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Nafeesa Nizami: Intersectionality as an intervention in in radically social times

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Nafeesa explores Intersectionality as an intervention in radically social times, using the frame of intersectionality as a radical activist intervention to address systemic social issues such as racism, gender inequalities and discrimination in the era of rising global populism. Nafeesa will draw upon theories of feminism, colonialism, philosophy and politics, nuanced with punctuations of humour and entertainment.

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Kimberlé Crenshaw: The urgency of intersectionality

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Now more than ever, it's important to look boldly at the reality of race and gender bias -- and understand how the two can combine to create even more harm. Kimberlé Crenshaw uses the term "intersectionality" to describe this phenomenon; as she says, if you're standing in the path of multiple forms of exclusion, you're likely to get hit by both.

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When using this in my practice I would need to consider the application of intersectionality more with the parents of my learners, as I work in a Baby-Room. However any discrimination that the parents may face, I should also consider that there is a likelihood, the children in my care will also face this discrimination at some point.

I feel intersectionality also has a link when looking at Bronfenbrennar's Ecological Systems as discrimination and the importance of inclusion can effect the learners in my practice, through the influence of the systems around the child as well as the influence of the parents and surrounding culture.

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Intersectionality is the recognition that  people with a common identity (gender, sexuality, religion, race) exist intragroup differences. It can be used to understand a wide variety of social interactions and complex social hierarchies. (Burton, 2020)

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Intersectionality – Subcultures and Sociology

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“the interconnected nature of social categorizations such as race, class, and gender as they apply to a given individual or group, regarded as creating overlapping and interdependent systems of discrimination or disadvantage.” -Oxford Dictionaries

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The term intersectionality was first introduced by Professor Kimberlé Crenshaw in 1989 to describe individuals and groups experiencing oppression and social disadvantages as a result of a combination of multiple social identities, including race, gender, sexuality, and class.

In practice, intersectionality can be used to ensure that education is inclusive for all pupils. According to OFSTED (2000, p.4) inclusion is providing equal opportunities for all regardless of age, gender, ethnicity, disability, attainment and background. Working in early years I feel that intersectionality is important as there is an opportunity to educate children about diversity from an early stage. Targowska (2001) states that from a young age children are aware of social attitudes which exist within their lives and that their perception of differences is influenced by their environments.

References

OfSTED (2004) Special educational needs and disability. Towards inclusive schools(London, OfSTED)

Targowska, A. (2001). Exploring young children’s ‘racial’ attitudes in an Australian context—The link between research and practice. Paper presented at the Association for Active Educational Researchers Conference, Fremantle, Western Australia.

Wider reading

https://www.genderaction.co.uk/latest-news/2019/3/28/what-is-intersectionality

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Intersectionality is a theoretical framework that consists of multiple social categories (e.g., race, ethnicity, gender, sexual orientation, socioeconomic status). These intersect at the micro level of individual experience to reflect multiple interlocking systems of privilege and oppression at the macro, social-structural level such as racism, sexism and hetrosexism (Bowleg,2012)

How could this work in practice:
Providing equity within educational practice is grounded in the examination of policies and procedures and how these operate within intersectionality. It is a dynamic tool that promotes critical, reflexive practice and the review of power struggles within the classroom,whilst promoting sensitivity to relationships. Providing positive scope in promoting inclusivity; intersectionality highlights marginalisation and oppression within specific characteristic groupings on an individual basis and at an institutional level also .

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Abstract

Intersectionality is a theoretical framework that posits that multiple social categories (e.g., race, ethnicity, gender, sexual orientation, socioeconomic status) intersect at the micro level of individual experience to reflect multiple interlocking systems of privilege and oppression at the macro, social-structural level (e.g., racism, sexism, heterosexism). Public health's commitment to social justice makes it a natural fit with intersectionality's focus on multiple historically oppressed populations. Yet despite a plethora of research focused on these populations, public health studies that reflect intersectionality in their theoretical frameworks, designs, analyses, or interpretations are rare. Accordingly, I describe the history and central tenets of intersectionality, address some theoretical and methodological challenges, and highlight the benefits of intersectionality for public health theory, research, and policy.

The term women and minorities is ubiquitously wedded in public health discourse, policy, and research. Take, for example, the NIH [ National Institutes of Health] Policy and Guidelines on the Inclusion of Women and Minorities as Subjects in Clinical Research. 1 The 2001 amended guidelines provide guidance on including women and minorities as participants in research and reporting on sex/gender and racial/ethnic differences. The problem with the "women and minorities" statement or the "ampersand problem" 2(p22) is the implied mutual exclusivity of these populations. Missing is the notion that these 2 categories could intersect, as they do in the lives of racial/ethnic minority women.

Further compounding the issue is that the word minority is multidefinitional. Although it typically modifies race/ethnicity in the United States, minority also can reference populations such as lesbian, gay, bisexual, and transgender (LGBT) people; people with physical and mental disabilities; or, depending on geographic context, White people. Thus, in addition to being vague, the term minority in conjunction with women obscures the existence of multiple intersecting categories as exemplified by, for instance, a low-income Latina lesbian with a physical disability.

The notion that social identities are multiple and interlocking is not limited to the women and minorities discourse. The introduction to the US Department of Health and Human Service's (DHHS's) recent HHS Action Plan to Reduce Racial and Ethnic Health Disparities acknowledges that

characteristics such as race or ethnicity, religion, SES [socioeconomic status], gender, age, mental health, disability, sexual orientation or gender identity, geographic location, or other characteristics historically linked to exclusion or discrimination are known to influence health status. 3(p2)

This acknowledgment illustrates another conjunction problem-that of the "or." Pursuant to this logic, one's sexual orientation or gender identity or race/ethnicity may have an adverse effect on health, but nowhere in the report is there any indication of how the intersection of being, for example, a low-income Black gay or bisexual man might influence health. Acknowledging the existence of multiple intersecting identities is an initial step in understanding the complexities of health disparities for populations from multiple historically oppressed groups. The other critical step is recognizing how systems of privilege and oppression that result in multiple social inequalities (e.g., racism, heterosexism, sexism, classism) intersect at the macro social-structural level to maintain health disparities.

Enter intersectionality. Intersectionality is a theoretical framework for understanding how multiple social identities such as race, gender, sexual orientation, SES, and disability intersect at the micro level of individual experience to reflect interlocking systems of privilege and oppression (i.e., racism, sexism, heterosexism, classism) at the macro social-structural level. 4-7 Far from being just an exercise in semantics, intersectionality provides the discipline of public health with a critical unifying interpretive and analytical framework for reframing how public health scholars conceptualize, investigate, analyze, and address disparities and social inequality in health. The aforementioned DHHS report on health disparities and the even newer National Prevention Strategy 8 assert that the reduction and elimination of health disparities are a top national public health priority. This priority is further reflected in public health and biomedical journals, which are replete with health disparities research. Yet a key omission from most policy and research is first and foremost the recognition of multiple intersecting social identities and next an acknowledgment of how the intersection of multiple interlocking identities at the micro level reflects multiple and interlocking structural-level inequality at the macro levels of society.

The need for intersectionality as a unifying public health framework is further underscored by the relative dearth of theory and research that specifically address the multiple and interlocking influence of systems of privilege and oppression such as racism, sexism, and heterosexism. Instead, most public health research typically examines each system independently, "thus impairing efforts to understand the health of people whose lives cut across these diverse realisms of experiences." 9(p99) Accordingly, I advocate for a greater awareness of intersectionality within public health. Intersectionality, I assert, provides a critical, insightful, and unifying theoretical framework for guiding public health theory, research, surveillance, and policy. Hereafter, I refer to intersectionality synonymously as a theoretical framework or perspective.

A BRIEF HISTORY OF INTERSECTIONALITY

Intersectionality is rooted in Black feminist scholarship. Although feminist legal scholar Kimberlé Crenshaw 6 coined the term intersectionality to describe the exclusion of Black women from White feminist discourse (which equated women with White) and antiracist discourse (which equated Black with men) in the 1990s, the intersectionality concept is hardly new. Freed slave Sojourner Truth's 10 interrogation of the intersections of race and gender in her famous "Ain't I a Woman?" speech at the 1851 Women's Convention in Akron, Ohio, is one of the earliest recorded accounts of the intersectionality perspective. In the speech, Truth challenged the notion that being a woman (i.e., gender) and Black (i.e., race) are mutually exclusive:

That man over there says that women need to be helped into carriages, and lifted over ditches, and to have the best place everywhere. Nobody ever helps me into carriages, or over mud-puddles, or gives me any best place! And ain't I a woman?

The topic of intersectionality is a staple of women's studies and feminist legal studies, 4 is nascent in psychology 11,12 and interdisciplinary gender studies, but remains relatively scarce within mainstream public health. A November 10, 2011, PubMed search of the keyword intersectionality yielded just 49 results; not a single one was in a mainstream public health journal. Even an insightful 2008 article on intersectionality published in Critical Public Health 13 did not make the list. A same-date keyword search for intersectionality within the American Journal of Public Health ( AJPH) found 7 records dating back to 2005. Of these, 4 referred to citations in the reference list, not the main text. Another AJPH keyword search for intersection* returned 267 results, most of which referred to intersections of streets or disciplines. Only 26 of the 267 (10%) were articles that used the term intersection to refer to the intersection of race, ethnicity, gender, sexual orientation, and SES. Thus, for mainstream public health, a focus on intersectionality is both timely and overdue. The Institute of Medicine's Committee on LGBT Health's 14 2011 report provides another case in point. Recognizing the promise of intersectionality for advancing research on LGBT health, the committee included intersectionality as 1 of 4 conceptual perspectives that shaped its work. Alas, the glossary's definition of intersectionality as "a theory used to analyze how social and cultural categories intertwine"(p318) and attribution of this definition to a 2006 conference presentation rather than the scholarly or peer-reviewed literature on intersectionality underscore a critical need for greater awareness of intersectionality within public health.

CORE TENETS OF INTERSECTIONALITY RELEVANT TO PUBLIC HEALTH

Although scholars sometimes refer to intersectionality as a theory, 4 it is not the kind of theory with which most social scientists are familiar. That is, intersectionality has no core elements or variables to be operationalized and empirically tested. For this reason, I avoid the term theory in favor of terms such as theoretical framework or perspective that denote intersectionality as more of an analytical framework or paradigm than a traditional testable theory. Indeed, intersectionality departs from traditional biomedical, biobehavioral, and psychosocial paradigms that have shaped medicine, public health, and the other social sciences in several key ways. A comprehensive discussion of these differences is beyond the scope of this article. Instead, I refer readers to Weber and Parra-Medina's 15 excellent chapter on intersectionality and women's health in which they elucidate the differences between the traditional biomedical, biobehavioral, and psychosocial paradigms and intersectionality.

I consider the core tenets of intersectionality most relevant to public health to be as follows: (1) social identities are not independent and unidimensional but multiple and intersecting, (2) people from multiple historically oppressed and marginalized groups are the focal or starting point, and (3) multiple social identities at the micro level (i.e., intersections of race, gender, and SES) intersect with macrolevel structural factors (i.e., poverty, racism, and sexism) to illustrate or produce disparate health outcomes.

Multiple Intersecting Identities

The most elemental tenet of intersectionality is the notion that social categories (e.g., race, SES, gender, sexual orientation) are not independent and unidimensional but rather multiple, interdependent, and mutually constitutive. 6,16,17 Far from representing a simple addition of social identities such as race (e.g., Black) plus gender (e.g., woman), the intersectionality perspective asserts that race and gender constitute each other such that one identity alone (e.g., gender) cannot explain the unequal or disparate outcomes without the intersection of the other identity or identities. Thus, harkening back to Sojourner Truth's "Ain't I a Woman?" query, the notion of her gender as a woman did not sufficiently explain the inequitable treatment she experienced without its intersection with her race. Fast forward 160 years after Truth's speech, and the unrelenting hold of health disparities among racial and ethnic minorities in the United States provides ample cause and opportunities to examine how multiple identities intersect to adverse effect. From an intersectionality point of view, attempting to understand or address health disparities via a single analytical category (e.g., gender or race or sexual orientation), as the DHHS report on health disparities implies, elides the complex ways in which multiple social categories intersect with social discrimination based on those multiple intersecting categories to create disparity and social inequality in health.

Historically Oppressed and Marginalized Populations

Technically speaking, we all have multiple intersecting identities. Universal intersectionality is not the province of intersectionality, however. Rather, another core tenet of intersectionality is its focus on the intersecting identities of people from historically oppressed and marginalized groups such as racial/ethnic minorities, LGBT people, low-income people, and those with disabilities. Because people from multiple historically oppressed and marginalized populations are its starting point, intersectionality examines the health of these populations in their own context and from their vantage point rather than their deviation from the norms of White middle-class people. 15 Turns out, this makes good sense practically, not just theoretically.

Examples from HIV prevention research and practice with Black individuals, who represented 52% of new HIV cases in 2009 despite representing just 13% of the US population, 18 accentuate why fashioning health policy and prevention messages exclusively from the perspective of White middle-class populations does not always equal good public health practice. Take the case of Black men who have sex with men (MSM) who in 2009 represented 42% of new HIV cases among MSM. 18 Early in the HIV/AIDS epidemic, the Centers for Disease Control and Prevention (CDC) learned that HIV prevention messages targeted to gay and bisexual men were failing to resonate with Black and Latino MSM who did not identify as gay or bisexual. This recognition prompted a policy change of using the MSM nomenclature in HIV/AIDS surveillance activities and reports that is now well established in HIV prevention theory, research, and practice. The solution is far from perfect. MSM is a behavioral category, not an identity category. Thus, some MSM do not identify as MSM. Nonetheless, this policy change confirms the importance of shaping health policy from the perspective of multiple historically oppressed populations.

In 2009, Black women constituted 66% of women newly diagnosed with HIV despite representing just 13% of the female US population. 18 Many feminist HIV prevention scholars have chided the implicit White middle-class bias of many HIV/AIDS prevention messages targeted to racial/ethnic minority women. In an early critique of these messages, Mays and Cochran 19 derided as a "rather middle class notion"(p954) the public health directive that women should negotiate or communicate with their sexual partners about condom use and HIV risk. They explained that verbal communication about risk may be unrealistic and inapplicable to the lives of poor women who "may not bother to ask men about previous sexual or drug use behaviors because they know the men will lie or discount the risk "(p954) and cautioned developers of HIV prevention messages for low-income women of color to remember that "poor people do not always have the luxury of honesty, which is much easier when there is sufficient money and resources to guide one's choices. "(p954)

Yet despite its emphasis on multiple socially disadvantaged statuses as a focal point, intersectionality does not presume that all interlocking identities are equally disadvantaged. Rather, intersectionality considers how low (e.g., racial minority, LGBT persons) and high (e.g., upper- or middle-class SES) status social identities intersect to yield disparity and advantage. 7,20 Accordingly, the intersectionality paradox is another of intersectionality's noteworthy, albeit underresearched, contributions to public health. The intersectionality paradox describes the result of adverse health outcomes at the intersection of a high status identity (i.e., middle-class SES) with race and gender for Black middle-class women and men. 21 An abundant empirical base documents the relation between higher SES and better health outcomes. 9,22-25 Paradoxically, this is not always the case for Black middle-class men and women as the disproportionate rates of infant mortality among highly educated Black women and homicide rates among Black middle-class men illustrate. 21 Infant mortality is a widely recognized indicator of a population's health. 26 Non-Latino Black people in the United States had an infant mortality rate 2.4 times that of non-Latino White people in 2006. 27 This disparity persists despite Black women's higher levels of education, a key measure of SES. The infant mortality rate for Black women with more than 13 years of education was almost 3 times higher than that for non-Latino White women in 2005. 27 Historically, the infant mortality rate of highly educated Black women has exceeded that of non-Latino White women with less education, 21 highlighting the paradox of the intersection of SES, race, and gender for Black women in the United States.

The paradox is also evident for Black men, for whom homicide is a critical public health issue. Homicide does not appear on the list of the 10 leading causes of death for men in the aggregate. In 2008, however, homicide was the fifth leading cause of death for Black men of all ages in the United States and the leading cause of death for Black males aged 15 to 44 years. 28 Lower homicide rates are often inversely associated with higher SES, 29,30 but the higher SES of Black men conveys no such advantage. In 1994, the homicide rate for Black men with some college education was 11 times that of White men with similar levels of education. Emphatically, Jackson and Williams 21 concluded, "strikingly, the homicide rate of Black males in the highest education category exceeds that of White males in the lowest education group!"(p148) Thus, intersectionality provides a more comprehensive insight into how multiple social identities intersect in complex ways to show social inequality. This notwithstanding, it is important to segue here and note that although updated homicide rate data by age, race, gender, and Hispanic origin are easily locatable at the CDC's National Vital Statistics System Web site, education data are not. The omission of education data (or at least easily retrievable data) shows how the absence of critical data such as SES obscures the more complex understanding of public health issues that an intersectionality analysis facilitates.

Social-Structural Context of Health

Whether using language such as "social determinants of health," 31 "social discrimination or social inequality," 9,32 "fundamental causes," 33-35 "structural factors or influences," 36 or "ecological or ecosocial influences," 37,38 an ever-growing chorus of public health scholars have advocated for a greater focus on how social-structural factors beyond the level of the individual influence health. This too is a core tenet of intersectionality. Moreover, a central consideration of intersectionality is how multiple social identities at the individual level of experience (i.e., the micro level) intersect with multiple-level social inequalities at the macro structural level. From an intersectionality perspective, a middle-class Latina lesbian's negative experiences at her physician's office are linked to multiple and interlocking sexism, heterosexism, and racism at the macro level. Her microlevel experiences at the intersection of her race/ethnicity, sexual orientation, and gender correspond with empirically documented evidence of the heterosexism that lesbian and bisexual women often encounter when they seek health care services 39,40 and the intersection of racism and sexism well documented in research on racial/ethnic minority women's health care experiences. 9,41,42 Alas, with the exception of a 1988 study focused on Black lesbian and bisexual women's experiences of disclosing their sexual identity to physicians, 43 much of the research on lesbian and bisexual women's experiences in health care settings stems from research with predominantly White middle-class lesbian and bisexual women. Similarly, much of the research on racial/ethnic minority women's experiences in health care settings does not include or report sexual orientation data or presumes heterosexuality, thereby limiting an in-depth understanding of women's experiences in health care settings beyond the intersections of gender and race.

THEORETICAL AND METHODOLOGICAL CHALLENGES

Feminist sociologist Leslie McCall 44 has heralded intersectionality as "the most important theoretical contribution that women's studies, in conjunction with related fields, has made so far."(p1771) Although many scholars concur with McCall's assessment, many continue to "grapple with intersectionality's theoretical, political, and methodological murkiness." 20(p1) This murkiness may simultaneously be a strength because it provides seemingly endless opportunities for debate, theorizing, and research. 4

Theoretical Challenges

At least 2 theoretical challenges relevant to the integration of intersectionality within public health exist: (1) determining which social categories intersectionality should include and (2) recognizing that intersectionality was not developed to predict behavior or mental processes 45 or health. First, as I have noted previously, Black women were the original subjects of intersectionality. Accordingly, the intersections of race and (female) gender in the lives of women of color 6,7,17,46 and women's health 11,15,47 have been the primary focus of intersectionality. Contemporary critiques of intersectionality's historic focus on race and gender have problematized the issue of treating Black women as a monolith, obscuring within-group differences such as sexual orientation and SES, for example. 20 Other critiques note that social identities are not " trans-historical constants" 20(p5) but vary historically and by context.

Framed from a public health perspective, however, intersectionality's promise lies in its potential to elucidate and address health disparities across a diverse array of intersections including, but not limited to, race, ethnicity, gender, sexual orientation, SES, disability, and immigration and acculturation status. Thus, consistent with Collins's notion of an intersectional "matrix of domination," 7(p225) my view of intersectionality includes and transcends women of color to include all people whose microlevel and macrolevel experiences intersect at the nexus of multiple social inequalities and is broad enough to include populations who inhabit dimensions of social privilege and oppression simultaneously (e.g., Black heterosexual men; White low-income women). Hankivsky and Christoffersen 13 aptly sum up intersectionality's theoretical complexity: "Without doubt, this framework complicates everything."(p279)

Another challenge is how to transform a perspective that was designed primarily as an analytical framework into one that can empirically examine multiple intersecting social identities and resultant multiple macrolevel structural inequality. Predicting and testing the effect of intersectionality on health behavior outcomes and mental processes have never been the focus of intersectionality. 45 Thus, for public health and other social science researchers, the absence of theoretically validated constructs that can be empirically tested poses not only a major challenge but also tremendous opportunities for advancing the study of intersectionality from a public health perspective.

Methodological Challenges

As for methodological challenges, there is ample consensus that a paucity of knowledge about how to conduct intersectionality research exists. 12,13,20,44,48 Although qualitative methods or mixed methods appear to be ideally suited to intersectionality's implicit complexity and multiplicity, 13,16,48 the challenges of conducting intersectionality research quantitatively are especially daunting. 44,48 Among the many challenges are (1) the absence of guidelines for quantitative researchers who wish to conduct intersectionality research 12; (2) the fact that the task of investigating "multiple social groups within and across analytical categories and not on complexities within single groups, single categories or both" 44(p1786) is often complex and complicated, necessitating the use of interaction effects or multilevel or hierarchal modeling, which bring further "complexity in estimation and interpretation than the additive linear model" 44(p1788); and (3) the fact that many statistical methods often rely on assumptions of linearity, unidimensionality of measures, and uncorrelated error components 49 that are incongruent with the complex tenets of intersectionality. More quantitative methodologies are critically needed "to fully engage with the set of issues and topics falling broadly under the rubric of intersectionality." 44(p1774)

Even so, public health scholars need not wait for the methodological challenges of intersectionality to be resolved to incorporate intersectionality into their theoretical frameworks, designs, analyses, and interpretations. Methodological revolution is simply not essential to the advancement of intersectionality. Instead, what is needed is an intersectionality-informed stance. This stance involves a natural curiosity and commitment to understanding how multiple social categories intersect to identify health disparity. It also involves the a priori development of questions and measures to facilitate analyses about intersectionality. At a minimum, this would involve collecting data on race, ethnicity, age, SES, gender (including gender categories relevant to transgender people), sexual identity, sexual behavior (see my earlier comments about MSM), and disability status. At the interpretation phase, the stance would include an interdisciplinary approach in which "the researcher locates the particular sample within historical and socioeconomic circumstances, regardless of the particular character of the sample." 16(p177) How researchers interpret their data is as important as the methodological choices they make about sampling, sample sizes, or using qualitative or quantitative methods. 16 The definition of data can be expanded to include empirically collected data "AND other sources of information"(p177) such as historical materials, results from other studies, social theories, and the analysts' tacit knowledge. Cuadraz and Uttal 16 caution researchers not to "subsume or privilege"(pp177-178) one social category over another but rather to

strive to contextualize data within the multiple intersectionalities of historical structures, cultures, ideologies and policies. [This will result] in studies that more accurately reflect the social realities of inequality and power in society, yet at the same time not lose site [sic] of the individual experiences that reflect, shape, and construct those social structures.(p178)

INTERSECTIONALITY'S BENEFITS FOR PUBLIC HEALTH

Intersectionality is ideally suited to join the ranks of other critical theories such as critical race theory 50-52 and various feminist 53 and gender 54-56 theories applied to public health issues. Intersectionality is an especially close ally of critical race theory. Indeed, key intersectionality theorists such as Kimberlé Crenshaw 57 and Patricia Hill Collins 7 are also critical race theorists. Developed in the 1970s by legal scholars, lawyers, and activists, critical race theory asserts at least 5 key tenets. 58 First, racism in the United States is not aberrant but an ordinary and immutable characteristic of everyday life for people of color. Second, critical race theory asserts that White supremacy manifests in 2 features that serve psychic and material purposes: ordinariness and interest convergence. Ordinariness highlights the mundane and seemingly incurable nature of racism. That is, because racism is so commonplace and ordinary, "color-blind" legal remedies that tout meritocracy mainly serve the material interests of White elite individuals and the psychic interests of White working class people. Interest convergence, a term coined by Derrick Bell, 59 one of the pioneers of critical race theory, posits that White people will support and encourage policies and initiatives that advance the interests of Black people only to the extent that these policies and initiatives serve the interests of White people. This was the crux of Bell's provocative argument that Brown v. Board of Education, 60 the landmark 1954 US Supreme Court civil rights public school desegregation case, was more motivated by White people's self-interest than by interest in advancing the legal rights of Black people. Third, critical race theory focuses on the social construction of race. The notion that race is not a biological reality but a socially constructed one is well documented in the scientific literature. 61,62 The fact that society routinely ignores scientific evidence about the socially constructed nature of race bolsters critical race theory's assertions about the salience and permanence of racism as a defining and enduring characteristic of everyday life for people of color in the United States. Moreover, because race is socially constructed, many contemporary critical race theorists emphasize how dominant groups have historically racialized different minority groups to respond to the varying needs of the labor market. Critical race theory's focus on the socially constructed nature of race dovetails with contemporary intersectionality theorists' emphasis on the socially constructed nature of social identities. 20,63 That is, critical race theory recognizes that race and racism intersect with other social identities such as gender, sexual orientation, and SES and interlocking systems of oppression such as sexism, heterosexism, and classism. Fourth, critical race theory emphasizes the importance of narratives or "storytelling" from people of color to counter White supremacy and privilege the voices of people of color. In this way, critical race theory's focus on the centrality of the experiences and voices of people of color parallels intersectionality's emphasis on historically marginalized people as its focal point. 15 Last, but hardly least, critical race theorists, like intersectionality theorists, share a commitment to social justice and advocacy. Although critical race theory has had its debut in the mainstream public health literature, 50-52 intersectionality has not.

One of intersectionality's greatest strengths is its broad embrace of multiple intersecting identities and multiple interlocking privilege and oppression. No social category or form of social inequality is more salient than another from an intersectionality perspective. Social categories are not additive and thus cannot be ranked. As such, intersectionality is a substantially useful but woefully underused critical theoretical framework for public health.

Although intersectionality provides no methodological panacea for the myriad and complex health issues and problems that are the province of public health, the advantages of intersectionality for public health theory and research far outweigh the challenges. Intersectionality stands to benefit public health in at least 5 noteworthy ways. First, intersectionality provides a unifying language and theoretical framework for public health scholars who are already engaged in investigating intersections of race, ethnicity, gender, sexual orientation, SES, and disability to reduce and eliminate health disparities. Having scholars from diverse disciplines incorporate the intersectionality framework as an analytical perspective regardless of methodological approach 16 and explicitly use the word intersectionality in their titles, keywords, abstracts, or articles would facilitate a cohesive body of theoretical and empirical knowledge about multiple intersecting social categories and social inequality that could inform health policy, practice, and interventions and further theoretical and methodological advancement and refinement of intersectionality.

Second, intersectionality prompts public health scholars to conceptualize and analyze disparities and social inequalities in health in the complex and multidimensional ways that mirror the experiences of the populations for whom adverse health outcomes are most disproportionate. From intersectionality's perspective, single or dual analytical categories such as race and gender offer limited explanatory power. Intersectionality also provides a theoretical lens for interpreting novel or unanticipated findings. This was the conclusion that Kertzner et al. 64 reached when they determined that their additive social stress model showed no diminished well-being among racial/ethnic minority lesbians or gay men: "Studying identity intersection (Black poor women) will be more informative than studying Blacks, women and poor individuals separately."(p508)

Third, intersectionality's focus on the importance of macrolevel social-structural factors aligns well with contemporary advocacy to consider the substantial effect of factors beyond the level of the individual on health. SES, for example, is one of the best predictors of health status. 65 Furthermore, intersectionality expands this focus to consider the intersection of multiple-level social-structural factors as well as the intersection between multiple microlevel and macrolevel factors. Privileging a focus on structural-level factors rather than an exclusive focus on the individual is likely to facilitate the development of structural-level interventions more likely to affect the "fundamental causes" (e.g., poverty, social discrimination) of social inequalities in health in the United States. 15,21,33-35,66

Fourth, because intersectionality takes the experiences of historically oppressed or marginalized populations as its vantage point, it can facilitate and inform the development of well-targeted and cost-effective health promotion messages, interventions, and policies. Indeed, this was one of the rationales that Dr. Garth Graham, 67 the DHHS Director of Minority Health, advanced in response to the DHHS new draft standards for health data collection:

These new data standards, once finalized, will help us target our research and tailor stronger solutions for underserved and minority communities. To fully understand and meet the needs of our communities, we must thoroughly understand who we are serving.(p1)

Finally, the intersectionality perspective naturally summons and supports the collection, analysis, and presentation of surveillance and health data that allow examination of multiple interlocking social identities across several categories beyond race and gender. A critical need exists, for example, for more health data on SES at the individual, household, and neighborhood level 65 to advance knowledge about how SES intersects with other social identities to influence disparities and social inequality in health. The DHHS's 67 June 29, 2011, announcement of its draft guidelines to improve how the nation's health data are collected and reported by race, ethnicity, sex, primary language, and disability status and of its plans to collect LGBT health data is noteworthy. Collection of these data can facilitate greater understanding of the effect of multiple intersecting identities on social inequalities in health. Yet the absence of any mention of SES is a curious and critical omission from the list of data essential to understanding and addressing health disparities and social inequality.

TOWARD AN INTERSECTIONALITY-INFORMED PUBLIC HEALTH

Intersectionality is critical to public health because it "embraces rather than avoids the complexities that are essential to understanding social inequities, which in turn manifest in health inequities." 13(p279) This makes the relative invisibility of intersectionality within the discipline of public health all the more puzzling. The discipline of public health, like intersectionality, is interdisciplinary. More importantly, public health's commitment, as the American Public Health Association's 68 mission statement affirms, to "working to improve the public's health and to achieve equity in health status for all"(p1) is an ideal mesh with intersectionality's social justice bent. 13 Complex multidimensional issues such as entrenched health disparities and social inequality among people from multiple historically oppressed and marginalized populations beg novel and complex multidimensional approaches. Intersectionality is the critical, unifying, and long overdue theoretical framework for which public health has been waiting.

Acknowledgments

I am grateful to the graduate students in my Spring 2011 Intersectionality and Public Health course for their intellectual and passionate engagement with the course's materials. Their enthusiasm for learning about intersectionality and stated desire to have intersectionality infused throughout the graduate public health curriculum served as the catalyst for this article. I also appreciate the assistance of my project director, Jenné Massie, MHS, and Brogan Piecara, an undergraduate summer intern who provided research assistance for this article.

Human Participant Protection

Institutional review board approval was not needed because no human participants were involved.

References

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The Problem With the Phrase Women and Minorities: Intersectionality-an Important Theoretical Framework for Public Health

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Intersectionality is a theoretical framework that posits that multiple social categories (e.g., race, ethnicity, gender, sexual orientation, socioeconomic status) intersect at the micro level of individual experience to reflect multiple interlocking systems of privilege and oppression at the macro, social-structural level (e.g., racism, sexism, heterosexism).

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Intersectionality focuses on social contexts and systems which identify an individual’s unique
experiences of oppression and privilege through assumed societal identity eg. race, gender, sexual
orientation, disability, and socio-economic status. As a theoretical framework intersectionality lends
itself to better understanding the roots and characteristics of social inequalities, and the processes
which generate and uphold them so is an approach for analysing social problems.

Within my own practice, I see the intersectional approach as helping to underpin an inclusive ethos,
increasing awareness of diversity and importance of understanding each child in their own right and
how internal/external processes will cause advantage/disadvantage.This will enable a more conscious approach to lesson planning and environment. Also, supporting me as the
educational activist when challenging educational status quo and deeply embedded politically driven
didactic systems opens up questions when reviewing research and policies, questioning assumptions
made, who may inadvertently favoured or marginalised in the process of a program or policy being
developed locally/nationally and how it connects to wider issues.

I found the diagram below a useful visual representation of potential occurring divides however it is
notable that the diagram will need to be fluid as different social identities evolve.

https://www.researchgate.net/profile/Christopher_Erwin5/publication/320067302_Making_the_invisible_visible_advancing_quantitative_methods_in_higher_education_using_critical_race_theory_and_intersectionality/links/5c805967299bf1268d4053e5/Making-the-invisible-visible-advancing-quantitative-methods-in-higher-education-using-critical-race-theory-and-intersectionality.pdf

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Intersectionality described the interconnected nature of social categorisations such as race, class, gender, sexual orientation, physical ability etc. These categories create overlapping and interdependent systems of discrimination or disadvantage. An intersectionality perspective acknowledges that everyone has their own unique experience of discrimination and oppression where any categorisation can lead to marginalisation.

The term was first coined by Professor Kimberlé Crenshaw in 1989. It has since been heralded as one of the most important contributions to feminist scholarship (womankind.org.uk, 2020).

The acknowledgment of intersectionality allows the education practitioner to consider the path each student has trodden, and the impact of their own unique lived experiences on their ‘now’. Accepting others’ experiences will allow practitioners to develop a more considered response to behaviours in school, reacting to the whole child needs rather than to the behaviour itself. I believe no two student experiences will ever be the same, however some understanding can be drawn from each student and used to support others. These shared findings may contribute to future policy writing in areas such as equality and inclusivity.

I cant hyperlink the below journal at the moment as my Greenwich portal log-in isn't working so I can't access it. However, I have read it recently and its relevant and very current.

Intersectionality in the Classroom: Black Lives Matter as a Consummate Example

Spencer, Leland G.

Publication Date 2019

Source: Journal of Pan African Studies. March, 2019, Vol. 12 Issue 9, p77, 18 p

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Intersectionality

A term originally used by Kimberlé Crenshaw in 1989, to attempt to explain the oppression of African-American women, intersectionality describes how individual characteristics of race, class, gender and other identified characteristics converge and overlap. This ‘intersect’ of characteristics creates a uniquely experienced oppression for both individuals and social groups.

For the education practitioner, recognising unique and complex identities, can further support strategies to empower individuals in the classroom and create an environment which welcomes diversity.  Having a greater insight into an individual or group’s challenges, whilst recognising their own privileges, can also give the education practitioner the confidence and empathy to confront prejudices within a school/class.

I have included the following link as I feel it identifies the need for a greater understanding of intersectionality, an increased awareness of the language needed to describe the concept and because it recognises the lack of research currently available to truly understand the impact.

INTERSECTIONALITY AS EDUCATION POLICY REFORM: CREATING SCHOOLS THAT EMPOWER TELLING Brittney Beck, 2016/17

http://web.a.ebscohost.com/ehost/detail/detail?vid=5&sid=6b3611ce-b02b-4d15-897f-ed252c785c05%40sessionmgr4008&bdata=JmF1dGh0eXBlPXNoaWImc2l0ZT1laG9zdC1saXZl#AN=EJ1143315&db=eric

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Intersectionality, first coined by Kimberlé Crenshaw in 1989, describes how a person may be discriminated or placed in privilege due to combined social and political circumstances and create unique experiences. These circumstances include race, religion, class, nationality, disability, gender identity and sexual orientation. To understand Intersectionality opens opportunity to understand and acknowledge the differences between us.

In practice
In practice, an understanding of Intersectionality allows planning of a more inclusive delivery. It also can have a more focused affect. For example, in the case of SEN, Gillborn (2015) researched the relationship between race and SEN and concluded that for a majority of non-white families they had to fight the hardest for assessment or an acknowledgement. This was also highlighted by Vincent & Ball (2012) who concluded that a lower performance is seen as a low potential rather than a disability.  Intersectionality also allows for a more equal class structure and less pre-determined expectations, where certain students usually more likely to be labelled.

Gillborn, D., Rollock, N., Vincent, C., and Ball, S. (2012). “You got a pass, so what more do you want?”: Race, class and gender intersections in the educational experiences of the Black middle class. Race Ethnicity and Education, 15, pp.121-139. DOI: 10.1080/13613324.2012.638869

Gillborn, D. (2015). Intersectionality, critical race theory, and the primacy of racism: Race, class, gender, and disability in education. Qualitative Inquiry, 21(3), pp.277-287. DOI: https://doi.org/10.1177/1077800414557827

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Critical Race Theory recognises that no person has a single, simplistic unitary identity (Rollock et al, 2011). The Term “Intersectionality” was coined by and originated in the work of Kimberlé Crenshaw (1995), a Critical Racism Theorist from the United States. In its most basic form intersectionality is  theorising identity and oppression to the notion that subjectivity is constituted by mutually reinforcing vectors of race, gender, class and sexuality. Brah & Phoenix recognise that by “adopting an intersectional framework” this allows for the exploration of differences within and between groups taking account of issues such as historical and socio-political context while still maintaining awareness of racial inequalities (2004).

Nash states that Intersectionality serves a few theoretical and political purposes for anti-racist scholars claiming that intersectionality  could be seen to undermine race binaries in order to theorise and view identity in a complex fashion (2008). This can be seen in the destabilisation of race and gender binaries that enable necessary and healthy analyses of challenges that could implicate race in negative connotations (e.g. OJ Simpson trial). Other criticisms of the term include ‘intersectionality’ being viewed as a buzz-word and having an absence of clarity and authentic understanding of the term (Davis, 2008). Delgado recognises the same challenge
by pointing out that even though the term is widely used it is often a misunderstood concept (2011).  In agreeing with this Nash states that intersectionality has emerged as the primary theoretical tool designed to combat hegemony and exclusivity in racial issues (2008). We currently live at a time when racist inequities continue to scar the economy, education, health, and criminal justice systems (Equality & Human Rights Commission EHRC, 2010). Therefore, If we are to change the racial and racist systemic “status quo”, we must refuse the growing mainstream assertion that racism is irrelevant or even non-existent. A shared analysis of the racism that patterns everyday life can provide a powerful point of coherence for activism and politics.
In Practice:
In a mainstream primary school:  Recognising intersectionality and the individual challenges that each unique and individual child faces or will face is exceptionally important to be able to support students wellbeing and social emotional mental health. If support staff in the setting ensure that all students recognise each others individual struggles and challenges teach class teacher and school leader can create a safe and empathetic community within the classroom which will both empower students with challenges as well as making an inclusive school environment for all students.

References:

Brah, A. & Phoenix, A. (2004) Ain’t I a Woman? Revisiting Intersectionality, Journal of International Women’s Studies. 5(3): 75-86.

Crenshaw, K. W. (1995). Mapping the margins: Intersectionality, identity politics, and violence against women of color. In K. Crenshaw, N. Gotanda, G. Peller, & K. Thomas (Eds.), Critical race theory: The key writings that formed the move- ment (pp. 357-383). New York, NY: New Press.

Davis, K. (2008). Intersectionality as buzzword: A sociology of science perspective on what makes a feminist theory successful. Feminist Theory, 9, 67-85.

Delgado, R. (2011). Rodrigo’s reconsideration: Intersectionality and the future of critical race theory. Iowa Law Review, 96, 1247-1288.

Equality & Human Rights Commission. (2010). How fair is Britain? Equality, human rights and good relations in 2010. The first triennial review. London, England: Author.

Gillborn, D., 2015. Intersectionality, Critical Race Theory, and the Primacy of Racism. Qualitative Inquiry, 21(3), pp.277-287.

Nash, J., 2008. re-thinking intersectionality. Feminist Review, 89(1), pp.1-15.

Rollock, N. and Gillborn, D. (2011) Critical Race Theory (CRT), British Educational Research Association online resource. Available online at: [https://www.bera.ac.uk/wp-content/uploads/2014/03/Critical-Race-Theory-CRT-.pdf] Last accessed [13/08/2020].

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Definition

Intersectionality is the concept that all oppression is linked. With there being many forms of oppression in existence, like racism, ageism and sexism, intersectionality suggests that an individual may experience a unique and compounded oppression due to the potential of the various forms being present or active at the same time.

How it could work

For an education practitioner, acknowledging that unique oppressions exist might support their professional duties in promoting an inclusive environment. For example, listening to others and examining their own privileges might lead to them asking questions as to who might be affected or excluded by their professional actions. Consequently, this could support work towards addressing issues around privilege and power, like targeting inequitable policies, with the aim to enabling all learners the opportunity to access and participate in quality learning.

Academic Resource

-Peter Hopkins

-Newcastle University

https://journals.sagepub.com/doi/pdf/10.1177/0309132517743677

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Intersectionality is a theoretical framework that consists of multiple social categories (e.g., race, ethnicity, gender, sexual orientation, socioeconomic status). These intersect at the micro level of individual experience to reflect multiple interlocking systems of privilege and oppression at the macro, social-structural level such as racism, sexism and hetrosexism (Bowleg,2012)

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Abstract

Intersectionality is a theoretical framework that posits that multiple social categories (e.g., race, ethnicity, gender, sexual orientation, socioeconomic status) intersect at the micro level of individual experience to reflect multiple interlocking systems of privilege and oppression at the macro, social-structural level (e.g., racism, sexism, heterosexism). Public health's commitment to social justice makes it a natural fit with intersectionality's focus on multiple historically oppressed populations. Yet despite a plethora of research focused on these populations, public health studies that reflect intersectionality in their theoretical frameworks, designs, analyses, or interpretations are rare. Accordingly, I describe the history and central tenets of intersectionality, address some theoretical and methodological challenges, and highlight the benefits of intersectionality for public health theory, research, and policy.

The term women and minorities is ubiquitously wedded in public health discourse, policy, and research. Take, for example, the NIH [ National Institutes of Health] Policy and Guidelines on the Inclusion of Women and Minorities as Subjects in Clinical Research. 1 The 2001 amended guidelines provide guidance on including women and minorities as participants in research and reporting on sex/gender and racial/ethnic differences. The problem with the "women and minorities" statement or the "ampersand problem" 2(p22) is the implied mutual exclusivity of these populations. Missing is the notion that these 2 categories could intersect, as they do in the lives of racial/ethnic minority women.

Further compounding the issue is that the word minority is multidefinitional. Although it typically modifies race/ethnicity in the United States, minority also can reference populations such as lesbian, gay, bisexual, and transgender (LGBT) people; people with physical and mental disabilities; or, depending on geographic context, White people. Thus, in addition to being vague, the term minority in conjunction with women obscures the existence of multiple intersecting categories as exemplified by, for instance, a low-income Latina lesbian with a physical disability.

The notion that social identities are multiple and interlocking is not limited to the women and minorities discourse. The introduction to the US Department of Health and Human Service's (DHHS's) recent HHS Action Plan to Reduce Racial and Ethnic Health Disparities acknowledges that

characteristics such as race or ethnicity, religion, SES [socioeconomic status], gender, age, mental health, disability, sexual orientation or gender identity, geographic location, or other characteristics historically linked to exclusion or discrimination are known to influence health status. 3(p2)

This acknowledgment illustrates another conjunction problem-that of the "or." Pursuant to this logic, one's sexual orientation or gender identity or race/ethnicity may have an adverse effect on health, but nowhere in the report is there any indication of how the intersection of being, for example, a low-income Black gay or bisexual man might influence health. Acknowledging the existence of multiple intersecting identities is an initial step in understanding the complexities of health disparities for populations from multiple historically oppressed groups. The other critical step is recognizing how systems of privilege and oppression that result in multiple social inequalities (e.g., racism, heterosexism, sexism, classism) intersect at the macro social-structural level to maintain health disparities.

Enter intersectionality. Intersectionality is a theoretical framework for understanding how multiple social identities such as race, gender, sexual orientation, SES, and disability intersect at the micro level of individual experience to reflect interlocking systems of privilege and oppression (i.e., racism, sexism, heterosexism, classism) at the macro social-structural level. 4-7 Far from being just an exercise in semantics, intersectionality provides the discipline of public health with a critical unifying interpretive and analytical framework for reframing how public health scholars conceptualize, investigate, analyze, and address disparities and social inequality in health. The aforementioned DHHS report on health disparities and the even newer National Prevention Strategy 8 assert that the reduction and elimination of health disparities are a top national public health priority. This priority is further reflected in public health and biomedical journals, which are replete with health disparities research. Yet a key omission from most policy and research is first and foremost the recognition of multiple intersecting social identities and next an acknowledgment of how the intersection of multiple interlocking identities at the micro level reflects multiple and interlocking structural-level inequality at the macro levels of society.

The need for intersectionality as a unifying public health framework is further underscored by the relative dearth of theory and research that specifically address the multiple and interlocking influence of systems of privilege and oppression such as racism, sexism, and heterosexism. Instead, most public health research typically examines each system independently, "thus impairing efforts to understand the health of people whose lives cut across these diverse realisms of experiences." 9(p99) Accordingly, I advocate for a greater awareness of intersectionality within public health. Intersectionality, I assert, provides a critical, insightful, and unifying theoretical framework for guiding public health theory, research, surveillance, and policy. Hereafter, I refer to intersectionality synonymously as a theoretical framework or perspective.

A BRIEF HISTORY OF INTERSECTIONALITY

Intersectionality is rooted in Black feminist scholarship. Although feminist legal scholar Kimberlé Crenshaw 6 coined the term intersectionality to describe the exclusion of Black women from White feminist discourse (which equated women with White) and antiracist discourse (which equated Black with men) in the 1990s, the intersectionality concept is hardly new. Freed slave Sojourner Truth's 10 interrogation of the intersections of race and gender in her famous "Ain't I a Woman?" speech at the 1851 Women's Convention in Akron, Ohio, is one of the earliest recorded accounts of the intersectionality perspective. In the speech, Truth challenged the notion that being a woman (i.e., gender) and Black (i.e., race) are mutually exclusive:

That man over there says that women need to be helped into carriages, and lifted over ditches, and to have the best place everywhere. Nobody ever helps me into carriages, or over mud-puddles, or gives me any best place! And ain't I a woman?

The topic of intersectionality is a staple of women's studies and feminist legal studies, 4 is nascent in psychology 11,12 and interdisciplinary gender studies, but remains relatively scarce within mainstream public health. A November 10, 2011, PubMed search of the keyword intersectionality yielded just 49 results; not a single one was in a mainstream public health journal. Even an insightful 2008 article on intersectionality published in Critical Public Health 13 did not make the list. A same-date keyword search for intersectionality within the American Journal of Public Health ( AJPH) found 7 records dating back to 2005. Of these, 4 referred to citations in the reference list, not the main text. Another AJPH keyword search for intersection* returned 267 results, most of which referred to intersections of streets or disciplines. Only 26 of the 267 (10%) were articles that used the term intersection to refer to the intersection of race, ethnicity, gender, sexual orientation, and SES. Thus, for mainstream public health, a focus on intersectionality is both timely and overdue. The Institute of Medicine's Committee on LGBT Health's 14 2011 report provides another case in point. Recognizing the promise of intersectionality for advancing research on LGBT health, the committee included intersectionality as 1 of 4 conceptual perspectives that shaped its work. Alas, the glossary's definition of intersectionality as "a theory used to analyze how social and cultural categories intertwine"(p318) and attribution of this definition to a 2006 conference presentation rather than the scholarly or peer-reviewed literature on intersectionality underscore a critical need for greater awareness of intersectionality within public health.

CORE TENETS OF INTERSECTIONALITY RELEVANT TO PUBLIC HEALTH

Although scholars sometimes refer to intersectionality as a theory, 4 it is not the kind of theory with which most social scientists are familiar. That is, intersectionality has no core elements or variables to be operationalized and empirically tested. For this reason, I avoid the term theory in favor of terms such as theoretical framework or perspective that denote intersectionality as more of an analytical framework or paradigm than a traditional testable theory. Indeed, intersectionality departs from traditional biomedical, biobehavioral, and psychosocial paradigms that have shaped medicine, public health, and the other social sciences in several key ways. A comprehensive discussion of these differences is beyond the scope of this article. Instead, I refer readers to Weber and Parra-Medina's 15 excellent chapter on intersectionality and women's health in which they elucidate the differences between the traditional biomedical, biobehavioral, and psychosocial paradigms and intersectionality.

I consider the core tenets of intersectionality most relevant to public health to be as follows: (1) social identities are not independent and unidimensional but multiple and intersecting, (2) people from multiple historically oppressed and marginalized groups are the focal or starting point, and (3) multiple social identities at the micro level (i.e., intersections of race, gender, and SES) intersect with macrolevel structural factors (i.e., poverty, racism, and sexism) to illustrate or produce disparate health outcomes.

Multiple Intersecting Identities

The most elemental tenet of intersectionality is the notion that social categories (e.g., race, SES, gender, sexual orientation) are not independent and unidimensional but rather multiple, interdependent, and mutually constitutive. 6,16,17 Far from representing a simple addition of social identities such as race (e.g., Black) plus gender (e.g., woman), the intersectionality perspective asserts that race and gender constitute each other such that one identity alone (e.g., gender) cannot explain the unequal or disparate outcomes without the intersection of the other identity or identities. Thus, harkening back to Sojourner Truth's "Ain't I a Woman?" query, the notion of her gender as a woman did not sufficiently explain the inequitable treatment she experienced without its intersection with her race. Fast forward 160 years after Truth's speech, and the unrelenting hold of health disparities among racial and ethnic minorities in the United States provides ample cause and opportunities to examine how multiple identities intersect to adverse effect. From an intersectionality point of view, attempting to understand or address health disparities via a single analytical category (e.g., gender or race or sexual orientation), as the DHHS report on health disparities implies, elides the complex ways in which multiple social categories intersect with social discrimination based on those multiple intersecting categories to create disparity and social inequality in health.

Historically Oppressed and Marginalized Populations

Technically speaking, we all have multiple intersecting identities. Universal intersectionality is not the province of intersectionality, however. Rather, another core tenet of intersectionality is its focus on the intersecting identities of people from historically oppressed and marginalized groups such as racial/ethnic minorities, LGBT people, low-income people, and those with disabilities. Because people from multiple historically oppressed and marginalized populations are its starting point, intersectionality examines the health of these populations in their own context and from their vantage point rather than their deviation from the norms of White middle-class people. 15 Turns out, this makes good sense practically, not just theoretically.

Examples from HIV prevention research and practice with Black individuals, who represented 52% of new HIV cases in 2009 despite representing just 13% of the US population, 18 accentuate why fashioning health policy and prevention messages exclusively from the perspective of White middle-class populations does not always equal good public health practice. Take the case of Black men who have sex with men (MSM) who in 2009 represented 42% of new HIV cases among MSM. 18 Early in the HIV/AIDS epidemic, the Centers for Disease Control and Prevention (CDC) learned that HIV prevention messages targeted to gay and bisexual men were failing to resonate with Black and Latino MSM who did not identify as gay or bisexual. This recognition prompted a policy change of using the MSM nomenclature in HIV/AIDS surveillance activities and reports that is now well established in HIV prevention theory, research, and practice. The solution is far from perfect. MSM is a behavioral category, not an identity category. Thus, some MSM do not identify as MSM. Nonetheless, this policy change confirms the importance of shaping health policy from the perspective of multiple historically oppressed populations.

In 2009, Black women constituted 66% of women newly diagnosed with HIV despite representing just 13% of the female US population. 18 Many feminist HIV prevention scholars have chided the implicit White middle-class bias of many HIV/AIDS prevention messages targeted to racial/ethnic minority women. In an early critique of these messages, Mays and Cochran 19 derided as a "rather middle class notion"(p954) the public health directive that women should negotiate or communicate with their sexual partners about condom use and HIV risk. They explained that verbal communication about risk may be unrealistic and inapplicable to the lives of poor women who "may not bother to ask men about previous sexual or drug use behaviors because they know the men will lie or discount the risk "(p954) and cautioned developers of HIV prevention messages for low-income women of color to remember that "poor people do not always have the luxury of honesty, which is much easier when there is sufficient money and resources to guide one's choices. "(p954)

Yet despite its emphasis on multiple socially disadvantaged statuses as a focal point, intersectionality does not presume that all interlocking identities are equally disadvantaged. Rather, intersectionality considers how low (e.g., racial minority, LGBT persons) and high (e.g., upper- or middle-class SES) status social identities intersect to yield disparity and advantage. 7,20 Accordingly, the intersectionality paradox is another of intersectionality's noteworthy, albeit underresearched, contributions to public health. The intersectionality paradox describes the result of adverse health outcomes at the intersection of a high status identity (i.e., middle-class SES) with race and gender for Black middle-class women and men. 21 An abundant empirical base documents the relation between higher SES and better health outcomes. 9,22-25 Paradoxically, this is not always the case for Black middle-class men and women as the disproportionate rates of infant mortality among highly educated Black women and homicide rates among Black middle-class men illustrate. 21 Infant mortality is a widely recognized indicator of a population's health. 26 Non-Latino Black people in the United States had an infant mortality rate 2.4 times that of non-Latino White people in 2006. 27 This disparity persists despite Black women's higher levels of education, a key measure of SES. The infant mortality rate for Black women with more than 13 years of education was almost 3 times higher than that for non-Latino White women in 2005. 27 Historically, the infant mortality rate of highly educated Black women has exceeded that of non-Latino White women with less education, 21 highlighting the paradox of the intersection of SES, race, and gender for Black women in the United States.

The paradox is also evident for Black men, for whom homicide is a critical public health issue. Homicide does not appear on the list of the 10 leading causes of death for men in the aggregate. In 2008, however, homicide was the fifth leading cause of death for Black men of all ages in the United States and the leading cause of death for Black males aged 15 to 44 years. 28 Lower homicide rates are often inversely associated with higher SES, 29,30 but the higher SES of Black men conveys no such advantage. In 1994, the homicide rate for Black men with some college education was 11 times that of White men with similar levels of education. Emphatically, Jackson and Williams 21 concluded, "strikingly, the homicide rate of Black males in the highest education category exceeds that of White males in the lowest education group!"(p148) Thus, intersectionality provides a more comprehensive insight into how multiple social identities intersect in complex ways to show social inequality. This notwithstanding, it is important to segue here and note that although updated homicide rate data by age, race, gender, and Hispanic origin are easily locatable at the CDC's National Vital Statistics System Web site, education data are not. The omission of education data (or at least easily retrievable data) shows how the absence of critical data such as SES obscures the more complex understanding of public health issues that an intersectionality analysis facilitates.

Social-Structural Context of Health

Whether using language such as "social determinants of health," 31 "social discrimination or social inequality," 9,32 "fundamental causes," 33-35 "structural factors or influences," 36 or "ecological or ecosocial influences," 37,38 an ever-growing chorus of public health scholars have advocated for a greater focus on how social-structural factors beyond the level of the individual influence health. This too is a core tenet of intersectionality. Moreover, a central consideration of intersectionality is how multiple social identities at the individual level of experience (i.e., the micro level) intersect with multiple-level social inequalities at the macro structural level. From an intersectionality perspective, a middle-class Latina lesbian's negative experiences at her physician's office are linked to multiple and interlocking sexism, heterosexism, and racism at the macro level. Her microlevel experiences at the intersection of her race/ethnicity, sexual orientation, and gender correspond with empirically documented evidence of the heterosexism that lesbian and bisexual women often encounter when they seek health care services 39,40 and the intersection of racism and sexism well documented in research on racial/ethnic minority women's health care experiences. 9,41,42 Alas, with the exception of a 1988 study focused on Black lesbian and bisexual women's experiences of disclosing their sexual identity to physicians, 43 much of the research on lesbian and bisexual women's experiences in health care settings stems from research with predominantly White middle-class lesbian and bisexual women. Similarly, much of the research on racial/ethnic minority women's experiences in health care settings does not include or report sexual orientation data or presumes heterosexuality, thereby limiting an in-depth understanding of women's experiences in health care settings beyond the intersections of gender and race.

THEORETICAL AND METHODOLOGICAL CHALLENGES

Feminist sociologist Leslie McCall 44 has heralded intersectionality as "the most important theoretical contribution that women's studies, in conjunction with related fields, has made so far."(p1771) Although many scholars concur with McCall's assessment, many continue to "grapple with intersectionality's theoretical, political, and methodological murkiness." 20(p1) This murkiness may simultaneously be a strength because it provides seemingly endless opportunities for debate, theorizing, and research. 4

Theoretical Challenges

At least 2 theoretical challenges relevant to the integration of intersectionality within public health exist: (1) determining which social categories intersectionality should include and (2) recognizing that intersectionality was not developed to predict behavior or mental processes 45 or health. First, as I have noted previously, Black women were the original subjects of intersectionality. Accordingly, the intersections of race and (female) gender in the lives of women of color 6,7,17,46 and women's health 11,15,47 have been the primary focus of intersectionality. Contemporary critiques of intersectionality's historic focus on race and gender have problematized the issue of treating Black women as a monolith, obscuring within-group differences such as sexual orientation and SES, for example. 20 Other critiques note that social identities are not " trans-historical constants" 20(p5) but vary historically and by context.

Framed from a public health perspective, however, intersectionality's promise lies in its potential to elucidate and address health disparities across a diverse array of intersections including, but not limited to, race, ethnicity, gender, sexual orientation, SES, disability, and immigration and acculturation status. Thus, consistent with Collins's notion of an intersectional "matrix of domination," 7(p225) my view of intersectionality includes and transcends women of color to include all people whose microlevel and macrolevel experiences intersect at the nexus of multiple social inequalities and is broad enough to include populations who inhabit dimensions of social privilege and oppression simultaneously (e.g., Black heterosexual men; White low-income women). Hankivsky and Christoffersen 13 aptly sum up intersectionality's theoretical complexity: "Without doubt, this framework complicates everything."(p279)

Another challenge is how to transform a perspective that was designed primarily as an analytical framework into one that can empirically examine multiple intersecting social identities and resultant multiple macrolevel structural inequality. Predicting and testing the effect of intersectionality on health behavior outcomes and mental processes have never been the focus of intersectionality. 45 Thus, for public health and other social science researchers, the absence of theoretically validated constructs that can be empirically tested poses not only a major challenge but also tremendous opportunities for advancing the study of intersectionality from a public health perspective.

Methodological Challenges

As for methodological challenges, there is ample consensus that a paucity of knowledge about how to conduct intersectionality research exists. 12,13,20,44,48 Although qualitative methods or mixed methods appear to be ideally suited to intersectionality's implicit complexity and multiplicity, 13,16,48 the challenges of conducting intersectionality research quantitatively are especially daunting. 44,48 Among the many challenges are (1) the absence of guidelines for quantitative researchers who wish to conduct intersectionality research 12; (2) the fact that the task of investigating "multiple social groups within and across analytical categories and not on complexities within single groups, single categories or both" 44(p1786) is often complex and complicated, necessitating the use of interaction effects or multilevel or hierarchal modeling, which bring further "complexity in estimation and interpretation than the additive linear model" 44(p1788); and (3) the fact that many statistical methods often rely on assumptions of linearity, unidimensionality of measures, and uncorrelated error components 49 that are incongruent with the complex tenets of intersectionality. More quantitative methodologies are critically needed "to fully engage with the set of issues and topics falling broadly under the rubric of intersectionality." 44(p1774)

Even so, public health scholars need not wait for the methodological challenges of intersectionality to be resolved to incorporate intersectionality into their theoretical frameworks, designs, analyses, and interpretations. Methodological revolution is simply not essential to the advancement of intersectionality. Instead, what is needed is an intersectionality-informed stance. This stance involves a natural curiosity and commitment to understanding how multiple social categories intersect to identify health disparity. It also involves the a priori development of questions and measures to facilitate analyses about intersectionality. At a minimum, this would involve collecting data on race, ethnicity, age, SES, gender (including gender categories relevant to transgender people), sexual identity, sexual behavior (see my earlier comments about MSM), and disability status. At the interpretation phase, the stance would include an interdisciplinary approach in which "the researcher locates the particular sample within historical and socioeconomic circumstances, regardless of the particular character of the sample." 16(p177) How researchers interpret their data is as important as the methodological choices they make about sampling, sample sizes, or using qualitative or quantitative methods. 16 The definition of data can be expanded to include empirically collected data "AND other sources of information"(p177) such as historical materials, results from other studies, social theories, and the analysts' tacit knowledge. Cuadraz and Uttal 16 caution researchers not to "subsume or privilege"(pp177-178) one social category over another but rather to

strive to contextualize data within the multiple intersectionalities of historical structures, cultures, ideologies and policies. [This will result] in studies that more accurately reflect the social realities of inequality and power in society, yet at the same time not lose site [sic] of the individual experiences that reflect, shape, and construct those social structures.(p178)

INTERSECTIONALITY'S BENEFITS FOR PUBLIC HEALTH

Intersectionality is ideally suited to join the ranks of other critical theories such as critical race theory 50-52 and various feminist 53 and gender 54-56 theories applied to public health issues. Intersectionality is an especially close ally of critical race theory. Indeed, key intersectionality theorists such as Kimberlé Crenshaw 57 and Patricia Hill Collins 7 are also critical race theorists. Developed in the 1970s by legal scholars, lawyers, and activists, critical race theory asserts at least 5 key tenets. 58 First, racism in the United States is not aberrant but an ordinary and immutable characteristic of everyday life for people of color. Second, critical race theory asserts that White supremacy manifests in 2 features that serve psychic and material purposes: ordinariness and interest convergence. Ordinariness highlights the mundane and seemingly incurable nature of racism. That is, because racism is so commonplace and ordinary, "color-blind" legal remedies that tout meritocracy mainly serve the material interests of White elite individuals and the psychic interests of White working class people. Interest convergence, a term coined by Derrick Bell, 59 one of the pioneers of critical race theory, posits that White people will support and encourage policies and initiatives that advance the interests of Black people only to the extent that these policies and initiatives serve the interests of White people. This was the crux of Bell's provocative argument that Brown v. Board of Education, 60 the landmark 1954 US Supreme Court civil rights public school desegregation case, was more motivated by White people's self-interest than by interest in advancing the legal rights of Black people. Third, critical race theory focuses on the social construction of race. The notion that race is not a biological reality but a socially constructed one is well documented in the scientific literature. 61,62 The fact that society routinely ignores scientific evidence about the socially constructed nature of race bolsters critical race theory's assertions about the salience and permanence of racism as a defining and enduring characteristic of everyday life for people of color in the United States. Moreover, because race is socially constructed, many contemporary critical race theorists emphasize how dominant groups have historically racialized different minority groups to respond to the varying needs of the labor market. Critical race theory's focus on the socially constructed nature of race dovetails with contemporary intersectionality theorists' emphasis on the socially constructed nature of social identities. 20,63 That is, critical race theory recognizes that race and racism intersect with other social identities such as gender, sexual orientation, and SES and interlocking systems of oppression such as sexism, heterosexism, and classism. Fourth, critical race theory emphasizes the importance of narratives or "storytelling" from people of color to counter White supremacy and privilege the voices of people of color. In this way, critical race theory's focus on the centrality of the experiences and voices of people of color parallels intersectionality's emphasis on historically marginalized people as its focal point. 15 Last, but hardly least, critical race theorists, like intersectionality theorists, share a commitment to social justice and advocacy. Although critical race theory has had its debut in the mainstream public health literature, 50-52 intersectionality has not.

One of intersectionality's greatest strengths is its broad embrace of multiple intersecting identities and multiple interlocking privilege and oppression. No social category or form of social inequality is more salient than another from an intersectionality perspective. Social categories are not additive and thus cannot be ranked. As such, intersectionality is a substantially useful but woefully underused critical theoretical framework for public health.

Although intersectionality provides no methodological panacea for the myriad and complex health issues and problems that are the province of public health, the advantages of intersectionality for public health theory and research far outweigh the challenges. Intersectionality stands to benefit public health in at least 5 noteworthy ways. First, intersectionality provides a unifying language and theoretical framework for public health scholars who are already engaged in investigating intersections of race, ethnicity, gender, sexual orientation, SES, and disability to reduce and eliminate health disparities. Having scholars from diverse disciplines incorporate the intersectionality framework as an analytical perspective regardless of methodological approach 16 and explicitly use the word intersectionality in their titles, keywords, abstracts, or articles would facilitate a cohesive body of theoretical and empirical knowledge about multiple intersecting social categories and social inequality that could inform health policy, practice, and interventions and further theoretical and methodological advancement and refinement of intersectionality.

Second, intersectionality prompts public health scholars to conceptualize and analyze disparities and social inequalities in health in the complex and multidimensional ways that mirror the experiences of the populations for whom adverse health outcomes are most disproportionate. From intersectionality's perspective, single or dual analytical categories such as race and gender offer limited explanatory power. Intersectionality also provides a theoretical lens for interpreting novel or unanticipated findings. This was the conclusion that Kertzner et al. 64 reached when they determined that their additive social stress model showed no diminished well-being among racial/ethnic minority lesbians or gay men: "Studying identity intersection (Black poor women) will be more informative than studying Blacks, women and poor individuals separately."(p508)

Third, intersectionality's focus on the importance of macrolevel social-structural factors aligns well with contemporary advocacy to consider the substantial effect of factors beyond the level of the individual on health. SES, for example, is one of the best predictors of health status. 65 Furthermore, intersectionality expands this focus to consider the intersection of multiple-level social-structural factors as well as the intersection between multiple microlevel and macrolevel factors. Privileging a focus on structural-level factors rather than an exclusive focus on the individual is likely to facilitate the development of structural-level interventions more likely to affect the "fundamental causes" (e.g., poverty, social discrimination) of social inequalities in health in the United States. 15,21,33-35,66

Fourth, because intersectionality takes the experiences of historically oppressed or marginalized populations as its vantage point, it can facilitate and inform the development of well-targeted and cost-effective health promotion messages, interventions, and policies. Indeed, this was one of the rationales that Dr. Garth Graham, 67 the DHHS Director of Minority Health, advanced in response to the DHHS new draft standards for health data collection:

These new data standards, once finalized, will help us target our research and tailor stronger solutions for underserved and minority communities. To fully understand and meet the needs of our communities, we must thoroughly understand who we are serving.(p1)

Finally, the intersectionality perspective naturally summons and supports the collection, analysis, and presentation of surveillance and health data that allow examination of multiple interlocking social identities across several categories beyond race and gender. A critical need exists, for example, for more health data on SES at the individual, household, and neighborhood level 65 to advance knowledge about how SES intersects with other social identities to influence disparities and social inequality in health. The DHHS's 67 June 29, 2011, announcement of its draft guidelines to improve how the nation's health data are collected and reported by race, ethnicity, sex, primary language, and disability status and of its plans to collect LGBT health data is noteworthy. Collection of these data can facilitate greater understanding of the effect of multiple intersecting identities on social inequalities in health. Yet the absence of any mention of SES is a curious and critical omission from the list of data essential to understanding and addressing health disparities and social inequality.

TOWARD AN INTERSECTIONALITY-INFORMED PUBLIC HEALTH

Intersectionality is critical to public health because it "embraces rather than avoids the complexities that are essential to understanding social inequities, which in turn manifest in health inequities." 13(p279) This makes the relative invisibility of intersectionality within the discipline of public health all the more puzzling. The discipline of public health, like intersectionality, is interdisciplinary. More importantly, public health's commitment, as the American Public Health Association's 68 mission statement affirms, to "working to improve the public's health and to achieve equity in health status for all"(p1) is an ideal mesh with intersectionality's social justice bent. 13 Complex multidimensional issues such as entrenched health disparities and social inequality among people from multiple historically oppressed and marginalized populations beg novel and complex multidimensional approaches. Intersectionality is the critical, unifying, and long overdue theoretical framework for which public health has been waiting.

Acknowledgments

I am grateful to the graduate students in my Spring 2011 Intersectionality and Public Health course for their intellectual and passionate engagement with the course's materials. Their enthusiasm for learning about intersectionality and stated desire to have intersectionality infused throughout the graduate public health curriculum served as the catalyst for this article. I also appreciate the assistance of my project director, Jenné Massie, MHS, and Brogan Piecara, an undergraduate summer intern who provided research assistance for this article.

Human Participant Protection

Institutional review board approval was not needed because no human participants were involved.

References

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The Problem With the Phrase Women and Minorities: Intersectionality-an Important Theoretical Framework for Public Health

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Intersectionality is a theoretical framework that posits that multiple social categories (e.g., race, ethnicity, gender, sexual orientation, socioeconomic status) intersect at the micro level of individual experience to reflect multiple interlocking systems of privilege and oppression at the macro, social-structural level (e.g., racism, sexism, heterosexism).