PAPER: Women’s health, men’s health, and gender and health: Implications of Intersectionality

Women’s health, men’s health, and gender and health: Implications of Intersectionality

Plena Hankivsky

REFERENCE

Hankivsky, O. (2012). Women’s health, men’s health, and gender and health: Implications of intersectionality. Social science & medicine, 74(11), 1712-1720.

https://www.sciencedirect.com/science/article/pii/S0277953612000408#bib44

Abstract

Although intersectionality is now recognized in the context of women’s health, men’s health, and gender and health, its full implications for research, policy, and practice have not yet been interrogated. This paper investigates, from an intersectionality perspective, the common struggles within each field to confront the complex interplay of factors that shape health inequities. Drawing on developments within intersectionality scholarship and various sources of research and policy evidence (including examples from the field of HIV/AIDS), the paper demonstrates the methodological feasibility of intersectionality and in particular, the wide-ranging benefits of de-centering gender through intersectional analyses.

Highlights

► Implications of intersectionality have not been fully explored in the context of women’s health, men’s health and gender and health. ► Intersectionality unsettles the fundamental importance of gender (and sex). ► It raises important questions for scholars and researchers concerned with health inequities.

Conclusion

Although applications of intersectionality are still developing, emerging research does show that theoretical foundations do influence and direct the way health inequities are conceptualized, studied, and responded to (Krieger et al., 2010). Intersectionality raises critical lines of enquiry. First, it brings to the fore the limitations of research that emphasizes pre-determined classifications (e.g. man and woman) or prioritizes any one single category (e.g. sex or gender) or even a set constellation of variables (e.g. sex and gender) within a contextual analysis. Significantly, when sex and gender-based inequities are recognized as inseparable from other social locations such as class, race/ethnicity, sexual orientation, immigration status, geography, and ability, without any presumption of ranking (Weber & Fore, 2007), this raises the critical issue of whether centering sex and gender is useful, to what extent, and in which circumstances.

Some researchers have suggested that gender may be a logical starting place for an analysis of intersectionality (e.g. Bowleg, 2008; Shields, 2008b). However, as has been emphasized in this paper, it is also important for researchers to be vigilant. Warner (2008) is thus correct in asserting that “one cannot assume that a master category is a valid form of representation unless one tests this assumption in research” (p. 458). As growing evidence shows, when gender is not found to always be salient and meaningful, the question becomes: What is gained but perhaps more importantly what is lost in terms of the knowledge and evidence that is produced when gender and gender comparisons are without exception, the preferred axes through which to frame research?

Lagro-Janssen, among others, worries that de-centering gender will result in the loss of its importance (2007). Arguably, moving beyond the confines of established frameworks is not, however, about making gender invisible. Viewing gender within a logic of intersectionality certainly redefines it as a constellation of ideas and social practices that are historically situated and that mutually construct multiple systems of oppression (Collins, 2000, p. 263). The implications are also further reaching. The list of potential intersecting factors extends beyond gender but also may or may not include gender at the forefront when determinations are made about what profoundly affects life chances, opportunities, and health, including manifestations of disease and illness. The key is to continue the process of interrogating when and how gender (and sex) are salient for examining, elucidating, and responding to health inequities and to ensure that researchers who may be entrenched in certain ways of doing things, do not only see what they want to see in their research (Weber, 2007).

What might be the political consequences of such shifts in framing? What for example might be lost from a sustained focus for example on women’s health or men’s health? To a great extent these fields are based on identity politics. They assume, for example, that the members of a social category face similar problems that require similar solutions when in fact no such ‘unitary’ group exists. Moreover, intersectionality may open possibilities to transcend the “Oppression Olympics” (Martinez, 1993) which often characterize competition for scarce resources and policy attention between these two fields. Gender and health researchers may also find new possibilities and new opportunities for collaboration, coalition, and action with other researchers and activists who may be focused on certain categories such as race, sexuality, class, and disability, developing “integrated knowledge across systems of oppression” (Weber & Parra-Medina, 2003, p. 200). Evidence that public policy is moving in this direction can also be found for example in the EU (Lombardo et al., 2009), a pioneer in gender equality policies. Member countries are moving from predominately attending to gender inequality towards policies that address various interlocking strands of inequality. The adoption of intersectionality in these jurisdictions is seen as necessary for the development of inclusive and better quality policies.

In the final analysis, while dealing with multiple and intersecting dimensions is difficult terrain, full of enormous trials, intersectionality does make apparent the importance of new ways of framing the complexity of human life and social inequities. The challenges presented by intersectionality, which have been lurking in the shadows in mainstream health research for some time now, are now firmly in the spotlight and raise important questions about what is required for inclusive and effective research. To remain on the cutting edge, researchers situated in the fields of women’s health, men’s health, and gender health should continue to explore, discuss and debate the implications of intersectionality and find ways to more systematically adopt and apply intersectionality as a framework for improving understandings of and responses to the complexities of people’s lives and experiences.

IMPORTANT QUOTATIONS

Intersectionality challenges practices that privilege any specific axis of inequality, such as race, class, or gender and emphasizes the potential of varied and fluid configurations of social locations and interacting social processes in the production of inequities. 

While the fields of women’s health, men’s health, and gender and health have started to explicitly acknowledge and engage with the theoretical and methodological insights of intersectionality, the extent to which current practices align with the tenets of intersectionality is largely uninvestigated.

The purpose of this paper is to explore the implications of intersectionality in the context of these fields and to raise important questions for dialogue and debate

Intersectionality “moves beyond single or typically favoured categories of analysis (e.g. sex, gender, race and class) to consider simultaneous interactions between different aspects of social identity…as well as the impact of systems and processes of oppression and domination” (Hankivsky & Cormier, 2009, p. 3).

Gender is often interpreted as synonymous with women and as a result, men’s gender-specific needs receive insufficient attention (Doyal, 2001; Hankivsky, 2007; Varanka, 2008). It is inconsistent with intersectionality, which does not view gender as a fixed category but rather changeable and contingent in nature.

Primal focus on gender (and or sex)-pp1711

Studies in the field of violence (Bent-Goodley, 2007; Craig-Taylor, 2008; Crenshaw, 1995; Nixon & Humphreys, 2010; Sandelowski, Barroso, & Voils, 2009) show that violence against women is not only a matter of gendered power relationships but is co-constructed with racial and class stratification, heterosexism, ageism, and other systems of oppression, some of which may be more salient within such interactions.

Finally, HIV/AIDS research (Dworkin, 2005; Elford, Anderson, Bukutu, & Ibrahim, 2006; Jackson & Reimer, 2008; Meyer, Costenbader, Zule, Otiashvili, & Kirtadze, 2010; Young & Meyer, 2005) demonstrates that gender and sexuality cannot be separated from other axes including race, class, age, religious affiliation, and immigration status and the structural economic, political, and social processes that shape them. For example, in her analysis of surveillance categories for HIV, Dworkin (2005) argues that pushing beyond a singular sex/gender system to explore the simultaneity of race, class, and shifting gender relations is vital to the future of the HIV epidemic and in particular, for making visible bisexual and lesbian transmission risks.

Further, the emphasis on gender (and sex) often leads to a focus on differences between women and men. This helps to explain why so much data continues to be collected, organized, and presented solely around sex and gender differences even when similarities between women and men are demonstrated (e.g. Hyde, 2005; Petersen, 2009), differences among women and among men are often as significant if not more than between women and men (Crawshaw & Smith, 2009; Varcoe, Hankivsky, & Morrow, 2007), and men are sometimes subordinate to some women and some women exercise power over some men (Pease, 2006).

Clow et al. (2009) state, “SGBA-Sex and Gender Based Analysis” reminds us to ask questions about similarities and differences among women and men, such as: Do women and men have the same susceptibility to lung disease from smoking? Are women at the same risk as men of contracting HIV/AIDS through heterosexual intercourse? Are the symptoms of heart disease the same in women and men?.” (p. 1). Within this type of construct, differences that are shaped and formed by factors outside of sex and gender are treated as secondary in importance, if at all.

Inadequate conceptualization and empirical modelling of diversity-pp 1714

In gender and health literature, the recognition of diversity (Annandale, 2010; Clow et al., 2009; Lagro-Janssen, 2007; Read & Gorman, 2010; Sen & Östlin, 2007) is exemplified in the growing acceptance of the fluid and flexible nature of sex and gender, acknowledgement of the differences among women and men, and the recognition of gender as a social location and determinant of health that is shaped by and in constant interaction with other determinants (Benoit & Shumka, 2009; CIHR-IGH, 2009; Hankivsky & Christoffersen, 2008).

Fausto-Sterling’s dynamic systems theory has explored how the biology of sex and gender are shaped by culture (2000; 2005).

Bekker’s Multi-Facet Gender and Health Model (2003) shows how the relationship between sex and gender can be moderated by various sets of factors including daily life or social circumstances, person-related characteristics, and health care factors. 

Annandale (2009) has proposed a conceptual framework she refers to as a ‘new single system’ model of patriarchal capitalism, intended to account for destabilized sex/gender identities and more complex patterns of equality and inequality and how they are “…written not only on the body, but into the body in new experiences of health and illness” (p. 11).

Bird and Rieker’s ‘constrained choices’ (2008) multi-level model which contextualizes women’s and men’s personal health ‘choices’ and outcomes as influenced and shaped by the communities in which they live and the range of social policies that directly impact on their lives.

 Annandale (2009) explores how sex and gender are “intimately connected with particular forms of the operation of capitalism” (p. 108-109) which shape women’s circumstance and their health. Bird and Rieker’s model considers interactions between social and economic factors on gendered health patterns. And Springer et al. (2012) explicitly signal the importance of intersectionality for their conceptualization of sex/gender and for understanding how “aspects of social status (e.g., gender, race, socioeconomic status, and sexuality) are understood to affect health outcomes in complex, multiplicative ways that can never properly be captured by attempts to parcel out the individual contributions of single social domains” (p. 8)

Annandale and Kuhlmann (2010) are correct in observing that biological sex and social gender “are so deeply and often unproblematically fixed in the research and policy imagination that they fail to yield to the periodic reflection that is necessary to ensure their continued relevance and to retain their critical edge” (p. 455). From an intersectionality perspective, it is the hegemony of gender and sex as key drivers of difference and gender as a dominant axis of analysis that have not been adequately interrogated or challenged. This raises the question of whether even the most evolved, contextually sensitive approaches proposed by gender and health researchers may sometimes be inadvertently masking the real and complex interplay of other intersecting factors that shape and determine health outcomes. This line of enquiry also raises the practical issue of how an intersectional framework may transform research and policy – when gender is not always a priori deemed the most important axis for examining and responding to health inequities. And this necessitates concretely showing how the employment of an intersectionality framework improves on the identification of the range, salience and relationships of oppressions affecting health.

Elucidating the implications of Intersectionality

At the same time, it is critical to note that as a research paradigm (Dhamoon, 2011; Hancock, 2007) intersectionality is not ‘prescriptive’ nor does it insist on any particular research design or unified way to conduct research. Its goal is to bring about a conceptual shift in how researchers understand social categories, their relationships, and interactions and then to have this different understanding transform how researchers interrogate processes and mechanisms of power that shape health inequities. An ‘intersectionality shift’ encourages researchers to reflect on the complexity of their own social locations, how their values, experiences, and interests shape the type of research they engage with, including the problems they choose to study, and how they view problems and affected populations (including what types of research questions or hypotheses they pose).

From an intersectionality perspective, multiple factors are always at play in shaping people’s lives and health experiences.

Self-identified intersectionality scholars struggle with how to operationalize the theoretical tenets of intersectionality and as Bowleg puts it, researchers “often have to self-teach and learn from trial and error” (Bowleg, 2008, p. 313). Compared to other approaches, intersectionality is in nascent stages of development. 

To assist in such analysis, Bowleg (2008) has suggested for example that qualitative researchers avoid questions about specific identities such as gender and instead construct questions that are ‘intersectional by design’ such as “What are some of the day to day challenges that you face in terms of your identity?” to generate information about the mutuality of identities and complexity of experiences. Because the focus of an intersectionality-type analysis is not only on intersections themselves but what they reveal about power (Dhamoon & Hankivsky, 2011),-pp 1715

The application of these questions should, however, be grounded in the theoretical tenets of an intersectionality research paradigm in order to realize their intended operational objectives: the destabilization of a priori primacy and stability of singular categories; the avoidance of additive lists; and the focus on the fluid and interactive nature of multi-level complex processes and systems that shape health inequities. They include the following lines of enquiry:-pp 1716

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Who is being studied? Who is being compared to whom? Why? (Lorber, 2006)

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Who is the research for and does it advance the needs of those under study? (Hankivsky et al., 2010)

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Is the research framed within the current cultural, political, economic, societal, and/or situational context, and where possible, does it reflect self-identified needs of affected communities? (Hankivsky & Cormier, 2009)

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Which categories are relevant or not directly relevant? Why? (Winker & Degele, 2011)

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What is the presumed makeup of each category? (Hancock, 2007)

Is the sample representative of the experiences of diverse groups of people for whom the issue under study is relevant? (Hankivsky & Cormier, 2009)

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Is the tool of enquiry suited to collecting micro or macro data or a combination of both? (Hankivsky & Cormier, 2009)

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How will interactions between salient categories be captured by the proposed coding strategy?

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How will interactions at individual levels of experience be linked to social institutions and broader structures and processes of power?

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What issues of domination/exploitation and resistance/agency are addressed by the research? (Hankivsky & Cormier, 2009)

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How will human commonalities and differences be recognized without resorting to essentialism, false universalism, or be obliviousness to historical and contemporary patterns of inequality? (Cole, 2008)