In this blog, Dr Stan Papoulias, co-chair of the workshop, explores how the concept developed out of work done by black women’s activists groups in the US and beyond, some of the challenges of working with intersectionality in health research, and why it provides a vital analytical lens for health and care researchers engaging with marginalised groups.
To highlight the challenges of applying an intersectional approach to health research I want to start with two vignettes:
One: In August 2023, in a blog post for The King’s Fund entitled ‘Back to basics: understanding lived experience and intersectionality in health and care’ [1]. Loreen Chikwira reminds us of a grim statistic: in the UK black women are almost four times more likely to die in childbirth than white women [2]. She argues that in order to really get to grips with such health inequalities, it is not enough to centre lived experience, in this case, black women’s voices. We must also adopt intersectional approaches when doing so. What this means is shifting from focusing on “people’s behaviours to identifying and addressing ways of working that create and reinforce inequalities and poor experiences of care.”
Two: also in recent years, I collaborated in a major application to a health research funder, whose equality, diversity and inclusion (EDI) strategy emphasised the importance of using intersectional approaches in the research they fund. I therefore tried to engage intersectional frameworks in writing my section of the bid. However my efforts were checked by senior members of the team with knowledge of the funder’s inner workings, who cautioned me against using such terms. The funder’s EDI teams are not on the reviewing committee, they advised me. An application that makes use of terms associated with ‘theory’ is unlikely to go down well with reviewers. For a more competitive edge, I was urged to replace 'intersectionality' with references to 'health inequalities'.
I want you to hold these two stories in mind at the same time because they exemplify both the challenges and the necessity, both the urgency for and the resistance to bringing an intersectional perspective into health research.
The term is associated with African American legal scholar Kimberlé Crenshaw’s writings in the late 1980s and early 90s. Crenshaw used the term as an analytical tool to help her shed light on how legal and policy frameworks failed Black women workers in the US, because such frameworks could not engage with the specificity of their experience and discrimination in the workplace. Crenshaw cites a lawsuit brought by Black women workers against General Motors in the 1970s, where they could not prove they had been discriminated against, since there was no evidence of discrimination against all black people or against all women. Therefore, black women workers lost the case because there was no category available to them to claim discrimination distinctly from black men and white women. As Crenshaw says:
Black women [….] sometimes experience discrimination as Black women, not the sum of race and sex discrimination, but as Black women…. Black women's experiences are much broader than the general categories that discrimination discourse provides. [3]
To allow us to better understand this, Crenshaw asks us to imagine a busy traffic intersection with cars coming in all directions, with traffic lights, pedestrian crossings and so on. If an accident happens, it is not always possible to identify who exactly caused this. Even when the culprit is identifiable, we conclude that the accident was not caused by them alone, but rather by the interaction between one vehicle and all other vehicles actually or even potentially occupying that space. I say potentially because we need to also understand the shape and rules governing the intersection as contributing factors.
Some thirty years after Crenshaw, American sociologists Patricia Hill Collins and Sarah Bilge produce the following definition:
Intersectionality investigates how intersecting power relations influence social relations across diverse societies as well as individual experiences in everyday life. As an analytical tool, intersectionality views categories such as race, class, gender, sexuality, nation, ability ethnicity and age – among others - as interrelated and mutually shaping one another” [4].
Collins and Bilge tell us that in order to understand lived experience we must go beyond simple demographics and individual categories, to consider instead the traffic lights and the shapes of the intersections, the skein of power, in which our lives are lived.
I mentioned that intersectionality travelled from the social sciences to health research. That’s not quite right. While the term may come from Crenshaw, the approach does not, and Crenshaw makes clear her indebtedness to the work of 19th century black women abolitionists such as Sojourner Truth and Anna Julia Cooper who understood how gender race and class work together as axes of oppression. To these we could add figures such as Savitribai Phule, a Dalit woman in 19th century India who fought against the caste system while also supporting Muslim rights as well as those of workers and women. A more immediate antecedent is the Combahee River Collective, a black lesbian feminist group formed in the 1970s specifically to combat what they saw as the racism of the white dominated feminist movement and who called for combined action against sexism, racism and class-based inequality [5].
Now what does all this mean for health research? And why might some funders retreat from using the term? A recent article by Holman and colleagues on the perspectives of professional stakeholders around intersectional approaches to health inequalities might shed some light here [6]. The article argues that researchers and policymakers display ambivalence towards the term: there is at once an acknowledgement of its utility and a concern with its status as a mere buzzword. Many voiced methodological concerns: researchers spoke of a dearth of datasets complex enough to enable intersectional analysis and cited methodological challenges of attempting such analysis. Others cited policymakers’ preference for simple solutions and their suspicion against convoluted academic-sounding terms.
But these concerns were underpinned by a broader issue: a reluctance to undo established habits of work and established ways of thinking about health. Adopting an intersectional approach means changing the way we conduct health research in three fundamental ways: first, it means moving away from individualising approaches to health policy and health interventions (a focus on individual and group behaviours) to understanding health inequalities through the interplay of power relations and systems of oppression and minoritisation. It means shifting emphasis from downstream to upstream.
Second, such approaches demand sustained work with those experiencing health inequalities, not as informants or helpful advisors but as research actors whose experiences of exclusion are not harvested or extracted as data but become a standpoint through which to reshape research practice. And third, and perhaps this is the biggest hurdle of all, it means politicising research. Or rather it means acknowledging that all knowledge production, all science, is inherently political. Intersectionality may be a term coined in law schools and sociology departments, but it is also an approach forged through liberation struggles of minoritised and marginalised populations – specifically, but not exclusively, Black women and women of the global south [6].
If this approach is to be avoided in health research, precisely because of this ‘baggage’, then what are we doing when we speak of the importance of centring lived experience? Can we even speak of centring lived experience when we ignore the sociopolitical structures and power relations which constitute advantage and oppression alike, the traffic lights and intersections through which our lives are lived? To quote Loreen Chikwira again,
Organisations need to think about what it means to use an intersectional lens and create an inclusive environment where services engage with marginalised groups whose voices are seldom heard in a meaningful way.
The workshop on intersectional approaches to researching health inequalities was co-chaired by Savi Hensman, patient, service user, carer and public involvement coordinator, and Dr Stan Papoulias, research fellow and deputy lead for the ARC’s PPI research theme.