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.
Intersectionality
Review
2012 Elsevier Ltd. All rights reserved.

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

0277-9536/$ e see front matter 2012 Elsevier Ltd. All rights reserved.
doi:10.1016/j.socscimed.2011.11.029
 O. Hankivsky / Social Science & Medicine 74 (2012) 1712e1720
(Hankivsky & Cormier, 2009, p. 3). Although there are multiple
conceptions of intersectionality, there are also a number of iden-
tiable central theoretical tenets including the idea that human
lives cannot be reduced to single characteristics; human experi-
ences cannot be accurately understood by prioritizing any one
single factor or constellation of factors; social categories such as
race/ethnicity, gender, class, sexuality, and ability are socially con-
structed, uid, and exible; and social locations are inseparable and
shaped by the interacting and mutually constituting social
processes and structures that are inuenced by both time and
place. These tenets are intended to provide the basis for a new
avenue of enquiry where no category of oppression is automatically
considered as the most damaging and where some differences are
not continuously highlighted to the exclusion of others.
What also distinguishes this approach from others that have
attempted to be responsive to diversity is that intersectionality is
not an additive approach. It does not estimate the collective impact
of gender, race, and classdmeasured as several simple binariesdas
the sum of their independent effects (e.g. genderclassrace/
ethnicity). This type of additive approach is critiqued for layering
several simultaneous oppressions (King, 1988, p. 47) without
interrogating their relationships and mutually constructive
processes. In comparison, intersectionality focuses on examining
how social locations and structural forces interact to shape and
inuence human experiences. It requires, as Andersen and Collins
(2001) explain, recognizing and analyzing the hierarchies and
systems of domination that permeate society and that systemati-
cally exploit and control people (p. 5e6). In this way, inter-
sectionality seeks to be a multi-level analysis that incorporates
attention to power and social processes at both micro and macro
levels through which subject formation occurs (Dhamoon &
Hankivsky, 2011). It is also important to note that intersection-
ality is not only applicable to advancing understandings of
marginalized or so-called disadvantaged groups in order to
promote social justice, but explains how social organization shapes
all of our lives (Weldon, 2008). It also leaves open the possibility of
simultaneously experiencing the effects of privilege and penalty,
thus challenging binary thinking which tends to place certain
groups in opposition to one another (e.g. women/men; black/
white; Aboriginal/non-Aboriginal).
Literature examining the theoretical and applied potential of
intersectionality has grown exponentially over the last decade
(Choo & Ferree, 2010; Cole, 2009; Dhamoon, 2011; Hancock, 2007;
McCall, 2005; Warner, 2008; Weber, 2009; Weldon, 2008) driven
by the extent to which this framework advances more accurate and
sophisticated understandings of the multidimensional reality of
human lives. The growing pressure to nd better ways to account
for differences and respond to the various and intersecting factors
that inuence health for both women and men has also led
researchers and policy actors to recognize intersectionality as
a valuable resource for re-thinking existing research methods,
models, practices, and health policies (Broom & Tovey, 2009; Clow,
Pederson, Haworth-Brockman, & Bernier, 2009; Hankivsky &
Cormier, 2009; Hankivsky et al., 2010; Hurtado & Sinha, 2008; Read
& Gorman, 2010; Sen & stlin, 2007; Varanka, 2008). In the elds of
womens health, mens health, and gender and health, the promise
of an intersectionality analysis is that it advances a new order of
complexity for understanding how sex and gender intersect with
other dimensions of inequality, particularly historic and geographic
contexts, to create unique experiences of health.
Womens health, mens health, and gender and health
While there are somewhat different approaches that can be
identied as womens health, mens health, and gender and health,
1713
especially in the context of political activism and policy, there are
many ways in which they overlap and articulate with one another.
Importantly, each prioritizes the dimension of sex/gender above all
other axes of social identity and power. From an intersectionality
perspective, these practices, which are briey reviewed below,
undermine theoretical and empirical efforts to fully understand
and address health inequities.
Conation of gender with women
In research and policy practices, gender and gender and health
are often conated with women and womens health (Richardson &
Carroll, 2009; Smith & Robertson, 2008; Wilkins & Savoye, 2009).
Turshen (2007) has correctly observed for example, that studies
with gender in the title still too often mistakenly use the word as
a synonym for women, or open with a nod to gender and then glide
on to women (p. 320). Moreover, because historically women have
been the driving force behind the development of gender equality
policies, gender mainstreaming, with the exception of the UK and
Norway, has been largely shaped in terms of what women can gain
from greater gender equality (Hearn, 2006). Gender is often inter-
preted as synonymous with women and as a result, mens gender-
specic needs receive insufcient attention (Doyal, 2001;
Hankivsky, 2007; Varanka, 2008). It is inconsistent with inter-
sectionality, which does not view gender as a xed category but
rather changeable and contingent in nature.
Primal focus on gender (and or sex)
The emphasis placed on gender or sex is often motivated by
concerns over the lack of attention to these factors (Doull et al.,
2010; Gochfeld, 2010; Nieuwenhoven & Klinge, 2010) and/or
a lack of clarity about sex (aspects of the body) versus gender
(personal identities and social roles designated as masculine
versus feminine) and the relationship between sex and gender in
health research (Hankivsky, 2007; Klinge, 2008; Krieger, 2003).
Using an intersectionality framework, researchers have noted
the explanatory limitations of single axis designs centered on sex
and gender. Cole (2009) has warned that analyses that focus on
gender are problematic because they often implicitly assume
a host of other social statuses that usually go unnamed in American
culture: middle-class standing, heterosexuality, able-bodiedness
and White race (p. 173). Others have explicated similar limita-
tions. For example, studies in the eld 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 relation-
ships but is co-constructed with racial and class stratication,
heterosexism, ageism, and other systems of oppression, some of
which may be more salient within such interactions. Research on
cardiovascular disease (CVD) (Brister, Hamdulay, Verma, Maganti, &
Buchanan, 2007; King, LeBlanc, Carr, & Quan, 2007; King, LeBlanc,
Sanguins, & Mather, 2006) shows that focussing on sex and
gender often obscures the fact that CVD is disproportionately
experienced by racial ethnic and low-income groups whose lives
are shaped by intersecting processes of differentiation along the
lines of age, sex, ethnic group afliation, socioeconomic class, and
geography. 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
afliation, 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
1714 O. Hankivsky / Social Science & Medicine 74 (2012) 1712e1720
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. Emerging research thus
demonstrates that there are many groups which do not necessarily
identify gender oppression as the primary frame through which
they understand their lives (Nixon & Humphreys, 2010, p. 150). In
Canada, as in many other jurisdictions, this is especially apparent
with growing immigrant populations whose health is primarily
affected by dislocation, isolation, loss of identity, culture, and
meaningful employment and Aboriginal/Indigenous populations
whose health and well-being is largely determined by unresolved
colonial injustices and ongoing experiences of racism and poverty
(Alfred, 2005; Waldrum, Herring, & Young, 2006).
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 signicant 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). Nevertheless,
numerous reviews of sex based and gender differences continue to
be produced (Gochfeld, 2010; Read & Gorman, 2010). Moreover,
even in some frameworks that seek to include considerations of
both sex and gender, as in the sex and gender based analysis (SGBA)
tool developed in Canada (e.g. Clow et al., 2009), proposed guides
construct lines of interrogation that prioritize examinations of
similarities and differences between women and men. As Clow et al.
(2009) state, SGBA 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.
Research that focuses on differences between men and women
can also perpetuate false dichotomies that fail to reect the diversity
between different groups of women and men or open the possibility
of examining different types of population groups. Within the
connes of such discourses, there appears little space either
conceptually or practically for moving beyond two denable sexes
and genders, even though intersex and transgendered persons and
practices directly destabilize such binary classications (Fish, 2008;
Geller, 2008; Harper, 2007). This is also why intersectionality holds
so much promise. In the realm of policy for example, it points to the
existence of more than two genders e that is, multiple groups of
stakeholders and beneciaries (Bishwakarma et al., 2007).
Inadequate conceptualization and empirical modelling of diversity
At the same time that binary practices persist, there is also
a very strong impetus for health researchers to be more inclusive of
and responsive to diversity. For example, important questions have
been raised regarding the extent to which womens health and
mens health are adequate and sustainable generic categories for
the purpose of research and policy given the wide-ranging differ-
ences among women and men (Smith, White, Richardson,
Robertson, & Ward, 2009; Varcoe et al., 2007; Wilkins & Savoye,
2009). In gender and health literature, the recognition of diversity
(Annandale, 2010; Clow et al., 2009; Lagro-Janssen, 2007; Read &
Gorman, 2010; Sen & stlin, 2007) is exemplied in the growing
acceptance of the uid and exible 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).
A signicant number of gender and health researchers also
explicitly emphasize that sex is shaped by social context (Einstein &
Shildrick, 2009; Gochfeld, 2010; Vanwesenbeeck, 2009) and that
gender is not a stand alone variable but one that can only be
understood in relation to biological factors and other social loca-
tions and systems of oppression. Some of the best examples of
developments along these lines are integrative models that explore
biological and social processes. For example, Fausto-Sterlings
dynamic systems theory has explored how the biology of sex and
gender are shaped by culture (2000; 2005). Bekkers 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 char-
acteristics, 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 destabi-
lized 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).
Another noteworthy example is Bird and Riekers constrained
choices (2008) multi-level model which contextualizes womens
and mens personal health choices and outcomes as inuenced
and shaped by the communities in which they live and the range of
social policies that directly impact on their lives. Most recently,
Springer, Stellman, & Jordan-Young (2012), have developed a sex/
gender entanglement good practices guidelines for research on
male-female health differences.
These developments are important as they move away from
separate foci on sex and gender. Drawing connections between
biological and social processes advances understandings of gender
and its relationship to sex and illuminates why social context is so
important for the construction of gendered health outcomes. By
looking at interactions between sex, gender, and other multi-level
dimensions of social inequality, these models also make impor-
tant inroads vis vis intersectionality. For example, Annandale
(2009) explores how sex and gender are intimately connected
with particular forms of the operation of capitalism (p. 108-109)
which shape womens circumstance and their health. Bird and
Riekers 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). However, the consistent and sustained focus
on gender and sex as central categories within these models creates
signicant tensions in terms of what intersectionality demands -
namely leaving open the relative importance of different axes of
analysis beyond the singular focus on sex and gender, and how
these interact in any given situation.
Annandale and Kuhlmann (2010) are correct in observing that
biological sex and social gender are so deeply and often unpro-
blematically xed in the research and policy imagination that they
fail to yield to the periodic reection 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
 O. Hankivsky / Social Science & Medicine 74 (2012) 1712e1720
of analysis that have not been adequately interrogated or chal-
lenged. 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 e 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
identication of the range, salience and relationships of oppres-
sions affecting health.
Elucidating the implications of Intersectionality
Well-rehearsed critiques of an intersectionality perspective
include claims that it does not have any methods associated with it or
that it can draw upon (Phoenix & Pattynama, 2006, p. 189) or that it
does not provide a sufcient foundation for action aimed at
improving population health and reducing health disparities because
as an approach that has focused on societal structures it was not
intended to identify points for health intervention (Bird, Lang, &
Reiker, 2010, p. 130). This has led scholars to question how inter-
sectionality can transform empirical research, what new and better
knowledge it may generate, and how this can translate into
improvements in practices and policy. As is widely acknowledged,
translating theory into methodological practices is not easy. Self-
identied intersectionality scholars struggle with how to operation-
alize 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, intersection-
ality is in nascent stages of development. However, for researchers
seeking methodological traction there is a growing body of literature
that provides normative and operational guidance for the application
of intersectionality in qualitative and quantitative health research and
policy (e.g. Choo & Ferree, 2010; Cole, 2009; Hancock, 2007; Hankivsky
& Cormier, 2009; Hankivsky et al., 2010; McCall, 2005).
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
unied 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 inter-
sectionality shift encourages researchers to reect on the
complexity of their own social locations, how their values, experi-
ences, 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). Moreover, because
intersectionality rejects hierarchical ordering of oppression,
researchers applying this perspective would refrain from
presuming before the start of any project which dimensions have
greater inuence (Siltanen & Doucet, 2008, p. 27). Indeed, salient
axes in any research cannot be pre-determined but differ by time,
nation, culture, political and economic contexts, and geographic
setting (Yuval-Davis, 2006). For researchers concerned with gender,
this would necessitate carefully investigating rather than auto-
matically assuming the primacy and/or signicance of gender
(Siltanen & Doucet, 2008, p. 178). This type of de-centering of
gender allows for more exibility and arguably accuracy in deter-
mining salient dimensions in all stages of research whether in the
design of research questions, choice of sample, analysis and
1715
interpretation of data, or even the dissemination of research,
including the wording of article and book titles.
Not only does intersectionality reject the automatic prioritiza-
tion of any one category, it also rejects looking at various dimen-
sions that affect health separately, thus disrupting the primacy and
stability of categories of mens and womens health. From an
intersectionality perspective, multiple factors are always at play in
shaping peoples lives and health experiences. Not surprisingly, an
often cited concern is that the demands of intersectionality are too
high, that all potential variables that need to be included in any one
research design would make national studies or international
comparative studies impossible to undertake. Researchers have
claried that intersectionality does not lead to such paralysis. It
does not necessitate taking into account all possible factors in any
given research design but instead prompts researchers to be
explicit about which ones are chosen and why, and what is
subsequently set aside or under-analyzed as a result. Such decisions
are of course shaped by available knowledge of the research topic,
data availability, which groups are most directly impacted,
government and media agendas, and what affected populations
identify as a priority. But in making choices, researchers are
cautioned against falling back on familiar, often assumed master
categories (e.g. gender, race, or class) and are encouraged to care-
fully think through how their selections may alter results and
interpretations of research results (Warner, 2008).
In terms of investigating multiple factors, intersectionality
rejects simple enumeration or addition, that is, the measurement of
multiple main effects of separate and independent inequalities
(Choo & Ferree, 2010). It directs researchers to explore how various
forms of social stratication relate and co-constitute one another
but also emphasizes that the exact relationship between different
types of social subordination cannot be pre-determined but is
an open empirical question (Hancock, 2007). To assist in such
analysis, Bowleg (2008) has suggested for example that qualitative
researchers avoid questions about specic 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 mutu-
ality 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), Cole (2009) has advised quantitative researchers
for instance to always interpret their data within historical contexts
of oppressed and privileged groups experiences.
Even though there is no single way to do intersectionality
research at the outset of any research project, to ensure analytic
clarity, researchers should explain their approach to/denition of
intersectionality (Hankivsky, 2011). Moreover, there are specic
questions (a select number are listed below) that are useful guides
for researchers who seek to navigate this nascent terrain at every
stage of designing a research project. Each has differential applica-
bility to qualitative and quantitative research designs and
researchers may choose to focus more closely on some over others.
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 destabi-
lization of a priori primacy and stability of singular categories; the
avoidance of additive lists; and the focus on the uid and interactive
nature of multi-level complex processes and systems that shape
health inequities. They include the following lines of enquiry:
 Who is being studied? Who is being compared to whom?
Why? (Lorber, 2006)
 Who is the research for and does it advance the needs of those
under study? (Hankivsky et al., 2010)
1716 O. Hankivsky / Social Science & Medicine 74 (2012) 1712e1720
 Is the research framed within the current cultural, political,
economic, societal, and/or situational context, and where
possible, does it reect self-identied needs of affected
communities? (Hankivsky & Cormier, 2009)
 Which categories are relevant or not directly relevant? Why?
(Winker & Degele, 2011)
 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)
 Is the tool of enquiry suited to collecting micro or macro data or
a combination of both? (Hankivsky & Cormier, 2009)
 How will interactions between salient categories be captured
by the proposed coding strategy?
 How will interactions at individual levels of experience be
linked to social institutions and broader structures and
processes of power?
 What issues of domination/exploitation and resistance/agency
are addressed by the research? (Hankivsky & Cormier, 2009)
 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)
Intersectionality scholars also emphasize that no individual
study is able to address the whole of a complex problem and that
researchers should instead develop programs of research with
different studies aimed at different aspects of a problem and which
can sequentially build upon one another (Rogers & Kelly, 2011).
While operational guidance for empirical research is essential, it is
equally important to note that researchers are already demonstrating
the transformative value of intersectionality. To date, it is generally
thought that qualitative methods lend themselves more easily to an
intersectionality analysis (McCall, 2005; Shields, 2008a), and this is
evidenced for instance by studies that dominate edited collections
on intersectionality health research (e.g. Hankivsky, 2011; Schulz
& Mullings, 2006). In comparison, quantitative researchers have
acknowledged the tensions between conventional research designs,
which are intended to test for independent effects of dimensions of
inequality typically measured as binaries, and intersectionality which
seeks knowledge about the processes of interaction between uid
social identities (Shields, 2008b; Bowleg, 2008). This has not impeded
the emergence of intersectionality-informed quantitative studies that
utilize techniques to examine signicant interactions which consti-
tute health (rather than simply adding variables of interest) and to
produce what may be interpreted as counter-intuitive research
results. For example, Veenstra (2011) has compared additive and
multiplicative approaches to demonstrate how intersectional models
lead to more accurate predictions of health outcomes. In an additive
model of self-reported health, he found that South Asian Canadians
were signicantly more likely than White Canadians to report fair/
poor health and that women were not signicantly more (or less)
likely than men to report fair/poor health. In the words of Veenstra,
South Asian Canadians appear to be at relatively high risk of poorer
self-rated health, and gender appears to be unrelated to self-rated
health. In comparison, by employing a multiplicative model, he
found a signicant race  gender interactiondamong women, South
Asians were much more likely than Whites to report fair/poor self-
rated health, whereas South Asian men were not more likely than
White men to report fair/poor self-rated health. That is, these men
and women experience the health effects of race differently, with
a race effect evident among women and not among men. Stated
otherwise, the effect of gender on self-reported health is contingent
on race.
Jackson and Williams (2006) have demonstrated that attention
to the interactions of gender, race, and class challenges widely held
assumptions about SES by showing that on many health indices
(including infant mortality and elevated risk of suicide) highly
educated blacks fare no better than whites with the lowest
education. Specically their research reveals that SES, typically
thought to afford adults the ability to benet from material
resources and engage in preventative care, is signicantly mitigated
for middle-class black women and men by the inuences of insti-
tutional racism and gender stereotypes. For Jackson and Williams
(2006), intersectionality theory provides a lens for understanding
the full effects of these interactions and for revealing how power
within gendered and raced institutional settings operates to
undermine access to and use of resources that would otherwise be
available to individuals of certain class standings.
Sen et al. (2009) have also developed a method for operation-
alizing intersectionality that they describe as a technique to test for
differences along the entire span of the social spectrum (not just
between the extremes) which they have applied to the examination
of health care for long term illness in India to show that class works
through gender when it comes to obtaining necessary health care.
It is important to note, however, that the reverse can also be true.
Gender can work not only through class but many other variables.
And in some instances, when numerous factors are considered
simultaneously, the effects of gender may even be negligible. For
example, in a study of exposure to stress related to sexual orien-
tation, gender, and race/ethnicity, Meyer, Schwarz, & Frost (2008)
concluded, contrary to prevailing assumptions in the literature,
that gender does not matter in the way that the predominant
social stress models describe (p. 377).
To further grasp the analytic purchase of intersectionality, one
can also turn to specic examples such HIV/AIDS, where applica-
tions of this paradigm are facilitating better understandings of
under-researched dynamics, groups, and relationships. In her study
of black HIV-positive African migrants in East London, Doyal (2009)
uses Black African, migrant and HIV-positive as key intersecting
analytic categories. Doyal emphasizes the importance of displacing
gender as the most salient inuence in these narratives of HIV-
positive migrants because it obscures an accurate understanding
of the complex experiences of this group. She demonstrates how
gender, sexuality, race/ethnicity, and migrant and HIV status
intersect, to reveal different effects among and between hetero-
sexual women and men, and gay/bisexual men in relation to stig-
matizing and discriminatory social processes, sources of supports
(including spirituality and religion), and voluntary organizations
designed to respond to the needs of African communities affected
by HIV/AIDS. According to Doyal (2009), this study demonstrates
the value of.opening up a number of important issues that are
too often left unexplored in existing literature on living with HIV
(p. 184) and how intersectionality research creates nuanced and
context specic evidence to improve HIV policies in the context of
global, regional, and local diversity.
In a study of the experiences of inner-city Latina women with
severe mental illness living in New York, Collins, von Unger, &
Armbrister (2008) illustrate the complex interconnections
between gender, race/ethnicity, class, and the stigma of mental
illness and its implications for HIV risk. The study shows that bi-
polar womens sexual relationships and behaviours are closely
intertwined with immigration, poverty, gender, and race/ethnicity
leading to contradictory outcomes. On one hand, women often
experience conict with gender norms in their ethnic communities
in ways that lower their social status and power. This leads to
vulnerability within intimate relationships and engagement in
sexual behaviours (e.g. lack of condom use) that increases the risk
of HIV. On the other hand, the effects of these same intersections
 O. Hankivsky / Social Science & Medicine 74 (2012) 1712e1720
are not always negative as the mental illness experienced by these
Latina women allows them to free themselves from abusive male
partners by accessing government entitlements and supports. The
ndings highlight why HIV prevention activities can only be
effective if they acknowledge multiple layers of vulnerability and
resources both at individual and structural levels, without erasing
gendering effects.
In their research with two urban Aboriginal health centres in
Vancouver, Browne, Varcoe, & Fridkin (2011) reveal how inter-
sectionality widens the scope of what is conventionally identied
as a problem in health services delivery. They explain that when
stigmatized diseases are decontextualized from their underlying
causes, people who are HIV are blamed or held responsible for
their status, including their problematic behaviours (e.g. unpro-
tected sex and injection drug use). In comparison, intersectionality
moves beyond this type of individual focus to consider multi-level
root causes of HIV including historical trauma, poverty, unem-
ployment, abuse, racism and medical involvement such as
prescribing practices.global economics, ideologies of racial
superiority, capitalist priorities, ongoing clawbacks to social
welfare systems, welfare colonialism, and state policies regarding
distribution (Browne, Varcoe et al., 2011, p. 301), and the rela-
tionship between these factors. This type of reframing is essential
for creating primary health services that not only respond to the
effects of HIV, but begin to address the underlying problems of HIV
so that treatment interventions are more nely attuned for
different types of populations groups.
Finally, in her examination of HIV/AIDS policy in Sweden,
Brdstrom (2006) has critiqued the treatment of race, ethnicity,
culture, and religion as merely additional to gender and sexuality.
For Brdstrom, this type of narrow focus is a problem not only for
analysis but also for effective sexual health policy because it
renders invisible constructions of privilege as well as vulnerability
among men and women, especially among migrants and refugees.
She explains that through the gender and sexuality idiom, notions
of otherness are constructed which deem some women as victims
of culture, religion and tradition, and depict immigrant men as
more patriarchal and misogynist and thus a greater threat to the
spread of HIV/AIDS. This type of analysis prevents more dominant
forms of heterosexual masculinity from being targeted, thus
leaving unchallenged hegemonic power. For Brdstrom (2006),
sexual health policies that lack a critical perspective on how race,
class and ethnicity intersect with gender and sexuality might very
well contribute to a reication of the very hierarchy they intend to
dethrone (p. 241), especially in a political context where these
factors are inseparable from the experiences of marginalized non-
white men and women.
Ongoing challenges and gaps
At the same time that intersectionality is making inroads, there
continue to be ongoing challenges for intersectionality-informed
research and policy. Different versions of intersectionality have
different research utility (McCall, 2005; Weldon, 2008). Researchers
continue to be challenged by the choices of which social divisions,
intersections, or data categories to study and how to best account for
within category differences. Intersectionality research to date is
often focused on the trinity of race, class, and gender obscuring other
types of experiences emerging from intersecting frameworks of
religion, spirituality, culture, geography, place, and age (Hankivsky,
2011). As well, research continues to focus on the experiences of
vulnerable populations while less attention has been given to
exploring and documenting agency, resiliency, and resistance to
domination (Hankivsky et al., 2010) or to interrogating privilege,
including whiteness and middle-classness (Levine-Raskey, 2011).
1717
Another important gap is also the lack of attention by intersection-
ality scholars to issues of health across the lifespan. Importantly,
there is near universal agreement that continued efforts are required
to advance strategies for applying intersectionality in not only
qualitative and quantitative studies but also mixed method designs.
Moreover, there are specic areas of research and policy where
the implications of intersectionality are only starting to be
explored. To date, the relationship of intersectionality to biomedi-
cine is just beginning to be interrogated (e.g. Kelly, 2009; van Mens-
Verhulst & Radtke, 2006; Weber, 2006) but scholars are pointing to
the potential for drawing on intersectionality to more fully explore
the complex social processes that become inscribed on to the body.
And although evidence on intersectionality in the context of clinical
nursing practices is emerging, namely how acknowledging and
responding to privilege and oppression and the associated power
dynamics transforms therapeutic encounters (Browne, Smye et al.,
2011; Reimer-Kirkham & Sharma, 2011; Van Herk, Smith, &
Andrew, 2011), this is also another area ripe for further research.
Finally, innovative approaches to intersectionality-based policy
analysis models are starting to take shape but require sustained
efforts to realize their full potential (Hankivsky & Cormier, 2011).
Conclusion
Although applications of intersectionality are still developing,
emerging research does show that theoretical foundations do
inuence 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 limi-
tations of research that emphasizes pre-determined classications
(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. Signicantly, 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 presump-
tion 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 connes of established frameworks is not, however,
about making gender invisible. Viewing gender within a logic of
intersectionality certainly redenes 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
1718 O. Hankivsky / Social Science & Medicine 74 (2012) 1712e1720
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 womens health or mens health? To a great extent
these elds are based on identity politics. They assume, for
example, that the members of a social category face similar prob-
lems 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 elds. Gender and health researchers may also
nd 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 predomi-
nately attending to gender inequality towards policies that address
various interlocking strands of inequality. The adoption of inter-
sectionality in these jurisdictions is seen as necessary for the
development of inclusive and better quality policies.
In the nal analysis, while dealing with multiple and inter-
secting dimensions is difcult 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 rmly 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 elds of womens
health, mens health, and gender health should continue to explore,
discuss and debate the implications of intersectionality and nd
ways to more systematically adopt and apply intersectionality as
a framework for improving understandings of and responses to the
complexities of peoples lives and experiences.
Acknowledgments
I would like to thank the Gender and Health Working Group at
Columbia University for their insightful feedback on an earlier
version of this paper, my editors Lisa Bates and especially Kristen
Springer, for their steadfast support and encouragement. I would
also like to thank the anonymous reviewers of this article as well as
Lynn Weber, Rita Kaur Dhamoon and Ange-Marie Hancock for their
comments on earlier drafts of this paper. Thank you to Gemma
Hunting for assistance with references. Finally I acknowledge the
support of the Canadian Institutes of Health Research, the Michael
Smith Foundation for Health Research, the Robert Wood Johnson
Health & Society Scholars Program and the Center for the Study of
Social Inequalities and Health at Columbia University.
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