INTRODUCTION

From both the perspective of social determinants of health and the socio anthropological perspective of health and disease, the fields of public health and collective health have long since contemplated the social markers of class, gender and race/ethnicity as important references in the analysis of differentiations in social inequalities.^1,2 More recently, other social markers such as sexual orientation and generation have been incorporated as important empirical and conceptual references in studies regarding health inequalities among different social sectors as well as those focused on sociocultural processes in health, disease, death, and care in specific or minority social groups.^3,4

The categories of social differentiation, or markers of social differentiation, can be defined as social constructions established prior to the existence of the subjects that work together to produce greater or lesser social inclusion or exclusion depending on the positions occupied by each subject in the classification systems; that is, the way in which social positions are represented, the type of social control exercised over subjects, and the subjects’ agency in the complex social system in which they are immersed. Additionally, in the process of shaping the social identities of subjects, social markers act dynamically, fluidly and flexibly based on particular historical contexts, power dynamics, and according to privileges and structural processes of oppression.

Intersectionality has recently emerged as an alternative and promising theoretical and methodological option in analyses that look into the dynamics and complexities of the interactions of social markers at the individual, institutional and structural levels by taking into consideration the multiple levels of articulation of social markers in the production of the social processes of domination and oppression and their impacts in the health-disease process.⁵

Originating in the American critical feminist production on race and gender at the end of the 1980s and beginning of the 1990s,⁶ intersectionality constitutes a theoretical-methodological perspective of a transdisciplinary character oriented toward understanding the complexity of identities and their relationships with social inequalities. Using an integrated approach, the epistemic base of which is rooted in the refutation of the compartmentalization and hierarchization of markers of social difference (gender, class, race, ethnicity, disability and sexual orientation),⁷ the intersectionality movement has grown within different disciplines, and has also questioned rigid disciplinary borders, constructing bridges for debate in methodological and theoretical terms. In this sense, since the start of the 2000s there has been an extrapolation of intersectionality, from an approach centered in critical black feminist thought to consider the experiences of black women in systems of oppression, to the analysis of a broad set of topics, objects, and social groups in Europe and countries like the US and Canada.⁶

In Latin America, given the existence of profound social inequalities, markers of class, gender, and race have been a part of academic debates and political agendas in the region for over two decades,⁸ especially due to public and political interventions of black women in the feminist movement. Looking mainly at the experiences of poor, black or Afro-descendant women, discussions of topics such as the position of women in the labor market, public and private forms of violence, health issues, and representations of women in the media signal social and health inequalities and oppressive processes that deepen when analyzed from a racial perspective. The supposedly universal female gender, installed in society at that time, made invisible the experiences of oppression of these women. After this universalizing category was rejected by local black feminists in Brazil, guidelines were established by governmental agencies to generate actions that could combat social inequalities based on gender and racial disparities.⁹

The approach of intersectionality has been critically utilized by Latin American researchers, highlighting that the analysis of social inequalities marked simultaneously by class, gender and race/ethnicity must be carried out in conjunction with a critique of the colonizing, capitalist and globalized system of subordination characteristic of local societies.^8,10 This system of power socially classifies subjects and, in the social hierarchy, relegates as inferior those who do not match the physical and sexual stereotype of the occidental colonizer: male, white, heterosexual, middle or upper class. Colonialism penetrates all aspects of social life, presenting itself in material domination as well as in people’s personal experiences.¹⁰⁾ Among other aspects, compulsory heteronormative sexuality is highlighted in terms of class, gender and citizenship status.¹¹

In the feminist academic production of the last decade, intersectionality has been deemed the most important theoretical contribution of feminism,¹² given its promising attempt to constitute both a theoretical approach and approach for the production of empirical investigations;¹³ in addition to serving the renewed political impetus of feminist academic production. As can be seen in reviews from the fields of psychology,¹⁴ sociology,¹⁵ and public health,^16,17 the acceptance of intersectionality as a perspective, approach, or field of study is growing.¹⁸

In relation to health-disease processes, intersectionality has been gradually incorporated into the field of public health.^16,17,18,19 For authors like Hankivsky,¹⁹ intersectionality is a research paradigm, the aim of which is to consider the complexity surrounding the creation and maintenance of health disparities. Taking into account the dissemination and growing utilization of intersectionality in research on disparities and inequalities in health-disease processes, and the lack of studies analyzing the state of the issue in the field of public and collective health, this study seeks to answer the following questions: What is the current state of the theoretical-methodological debate of intersectionality in the field of public and collective health? How do authors in the field utilize the theoretical language and methodological justifications of intersectionality? What are the possibilities and limitations of intersectionality in the study of health inequalities and inequality in the contemporary agenda of public and collective health? The final objective is to situate the theoretical-conceptual and methodological debate of intersectionality in the field of public and collective health.

METHODS

We present a descriptive-analytic narrative review based on the scientific production of different areas of study that mention the incorporation of intersectionality in topics of public and collective health. Selection criteria: the articles selected were published in Spanish, English or Portuguese and consisted of essays of a theoretical or methodological character, that discussed intersectionality in the field of public and collective health or topics related to that field, such as: disparities in health care; inequalities and health; gender and health; sexual orientation and health; race, ethnicity and health; social class and health. Exclusion criteria: Articles based on empirical studies were excluded, both those of a qualitative and of a quantitative nature, as were those that only cited intersectionality without discussing the incorporation, potential and/or limitations of the approach in the field, the topic or object under study.

In relation to the operational process, the selection phase of the articles through the screening of titles was carried out independently by two researchers, and a third researcher weighed in on any discrepancies found. All researchers took part in the phase of full-text reading, data extraction and development of the interpretative analysis.

The searches were carried out in April 2017. In the first, in the PubMed portal, the nomenclature most sensitive to the research question was identified: intersectionality AND (“health” OR “health”). The search was applied in all the databases except Sociological Abstracts, in which the term intersectionality did not exist and the word intersection was used. In the different scientific literature databases, combinations of search terms were utilized based on the nomenclature accepted by each source.

In the search strategy, seven informational resources were used, six of which were scientific literature databases: Web of Science (multidisciplinary); Embase (biomedicine and health sciences); CINAHL - Cumulative Index to Nursing and Allied Health Literature (nursing, biomedicine and health sciences); Scopus (multidisciplinary); Sociological Abstracts (sociology); LILACS - Literatura Latinoamericana y del Caríbe en Ciencias de la Salud, (biomedicine and health sciences); and the portal Pubmed, which encompasses Medline (biomedicine and health sciences). In the second phase, the references listed in the selected publications were examined to find those not captured in the previous searches.

The analysis of the material began with the extraction of information regarding the authors (gender and country of institutional affiliation of the lead author) and the articles (year and journal of publication). Information was then sought regarding the topics under investigation, the markers of social difference included, and the theoretical references on intersectionality cited. In the following phase, the articles were grouped into three themes: 1) theoretical-methodological debates on intersectionality and health; 2) social markers of gender, race, ethnicity and sexual orientation, intersectionality and health; and 3) health policies and practices. Based on these themes, the articles were read with the objective of understanding the general content and identifying the conceptual framework. In the last phase, the different thematic nuclei were compared in terms of the theoretical-methodological incorporation of intersectionality and the final interpretive analysis was carried out.

RESULTS AND DISCUSSION

The initial search strategy yielded 1,763 articles, which were exported into the citation manager EndNote Web to eliminate duplicates. Once excluded (n=629), 1,134 articles remained. After reading the titles and abstracts 1,106 were eliminated, and 28 articles remained to be read in full text that met established inclusion criteria. Two articles found after the exploration of the references of the material read in full text were added. Therefore, 30 articles were included in the corpus (Figure 1).

Source: Own elaboration.

Figure 1 - Flow diagram of the selection of articles on intersectionality in the field of public and collective health. 2017. 

Editorials, commentaries, theses, dissertations and book chapters were among the 1,106 references excluded, as well as articles from the areas of education, psychology, law, news media that discuss intersectionality, but without connection to the health field. Regarding the empirical articles excluded, although an intersectionality methodology was used in the research practice, they did not include the deep methodological-theoretical discussion central to this article.

In relation to the year of publication, the first studies are from 2006 and a growing tendency can be seen over the last 12 years, with a greater concentration in 2014, with seven articles, and 2016, with six. In relation to the country of origin, considering the institutional affiliation of the lead author, the countries that most contributed were the US (n=13), Canada (n=10) and Australia (n=3). The journals that published the selected articles are varied yet concentrated - as would be expected - in the health field. If only these last two aspects are considered - country of origin and journal in which the articles are published - it is worth recognizing that in this literature review, the intersectionality approach in the health field is strongly produced in developed English-speaking countries. The production is also mostly female, given that women are the lead authors (first or corresponding authors) in 27 articles. The social markers considered were: race, ethnicity, social class, gender, generation, sexual orientation, migratory status, geographic location and socioeconomic status.

Table 1 presents the selected articles, classified according to themes and authorship; with the years of publication, the gender of the lead author, the name of the journal, the country of academic affiliation of the lead author and the social markers included.

FINAL CONSIDERATIONS

The work analyzed - including both articles taking on theoretical, epistemological and methodological debates and those that examine well-established issues in the field of public and collective health - strongly calls for the field to move towards the incorporation of intersectionality, given its potential to support empirical studies and formulate health policies committed to social justice in the face of growing health inequalities worldwide.

According to the studies analyzed, research into the social determinants of health is particularly significant in Canada and has historically oriented critical analyses of health-disease processes. This area of research has incorporated the most feminist perspective of intersectionality. The search to overcome the reductionist tendencies increasingly present in the examination of the social determinants of health, added to the need to include other aspects of social life beyond those related to economic dimensions (work, housing, sanitation, education, income, etc.), brings authors like Bauer²², Nygren, Olofsson¹⁶ and Hankivsky¹⁹ to the feminist social theory of intersectionality. This approximation has to do with recognizing that science can produce not only a scientific paradigm, but a social one as well: that of a decent life.⁵²

To this end, it is recommended that care be taken on a theoretical-methodological level. These precautions include avoiding hierarchization of categories of social difference in comprehending processes of oppression and marginalization that shape health inequalities. Given their complexity, these processes require multiple analytical approaches, historical contextualization and the articulation of different social categories to understand the empirical reality that creates them.

Another aspect to consider, based on the work analyzed here, is the multidimensionality of the markers of social differentiation in the processes of health inequalities which cannot be understood using “arithmetical” operations, merely adding multiplying, dividing or subtracting markers. This precept appeared in the studies debating theories and methodologies as well as in those from thematic areas such as gender and women’s health - significantly more advanced in the application of an intersectionality perspective - and HIV-AIDs, sexual and reproductive health, health of LGBTQ+ populations, and race, ethnicity and cultural minorities.

In conclusion, intersectionality, originally stemming from the field of feminist studies, has come to contribute to the field of public and collective health given its capacity to establish itself as a theoretical perspective and a framework for empirical research. The analysis of the production carried out shows the growing acceptance of the perspective, the tensions and challenges it poses for the health field, and above all, the recognition that exists that this perspective can shed light on and broaden the view of both well-established and novel issues and objects in conceptual and methodological terms. The growing application of intersectionality in studies in the health field, and the ensuing debates, reinvigorate interdisciplinary production in public and collective health.