The death of George Floyd, a 46-year-old black man, at the hands of police galvanized worldwide, sweeping conversations about race relations and police brutality. Protests occurred concurrently within the context of the COVID-19 pandemic and its disproportionate burden of illness and death on African American/black and Latina/Hispanic people.1 These events have coalesced to create opportunities for broader conversations about long-standing health disparities, marginalization, microagressions, and inequities. Many health care providers and staff, including nurses, have contributed to these important discussions and have joined protest marches by taking up the mantra that Black Lives Matter as they seek to understand how they might contribute to meaningful and sustained change, particularly change related to social determinants of health and health outcomes.
Nurses and health care colleagues may benefit from examining models and concepts that provide critical lenses through which to view troubling aspects of the health care system that are in great need of deliberate, purposeful change. Persistent inequities and stigma contribute to disparate health outcomes between white people and members of less privileged groups. Institutional racism influences health care system encounters in ways that are detrimental to the health of those who may already be particularly vulnerable to health compromise. Implicit biases are instilled into most people from their life experiences and culture.2 These biases lead to automatic discriminatory practices and responses on an unconscious level that are likely unrecognized by the perpetrators but typically recognized by communication recipients.
Intersectional stigma or intersectionality is a concept that facilitates understanding as to how varied stigmatized identities of individuals or groups collectively affect health, well-being, and life experiences. Conceptual understanding of intersectional stigma initially developed in response to seeking a more robust analysis of the interchange between race, gender/sex, and class.3 When an individual has more than 1 stigmatized identity, these intersecting stigmas have a compounding effect on the overall stigma impacting the individual or group.
Intersectional stigma is complex, and its influence on health outcomes and risks is not fully elucidated. However, the importance of coming to a better understanding of intersectional stigma is widely accepted,3 particularly so that nurses and other health professionals can design interventions that can buttress positive identity-building strategies and stigma-reduction approaches. Intersectionality is an important component of holistic nurse practice as this concept relates to the whole being and the varied ways that stigma, including biases expressed by nurses, affects health.
Intersectional theory recognizes that individual differences such as race, poverty, gender expression, or sexual orientation collectively contribute to stigma and not in mathematical fashion. Health professionals need to give thought to the inequities and power differentials that are related to intersectional stigma so that the lived experiences and circumstances of individuals and groups are more fully appreciated and health interventions are appropriately designed and provided. Turan et al2 assert that intersectional stigmas cluster into categories that include physical health ailments, affiliations with marginalized groups, and factors attributed to moral failings and behaviors. They note
Interventions that deal solely with a single health-related stigma, without considering the co-experience of stigmas, marginalization, and resilience associated with other conditions, identities, or behaviors, are likely to have limited success in reducing health disparities and making lasting improvements in health.2(p2)
People may belong to several stigmatized groups, and the intersections of these stigmas are associated with worsened outcomes.
Nurses may find value in a composite vignette describing a nurse practitioner's (NP's) public health practice experience. The NP described the challenges confronting low-income, HIV-positive young black women. These women experienced stigma related to their race, class, sex, age, and HIV status, and this stigma had a markedly adverse effect on their opportunities to achieve their best potential health status. The NP commented that people living with mental-behavioral health diagnoses, substance use challenges, nonconforming gender identities, nonheterosexual orientations, nonwhite ethnicities, and many other characteristics often experience marginalization, a critical influence on health. She recognized this marginalization by noting that individuals with these attributed characteristics are often deprived of resources, humiliated, exploited, and devoid of political and economic power. The NP also observed that some of these women found support in groups with other women similarly stigmatized. Published literature supports that there are opportunities for diminishing the effects of intersectionality by encouraging supportive group processes and relationships.2 More research is needed to explore potential opportunities to counter intersectionality. This vignette illustrates the intersectional stigma that nurses and others are obliged to explore and address as a means of creating socially just systems of health care delivery.
Intersectional analysis of race and stigma provide opportunity for enhanced understanding of intra- and intergroup differences in health outcomes of interest, and this richer understanding may inform improved interventions.4 Hogan et al3
identify shifts in thinking about racism and its effects on health explicated by findings from a qualitative study exploring the life experiences of black, white, and mixed-race Brazilian women. Intersections of race, class, and gender were found to attract additional layers of disadvantage that adversely affected the children of these women as well as their other familial and nonfamilial charges.4 Hogan et al3 make the case that racism is a critical social determinant of health and that intersectionality must be considered because the solutions to some of the barriers to good health require understanding of nuances and complexities that are probably underappreciated when considered from a singular rather than intersectional viewpoint.
Nurse researchers and interprofessional scientists are challenged to establish valid and reliable tools for measuring intersectional stigma. These tools will be important to future efforts focused on determining effective interventions to address intersectionality. Turan et al2 note that drivers and mechanisms of intersectional stigma need description and interpretation. Nurse and physician educators need a science-driven understanding of intersectionality to create learning environments and experiences that assist students in their interactions with individual patients and groups so that implicit biases and microaggressions, often related to stigma, are eliminated from the health care experience. Microaggressions are subtle, intentional, or nonintentional behavioral manifestations of bias related to privileged position and implicit bias. Examples of microagressions might include expressions of surprise when a person of color identifies employment as a chief executive officer or when a person from a minority group introduces his or her role as that of physician or nurse researcher.
Hall and Carlson4 remind nurses of their obligation to understand the sociopolitical process underlying marginalization because of the profession's duty to promote political and social justice related to health care. Hall and Carlson4 revisit the concept of marginalization with incorporation of newer scholarship pertaining to globalization, intersectionality, privilege, microaggressions, and implicit biases. Nurses interested in broadening their understanding of marginalization are encouraged to consider this work. Nurses and health professionals should also reflect on microaggressions and privilege as they consider intersectionality and their personal contribution to perpetuating stigma. Privilege, unearned advantages that accumulate to an “in-group based on ideologies of supremacy and structural inequities stemming from historical roots,”4(p206) must be seriously considered by nurses and other health professionals, including the ways that privilege manifests within organizational structures and nurse-patient encounters.
The recent events triggered by yet another death of an African American man at the hands of police in the midst of a relentless pandemic that is claiming an unequal burden on black and brown people have led to opportunities for reimagining a collective future that is just and equitable. Nurses have a responsibility to contribute to this future. A first step in this change process is to carefully and respectfully listen and learn. Intersectionality provides a lens of understanding and a portal to assist holistic care providers in recognizing stigma, marginalization, implicit bias, and microaggressions and responding to these challenges as individuals and as professionals who enjoy the varied privileges bestowed on nurses.
1. Centers for Disease Control and Prevention. COVID-19 in racial and ethnic minority groups. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/racial-ethnic-minorities.html
. Updated June 4, 2020. Accessed June 15, 2020.
2. Turan JM, Elafros MA, Logie CH, et al. Challenges and opportunities in examining and addressing intersectional stigma and health. BMC Med. 2019;17:7. doi:10.1186/s12916-018-1246-9.
3. Hogan VK, de Araujo EM, Caldwell KL, et al. “We black women have to kill a lion everyday”: an intersectional analysis of racism and social determinants of health in Brazil. Soc Sci Med. 2018;199:96–105. doi:10.1016/j.socscimed2017.07008.
4. Hall JM, Carlson K. Marginalization: a revisitation with integration of scholarship on globalization, intersectionality, privilege, microaggressions, and implicit biases. ANS Adv Nurs Sci. 2016;39:200–215.