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Social Science & Medicine 74 (2012) 1712e1720

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Social Science & Medicine

journal homepage: www.elsevier.com/locate/socscimed

Womens health, mens health, and gender and health: Implications

of intersectionality
Olena Hankivsky
Simon Fraser University at Harbour Centre, School of Public Policy and Institute for Intersectionality Research and Policy, 515 West Hastings Street, Suite 3271, Vancouver,
British Columbia, V6B 5K3 Canada

a r t i c l e i n f o a b s t r a c t

Article history: Although intersectionality is now recognized in the context of womens health, mens health, and gender
Available online 25 January 2012 and health, its full implications for research, policy, and practice have not yet been interrogated. This
paper investigates, from an intersectionality perspective, the common struggles within each eld to
Keywords: confront the complex interplay of factors that shape health inequities. Drawing on developments within
Womens health intersectionality scholarship and various sources of research and policy evidence (including examples
Mens health
from the eld of HIV/AIDS), the paper demonstrates the methodological feasibility of intersectionality
Gender and health
and in particular, the wide-ranging benets of de-centering gender through intersectional analyses.
2012 Elsevier Ltd. All rights reserved.

Introduction practices within the elds of womens, mens, and gender and health.
The intent is to show, from an intersectionality perspective, how the
Increasingly, health researchers, policy makers, and practitioners treatment and ubiquitous favouring of gender (and sex) as core and
concerned with sex and gender are acknowledging the importance primary dimensions of health undermine efforts to understand the
of race/ethnicity, class, income, education, ability, age, sexual complexities of health experiences and outcomes. The paper seeks to
orientation, immigration status, and geography and are grappling bring into sharp relief the resulting mis-specications of the content
with how to best conceptualize and respond to issues of differences of any privileged identity/social location (including but not limited to
among women and men and how these shape lives and health. As gender), as well as the masking of health-related experiences of
work in this area progresses, intersectionality is being recognized as those whose lives are located at the intersection of multiple
a valuable normative and research paradigm for furthering under- dimensions of inequity. To illustrate the importance of an inter-
standings of the complexity of heath inequities (Bowleg, 2008; sectionality framework, the paper offers normative and operational
Hankivsky, 2011; Iyer, 2007; Iyer, Sen, & Ostlin, 2008; Schulz & guidance for empirical research, examples from emerging inter-
Mullings, 2006; Sen, Iyer, & Mukherjee, 2009; Weber, 2006). Inter- sectionality research, and in particular, evidence from the eld of
sectionality challenges practices that privilege any specic axis of HIV/AIDS. This discussion strives to demonstrate the trans-
inequality, such as race, class, or gender and emphasizes the formational possibilities of an intersectional analysis but also spec-
potential of varied and uid congurations of social locations and ies ongoing gaps and challenges related to applications of
interacting social processes in the production of inequities. While intersectionality that require further attention and research devel-
the elds of womens health, mens health, and gender and health opment. The paper concludes by considering some of the research,
have started to explicitly acknowledge and engage with the theo- policy, and political consequences of intersectionality for the elds of
retical and methodological insights of intersectionality, the extent to womens health, mens health, and gender and health.
which current practices align with the tenets of intersectionality is
largely uninvestigated. The purpose of this paper is to explore the Intersectionality
implications of intersectionality in the context of these elds and to
raise important questions for dialogue and debate. Originating in the work of African American feminist scholars
The paper begins with a brief overview of intersectionality, (Collins, 1990; Crenshaw, 1989; Hooks, 1990), intersectionality
including its relationship to diversity. It then moves to examine core moves beyond single or typically favoured categories of analysis
(e.g. sex, gender, race and class) to consider simultaneous interac-
tions between different aspects of social identity.as well as the
E-mail address: oah@sfu.ca. impact of systems and processes of oppression and domination

0277-9536/$ e see front matter 2012 Elsevier Ltd. All rights reserved.
O. Hankivsky / Social Science & Medicine 74 (2012) 1712e1720 1713

(Hankivsky & Cormier, 2009, p. 3). Although there are multiple especially in the context of political activism and policy, there are
conceptions of intersectionality, there are also a number of iden- many ways in which they overlap and articulate with one another.
tiable central theoretical tenets including the idea that human Importantly, each prioritizes the dimension of sex/gender above all
lives cannot be reduced to single characteristics; human experi- other axes of social identity and power. From an intersectionality
ences cannot be accurately understood by prioritizing any one perspective, these practices, which are briey reviewed below,
single factor or constellation of factors; social categories such as undermine theoretical and empirical efforts to fully understand
race/ethnicity, gender, class, sexuality, and ability are socially con- and address health inequities.
structed, uid, and exible; and social locations are inseparable and
shaped by the interacting and mutually constituting social Conation of gender with women
processes and structures that are inuenced by both time and
place. These tenets are intended to provide the basis for a new In research and policy practices, gender and gender and health
avenue of enquiry where no category of oppression is automatically are often conated with women and womens health (Richardson &
considered as the most damaging and where some differences are Carroll, 2009; Smith & Robertson, 2008; Wilkins & Savoye, 2009).
not continuously highlighted to the exclusion of others. Turshen (2007) has correctly observed for example, that studies
What also distinguishes this approach from others that have with gender in the title still too often mistakenly use the word as
attempted to be responsive to diversity is that intersectionality is a synonym for women, or open with a nod to gender and then glide
not an additive approach. It does not estimate the collective impact on to women (p. 320). Moreover, because historically women have
of gender, race, and classdmeasured as several simple binariesdas been the driving force behind the development of gender equality
the sum of their independent effects (e.g. genderclassrace/ policies, gender mainstreaming, with the exception of the UK and
ethnicity). This type of additive approach is critiqued for layering Norway, has been largely shaped in terms of what women can gain
several simultaneous oppressions (King, 1988, p. 47) without from greater gender equality (Hearn, 2006). Gender is often inter-
interrogating their relationships and mutually constructive preted as synonymous with women and as a result, mens gender-
processes. In comparison, intersectionality focuses on examining specic needs receive insufcient attention (Doyal, 2001;
how social locations and structural forces interact to shape and Hankivsky, 2007; Varanka, 2008). It is inconsistent with inter-
inuence human experiences. It requires, as Andersen and Collins sectionality, which does not view gender as a xed category but
(2001) explain, recognizing and analyzing the hierarchies and rather changeable and contingent in nature.
systems of domination that permeate society and that systemati-
cally exploit and control people (p. 5e6). In this way, inter- Primal focus on gender (and or sex)
sectionality seeks to be a multi-level analysis that incorporates
attention to power and social processes at both micro and macro The emphasis placed on gender or sex is often motivated by
levels through which subject formation occurs (Dhamoon & concerns over the lack of attention to these factors (Doull et al.,
Hankivsky, 2011). It is also important to note that intersection- 2010; Gochfeld, 2010; Nieuwenhoven & Klinge, 2010) and/or
ality is not only applicable to advancing understandings of a lack of clarity about sex (aspects of the body) versus gender
marginalized or so-called disadvantaged groups in order to (personal identities and social roles designated as masculine
promote social justice, but explains how social organization shapes versus feminine) and the relationship between sex and gender in
all of our lives (Weldon, 2008). It also leaves open the possibility of health research (Hankivsky, 2007; Klinge, 2008; Krieger, 2003).
simultaneously experiencing the effects of privilege and penalty, Using an intersectionality framework, researchers have noted
thus challenging binary thinking which tends to place certain the explanatory limitations of single axis designs centered on sex
groups in opposition to one another (e.g. women/men; black/ and gender. Cole (2009) has warned that analyses that focus on
white; Aboriginal/non-Aboriginal). gender are problematic because they often implicitly assume
Literature examining the theoretical and applied potential of a host of other social statuses that usually go unnamed in American
intersectionality has grown exponentially over the last decade culture: middle-class standing, heterosexuality, able-bodiedness
(Choo & Ferree, 2010; Cole, 2009; Dhamoon, 2011; Hancock, 2007; and White race (p. 173). Others have explicated similar limita-
McCall, 2005; Warner, 2008; Weber, 2009; Weldon, 2008) driven tions. For example, studies in the eld of violence (Bent-Goodley,
by the extent to which this framework advances more accurate and 2007; Craig-Taylor, 2008; Crenshaw, 1995; Nixon & Humphreys,
sophisticated understandings of the multidimensional reality of 2010; Sandelowski, Barroso, & Voils, 2009) show that violence
human lives. The growing pressure to nd better ways to account against women is not only a matter of gendered power relation-
for differences and respond to the various and intersecting factors ships but is co-constructed with racial and class stratication,
that inuence health for both women and men has also led heterosexism, ageism, and other systems of oppression, some of
researchers and policy actors to recognize intersectionality as which may be more salient within such interactions. Research on
a valuable resource for re-thinking existing research methods, cardiovascular disease (CVD) (Brister, Hamdulay, Verma, Maganti, &
models, practices, and health policies (Broom & Tovey, 2009; Clow, Buchanan, 2007; King, LeBlanc, Carr, & Quan, 2007; King, LeBlanc,
Pederson, Haworth-Brockman, & Bernier, 2009; Hankivsky & Sanguins, & Mather, 2006) shows that focussing on sex and
Cormier, 2009; Hankivsky et al., 2010; Hurtado & Sinha, 2008; Read gender often obscures the fact that CVD is disproportionately
& Gorman, 2010; Sen & stlin, 2007; Varanka, 2008). In the elds of experienced by racial ethnic and low-income groups whose lives
womens health, mens health, and gender and health, the promise are shaped by intersecting processes of differentiation along the
of an intersectionality analysis is that it advances a new order of lines of age, sex, ethnic group afliation, socioeconomic class, and
complexity for understanding how sex and gender intersect with geography. Finally, HIV/AIDS research (Dworkin, 2005; Elford,
other dimensions of inequality, particularly historic and geographic Anderson, Bukutu, & Ibrahim, 2006; Jackson & Reimer, 2008;
contexts, to create unique experiences of health. Meyer, Costenbader, Zule, Otiashvili, & Kirtadze, 2010; Young &
Meyer, 2005) demonstrates that gender and sexuality cannot be
Womens health, mens health, and gender and health separated from other axes including race, class, age, religious
afliation, and immigration status and the structural economic,
While there are somewhat different approaches that can be political, and social processes that shape them. For example, in her
identied as womens health, mens health, and gender and health, analysis of surveillance categories for HIV, Dworkin (2005) argues
1714 O. Hankivsky / Social Science & Medicine 74 (2012) 1712e1720

that pushing beyond a singular sex/gender system to explore the acceptance of the uid and exible nature of sex and gender,
simultaneity of race, class, and shifting gender relations is vital to acknowledgement of the differences among women and men, and
the future of the HIV epidemic and in particular, for making visible the recognition of gender as a social location and determinant of
bisexual and lesbian transmission risks. Emerging research thus health that is shaped by and in constant interaction with other
demonstrates that there are many groups which do not necessarily determinants (Benoit & Shumka, 2009; CIHR-IGH, 2009; Hankivsky
identify gender oppression as the primary frame through which & Christoffersen, 2008).
they understand their lives (Nixon & Humphreys, 2010, p. 150). In A signicant number of gender and health researchers also
Canada, as in many other jurisdictions, this is especially apparent explicitly emphasize that sex is shaped by social context (Einstein &
with growing immigrant populations whose health is primarily Shildrick, 2009; Gochfeld, 2010; Vanwesenbeeck, 2009) and that
affected by dislocation, isolation, loss of identity, culture, and gender is not a stand alone variable but one that can only be
meaningful employment and Aboriginal/Indigenous populations understood in relation to biological factors and other social loca-
whose health and well-being is largely determined by unresolved tions and systems of oppression. Some of the best examples of
colonial injustices and ongoing experiences of racism and poverty developments along these lines are integrative models that explore
(Alfred, 2005; Waldrum, Herring, & Young, 2006). biological and social processes. For example, Fausto-Sterlings
Further, the emphasis on gender (and sex) often leads to a focus dynamic systems theory has explored how the biology of sex and
on differences between women and men. This helps to explain why gender are shaped by culture (2000; 2005). Bekkers Multi-Facet
so much data continues to be collected, organized, and presented Gender and Health Model (2003) shows how the relationship
solely around sex and gender differences even when similarities between sex and gender can be moderated by various sets of factors
between women and men are demonstrated (e.g. Hyde, 2005; including daily life or social circumstances, person-related char-
Petersen, 2009), differences among women and among men are acteristics, and health care factors. Annandale (2009) has proposed
often as signicant if not more than between women and men a conceptual framework she refers to as a new single system
(Crawshaw & Smith, 2009; Varcoe, Hankivsky, & Morrow, 2007), and model of patriarchal capitalism, intended to account for destabi-
men are sometimes subordinate to some women and some women lized sex/gender identities and more complex patterns of equality
exercise power over some men (Pease, 2006). Nevertheless, and inequality and how they are .written not only on the body,
numerous reviews of sex based and gender differences continue to but into the body in new experiences of health and illness (p. 11).
be produced (Gochfeld, 2010; Read & Gorman, 2010). Moreover, Another noteworthy example is Bird and Riekers constrained
even in some frameworks that seek to include considerations of choices (2008) multi-level model which contextualizes womens
both sex and gender, as in the sex and gender based analysis (SGBA) and mens personal health choices and outcomes as inuenced
tool developed in Canada (e.g. Clow et al., 2009), proposed guides and shaped by the communities in which they live and the range of
construct lines of interrogation that prioritize examinations of social policies that directly impact on their lives. Most recently,
similarities and differences between women and men. As Clow et al. Springer, Stellman, & Jordan-Young (2012), have developed a sex/
(2009) state, SGBA reminds us to ask questions about similarities gender entanglement good practices guidelines for research on
and differences among women and men, such as: Do women and male-female health differences.
men have the same susceptibility to lung disease from smoking? Are These developments are important as they move away from
women at the same risk as men of contracting HIV/AIDS through separate foci on sex and gender. Drawing connections between
heterosexual intercourse? Are the symptoms of heart disease the biological and social processes advances understandings of gender
same in women and men?.. (p. 1). Within this type of construct, and its relationship to sex and illuminates why social context is so
differences that are shaped and formed by factors outside of sex and important for the construction of gendered health outcomes. By
gender are treated as secondary in importance, if at all. looking at interactions between sex, gender, and other multi-level
Research that focuses on differences between men and women dimensions of social inequality, these models also make impor-
can also perpetuate false dichotomies that fail to reect the diversity tant inroads vis vis intersectionality. For example, Annandale
between different groups of women and men or open the possibility (2009) explores how sex and gender are intimately connected
of examining different types of population groups. Within the with particular forms of the operation of capitalism (p. 108-109)
connes of such discourses, there appears little space either which shape womens circumstance and their health. Bird and
conceptually or practically for moving beyond two denable sexes Riekers model considers interactions between social and economic
and genders, even though intersex and transgendered persons and factors on gendered health patterns. And Springer et al. (2012)
practices directly destabilize such binary classications (Fish, 2008; explicitly signal the importance of intersectionality for their
Geller, 2008; Harper, 2007). This is also why intersectionality holds conceptualization of sex/gender and for understanding how
so much promise. In the realm of policy for example, it points to the aspects of social status (e.g., gender, race, socioeconomic status,
existence of more than two genders e that is, multiple groups of and sexuality) are understood to affect health outcomes in
stakeholders and beneciaries (Bishwakarma et al., 2007). complex, multiplicative ways that can never properly be captured
by attempts to parcel out the individual contributions of single
Inadequate conceptualization and empirical modelling of diversity social domains (p. 8). However, the consistent and sustained focus
on gender and sex as central categories within these models creates
At the same time that binary practices persist, there is also signicant tensions in terms of what intersectionality demands -
a very strong impetus for health researchers to be more inclusive of namely leaving open the relative importance of different axes of
and responsive to diversity. For example, important questions have analysis beyond the singular focus on sex and gender, and how
been raised regarding the extent to which womens health and these interact in any given situation.
mens health are adequate and sustainable generic categories for Annandale and Kuhlmann (2010) are correct in observing that
the purpose of research and policy given the wide-ranging differ- biological sex and social gender are so deeply and often unpro-
ences among women and men (Smith, White, Richardson, blematically xed in the research and policy imagination that they
Robertson, & Ward, 2009; Varcoe et al., 2007; Wilkins & Savoye, fail to yield to the periodic reection that is necessary to ensure
2009). In gender and health literature, the recognition of diversity their continued relevance and to retain their critical edge (p. 455).
(Annandale, 2010; Clow et al., 2009; Lagro-Janssen, 2007; Read & From an intersectionality perspective, it is the hegemony of gender
Gorman, 2010; Sen & stlin, 2007) is exemplied in the growing and sex as key drivers of difference and gender as a dominant axis
O. Hankivsky / Social Science & Medicine 74 (2012) 1712e1720 1715

of analysis that have not been adequately interrogated or chal- interpretation of data, or even the dissemination of research,
lenged. This raises the question of whether even the most evolved, including the wording of article and book titles.
contextually sensitive approaches proposed by gender and health Not only does intersectionality reject the automatic prioritiza-
researchers may sometimes be inadvertently masking the real and tion of any one category, it also rejects looking at various dimen-
complex interplay of other intersecting factors that shape and sions that affect health separately, thus disrupting the primacy and
determine health outcomes. This line of enquiry also raises the stability of categories of mens and womens health. From an
practical issue of how an intersectional framework may transform intersectionality perspective, multiple factors are always at play in
research and policy e when gender is not always a priori deemed shaping peoples lives and health experiences. Not surprisingly, an
the most important axis for examining and responding to health often cited concern is that the demands of intersectionality are too
inequities. And this necessitates concretely showing how the high, that all potential variables that need to be included in any one
employment of an intersectionality framework improves on the research design would make national studies or international
identication of the range, salience and relationships of oppres- comparative studies impossible to undertake. Researchers have
sions affecting health. claried that intersectionality does not lead to such paralysis. It
does not necessitate taking into account all possible factors in any
Elucidating the implications of Intersectionality given research design but instead prompts researchers to be
explicit about which ones are chosen and why, and what is
Well-rehearsed critiques of an intersectionality perspective subsequently set aside or under-analyzed as a result. Such decisions
include claims that it does not have any methods associated with it or are of course shaped by available knowledge of the research topic,
that it can draw upon (Phoenix & Pattynama, 2006, p. 189) or that it data availability, which groups are most directly impacted,
does not provide a sufcient foundation for action aimed at government and media agendas, and what affected populations
improving population health and reducing health disparities because identify as a priority. But in making choices, researchers are
as an approach that has focused on societal structures it was not cautioned against falling back on familiar, often assumed master
intended to identify points for health intervention (Bird, Lang, & categories (e.g. gender, race, or class) and are encouraged to care-
Reiker, 2010, p. 130). This has led scholars to question how inter- fully think through how their selections may alter results and
sectionality can transform empirical research, what new and better interpretations of research results (Warner, 2008).
knowledge it may generate, and how this can translate into In terms of investigating multiple factors, intersectionality
improvements in practices and policy. As is widely acknowledged, rejects simple enumeration or addition, that is, the measurement of
translating theory into methodological practices is not easy. Self- multiple main effects of separate and independent inequalities
identied intersectionality scholars struggle with how to operation- (Choo & Ferree, 2010). It directs researchers to explore how various
alize the theoretical tenets of intersectionality and as Bowleg puts it, forms of social stratication relate and co-constitute one another
researchers often have to self-teach and learn from trial and error but also emphasizes that the exact relationship between different
(Bowleg, 2008, p. 313). Compared to other approaches, intersection- types of social subordination cannot be pre-determined but is
ality is in nascent stages of development. However, for researchers an open empirical question (Hancock, 2007). To assist in such
seeking methodological traction there is a growing body of literature analysis, Bowleg (2008) has suggested for example that qualitative
that provides normative and operational guidance for the application researchers avoid questions about specic identities such as gender
of intersectionality in qualitative and quantitative health research and and instead construct questions that are intersectional by design
policy (e.g. Choo & Ferree, 2010; Cole, 2009; Hancock, 2007; Hankivsky such as What are some of the day to day challenges that you face in
& Cormier, 2009; Hankivsky et al., 2010; McCall, 2005). terms of your identity? to generate information about the mutu-
At the same time, it is critical to note that as a research paradigm ality of identities and complexity of experiences. Because the focus
(Dhamoon, 2011; Hancock, 2007) intersectionality is not of an intersectionality-type analysis is not only on intersections
prescriptive nor does it insist on any particular research design or themselves but what they reveal about power (Dhamoon &
unied way to conduct research. Its goal is to bring about Hankivsky, 2011), Cole (2009) has advised quantitative researchers
a conceptual shift in how researchers understand social categories, for instance to always interpret their data within historical contexts
their relationships, and interactions and then to have this different of oppressed and privileged groups experiences.
understanding transform how researchers interrogate processes Even though there is no single way to do intersectionality
and mechanisms of power that shape health inequities. An inter- research at the outset of any research project, to ensure analytic
sectionality shift encourages researchers to reect on the clarity, researchers should explain their approach to/denition of
complexity of their own social locations, how their values, experi- intersectionality (Hankivsky, 2011). Moreover, there are specic
ences, and interests shape the type of research they engage with, questions (a select number are listed below) that are useful guides
including the problems they choose to study, and how they view for researchers who seek to navigate this nascent terrain at every
problems and affected populations (including what types of stage of designing a research project. Each has differential applica-
research questions or hypotheses they pose). Moreover, because bility to qualitative and quantitative research designs and
intersectionality rejects hierarchical ordering of oppression, researchers may choose to focus more closely on some over others.
researchers applying this perspective would refrain from The application of these questions should, however, be grounded in
presuming before the start of any project which dimensions have the theoretical tenets of an intersectionality research paradigm in
greater inuence (Siltanen & Doucet, 2008, p. 27). Indeed, salient order to realize their intended operational objectives: the destabi-
axes in any research cannot be pre-determined but differ by time, lization of a priori primacy and stability of singular categories; the
nation, culture, political and economic contexts, and geographic avoidance of additive lists; and the focus on the uid and interactive
setting (Yuval-Davis, 2006). For researchers concerned with gender, nature of multi-level complex processes and systems that shape
this would necessitate carefully investigating rather than auto- health inequities. They include the following lines of enquiry:
matically assuming the primacy and/or signicance of gender
(Siltanen & Doucet, 2008, p. 178). This type of de-centering of  Who is being studied? Who is being compared to whom?
gender allows for more exibility and arguably accuracy in deter- Why? (Lorber, 2006)
mining salient dimensions in all stages of research whether in the  Who is the research for and does it advance the needs of those
design of research questions, choice of sample, analysis and under study? (Hankivsky et al., 2010)
1716 O. Hankivsky / Social Science & Medicine 74 (2012) 1712e1720

 Is the research framed within the current cultural, political, Jackson and Williams (2006) have demonstrated that attention
economic, societal, and/or situational context, and where to the interactions of gender, race, and class challenges widely held
possible, does it reect self-identied needs of affected assumptions about SES by showing that on many health indices
communities? (Hankivsky & Cormier, 2009) (including infant mortality and elevated risk of suicide) highly
 Which categories are relevant or not directly relevant? Why? educated blacks fare no better than whites with the lowest
(Winker & Degele, 2011) education. Specically their research reveals that SES, typically
 What is the presumed makeup of each category? (Hancock, thought to afford adults the ability to benet from material
2007) resources and engage in preventative care, is signicantly mitigated
 Is the sample representative of the experiences of diverse for middle-class black women and men by the inuences of insti-
groups of people for whom the issue under study is relevant? tutional racism and gender stereotypes. For Jackson and Williams
(Hankivsky & Cormier, 2009) (2006), intersectionality theory provides a lens for understanding
 Is the tool of enquiry suited to collecting micro or macro data or the full effects of these interactions and for revealing how power
a combination of both? (Hankivsky & Cormier, 2009) within gendered and raced institutional settings operates to
 How will interactions between salient categories be captured undermine access to and use of resources that would otherwise be
by the proposed coding strategy? available to individuals of certain class standings.
 How will interactions at individual levels of experience be Sen et al. (2009) have also developed a method for operation-
linked to social institutions and broader structures and alizing intersectionality that they describe as a technique to test for
processes of power? differences along the entire span of the social spectrum (not just
 What issues of domination/exploitation and resistance/agency between the extremes) which they have applied to the examination
are addressed by the research? (Hankivsky & Cormier, 2009) of health care for long term illness in India to show that class works
 How will human commonalities and differences be recognized through gender when it comes to obtaining necessary health care.
without resorting to essentialism, false universalism, or be It is important to note, however, that the reverse can also be true.
obliviousness to historical and contemporary patterns of Gender can work not only through class but many other variables.
inequality? (Cole, 2008) And in some instances, when numerous factors are considered
simultaneously, the effects of gender may even be negligible. For
Intersectionality scholars also emphasize that no individual example, in a study of exposure to stress related to sexual orien-
study is able to address the whole of a complex problem and that tation, gender, and race/ethnicity, Meyer, Schwarz, & Frost (2008)
researchers should instead develop programs of research with concluded, contrary to prevailing assumptions in the literature,
different studies aimed at different aspects of a problem and which that gender does not matter in the way that the predominant
can sequentially build upon one another (Rogers & Kelly, 2011). social stress models describe (p. 377).
While operational guidance for empirical research is essential, it is To further grasp the analytic purchase of intersectionality, one
equally important to note that researchers are already demonstrating can also turn to specic examples such HIV/AIDS, where applica-
the transformative value of intersectionality. To date, it is generally tions of this paradigm are facilitating better understandings of
thought that qualitative methods lend themselves more easily to an under-researched dynamics, groups, and relationships. In her study
intersectionality analysis (McCall, 2005; Shields, 2008a), and this is of black HIV-positive African migrants in East London, Doyal (2009)
evidenced for instance by studies that dominate edited collections uses Black African, migrant and HIV-positive as key intersecting
on intersectionality health research (e.g. Hankivsky, 2011; Schulz analytic categories. Doyal emphasizes the importance of displacing
& Mullings, 2006). In comparison, quantitative researchers have gender as the most salient inuence in these narratives of HIV-
acknowledged the tensions between conventional research designs, positive migrants because it obscures an accurate understanding
which are intended to test for independent effects of dimensions of of the complex experiences of this group. She demonstrates how
inequality typically measured as binaries, and intersectionality which gender, sexuality, race/ethnicity, and migrant and HIV status
seeks knowledge about the processes of interaction between uid intersect, to reveal different effects among and between hetero-
social identities (Shields, 2008b; Bowleg, 2008). This has not impeded sexual women and men, and gay/bisexual men in relation to stig-
the emergence of intersectionality-informed quantitative studies that matizing and discriminatory social processes, sources of supports
utilize techniques to examine signicant interactions which consti- (including spirituality and religion), and voluntary organizations
tute health (rather than simply adding variables of interest) and to designed to respond to the needs of African communities affected
produce what may be interpreted as counter-intuitive research by HIV/AIDS. According to Doyal (2009), this study demonstrates
results. For example, Veenstra (2011) has compared additive and the value of.opening up a number of important issues that are
multiplicative approaches to demonstrate how intersectional models too often left unexplored in existing literature on living with HIV
lead to more accurate predictions of health outcomes. In an additive (p. 184) and how intersectionality research creates nuanced and
model of self-reported health, he found that South Asian Canadians context specic evidence to improve HIV policies in the context of
were signicantly more likely than White Canadians to report fair/ global, regional, and local diversity.
poor health and that women were not signicantly more (or less) In a study of the experiences of inner-city Latina women with
likely than men to report fair/poor health. In the words of Veenstra, severe mental illness living in New York, Collins, von Unger, &
South Asian Canadians appear to be at relatively high risk of poorer Armbrister (2008) illustrate the complex interconnections
self-rated health, and gender appears to be unrelated to self-rated between gender, race/ethnicity, class, and the stigma of mental
health. In comparison, by employing a multiplicative model, he illness and its implications for HIV risk. The study shows that bi-
found a signicant race  gender interactiondamong women, South polar womens sexual relationships and behaviours are closely
Asians were much more likely than Whites to report fair/poor self- intertwined with immigration, poverty, gender, and race/ethnicity
rated health, whereas South Asian men were not more likely than leading to contradictory outcomes. On one hand, women often
White men to report fair/poor self-rated health. That is, these men experience conict with gender norms in their ethnic communities
and women experience the health effects of race differently, with in ways that lower their social status and power. This leads to
a race effect evident among women and not among men. Stated vulnerability within intimate relationships and engagement in
otherwise, the effect of gender on self-reported health is contingent sexual behaviours (e.g. lack of condom use) that increases the risk
on race. of HIV. On the other hand, the effects of these same intersections
O. Hankivsky / Social Science & Medicine 74 (2012) 1712e1720 1717

are not always negative as the mental illness experienced by these Another important gap is also the lack of attention by intersection-
Latina women allows them to free themselves from abusive male ality scholars to issues of health across the lifespan. Importantly,
partners by accessing government entitlements and supports. The there is near universal agreement that continued efforts are required
ndings highlight why HIV prevention activities can only be to advance strategies for applying intersectionality in not only
effective if they acknowledge multiple layers of vulnerability and qualitative and quantitative studies but also mixed method designs.
resources both at individual and structural levels, without erasing Moreover, there are specic areas of research and policy where
gendering effects. the implications of intersectionality are only starting to be
In their research with two urban Aboriginal health centres in explored. To date, the relationship of intersectionality to biomedi-
Vancouver, Browne, Varcoe, & Fridkin (2011) reveal how inter- cine is just beginning to be interrogated (e.g. Kelly, 2009; van Mens-
sectionality widens the scope of what is conventionally identied Verhulst & Radtke, 2006; Weber, 2006) but scholars are pointing to
as a problem in health services delivery. They explain that when the potential for drawing on intersectionality to more fully explore
stigmatized diseases are decontextualized from their underlying the complex social processes that become inscribed on to the body.
causes, people who are HIV are blamed or held responsible for And although evidence on intersectionality in the context of clinical
their status, including their problematic behaviours (e.g. unpro- nursing practices is emerging, namely how acknowledging and
tected sex and injection drug use). In comparison, intersectionality responding to privilege and oppression and the associated power
moves beyond this type of individual focus to consider multi-level dynamics transforms therapeutic encounters (Browne, Smye et al.,
root causes of HIV including historical trauma, poverty, unem- 2011; Reimer-Kirkham & Sharma, 2011; Van Herk, Smith, &
ployment, abuse, racism and medical involvement such as Andrew, 2011), this is also another area ripe for further research.
prescribing practices.global economics, ideologies of racial Finally, innovative approaches to intersectionality-based policy
superiority, capitalist priorities, ongoing clawbacks to social analysis models are starting to take shape but require sustained
welfare systems, welfare colonialism, and state policies regarding efforts to realize their full potential (Hankivsky & Cormier, 2011).
distribution (Browne, Varcoe et al., 2011, p. 301), and the rela-
tionship between these factors. This type of reframing is essential Conclusion
for creating primary health services that not only respond to the
effects of HIV, but begin to address the underlying problems of HIV Although applications of intersectionality are still developing,
so that treatment interventions are more nely attuned for emerging research does show that theoretical foundations do
different types of populations groups. inuence and direct the way health inequities are conceptualized,
Finally, in her examination of HIV/AIDS policy in Sweden, studied, and responded to (Krieger et al., 2010). Intersectionality
Brdstrom (2006) has critiqued the treatment of race, ethnicity, raises critical lines of enquiry. First, it brings to the fore the limi-
culture, and religion as merely additional to gender and sexuality. tations of research that emphasizes pre-determined classications
For Brdstrom, this type of narrow focus is a problem not only for (e.g. man and woman) or prioritizes any one single category (e.g.
analysis but also for effective sexual health policy because it sex or gender) or even a set constellation of variables (e.g. sex and
renders invisible constructions of privilege as well as vulnerability gender) within a contextual analysis. Signicantly, when sex and
among men and women, especially among migrants and refugees. gender-based inequities are recognized as inseparable from other
She explains that through the gender and sexuality idiom, notions social locations such as class, race/ethnicity, sexual orientation,
of otherness are constructed which deem some women as victims immigration status, geography, and ability, without any presump-
of culture, religion and tradition, and depict immigrant men as tion of ranking (Weber & Fore, 2007), this raises the critical issue of
more patriarchal and misogynist and thus a greater threat to the whether centering sex and gender is useful, to what extent, and in
spread of HIV/AIDS. This type of analysis prevents more dominant which circumstances.
forms of heterosexual masculinity from being targeted, thus Some researchers have suggested that gender may be a logical
leaving unchallenged hegemonic power. For Brdstrom (2006), starting place for an analysis of intersectionality (e.g. Bowleg, 2008;
sexual health policies that lack a critical perspective on how race, Shields, 2008b). However, as has been emphasized in this paper, it
class and ethnicity intersect with gender and sexuality might very is also important for researchers to be vigilant. Warner (2008) is
well contribute to a reication of the very hierarchy they intend to thus correct in asserting that one cannot assume that a master
dethrone (p. 241), especially in a political context where these category is a valid form of representation unless one tests this
factors are inseparable from the experiences of marginalized non- assumption in research (p. 458). As growing evidence shows,
white men and women. when gender is not found to always be salient and meaningful, the
question becomes: What is gained but perhaps more importantly
Ongoing challenges and gaps what is lost in terms of the knowledge and evidence that is
produced when gender and gender comparisons are without
At the same time that intersectionality is making inroads, there exception, the preferred axes through which to frame research?
continue to be ongoing challenges for intersectionality-informed Lagro-Janssen, among others, worries that de-centering gender
research and policy. Different versions of intersectionality have will result in the loss of its importance (2007). Arguably, moving
different research utility (McCall, 2005; Weldon, 2008). Researchers beyond the connes of established frameworks is not, however,
continue to be challenged by the choices of which social divisions, about making gender invisible. Viewing gender within a logic of
intersections, or data categories to study and how to best account for intersectionality certainly redenes it as a constellation of ideas
within category differences. Intersectionality research to date is and social practices that are historically situated and that mutually
often focused on the trinity of race, class, and gender obscuring other construct multiple systems of oppression (Collins, 2000, p. 263).
types of experiences emerging from intersecting frameworks of The implications are also further reaching. The list of potential
religion, spirituality, culture, geography, place, and age (Hankivsky, intersecting factors extends beyond gender but also may or may not
2011). As well, research continues to focus on the experiences of include gender at the forefront when determinations are made
vulnerable populations while less attention has been given to about what profoundly affects life chances, opportunities, and
exploring and documenting agency, resiliency, and resistance to health, including manifestations of disease and illness. The key is to
domination (Hankivsky et al., 2010) or to interrogating privilege, continue the process of interrogating when and how gender (and
including whiteness and middle-classness (Levine-Raskey, 2011). sex) are salient for examining, elucidating, and responding to
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