What is intersectionality?

In 1976, five Black women sought legal redress for employment discrimination from General Motors. General Motors’ defence centred on demonstrating that it did not discriminate against either Black people or women. The court concurred and the case was lost.

Kimberlé Crenshaw, a civil rights advocate and scholar of critical race theory, took note. Crenshaw argued that a person’s social and political identities interact with power dynamics in wider society, to create unique forms of oppression and discrimination. The discrimination experienced by the General Motors employees could not be adequately explained with reference to misogyny and racism. Rather, a distinct and more powerful form of oppression existed at the intersection of these two forces. From this, the concept of intersectionality was born.

Different conceptions and formulations of the theory have emerged, some complementary, some in conflict. But the core idea remains: that by reducing an individual to a series of distinct identity characteristics, we fail to properly understand their experience and the discrimination they face.

From theory to practice: Why it’s easier to talk about than to apply

The idea has been widely taken up, and the term ‘intersectionality’ is often used in debates about the delivery and management of public services such as the NHS. Although generally accepted as a more authentic representation of experiences, it has proven more difficult to embrace in any practical sense. We might believe it, but how do we live it? 

One sign of this disconnection between debate and action can be seen in the way we report data on the effectiveness of health service provision. Where equity is considered (not often enough), results are almost always reported one dimension at a time: by sex, then by socio-economic group, then by ethnicity and so on. Intersectional analyses are few and far between.

There are several reasons for this. The social theory underpinning the concept is deep, complex, and somewhat contentious. Any analysis must embrace this, otherwise risk superficiality or worse, distorting important ideas. And it’s hard. Quantitative methodologies are developing but are complicated. Then there's the issue of dimensionality. The intersections between say, sex, ethnicity, socio-economic status are very large in number, and so the results of an intersectional analysis risks overwhelming decision-makers.

An Intersectional analysis: Dipping our toes in the water

It was in this context, that I, along with colleagues at the Strategy Unit and the University of Warwick decided to attempt a quantitative intersectional analysis. The results were published recently in the Social Science & Medicine journal.

We chose a subject matter we knew well: emergency hospital readmissions. Readmission shortly after discharge often indicates a failure in the healthcare system – whether in the initial hospital stay, discharge planning or poor or inadequate aftercare. The topic is well researched, and the data is extensive and well understood.

We used a more traditional method that we were familiar with, logistic regression with interaction terms, rather than one of the more modern but complex methods [For those more interested in methodological issues, please see the note at the end of this blog-post]. These design decisions were deliberate. They were intended to maximise our ability to understand and appropriately interpret the results.

Whilst many studies have highlighted the factors that put patients at increased risk of readmission - including clinical features of the patient or their treatment, as well as socio-demographic factors - we explored the risks of readmission at the intersections between sex, ethnicity and socio-economic deprivation.

Intersectionality theory suggests that where a patient experiences multiple disadvantages (e.g. associated with race and poverty) then these effects can combine and compound to further increase disadvantage. Advantages can compound too. The nature and direction of societal power dynamics are a central feature of intersectionality theory. The theory is by no means neutral, detached or dispassionate. We sought to measure effects at 10 intersections where the theory would indicate compounding advantage or disadvantage.

Mixed results

Our results were mixed. At two intersections, we saw evidence of compounding effects in line with intersectionality theory. In two other cases we found evidence of compounding effects at odds with the theory and in six cases we found no evidence of effect. The study was very well powered, so if an effect is present in these last six intersections, it is likely to be small.

Why generalising would be risky

At this point, when describing an analysis, I would normally be making the case that the findings might be cautiously generalised and that they are worth more than their face value. But in this case, I want to suggest the opposite. That the results tell us something very specific and efforts to generalise would be misplaced.

First, it would be wrong to generalise from effect to experience. Patients with similar risks of readmission might have very different experiences of the health system. Second, risk of readmission should not be seen as a proxy for other healthcare outcomes. We know very little about intersectional effects in other healthcare domains. We need a lot more research and analysis before we can draw more general conclusions. Third, this analysis reflects an average across England as a whole and over a specific time period, using a specific method. It is unclear whether other contexts or analytical approaches would have generated similar results.

So, what then is the value of this analysis?

We hope it contributes to the growing evidence base. Perhaps in the years to come this will be a piece of the jigsaw that systematic reviewers can use to create a rich picture of intersectional experiences and quantified effects in healthcare.

The research team also learned a lot, about the practicalities and challenges of these analyses and the underpinning theory, that we will bring to our future work.

And it is important to be clear: whilst, in this very specific context, we found limited evidence of intersectional effects, the bigger picture of disadvantage experienced by women, Black people, and people living in poverty was as clear as ever. 

Key message for decision-makers

Two key reflections from the research team for decision makers:

• Intersectionality theory has a long and rich history. The ideas have been explored extensively and qualitatively, but it may be some time before sufficient quantitative studies have been published so that these disciplines can meaningfully contribute.
• Intuitive and intriguing intersectional perspectives should not distract from action on well evidenced inequalities in health outcomes that demand attention. Analytical sophistication is valuable, but it should complement not delay efforts to tackle egregious and persistent disparities.