Intersectionality

Starting with a common understanding of key words, phrases, and potentially misunderstood related terms in DEI discussions helps ensure that all participants feel informed and welcome to participate in the discussion. Some terms have multiple definitions provided to help highlight nuances in the definitions.

Intersectionality: "The complex, cumulative way in which the effects of multiple forms of discrimination (such as racism, sexism, and classism) combine, overlap, or intersect especially in the experiences of marginalized individuals or groups."¹

Intersectionality: "The theory that various forms of discrimination centered on race, gender, class, disability, sexuality, and other forms of identity do not work independently but interact to produce particularized forms of social oppression. As such, oppression is the result of intersecting forms of exclusionary practices. It is thus suggested that the study of identity-based discrimination needs to identify and take account of these intersectionalities..."²

Intersectionality: "A metaphor for understanding the ways that multiple forms of inequality or disadvantage sometimes compound themselves and create obstacles that are often not understood within conventional ways of thinking about anti-racism or feminism or other social justice advocacy structures we have."³

Intersectionality: "Intersectionality theory provides a dynamic research model - a prism through which to analyze a range of social problems to ensure inclusive remedies and greater collaboration across social movements. Intersectionality moves beyond traditional frameworks that separate social problems into discrete challenges facing specific groups. It starts from the premise that people have multiple identities, and being members of more than one 'group,' they can simultaneously experience oppression and privilege. Intersectionality sheds light on the unique experiences that are produced when various forms of discrimination intersect with these converging identities. It is a dynamic strategy for linking the grounds of discrimination (e.g., race, gender, class, sexual identity, etc.) to historical, social, economic, political, and legal contexts and norms that intertwine to create structures of oppression and privilege."⁶

Intersectionality: "Intersectionality comes from the work of black feminist scholars and activists. It argues identities such as gender, race, sexuality, and other markers of difference intersect and reflect large social structures of oppression and privilege, such as sexism, racism, and heteronormativity. The reach of intersectionality now extends to the fields of public health and knowledge translation, which is a field of study and practice that aims to synthesize and evaluate research into an evidence base and move that evidence into health care practice."⁷

This section highlights the definitions of other words that may be used in discussion of this topic. Sometimes these words can be used interchangeably with the terms defined above, and sometimes they may have been used interchangeably historically, but have distinct meanings in DEI conversations that is helpful to recognize.

People will sometimes misuse the term intersectionality or intersectional to mean diverse (i.e. "We, an intersectional team of scientists..." or "This patient population exhibits high intersectionality."). When speaking about intersectionality, the primary meaning of the word is a framework for understanding overlapping social barriers and benefits. Use of the term as a descriptor (i.e. "intersectional") is often fraught with error.

As many users may have varying amounts of time to present this material, the authors have recommended which resources they would use with different timeframes for the presentation.

For a 1-minute presentation: Use the first minute of this Kimberle Crenshaw video to help explain intersectionality and cause reflection.

For a 10-minute presentation: Start with this brief video covering what intersectionality is, followed by the discussion question about what identities we each hold.

For a 30-minute presentation, Option A: Use the majority of the time watching this Kimberle Crenshaw Ted Talk, followed by the discussion questions.

For a 30-minute presentation, Option B: Start with this brief video about intersectionality and health, followed by the role playing scenarios.

This section provides an overview of this topic so that an educator who is not deeply familiar with it can understand the basic concepts in enough detail to introduce and facilitate a discussion on the topic. This introduction covers the importance of this topic as well as relevant historical background.

The term intersectionality was originally coined by Columbia law professor Kimberle Crenshaw. Professor Crenshaw is well known as a critical race theory scholar and civil rights activist. In 1989, Professor Crenshaw had witnessed an African American woman lose a court case where she alleged discrimination based on both her race and her gender that prevented her from getting a job with General Motors. The judge in the case ruled that a person could only allege one type of discrimination - she was either discriminated against due to her gender or her race, but it could not be both. The woman lost the case as the judge claimed that the employer had previously hired both African American or black men as well as white women so they could not be discriminating against the black woman. There was no acknowledgement that she could have been discriminated against due to both her race and her gender. This is the point in time when Professor Crenshaw felt there was a need for a new conceptual framework to help describe the intersection of more than one social identity that could lead to compounded discrimination.⁴ She wrote the paper “Demarginalizing the Intersection of Race and Sex: Black Feminist Critique of Antidiscrimination Doctrine, Feminist Theory and Antiracist Politics” which was instrumental in further describing the concept of intersectionality and how it helps explain the oppression of African American or black women.⁵

The term intersectionality was initially created and used solely in the academic arena. However the term is now considered mainstream, and the definition has shifted from helping to describe how African American women experience oppression to helping to describe how any person with overlapping social identities experience oppression or discrimination. Professor Crenshaw says this is not how she initially intended the framework to be used, but acknowledges the term applies to more than the black female.¹¹

Intersectionality was added as a word to the Oxford Dictionary in 2015.⁹ It is now frequently used in many non-academic arenas. For example, it is frequently used when discussing the higher incidence of police brutality in African American or black women which has resulted in increased awareness of this specific problem.⁴ It was also widely used during the Women’s March in 2017.⁹ It has even been used in the political arena, where to say its connotation is polarized is an understatement.⁹ Intersectionality has gone from solely a conceptual framework to better understand oppression and discrimination to a tool being used by activists for change.

As a concept and tool, intersectionality is crucial to uphold in DEI initiatives. While it is beneficial to concentrate on individual groups and develop broad frameworks for diversity and inclusion efforts, these methods may not fully capture the intricate dynamics present at the intersections of various identities and personal experiences.²⁰

While the term now encompasses various overlapping identities such as race, socioeconomic status, gender, and sexual orientation, it is underpinned by three core principles:

1. Patterns of discrimination and resulting inequalities are interconnected and cannot be understood by examining only one aspect of identity.
2. The interplay between different identities must be analyzed within the context of societal institutions and their power structures.
3. Though initially focused on addressing health disparities, an intersectional perspective also uncovers unique strengths and resilience within communities, which can be leveraged to improve public health outcomes.^5,20

It is important to recognize that examples of intersectionality can be observed across all aspects of society. In her TED Talk, "The Urgency of Intersectionality," Crenshaw discusses how people often struggle to understand facts that contradict their existing frames of reference. For instance, while police killings of unarmed black men are widely known, the similar fates of unarmed black women often go unnoticed. Crenshaw emphasizes the critical role of frames in shaping our understanding of social issues, noting that how we frame facts can either illuminate or obscure the true nature of social injustices. This concept is central to her discussion on intersectionality, as it underscores how different social categories intersect to create unique experiences of marginalization.¹⁹

Dr. Kimberly Eckstrand et al. developed six recommendations for advancing intersectional approaches in academic medicine.²⁰

1. Embrace Personal and Collective Loci of Responsibility: recognize historical and ongoing abuses in medicine, align professional responsibilities to address these, and ensure physician trainees can tackle these issues by graduation to foster innovative healthcare solutions.
2. Examine and Rectify Unbalanced Power Dynamics: address systemic inequalities by involving diverse stakeholders and supporting and celebrating efforts to make impactful change.
3. Celebrate Visibility and Intersectional Innovation: shift from a health equality focus to a health equity focus. Avoid a one-size-fits-all approach and instead embrace tailored strategies based on unique identities and foster community-oriented research and training while creating safe spaces for diverse ideas.
4. Engage All Stakeholders in the Process of Change: involve all members of the academic medical community and external stakeholders in promoting inclusive perspectives and challenging unconscious biases through training programs.
5. Select and Analyze Meaningful Metrics: use innovative and nuanced metrics to evaluate diversity and inclusion, ensuring transparency and diverse stakeholder involvement.
6. Sustain the Commitment to Achieving Multidimensional Participation and Health Equity: establish sustainable quality improvement processes to maintain intersectional health equity initiatives.

This section highlights the objective data available for this topic, which can be helpful to include to balance qualitative or persuasive analysis or to help define a starting point for discussion.

"African American girls are six times more likely to be suspended than white girls. That's probably a race and gender problem, it's not just a race problem and it's not just a gender problem."³

Trans people are at a higher risk of suicide than the general population, and trans people experiencing domestic violence are significantly more at risk than the rest of the trans population. "...those who were physically attacked in a place of public accommodation reported attempting suicide in the past year, which is over four times the prevalence among respondents who were not similarly attacked."¹³

Maternal Mortality Rate: Black women in the United States are 3-4 times more likely to die from pregnancy-related causes than white women.¹⁵

Severe Maternal Morbidity: Black women experience higher rates of severe maternal morbidity compared to white women, with disparities persisting even after controlling for socioeconomic status and access to healthcare.¹⁶

Depression and Anxiety: Gay black men experience higher rates of depression and anxiety compared to heterosexual black men and white gay men, due to stigma, discrimination, and intersectional minority stress.¹⁷

Transgender Discrimination in Healthcare: Transgender black people are more likely to experience discrimination in healthcare settings. The USTS found that 19% of black transgender respondents were refused medical care due to their gender identity, compared to 8% of white transgender respondents.¹⁸

Black Medical School Matriculants: Although the number of black medical school matriculants have remained stagnant for the past three decades, the number of black male matriculants has declined while the number of black female matriculants has increased.²⁰

Images and graphical representations can clarify concepts and enhance interest. Please cite the sources of these images appropriately if you use them in your presentation, found below. We purposefully avoided providing complete slide decks in this curriculum, and instead opted to offer easy building blocks for a great personalized presentation regardless of the format.

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This section should help the facilitator anticipate any questions, naysayers, rebuttals, or other feedback they may encounter when presenting the topic and allow preparation with thoughtful responses. Facilitators may experience concerns about their personal ability to present a specific DEI topic (i.e. a white facilitator presenting on antiracism or minority tax), and this section may address some of those tensions.

Due to its popularization and colloquialization, intersectionality has been misconstrued by many, including those attempting to understand it as a framework in good faith. One popular misconception is that intersectionality is a 'popularity contest of oppression,' or a theory which states that the person with the most cumulative oppressed identities is the person who gets the final say in matters of morals or ethics. Intersectionality as a conceptual framework makes no arguments about the morality or ethics of different beliefs, as it is a descriptive tool used to identify how the logic of oppression is utilized, changed, and upended by different compounding advantages and disadvantages.

Sometimes DEI topics can present depressing history and statistics. This section highlights glimmers of hope for the future: exciting projects, areas of study inspired by the topic, or even ironic twists where progress has emerged or may be anticipated in the future.

#SayHerName is a social movement to bring awareness to the increased rate of police brutality and violence against black women. The movement has shown a strong backing to bring about social reform and justice.

The questions below could start a meaningful discussion in a group of EM physicians on this topic. Consider brainstorming follow-up questions as well.

1. In the emergency department, how have you seen aspects of someone's social identity influence biases like premature closing or anchoring? What are other ways you have seen decision-making be influenced by this?
2. To what extend to you feel our personal identities affect how we provide care to others?
3. Are there certain aspects of your identity that you most easily relate to with patients (i.e. seeing someone of your same race or religion)? How does this end up affecting how you care for them?

The authors summarize their key points for this topic below. This could be useful to create a presentation closing.

1. Intersectionality is an analytical framework that incorporates the various identities held by a subject and examines how those identities form a unique compound identity which may experience aspects of oppression or privilege differently from their separate component identities.
2. Compound or 'intersectional' identity is important because a person may experience oppression that is unique to their compound identity, which is often not expressly defended by Title VII, Title IX, etc.
3. Intersectionality can and has been expounded on to help better understand why oppression may look different between similar groups of individuals, despite some shared characteristics.

Meaningful and relevant quotations (appropriately attributed) can be used to enhance presentations on this topic.

"That man over there says that women need to be helped into carriages, and lifted over ditches, and to have the best place everywhere. Nobody ever helps me into carriages, or over mud-puddles, or gives me any best place! And ain't I a woman?" -Excerpt from "Ain't I a Woman?" speech attributed to Sojourner Truth, spoken at the 1851 Women's Convention in Akron, Ohio.

The importance of this quote highlights the necessity of an intersectional analysis of opression. Sojourner Truth is a black woman speaking to an audience almost entirely comprised of white women. She points out she shares the same identity of 'woman' with the other members of the audience, yet she has never been treated the same way due to her status as a former slave and a black woman living in America. Her experience as a woman is categorically different from the white audience because her experience has been defined by more than one category.

Below are links to Emergency Medicine-specific resources for this topic.

1. Women in Medicine Modules: Women of Color. This module aims to develop comprehensive strategies to recruit, retain, and promote women of color; define and review examples of intersectionality; discuss strategies for success balanced with maintaining authenticity and identity in the workplace; and more.

Below are links to educational resources or supportive programs in the community that are working on this topic.

1. Center for Intersectionality and Social Policy Studies at the Columbia Law School. The director of this center is Professor Kimberle Crenshaw. The goal of this center is to provide a place for collaborative research over inequities and policy, as well as provide opportunities for open dialogue and advocacy.
2. Black Women's Health Through the Twin Pandemics. Episode in the "Intersectionality Matters with Kimberle Crenshaw" podcast series.
3. Under the Blacklight: COVID in Confinement. Episode in the "Intersectionality Matters with Kimberle Crenshaw" podcast series.
4. Under the Blacklight: The Intersectional Vulnerabilities that COVID Lays Bare. Episode in the "Intersectionality Matters with Kimberle Crenshaw" podcast series.
5. At the Intersection of Asian + American + Female + Physician + Leader (7a). Episode in "The DEI Shift" podcast series.
6. At the Intersection of Asian + American + Female + Physician + Leader (7b). Episode in "The DEI Shift" podcast series.
   

Below are links to videos that do an excellent job of explaining or discussing this topic. Short clips could be used during a presentation to spark discussion, or links can be assigned as pre-work or sent out for further reflection after a presentation.

1. Intersectionality 101. Learning for Justice. YouTube.

2. What is Intersectionality? National Association of Independent Schools. YouTube.

3. The Urgency of Intersectionality. TedWomen. YouTube.

4. Intersectionality and Health Explained. Sociological Studies Sheffield. YouTube.

1. Who invented the term 'intersectionality' in its current usage, and what specific circumstances were being discussed when the term was introduced?
2. True or False: intersectionality only examines the different ways in which people are oppressed by a society.
3. What can examining patients and the care we give through an intersectional lens answer for us?

1. Kimberle Crenshaw, Columbia law professor discussing the discrimination suit against an auto manufacturer who did not hire a black woman.
2. False - intersectionality helps examine both the oppressive forces and the privilege that affects someone through different facets of their identity.
3. Intersectionality can help us contextualize patient circumstances to better empathize with our patients, and helps us to scrutinize our own biases in service of delivering an equitable level of care to every patient that we see in the emergency department.

Below is a statement that inspires participants to commit to meaningful action related to this topic in their own lives. This could be used to prompt reflection, discussion, or could be used in presentation closing.

Intersectionality has transformed from merely a conceptual framework that started back in the seventies to a social movement for change today. Kimberle Crenshaw said it best, "if we aren't intersectional, some of us, the most vulnerable, are going to fall through the cracks."

All references mentioned in the above sections are cited sequentially here.

1. Intersectionality. Merriam-Webster Dictionary.
2. Intersectionality. Oxford Reference.
3. What is Intersectionality? National Association of Independent Schools. YouTube.
4. Kimberle Crenshaw on Intersectionality, More than Two Decades Later. Columbia Law.
5. Demarginalizing the Intersection of Race and Sex: A Black Feminist Critique of Antidiscrimination Doctrine, Feminist Theory, and Antiracist Politics. University of Chicago Legal Forum. Volume 1989, issue 1, article 8.
6. Center for Intersectionality and Social Policy Studies at Columbia Law School.
7. Kelly C, Kasperavicius D, Duncan D, et al. 'Doing' or 'Using' Intersectionality? Opportunities and Challenges in Incorporating Intersectionality into Knowledge Translation Theory and Practice. Int J Equity Health.
8. Kang M, Lessard D, Heston L, Nordmarken S. Introduction to Women, Gender, Sexuality Studies: Grounding Theoretical Frameworks and Concepts. UMass Amherst.
9. Coaston J. The Intersectionality Wars. Vox.
10. Taylor B. Intersectionality 101: What is it and Why is it Important? Womankind Worldwide.
11. Perlman M. The Origin of the Term Intersectionality. Language Corner.
12. Intersectional Health.
13. Herman JL, Brown T, Haas A. Suicide Thoughts and Attempts Among Transgender Adults. Williams Institute School of Law.
14. Attr. Sojourner Truth, December 1851. Internet Modern History Sourcebook: Sojourner Truth: "Ain't I a Woman?"
15. Hoyert DL. Maternal Mortality Rates in the United States. NCHS Health E-Stats.
16. Howell EA. Reducing Disparities in Severe Maternal Morbidity and Mortality. Clin Obstet Gynecol.
17. Meyer I, et al. Social Patterning of Stress and Coping: Does Disadvantaged Social Statuses Confer More Stress and Fewer Coping Resources? American Journal of Public Health.
18. Transgender Survey: Report on the Experiences of People of Color. National Center for Transgender Equality.
19. Crenshaw K. The Urgency of Intersectionality. TED Conferences.
20. Eckstrand KL, Eliason J, St Cloud T, Potter J. The Priority of Intersectionality in Academic Medicine. Academic Medicine.