This is part 1 of a 3 part series examining intersectional approaches in epidemiological research. Click here to scroll down to list of resources.
Social identities (i.e., gender, race, ethnicity, class, sexual orientation, age, etc.) are a key construct within epidemiological research, used to define populations and study the patterning of health and disease. And yet, epidemiologists have conceptualized identity in varied, shifting, and oftentimes problematic ways. There have been numerous calls to shift from a discrete and individualized framing of identity to a more nuanced and contextualized one, reflecting broader debates in epidemiology between theories of disease distribution that locate risk within the biology and behaviors of individuals and those that locate risk further upstream (Krieger, 2001).
Perhaps because of its potential to improve upon extant conceptualizations of identity as well as other core population health constructs, there has been a growing interest in intersectionality theory among epidemiologists. Originating in Black feminist activism and scholarship as a way to explain the unique forms of discrimination experienced by Black women (Collins, 1990; Crenshaw, 1989), intersectionality is a theoretical framework primarily concerned with the multidimensional, interlocking nature of social inequities. Within this framework, social identities are conceptualized as mutually constitutive, jointly shaping lived experience through their historical and ongoing relationships with systems of power. This has several implications for epidemiology: adopting an intersectional perspective could lead to a more nuanced (and valid) understanding of the population patterning of disease, a heightened focus on social determinants, and more structurally oriented interventions. However, there are well-articulated challenges involved in translating a theory aimed at describing complex realities (versus generating hypotheses or predictions) into a quantitative science such as epidemiology, as well as important questions over epistemological consistency.
Thankfully, epidemiologists and other population health researchers have made considerable developments in bridging intersectionality theory with epidemiological methods over the past decade. The following list attempts to reflect the dynamic and non-linear nature of this endeavor and is organized as follows. The first set of articles are conceptual, reviewing the why and how of incorporating an intersectional lens into epidemiological research. The second set of articles are methodological, presenting new or novel applications of existing analytic approaches to studying the distribution and determinants of health and disease. When possible, I mention published commentaries and responses to these articles to highlight the ongoing challenges involved in “quantifying” intersectionality and to emphasize the fact that no single method is inherently intersectional. Finally, because intersectionality theory is first and foremost a critical theory with the goal of enacting transformative social change, the third set of articles are focused on examining the process of epidemiological knowledge production itself as a means of reinforcing or challenging systems of power, as well as how epidemiological knowledge can be used to promote intersectional health equity. Of course, this list is nowhere near exhaustive, and is influenced by both extant interpretations of intersectionality theory in the field of epidemiology and my own social location, academic training, and worldview.
L. The problem with the phrase women and minorities: Intersectionality-an
important theoretical framework for public health. Am J Public Health.
In one of the first articles to explicitly advocate for an intersectional approach to epidemiological-related research, Bowleg provides a compelling case for adopting intersectionality theory as a critical public health framework, focusing on its potential to “[reframe] how public health scholars conceptualize, investigate, analyze, and address disparities and social inequality in health” (p. 1267). After providing a brief history of intersectionality and outlining its core tenets, she reviews the major theoretical and methodological challenges associated with incorporating the theory into public health research; however, she stresses that having an “intersectionality-informed stance” is more important than methodological refinement. Bowleg concludes by outlining five ways in which this intersectionality-informed stance will benefit public health, ranging from increased understanding of how intersecting social identities influence the patterning and determinants of health disparities to improved interventions and surveillance efforts.2
GR. Incorporating intersectionality theory into population health research methodology: Challenges and the potential to advance health equity. Soc Sci Med. 2014;110(10–17).
Another formative article, Bauer starts similarly by articulating the potential benefits of incorporating intersectionality theory into the broader field of population health sciences. She provides a detailed and nuanced description of the associated methodological challenges, with a focus on measurement- and analytic-related concerns, and offers guidelines for addressing them. The most useful aspect is Bauer’s discussion of how tensions within intersectional scholarship may be understood in the context of population health research. For example, questions such as “who” is intersectional (e.g., all social locations or only those with multiple marginalized identities) and whether all identities are relevant/intersectional in all contexts are addressed in terms of their significance for understanding the distribution and determinants of health and disease. She also considers how intersectionality meshes with epidemiologic theories, particularly Nancy Krieger’s ecosocial theory, with implications for the validity and social value of epidemiological research.3
A, Huijts T, Beckfield J, Bambra C. Understanding the micro and macro politics
of health: Inequalities, intersectionality & institutions – A research
agenda. Soc Sci Med. 2018;200:92–8.
Gkiouleka and colleagues review the theoretical and methodological underpinnings of using intersectionality as an analytic tool for studying health inequities and offer two research approaches relevant to epidemiology: “situational intersectionality” (i.e., focusing on the specific social identities relevant to a given research question, while exploring potential heterogeneity in such relevance across groups) and “institutional imbrication” (i.e., operationalizing institutions and other macro-level factors typically studied discreetly in epidemiology (e.g., neighborhoods and laws/policies) as intersectional). The article concludes with recommendations for measurement and analysis when using these research approaches and outlines seven actions that researchers can take to make their work more intersectional.4
L. When Black + lesbian + woman ≠ Black lesbian woman: The methodological
challenges of qualitative and quantitative intersectionality research. Sex
While not specific to epidemiology or even to population or public health, this earlier article by Bowleg nonetheless provides an excellent overview of measurement-, analytic-, and interpretation-related challenges to conducting intersectionality-informed research. For each of these domains, she provides specific guidelines for addressing the noted challenges, although she emphasizes that contextualization is paramount to defining intersectional scholarship.5
L. The complexity of intersectionality. Signs (Chic). 2005;30:1771–800.
This seminal article in intersectional scholarship laid the groundwork for how epidemiologists began to operationalize the theory for quantitative research. McCall presents three orientations for intersectionality-informed research, which represent a continuum of approaches to managing the complexity of multiple intersecting identities: “anticategorical intersectionality” (critique and deconstruct social identities), “intracategorical intersectionality” (reveal nuance within a particular social location), and “intercategorical intersectionality” (document inequalities across many social locations). After reviewing the underlying assumptions and analytic guidelines for each orientation, she calls for an expansion of methodologies used to answer intersectionality-informed research questions so as to “fully engage with the topics and issues of intersectionality” (p. 1774); on a personal note, I find this a strong argument for the incorporation of intersectionality theory into epidemiology!6
CR. Modeling the intersectionality of processes in the social production of
health inequalities. Soc Sci Med. 2019;226:249–53.
This article is a comprehensive overview of the types of intersectionality-informed epidemiological and population health studies. Evans provides a useful classification system for this growing body of research, distinguishing specific/intracategorical from comprehensive/intercategorical and descriptive from analytic studies, providing researchers with a common language to describe their objectives and analyses. She also suggests specific epidemiologic theories that are particularly well-aligned with intersectionality theory (and could thus be used in conjunction, advancing both fields) and outlines future research directions.