped by intersecting processes of differentiation along the lines of age, sex, ethnic group af �liation, socioeconomic class, and geography. Finally, HIV/AIDS research (Dworkin, 2005; Elford, Anderson, Bukutu, & Ibrahim, 2006; Jackson & Reimer, 2008; Meyer, Costenbader, Zule, Otiashvili, & Kirtadze, 2010; Young & Meyer, 2005) demonstrates that gender and sexuality cannot be separated from other axes including race, class, age, religious af �liation, and immigration status and the structural economic, political, and social processes that shape them. For example, in her analysis of surveillance categories for HIV, Dworkin (2005) argues ‘
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that pushing beyond a singular sex/gender system to explore the simultaneity of race, class, and shifting gender relations is vital to the future of the HIV epidemic and in particular, for making visible bisexual and lesbian transmission risks. Emerging research thus demonstratesthat there aremany groups which do not necessarily identify gender oppression as the primary frame through which they understand their lives (Nixon & Humphreys, 2010, p. 150). In Canada, as in many other jurisdictions, this is especially apparent with growing immigrant populations whose health is primarily affected by dislocation, isolation, loss of identity, culture, and meaningful employment and Aboriginal/Indigenous populations whose health and well-being is largely determined by unresolved colonial injustices and ongoing experiences of racism and poverty (Alfred, 2005; Waldrum, Herring, & Young, 2006 ). Further, the emphasis on gender (and sex) often leads to a focus on differences between women and men. This helps to explain why so much data continues to be collected, organized, and presented solely around sex and gender differences even when similarities between women and men are demonstrated (e.g. Hyde, 2005; Petersen, 2009), differences among women and among men are often as signi�cant if not more than between women and men (Crawshaw & Smith, 2009; Varcoe,Hankivsky, & Morrow, 2007),and men are sometimes subordinate to some women and some women exercise power over some men (Pease, 2006). Nevertheless, numerous reviews of sex based and gender differences continue to be produced (Gochfeld, 2010; Read & Gorman, 2010). Moreover, even in some frameworks that seek to include considerations of both sex and gender, as in the sex and gender based analysis (SGBA) tool developed in Canada (e.g. Clow et al., 2009), proposed guides construct lines of interrogation that prioritize examinations of similarities and differences between women and men. As Clowet al. (2009) state, SGBA reminds us to ask questions about similarities and differences among women and men, such as: Do women and menhave the same susceptibilityto lung disease from smoking? Are women at the same risk as men of contracting HIV/AIDS through heterosexual intercourse? Are the symptoms of heart disease the same in women and men?.. (p. 1). Within this type of construct, differences that are shaped and formedby factors outsideof sex and gender are treated as secondary in importance, if at all. Research that focuses on differences between men and women can also perpetuate false dichotomies that fail to re�ect the diversity between different groups of women andmen or open the possibility of examining different types of population groups. Within the con�nes of such discourses, there appears little space either conceptually or practically for moving beyond two de �nable sexes and genders, even though intersex and transgendered persons and practices directly destabilize such binary classi �cations (Fish, 2008; Geller, 2008; Harper, 2007). This is also why intersectionality holds so much promise. In the realm of policy for example, it points to the existence of more than two genders e that is, multiple groups of stakeholders and bene�ciaries (Bishwakarma et al., 2007). “
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Inadequate conceptualization and empirical modelling of diversity
At the same time that binary practices persist, there is also a very strong impetus for health researchers to be more inclusive of and responsive to diversity. For example, important questions have been raised regarding the extent to which women s health and men s health are adequate and sustainable generic categories for the purpose of research and policy given the wide-ranging differences among women and men (Smith, White, Richardson, Robertson, & Ward, 2009; Varcoe et al., 2007; Wilkins & Savoye, 2009). In gender and health literature, the recognition of diversity (Annandale, 2010; Clow et al., 2009; Lagro-Janssen, 2007; Read & Gorman, 2010; Sen & Östlin, 2007) is exempli �ed in the growing ‘
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acceptance of the �uid and �exible nature of sex and gender, acknowledgement of the differences among women and men, and the recognition of gender as a social location and determinant of health that is shaped by and in constant interaction with other determinants (Benoit & Shumka, 2009; CIHR-IGH, 2009; Hankivsky & Christoffersen, 2008). A signi�cant number of gender and health researchers also explicitly emphasize that sex is shaped by social context (Einstein & Shildrick, 2009; Gochfeld, 2010; Vanwesenbeeck, 2009) and that gender is not a stand alone variable but one that can only be understood in relation to biological factors and other social locations and systems of oppression. Some of the best examples of developments along these lines are integrative models that explore biological and social processes. For example, Fausto-Sterling s dynamic systems theory has explored how the biology of sex and gender are shaped by culture (2000; 2005). Bekker s Multi-Facet Gender and Health Model (2003) shows how the relationship between sex and gender can be moderatedby various sets of factors including daily life or social circumstances, person-related characteristics, and health care factors. Annandale (2009) has proposed a conceptual framework she refers to as a new single system model of patriarchal capitalism, intended to account for destabilized sex/gender identities and more complex patterns of equality and inequality and how they are .written not only on the body, but into the body in new experiences of health and illness (p. 11). Another noteworthy example is Bird and Rieker s constrained choices (2008) multi-level model which contextualizes women s and men s personal health choices and outcomes as in �uenced and shaped by the communities in which they live and the range of social policies that directly impact on their lives. Most recently, Springer, Stellman, & Jordan-Young (2012), have developed a sex/ gender entanglement good practices guidelines for research on male-female health differences. These developments are important as they move away from separate foci on sex and gender. Drawing connections between biological and social processes advances understandings of gender and its relationship to sex and illuminates why social context is so important for the construction of gendered health outcomes. By looking at interactions between sex, gender, and other multi-level dimensions of social inequality, these models also make important inroads vis à vis intersectionality. For example, Annandale (2009) explores how sex and gender are intimately connected with particular forms of the operation of capitalism (p. 108-109) which shape women s circumstance and their health. Bird and Rieker s model considers interactions between social and economic factors on gendered health patterns. And Springer et al. (2012) explicitly signal the importance of intersectionality for their conceptualization of sex/gender and for understanding how aspects of social status (e.g., gender, race, socioeconomic status, and sexuality) are understood to affect health outcomes in complex, multiplicative ways that can never properly be captured by attempts to parcel out the individual contributions of single social domains (p. 8). However, the consistent and sustained focus on gender and sex as central categories within these models creates signi�cant tensions in terms of what intersectionality demands namely leaving open the relative importance of different axes of analysis beyond the singular focus on sex and gender, and how these interact in any given situation. Annandale and Kuhlmann (2010) are correct in observing that biological sex and social gender are so deeply and often unproblematically � xed in the research and policy imagination that they fail to yield to the periodic re �ection that is necessary to ensure their continued relevance and to retain their critical edge (p. 455). From an intersectionality perspective, it is the hegemony of gender and sex as key drivers of difference and gender as a dominant axis ’
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of analysis that have not been adequately interrogated or challenged. This raises the question of whether even the most evolved, contextually sensitive approaches proposed by gender and health researchers may sometimes be inadvertently masking the real and complex interplay of other intersecting factors that shape and determine health outcomes. This line of enquiry also raises the practical issue of how an intersectional framework may transform research and policy e when gender is not always a priori deemed the most important axis for examining and responding to health inequities. And this necessitates concretely showing how the employment of an intersectionality framework improves on the identi�cation of the range, salience and relationships of oppressions affecting health. Elucidating the implications of Intersectionality
Well-rehearsed critiques of an intersectionality perspective include claims that it does not have any methods associated with it or that it can draw upon (Phoenix & Pattynama, 2006, p. 189) or that it does not provide a suf �cient foundation for action aimed at improving population health and reducinghealth disparities because as an approach that has focused on societal structures it was not intended to identify points for health intervention (Bird, Lang, & Reiker, 2010, p. 130). This has led scholars to question how intersectionality can transform empirical research, what new and better knowledge it may generate, and how this can translate into improvements in practices and policy. As is widely acknowledged, translating theory into methodological practices is not easy. Selfidenti�ed intersectionality scholars struggle with how to operationalize the theoretical tenets of intersectionality and as Bowleg puts it, researchers often have to self-teach and learn from trial and error (Bowleg, 2008, p. 313). Compared to other approaches, intersectionality is in nascent stages of development. However, for researchers seeking methodological traction there is a growing body of literature that provides normative and operational guidance for the application of intersectionality in qualitative and quantitative health research and policy(e.g. Choo& Ferree,2010; Cole, 2009;Hancock,2007; Hankivsky & Cormier, 2009; Hankivsky et al., 2010; McCall, 2005). At the same time, it is critical tonote that as a research paradigm (Dhamoon, 2011; Hancock, 2007) intersectionality is not prescriptive nor does it insist on any particular research design or uni�ed way to conduct research. Its goal is to bring about a conceptual shift in how researchers understand social categories, their relationships, and interactions and then to have this different understanding transform how researchers interrogate processes and mechanisms of power that shape health inequities. An intersectionality shift encourages researchers to re�ect on the complexity of their own social locations, how their values, experiences, and interests shape the type of research they engage with, including the problems they choose to study, and how they view problems and affected populations (including what types of research questions or hypotheses they pose). Moreover, because intersectionality rejects hierarchical ordering of oppression, researchers applying this perspective would refrain from presuming before the start of any project which dimensions have greater in�uence (Siltanen & Doucet, 2008, p. 27). Indeed, salient axes in any research cannot be pre-determined but differ by time, nation, culture, political and economic contexts, and geographic setting (Yuval-Davis, 2006). For researchers concerned with gender, this would necessitate carefully investigating rather than automatically assuming the primacy and/or signi�cance of gender (Siltanen & Doucet, 2008, p. 178). This type of de-centering of gender allows for more �exibility and arguably accuracy in determining salient dimensions in all stages of research whether in the design of research questions, choice of sample, analysis and “
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interpretation of data, or even the dissemination of research, including the wording of article and book titles. Not only does intersectionality reject the automatic prioritization of any one category, it also rejects looking at various dimensions that affect health separately, thus disrupting the primacy and stability of categories of men s and women s health. From an intersectionality perspective, multiple factors are always at play in shaping people s lives and health experiences. Not surprisingly, an often cited concern is that the demands of intersectionality are too high, that all potential variables that need to be included in any one research design would make national studies or international comparative studies impossible to undertake. Researchers have clari�ed that intersectionality does not lead to such paralysis. It does not necessitate taking into account all possible factors in any given research design but instead prompts researchers to be explicit about which ones are chosen and why, and what is subsequently set aside or under-analyzed as a result. Such decisions are of course shaped by available knowledge of the research topic, data availability, which groups are most directly impacted, government and media agendas, and what affected populations identify as a priority. But in making choices, researchers are cautioned against falling back on familiar, often assumed master categories (e.g. gender, race, or class) and are encouraged to carefully think through how their selections may alter results and interpretations of research results (Warner, 2008). In terms of investigating multiple factors, intersectionality rejects simple enumeration or addition, that is, the measurement of multiple main effects of separate and independent inequalities (Choo & Ferree, 2010). It directs researchers to explore how various forms of social strati �cation relate and co-constitute one another but also emphasizes that the exact relationship between different types of social subordination cannot be pre-determined but is an open empirical question (Hancock, 2007). To assist in such analysis, Bowleg (2008) has suggested for example that qualitative researchers avoid questions about speci �c identities such as gender and instead construct questions that are intersectional by design such as What are some of the day to day challenges that you face in terms of your identity? to generate information about the mutuality of identities and complexity of experiences. Because the focus of an intersectionality-type analysis is not only on intersections themselves but what they reveal about power (Dhamoon & Hankivsky, 2011), Cole (2009) has advised quantitative researchers for instance to always interpret their data within historical contexts of oppressed and privileged groups experiences. Even though there is no single way to do intersectionality research at the outset of any research project, to ensure analytic clarity, researchers should explain their approach to/de �nition of intersectionality (Hankivsky, 2011). Moreover, there are speci �c questions (a select number are listed below) that are useful guides for researchers who seek to navigate this nascent terrain at every stage of designing a research project. Each has differential applicability to qualitative and quantitative research designs and researchers may choose to focus more closely on some over others. The application of these questions should, however, be grounded in the theoretical tenets of an intersectionality research paradigm in order to realize their intended operational objectives: the destabilization of a priori primacy and stability of singular categories; the avoidance of additive lists; andthe focus on the �uid and interactive nature of multi-level complex processes and systems that shape health inequities. They include the following lines of enquiry: ’
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Who is being studied? Who is being compared to whom? Why? (Lorber, 2006) Who is the research for and does it advance the needs of those under study? (Hankivsky et al., 2010)
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Is the research framed within the current cultural, political, economic, societal, and/or situational context, and where possible, does it re�ect self-identi�ed needs of affected communities? (Hankivsky & Cormier, 2009) Which categories are relevant or not directly relevant? Why? (Winker & Degele, 2011) What is the presumed makeup of each category? (Hancock, 2007) Is the sample representative of the experiences of diverse groups of people for whom the issue under study is relevant? (Hankivsky & Cormier, 2009) Is the tool of enquiry suitedto collecting micro or macro data or a combination of both? (Hankivsky & Cormier, 2009) How will interactions between salient categories be captured by the proposed coding strategy? How will interactions at individual levels of experience be linked to social institutions and broader structures and processes of power? What issues of domination/exploitation and resistance/agency are addressed by the research? (Hankivsky & Cormier, 2009) How will human commonalities and differences be recognized without resorting to essentialism, false universalism, or be obliviousness to historical and contemporary patterns of inequality? (Cole, 2008)
Intersectionality scholars also emphasize that no individual study is able to address the whole of a complex problem and that researchers should instead develop programs of research with different studies aimed at different aspects of a problem and which can sequentially build upon one another (Rogers & Kelly, 2011). While operational guidance for empirical research is essential, it is equally important to note that researchers are already demonstrating the transformative value of intersectionality. To date, it is generally thought that qualitative methods lend themselves more easily to an intersectionality analysis (McCall, 2005; Shields, 2008a), and this is evidenced for instance by studies that dominate edited collections on intersectionality health research (e.g. Hankivsky, 2011; Schulz & Mullings, 2006). In comparison, quantitative researchers have acknowledged the tensions between conventional research designs, which are intended to test for independent effects of dimensions of inequality typically measured as binaries, and intersectionality which seeks knowledge about the processes of interaction between �uid social identities (Shields, 2008b; Bowleg, 2008). This has not impeded the emergence of intersectionality-informed quantitative studies that utilize techniques to examine signi�cant interactions which constitute health (rather than simply adding variables of interest) and to produce what may be interpreted as counter-intuitive research results. For example, Veenstra (2011) has compared additive and multiplicative approaches to demonstrate how intersectional models lead to more accurate predictions of health outcomes. In an additive model of self-reported health, he found that South Asian Canadians were signi�cantly more likely than White Canadians to report fair/ poor health and that women were not signi �cantly more (or less) likely than men to report fair/poor health. In the words of Veenstra, South Asian Canadians appear to be at relatively high risk of poorer self-rated health, and gender appears to be unrelated to self-rated health. In comparison, by employing a multiplicative model, he found a signi�cant race gender interactiondamong women, South Asians were much more likely than Whites to report fair/poor selfrated health, whereas South Asian men were not more likely than White men to report fair/poor self-rated health. That is, these men and women experience the health effects of race differently, with a race effect evident among women and not among men. Stated otherwise, the effect of gender on self-reported health is contingent on race.
Jackson and Williams (20 06) have demonstrated that attention to the interactions of gender, race, and class challenges widely held assumptions about SES by showing that on many health indices (including infant mortality and elevated risk of suicide) highly educated blacks fare no better than whites with the lowest education. Speci �cally their research reveals that SES, typically thought to afford adults the ability to bene�t from material resources and engage in preventative care, is signi�cantly mitigated for middle-class black women and men by the in �uences of institutional racism and gender stereotypes. For Jackson and Williams (2006), intersectionality theory provides a lens for understanding the full effects of these interactions and for revealing how power within gendered and raced institutional settings operates to undermine access to and use of resources that would otherwise be available to individuals of certain class standings. Sen et al. (2009) have also developed a method for operationalizing intersectionality that they describe as a technique to test for differences along the entire span of the social spectrum (not just between the extremes) which they have applied to the examination of health care for long term illness in India to show that class works through gender when it comes to obtaining necessary health care. It is important to note, however, that the reverse can also be true. Gender can work not only through class but many other variables. And in some instances, when numerous factors are considered simultaneously, the effects of gender may even be negligible. For example, in a study of exposure to stress related to sexual orientation, gender, and race/ethnicity, Meyer, Schwarz, & Frost (2008) concluded, contrary to prevailing assumptions in the literature, that gender does not matter in the way that the predominant social stress models describe (p. 377). To further grasp the analytic purchase of intersectionality, one can also turn to speci �c examples such HIV/AIDS, where applications of this paradigm are facilitating better understandings of under-researched dynamics, groups, and relationships. In her study of black HIV-positive African migrants in East London, Doyal (2009) uses Black African, migrant and HIV-positive as key intersecting analytic categories. Doyal emphasizes the importance of displacing gender as the most salient in �uence in these narratives of HIVpositive migrants because it obscures an accurate understanding of the complex experiences of this group. She demonstrates how gender, sexuality, race/ethnicity, and migrant and HIV status intersect, to reveal different effects among and between heterosexual women and men, and gay/bisexual men in relation to stigmatizing and discriminatory social processes, sources of supports (including spirituality and religion), and voluntary organizations designed to respond to the needs of African communities affected by HIV/AIDS. According to Doyal (2009), this study demonstrates the value of .opening up a number of important issues that are too often left unexplored in existing literature on living with HIV (p. 184) and how intersectionality research creates nuanced and context speci�c evidence to improve HIV policies in the context of global, regional, and local diversity. In a study of the experiences of inner-city Latina women with severe mental illness living in New York, Collins, von Unger, & Armbrister (2008) illustrate the complex interconnections between gender, race/ethnicity, class, and the stigma of mental illness and its implications for HIV risk. The study shows that bipolar women s sexual relationships and behaviours are closely intertwined with immigration, poverty, gender, and race/ethnicity leading to contradictory outcomes. On one hand, women often experience con�ict with gender norms in their ethnic communities in ways that lower their social status and power. This leads to vulnerability within intimate relationships and engagement in sexual behaviours (e.g. lack of condom use) that increases the risk of HIV. On the other hand, the effects of these same intersections “
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are not always negative as the mental illness experienced by these Latina women allows them to free themselves from abusive male partners by accessing government entitlements and supports. The �ndings highlight why HIV prevention activities can only be effective if they acknowledge multiple layers of vulnerability and resources both at individual and structural levels, without erasing gendering effects. In their research with two urban Aboriginal health centres in Vancouver, Browne, Varcoe, & Fridkin (2011) reveal how intersectionality widens the scope of what is conventionally identi �ed as a problem in health services delivery. They explain that when stigmatized diseases are decontextualized from their underlying causes, people who are HIV þ are blamed or held responsible for their status, including their problematic behaviours (e.g. unprotected sex and injection drug use). In comparison, intersectionality moves beyond this type of individual focus to consider multi-level root causes of HIV including historical trauma, poverty, unemployment, abuse, racism and medical involvement such as prescribing practices.global economics, ideologies of racial superiority, capitalist priorities, ongoing clawbacks to social welfare systems, welfare colonialism, and state policies regarding distribution (Browne, Varcoe et al., 2011, p. 301), and the relationship between these factors. This type of reframing is essential for creating primary health services that not only respond to the effects of HIV, but begin to address the underlying problems of HIV so that treatment interventions are more �nely attuned for different types of populations groups. Finally, in her examination of HIV/AIDS policy in Sweden, Brëdstrom (2006) has critiqued the treatment of race, ethnicity, culture, and religion as merely additional to gender and sexuality. For Brëdstrom, this type of narrow focus is a problem not only for analysis but also for effective sexual health policy because it renders invisible constructions of privilege as well as vulnerability among men and women, especially among migrants and refugees. She explains that through the gender and sexuality idiom, notions of otherness are constructed which deem some women as victims of culture, religion and tradition, and depict immigrant men as more patriarchal and misogynist and thus a greater threat to the spread of HIV/AIDS. This type of analysis prevents more dominant forms of heterosexual masculinity from being targeted, thus leaving unchallenged hegemonic power. For Brëdstrom (2006), sexual health policies that lack a critical perspective on how race, class and ethnicity intersect with gender and sexuality might very well contribute to a rei �cation of the very hierarchy they intend to dethrone (p. 241), especially in a political context where these factors are inseparable from the experiences of marginalized nonwhite men and women. ‘
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Another important gap is also the lack of attention by intersectionality scholars to issues of health across the lifespan. Importantly, there is near universal agreement that continued efforts are required to advance strategies for applying intersectionality in not only qualitative and quantitative studies but also mixed method designs. Moreover, there are speci �c areas of research and policy where the implications of intersectionality are only starting to be explored. To date, the relationship of intersectionality to biomedicine is just beginning to be interrogated (e.g. Kelly, 2009; van MensVerhulst & Radtke, 2006; Weber, 2006) but scholars are pointing to the potential for drawing on intersectionality to more fully explore the complex social processes that become inscribed on to the body. Andalthough evidence on intersectionality in the context of clinical nursing practices is emerging, namely how acknowledging and responding to privilege and oppression and the associated power dynamics transforms therapeutic encounters (Browne, Smye et al., 2011; Reimer-Kirkham & Sharma, 2011; Van Herk, Smith, & Andrew, 2011), this is also another area ripe for further research. Finally, innovative approaches to intersectionality-based policy analysis models are starting to take shape but require sustained efforts to realize their full potential (Hankivsky & Cormier, 2011).
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Ongoing challenges and gaps
At the same time that intersectionality is making inroads, there continue to be ongoing challenges for intersectionality-informed research and policy. Different versions of intersectionality have different research utility (McCall, 2005; Weldon, 2008). Researchers continue to be challenged by the choices of which social divisions, intersections, or data categories to study and how to best account for within category differences. Intersectionality research to date is often focused on the trinity of race, class, and gender obscuring other types of experiences emerging from intersecting frameworks of religion, spirituality, culture, geography, place, and age ( Hankivsky, 2011). As well, research continues to focus on the experiences of vulnerable populations while less attention has been given to exploring and documenting agency, resiliency, and resistance to domination (Hankivsky et al., 2010) or to interrogating privilege, including whiteness and middle-classness (Levine-Raskey, 2011).
Conclusion
Although applications of intersectionality are still developing, emerging research does show that theoretical foundations do in�uence and direct the way health inequities are conceptualized, studied, and responded to (Krieger et al., 2010). Intersectionality raises critical lines of enquiry. First, it brings to the fore the limitations of research that emphasizes pre-determined classi �cations (e.g. man and woman) or prioritizes any one single category (e.g. sex or gender) or even a set constellation of variables (e.g. sex and gender) within a contextual analysis. Signi �cantly, when sex and gender-based inequities are recognized as inseparable from other social locations such as class, race/ethnicity, sexual orientation, immigration status, geography, and ability, without any presumption of ranking (Weber & Fore, 2007), this raises the critical issue of whether centering sex and gender is useful, to what extent, and in which circumstances. Some researchers have suggested that gender may be a logical starting place for an analysisof intersectionality (e.g. Bowleg, 2008; Shields, 2008b). However, as has been emphasized in this paper, it is also important for researchers to be vigilant. Warner (2008) is thus correct in asserting that one cannot assume that a master category is a valid form of representation unless one tests this assumption in research (p. 458). As growing evidence shows, when gender is not found to always be salient and meaningful, the question becomes: What is gained but perhaps more importantly what is lost in terms of the knowledge and evidence that is produced when gender and gender comparisons are without exception, the preferred axes through which to frame research? Lagro-Janssen, among others, worries that de-centering gender will result in the loss of its importance ( 2007). Arguably, moving beyond the con�nes of established frameworks is not, however, about making gender invisible. Viewing gender within a logic of intersectionality certainly rede �nes it as a constellation of ideas and social practices that are historically situated and that mutually construct multiple systems of oppression ( Collins, 2000, p. 263). The implications are also further reaching. The list of potential intersecting factors extends beyondgender but also mayor maynot include gender at the forefront when determinations are made about what profoundly affects life chances, opportunities, and health, including manifestations of disease and illness. The key is to continue the process of interrogating when and how gender (and sex) are salient for examining, elucidating, and responding to “
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health inequities and to ensure that researchers who may be entrenched in certain ways of doing things, do not only see what they want to see in their research (Weber, 2007). What might be the political consequences of such shifts in framing? What forexample might be lost from a sustained focus for example on women s health or men s health? To a great extent these �elds are based on identity politics. They assume, for example, that the members of a social category face similar problems that require similar solutions when in fact no such unitary group exists. Moreover, intersectionality may open possibilities to transcend the Oppression Olympics (Martinez, 1993) which often characterize competition for scarce resources and policy attention between these two � elds. Gender and health researchers may also �nd new possibilities and new opportunities for collaboration, coalition, and action with other researchers and activists who may be focused on certain categories such as race, sexuality, class, and disability, developing integrated knowledge across systems of oppression (Weber & Parra-Medina, 2003, p. 200). Evidence that public policy is moving in this direction can also be found for example in the EU (Lombardo et al., 2009), a pioneer in gender equality policies. Member countries are moving from predominately attending to gender inequality towards policies that address various interlocking strands of inequality. The adoption of intersectionality in these jurisdictions is seen as necessary for the development of inclusive and better quality policies. In the �nal analysis, while dealing with multiple and intersecting dimensions is dif �cult terrain, full of enormous trials, intersectionality does make apparent the importance of new ways of framing the complexity of human life and social inequities. The challenges presented by intersectionality, which have been lurking in the shadows in mainstream health research for some time now, are now �rmly in the spotlight and raise important questions about what is required for inclusive and effective research. To remain on the cutting edge, researchers situated in the �elds of women s health, men s health, and genderhealth shouldcontinue to explore, discuss and debate the implications of intersectionality and �nd ways to more systematically adopt and apply intersectionality as a framework for improving understandings of and responses to the complexities of people s lives and experiences. ’
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Acknowledgments
I would like to thank the Gender and Health Working Group at Columbia University for their insightful feedback on an earlier version of this paper, my editors Lisa Bates and especially Kristen Springer, for their steadfast support and encouragement. I would also like to thank the anonymous reviewers of this article as well as Lynn Weber, Rita Kaur Dhamoon and Ange-Marie Hancock for their comments on earlier drafts of this paper. Thank you to Gemma Hunting for assistance with references. Finally I acknowledge the support of the Canadian Institutes of Health Research, the Michael Smith Foundation for Health Research, the Robert Wood Johnson Health & Society Scholars Program and the Center for the Study of Social Inequalities and Health at Columbia University.
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