Combatting Health Inequities

Considering Intersectionality in Biomedical Research

By Shu’ayb Simmons

Intersectionality’ is a term that has gained increasing recognition in recent years, and for good reason.

Coined by seminal legal scholar and civil rights activist Kimberlé Crenshaw in 1989, intersectionality refers to the connectedness of an individual’s social identities and how they shape one’s lived experience.1 Crenshaw initially used the term to describe how Black women experience racism and sexism simultaneously—thus, creating a unique form of oppression that cannot be fully understood by examining either identity in isolation.

Looking further, however, intersectionality is relevant in various fields, especially biomedicine, where it has become increasingly important to consider the role of social identities in shaping health outcomes to better health inequities.2 Social factors such as race, gender, socioeconomic status, sexual orientation, and immigration status can significantly impact an individual’s health. To this end, failing to acknowledge intersectionality can lead to health disparities and perpetuate outcome inequities.

Therefore, considering intersectionality and understanding its overarching implications in biomedicine is crucial. In this article, we will explore the concept of intersectionality and its relevance, then discuss practical strategies for incorporating it into research.

Social Identities and Health: The Importance of Social Identities on Outcomes

In biomedicine, it is crucial to recognize that social identities and interactions can significantly impact health outcomes. You can consider health outcomes as the result of a particular health condition (e.g., a cure, improvement, or death). Health outcomes are often employed to assess the effectiveness of medical interventions or public health programs. On the other hand, social determinants of health are the conditions in which people are born, grow, live, and age that can significantly shape overall health outcomes.3 It is important to note that health outcomes are not static across all social groups. Notably, social determinants of health play a critical role in perpetuating these disparate outcomes known as health inequities. Health inequities are differences in health outcomes that are avoidable, resulting from inequitable barriers that limit opportunities and access to resources for specific groups.

While race, gender, and socioeconomic status have been well-documented as significant determinants of health, it is essential to acknowledge that other identities, such as sexual orientation and immigration status, also play a critical role.4 For example, 2SLGBTQI+ individuals may face unique social-level challenges related to healthcare access and discrimination, leading to poorer health outcomes. Similarly, immigrants can experience barriers to healthcare access due to language barriers, lack of documentation, and discrimination— thus, resulting in delays in diagnosis and treatment. Due to differences in healthcare access, exposure to social stressors, and experiences of systemic discrimination and racism, minority populations are more likely to suffer worse health outcomes than their White counterparts.5 Therefore, understanding intersectionality within the context of biomedicine is crucial in promoting health equity for all and addressing health disparities in and beyond the Canadian medical system.

Intersectionality: The Compounding Effects of Social Identities on Outcomes

Intersectionality operates in complex and compounding ways by shaping individuals’ lived experiences6 and health outcomes among individuals who belong to multiple socially marginalized groups.7 The compounded effects of intersectionality have been documented in numerous other areas, including gender identity, sexual orientation, and immigration status.8 For example, a person who identifies as both a racial minority and from a low socioeconomic status household may face unique challenges pertaining to healthcare access and discrimination based on both their race and socioeconomic status. Therefore, one needs to consider the powerful and transcending impact that intersectionality continues to have in the design of healthcare policies and interventions. Importantly, by intentionally applying the intersectionality perspective, decision-makers in healthcare can start to address the unique barriers that marginalized groups face while accessing healthcare services. Therefore, by recognizing the compounding effects of intersectionality, biomedical professionals can take meaningful steps toward addressing the health disparities that marginalized groups continue to face.

So, what are some pragmatic ways to intentionally incorporate intersectionality in medical research? First, we must address the need for diversity in study populations participating in biomedical research. A recent 2017 meta-analysis aggregated 99 Canadian health studies between 1978 and 2014 and found that only five studies examined nationally representative data.9 Such paucity of racially and ethnically diverse data severely limits our understanding of how social identities impact health outcomes and continue to perpetuate population-level disparities. To combat these disparities, it is essential to prioritize the inclusion of diverse populations in biomedical research. Specifically, researchers must consider implementing culturally sensitive research protocols that recognize and incorporate different populations’ unique experiences and needs. Furthermore, researchers must also leverage publicly available data containing sociodemographic variables at all steps of the study development pipeline. Second, if collecting sociodemographic data, researchers must co-design studies with communities and engage in equitable data sharing while employing culturally appropriate outreach strategies. Finally, in addition to recruiting diverse study participants, it is imperative for researchers to consider intersectional variables in study design and analysis carefully. This can include using stratified analyses to explore differences in health outcomes across different demographic groups and including intersectional variables as covariates within statistical models. By doing so, we can better understand the unique relationships between social factors and health outcomes while maximizing study validity.

References

1. Crenshaw, Kimberlé (1989) “Demarginalizing the Intersection of Race and Sex: A Black Feminist Critique of Antidiscrimination Doctrine, Feminist Theory and Antiracist Politics,” University of Chicago Legal Forum: Vol. 1989, Article 8. Retrieved from https:// chicagounbound.uchicago.edu/uclf/vol1989/iss1/8/

2. Braveman, P., & Gottlieb, L. (2014). The Social Determinants of Health: It’s Time to Consider the Causes of the Causes. Public Health Reports, 129(Suppl 2), 19-31. https://doi. org/10.1177/00333549141291S206

3. Public Health Agency of Canada. (2022, June 14). Social determinants of health and health inequalities . Social determinants of health and health inequalities - Canada.ca. Retrieved April 27, 2023, from https://www.canada.ca/en/public-health/services/health-promotion/population-health/what-determines-health.html

4. Ghavami, N., Katsiaficas, D., & Rogers, L. O. (2016). Toward an Intersectional Approach in Developmental Science: The Role of Race, Gender, Sexual Orientation, and Immigrant Status. Advances in Child Development and Behavior, 50, 31-73. https://doi. org/10.1016/bs.acdb.2015.12.001

5. Williams DR, Yan Yu, Jackson JS, et al. (1997). Racial Differences in Physical and Mental Health: Socio-economic Status, Stress and Discrimination. J Health Psychol. Jul;2(3):335-51. https://doi. org/10.1177/135910539700200305

6. King, D. K. (1988). Multiple Jeopardy, Multiple Consciousness: The Context of a Black Feminist Ideology. Signs: Journal of Women in Culture and Society. https://doi.org/10.1086/494491

7. Cole, E. R. (2009). Intersectionality and Research in Psychology. The American Psychologist, 64(3), 170–180. https://doi.org/10.1037/ a0014564

8. Grzanka, P. R. (2020). From Buzzword to Critical Psychology: An Invitation to Take Intersectionality Seriously. Women & Therapy, 43(3-4), 244–261. https://doi.org/10.1080/02703149.2020.1729473

By taking a more intersectional approach to biomedical research, we can better understand how social identities and lived experiences interact to impact health and promote health equity. This includes prioritizing diversity in research, developing culturally sensitive protocols, and carefully considering intersectional variables in study design and analysis. As we move forward, biomedical researchers must continue to recognize the importance of intersectionality in health outcomes and promote health equity for all.

9. Khan, M.M., Kobayashi, K., Vang, Z.M. et al. (2017), “Are visible minorities “invisible” in Canadian health data and research? A scoping review”, International Journal of Migration, Health and Social Care, Vol. 13 No. 1, pp. 126-143. https://doi.org/10.1108/ IJMHSC-10-2015-0036