Over the rainbow: research with an intersectional perspective

Posted by Dr Mark Adley, Research Associate, Newcastle University

• LGBTQ+ is an abbreviation for lesbian, gay, bisexual, transgender, queer or questioning, with the "+" sign recognising the multiple permutations of sexual orientation and gender identity.

• Intersectionality looks at how social inequities such as racism, sexism, or classism can interact and shape people’s social experiences.

"Reaching Out", pencil and pen drawing and digital collage by artist Sarah Li (2024)

In this Question and Answer blog, Mark shares some of his reflections on intersectionality when working with marginalised groups, and the importance of taking extra steps to make sure that the quieter voices are also heard. LGBTQ+ people are not a single group, and sexism, racism, classism and other social inequities can create unexpected intersections.

What was the focus of your PhD research project?
My PhD examined marginalisation in health and social care services in North East England, specifically looking at multiply marginalised LGBTQ+ people – those who had faced additional experiences of, for example, homelessness, substance use, racism, or domestic abuse. Seventy-two people across the region took part in interviews – 33 with professionals and 39 with marginalised LGBTQ+ people.

How would you explain intersectionality to someone new to the concept?
The shortest explanation would be that 1+1 does not equal 2. Intersectionality examines how different aspects of our identities can interact – creating unique experiences of discrimination. For example, a Black woman's experience isn't simply the addition of being Black plus being a woman. She may experience racism differently than a Black man, and she may experience sexism differently than a White woman. Her experiences as a Black woman are a unique intersection of race and gender. As Zora Neale Hurston perfectly captured in 1928: ‘I feel most coloured when I am thrown against a sharp white background’.

What challenges did you face in participant recruitment?
One major challenge was ensuring diverse representation. I noticed early on that lesbians and bisexual women were underrepresented, so I paused recruitment to address this. This led to an unexpected complexity – navigating the cultural and political debates around gender identity, particularly around use of the word ‘woman’ – and how to distinguish between cisgender and transgender women without causing offence.

How did you handle the sensitive terminology around gender identity?

It required extensive consultation with five women who held different perspectives on this issue. We eventually reached what I'd call a diplomatic compromise on language – while no one was completely satisfied, no one was seriously offended either. This highlighted the importance of careful navigation in sensitive cultural debates.

Recruitment flyers for lesbian, bi, queer, and pansexual women (left) and LGBTQ+ people of colour (right)

What adjustments did you make to ensure racial diversity in your study?

By March 2023 I had interviewed nine LGBTQ+ people from non-White British backgrounds, but only six were from non-White ethnic groups. After reflecting on the specific experiences of discrimination and invisibility shared by LGBTQ+ people of colour, I paused recruitment again. Following consultation with queer people from ethnically minoritised groups we rebranded the study, including removing rainbow imagery in favour of a brown background, as the rainbow was perceived as ‘very White-presenting’.

What key lessons did you learn about conducting research with an intersectional perspective?
The research required a constant shift in my own focus as a researcher. First, looking inward through reflexivity – examining my own unchecked biases and assumptions and their impact on how the study was conducted. Second, looking outward to understand the broader systems of power that influenced people’s experiences of marginalisation. It's a complex balance that requires both zooming in and out, while avoiding what has been called the ‘fetishization of complexity’.

The study’s key findings and recommendations

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Findings from the study are available in several formats

PDFs can be downloaded from the project’s website, with videos on YouTube and an Open Access scoping review published in BMC Health Services Research. Mark is involved in ongoing work exploring the experiences of LGBTQ+ people of colour, and collaborations with local organisations in consideration of intersectionality across the North East and Cumbria. To contact Mark or receive project updates via the mailing list click here.
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This study was funded by the National Institute for Health and Care Research (NIHR) Applied Research Collaboration (ARC) North East and North Cumbria (NENC) (NIHR200173). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

Stigma: Where’s the Harm?

Posted by Dr Michelle Addison, Assistant Professor, Durham University

Stigma is a knotty, ugly problem we have in society: it marks out (often painfully) what is considered shameful, abject or contra to social norms, and impacts vulnerable and marginalised people the most. It seems intuitive to say it is unfair and unjust, but why then does it persist? 

Discussions of stigma are not new; we are all generally aware that stigma is something to be avoided and we could all very likely give some examples of it in action – benefit claimants, people who use drugs and ex-offenders are often easy targets and regularly feature in news headlines because stigma continues to be sensational – it elicits a voyeuristic feeling that is both intoxicating and a warning to us too. The use of stigma is further exacerbated by the ‘Cost of Living Crisis’, ‘Rising Interest Rates’, Fuel and Food poverty, and the withholding of the Government White Paper on Health Inequalities. We understand then that stigma is harmful, and yet we recognise it is powerful to those who can wield it.  

Erving Goffman discussed stigma using the concept of the ‘spoiled identity’ whereby certain aspects of who you are become discredited and devalued in his now infamous work Stigma: Notes on the Management of Spoiled Identity (1963/1990). This notion of a spoiled identity is also implicit in his observations of patients residing in ‘asylums’, the conditions impacting these people, and the roles of those working there (1961). Indeed, Goffman was acutely interested in the medicalisation and performance of roles in these settings and how behaviour was shaped by social expectations of ‘in-mates’, ‘guards’ and ‘medical staff’. The treatment of patients, he noted, was complexly bound up with expectations of socially acceptable roles and the reinforcement of discredited behaviours and identity.

What we learnt from this is that stigma matters in the social organisation and hierarchies of people and places in medicalised and wider social settings. But what tends to fly under the radar in early stigma research is the question of ‘in whose interests’ does stigma serve?  Professor Imogen Tyler later critiques Goffman’s work (2020) in her book ‘Stigma: The Machinery of Inequality’ for overlooking the power relations that are integral to how we understand stigma, and why indeed, stigma continues to persist. Tyler shows us that there is a ‘craft’ to how mechanisms of stigma operate and function to maintain political power and a social order that hinges on systemic and structural inequalities around class, race, gender (and not limited to) to reproduce privilege for the dominant factions. This is a hugely important step in stigma research because it draws attention upstream to how and why stigma is weaponised (Scambler, 2018) and the social harms that impact marginalised and minoritised individuals and communities in society – which is the subject of my forthcoming article (Addison, 2023). This is further evident in the recent Stigma Kills (2021, 2022) campaign launched by the NHS Addictions Provider-Alliance which gives credence in particular to the impact that stigma has on the health and wellbeing of those communities that are most harmed through health and social inequality.

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Stigma Kills. But it shouldn't have to be this way.

Introducing our new #StigmaKills campaign. https://t.co/wgVnROwb5P pic.twitter.com/Rc35eCxo1M

— NHS Addictions Provider Alliance (@NHS_APA) February 8, 2022

This growing concern about the effects of stigma on health and wellbeing, arising out of social harm, led to our recent Fuse event Inequalities, Social Harm and Weaponised Stigma: Emerging Research and future priorities which brought together academics, practitioners and the public to discuss these key issues. I presented work from my Wellcome Trust research looking at stigma and how this relates to health inequalities amongst people who use drugs. In this study I highlight how the weaponisation of stigma is harmful, negatively impacts physical and mental health, and inhibits health seeking behaviours for fear of being judged and marginalised by service providers and the wider public.

Joanne McGrath discussed her NIHR funded research into women living with multiple disadvantage and complex needs and how they access services. In this talk she highlighted how escalating problems around homelessness, stigma and deteriorating physical and mental health have a cumulative impact in women’s lives.

Our ‘expert by experience’, Margaret Ogden, shared moving insights into the effects of stigma on her own life and how her mental health was harmed as a result.

Later, Mark Adley discussed his Doctoral work (which is funded by the NIHR Applied Research Collaboration (ARC) North East and North Cumbria (NENC)) and his recently published paper which explores stigma within-groups towards people who use the drug Spice. In this talk, Mark showed how intersections of identity mattered and how increased contact with people who used Spice helped to reduce levels of stigma. He highlighted the role of education programmes within service provision to help draw attention to the harms arising out of stigma and how practitioners might mitigate these effects.

This event was also an opportunity to launch our new Palgrave edited collection Drugs, Identity and Stigma (Addison, McGovern and McGovern, 2022). Our book calls attention to the impact of stigma experienced by people who use illicit drugs, and through this we show that stigma is powerful: it can do untold harm to a person and place with longstanding effects. Through an exploration of themes of inequality, power, and feeling ‘out of place’ in neoliberal times, this collection focuses on how stigma is negotiated, resisted and absorbed by people who use drugs. Dr Kelly Stockdale, a contributor to the book, spoke at our Fuse event and shared insights from our research into the challenges of navigating a custodial environments (prison and police) and the impacts of stigma from the point of view of people who use novel psychoactive substances (NPS). Collectively, our work in this area brings together a range of frameworks and data and draws attention to the damaging effects stigma can have on health inequalities, recovery, mental health, recidivism, and social inclusion.

Our knowledge and understanding of the harms that stigma does to health and wellbeing is still growing – as such, it is critical that developing stigma research becomes a priority in future inequalities research agendas, against a backdrop of political and economic crises. Whilst the social determinants of health are often tangible and measurable, providing the much-needed evidence base to tackle widening health inequalities, it is imperative that we think differently and critically about how stigma operates. In my own research I have tried to show that stigma operates at a symbolic level meaning it is not possible to treat stigma as something which is material and objective, to say ‘here is stigma’ – we must think more deeply about stigma as inscribed with meaning that becomes apparent through its effect on and between people (see also Addison, McGovern and McGovern, 2022).

I called this blog ‘Stigma: Where’s the harm?’ to be a little provocative to you, reader – on the one hand, stigma is so normalised in our society that we forget to see it, so I encourage you to pause and reflect on where the harm resides – like a million little paper cuts, stigma is painful and gets under the skin doing very real harm. On the other hand, my question is also a call to action to understand how and why stigma is weaponised, and how it leads to social harm amongst under-heard and underserved people. It is my strong belief that this is vital work if we are to tackle and reduce widening health and social inequalities right now.  

 

References:

Addison, M. (forthcoming, March 2023) ‘Framing Stigma as an Avoidable Social Harm that Widens Inequality’ in Emery, J., Powell, R., and Crookes, L. (eds.) The Sociological Review Special Issue

ADDISON, M., MCGOVERN, W. & MCGOVERN, R. E. (eds.) (2022) Drugs, Identity and Stigma, Houndsmill, Basingstoke and Hampshire, Palgrave Macmillan.

ADLEY, M., ATKINSON, A. M. & SUMNALL, H. R. (2022). Including the multiply excluded: a mixed methods study exploring intragroup stigma towards people who use synthetic cannabinoid receptor agonists. Drugs: Education, Prevention and Policy. DOI: 10.1080/09687637.2022.2025766

GOFFMAN, E. (1990) Stigma: Notes on theManagement of Spoiled Identity, London, Penguin Books

GOFFMAN, E. (1961) Asylums: Essays on the Condition of the Social Situation of Mental Patients and Other Inmates, London, Penguin Books

SCAMBLER, G. (2018). ‘Heaping blame of shame: 'Weaponising stigma' for neoliberal times’. The Sociological Review Monograph, 66, 766 - 782.

SINGH, S. (2019) available at: https://samiasingh.com/

TYLER, I. (2020). Stigma, The Machinery of Inequality, London, Zed Books.

Images:

1) Artwork by Samia Singh, https://samiasingh.com @samiasingh_art

2) Book: Drugs, Identity and Stigma, © 2022 Springer Nature Switzerland AG. Part of Springer Nature, ISBN : 978-3-030-98285-0, https://link.springer.com/book/10.1007/978-3-030-98286-7#about-this-book

Intersectionality: buzzword or key to tackling health inequalities?

Posted by Dr Daniel Holman, Professor Sarah Salway, Dr Andrew Bell, University of Sheffield

Intersectionality – the idea that multiple axes of inequality overlap and interact – arguably holds great potential to understand and tackle health inequalities. But what do researchers and those working in policy and practice in this area actually think about the approach? What do they see as the key challenges and opportunities? We held a professional stakeholder workshop and consultation survey to find out. Our findings indicated a ‘cautiously optimistic’ view of an intersectional health perspective.

A growing interest in intersectionality and health

Intersectionality is currently something of a buzzword. A search of the scientific literature reveals an explosion in interest, with an eight-fold increase in papers mentioning the term in the last ten years, and a twenty-fold increase for those mentioning both ‘intersectionality’ and ‘health’:

Figure 1 - SCOPUS documents mentioning both 'intersectionality' and 'health' in title, abstract or keywords

The interest in applying intersectionality to health research, and specifically health inequalities research, has now also been fuelled by the pandemic. Ethnicity, deprivation, and age strongly influence Covid-19 outcomes. Calls for intersectional analysis of Covid-19 have now been published in BMJ Global Health and The Lancet.

Yet recent events have indicated significant political barriers. The Sewell Report essentially explained away ethnic health inequalities with reference to socioeconomic factors – anathema to intersectionality – and last year the UK Government declared itself ‘unequivocally against’ Critical Race Theory (within which intersectionality is rooted).

Further, policy-making is a process of dialogue, negotiation and ‘knowledge interaction’, with power relationships, varied sources of ‘evidence’ and competing drivers clearly at play. So, we should not expect the concept to straightforwardly impact how health inequalities are understood and addressed.

Theory vs. practice

In theory, intersectionality offers a critical, innovative approach for understanding and tackling diverse health inequalities. It essentially concerns the power structures and processes that drive these inequalities, and seeks to highlight how unjust systems of discrimination such as racism, sexism and classism operate in tandem to result in unequal, unfair life chances. The animation video below gives an overview of the approach:

 

Putting intersectionality to work entails a number of practical challenges. Many of our participants thought the term sounded like just another buzzword, questioning what it adds. Concerns were raised about the complexity of intersectionality both as a conceptual and methodological framework. For resource-strapped public health teams this was felt to be a particular barrier. Complexity can sometimes inhibit action because policy making processes support simplicity and certainty.

Methodologically, intersectionality includes a danger of over-disaggregation. Working with finer and finer categories to produce a granular picture of inequalities risks losing sight of the processes of disadvantage that impact across groups of people. Questions were also raised over how we can reveal mechanisms including discrimination, use mixed methods and participatory approaches, include marginalised populations, and access large, high quality datasets that intersectional analyses might require.

How might intersectionality actually be implemented? We asked respondents to consider two suggestions

First was the idea of using intersectionality to target and tailor interventions and policies. This raised numerous concerns that it potentially takes focus away from structural changes; assumes that all those in a particular intersection are the same; excludes those who do not fall into the targeted category, and; reinforces deficit and stigmatising narratives. Nonetheless, respondents thought that targeting could have value if marginalised groups were included in the process. They also suggested that geography should be considered when targeting as it is a key aspect of social context.

Second was the idea of monitoring and evaluating the impact of policies and programmes on different sub-groups. This approach was more popular, with participants keen to be able to demonstrate differential and unanticipated outcomes of initiatives. Again, the importance of meaningful engagement of marginalised groups and careful attention to understanding mechanisms, were highlighted.

What is the way forward? Our participants emphasised some key principles and points of action:

• Ensure a clear focus on systems of social discrimination and how they structure access to power, resources and life chances, especially via social institutions (such as schools).
• Wherever appropriate, participatory and co-productive approaches - entailing more equitable knowledge-production – should be used.
• Carefully consider complexity; arguably intersectionality’s biggest asset and challenge. What constitutes the right level of complexity and in which context? Trade-offs are inevitable.
• Develop clear methodological guidelines, possibly in the form of a toolkit, to help with implementing intersectionality, especially for non-academics with limited research resources.
• Big datasets with well measured social variables are essential.

Intersectionality holds much promise. It has the potential to help ensure that those experiencing multiple discrimination are not further disadvantaged by the Covid recovery phase. Acknowledging and addressing potential pitfalls and limitations of the approach is therefore crucial. Marginalised populations, researchers, policy and practice professionals all need to be part of the conversation.

To read more about the project from which this research originated, please take a look at the project website: http://intersectionalhealth.org