This article advances the field by integrating insights from intersectionality perspectives with the emerging literatures on structural racism and structural sexism—which point to promising new ways to measure systems of inequality at a macro level—to introduce a structural intersectionality approach to population health. We demonstrate an application of structural intersectionality using administrative data representing macrolevel structural racism, structural sexism, and income inequality in U.S. states linked to individual data from the Behavioral Risk Factor Surveillance System to estimate multilevel models (N = 420,644 individuals nested in 76 state-years) investigating how intersecting dimensions of structural oppression shape health. Analyses show that these structural inequalities: (1) vary considerably across U.S. states, (2) intersect in numerous ways but do not strongly or positively covary, (3) individually and jointly shape health, and (4) are most consistently associated with poor health for black women. We conclude by outlining an agenda for future research on structural intersectionality and health.
AgénorMadina. 2020. “Future Directions for Incorporating Intersectionality into Quantitative Population Health Research.”American Journal of Public Health110(6):803–806. doi:10.2105/AJPH.2020.305610.
2.
AilshireJennifer A.HouseJames S.2011. “The Unequal Burden of Weight Gain: An Intersectional Approach to Understanding Social Disparities in BMI Trajectories from 1986 to 2001/2002.” Social Forces90(2):397–423.
3.
AllisonPaul D.2001. Missing Data. Thousand Oaks, CA: SAGE Publications, Inc.
AneshenselCarol S.2005. “Research in Mental Health: Social Etiology Versus Social Consequences.”Journal of Health and Social Behavior46(3):221–28.
6.
AssariShervin. 2018. “Health Disparities Due to Diminished Return among Black Americans: Public Policy Solutions.”Social Issues and Policy Review12(1):112–45.
7.
AssariShervinLankaraniMaryam MoghaniBurgardSarah. 2016. “Black–White Difference in Long-Term Predictive Power of Self-Rated Health on All-Cause Mortality in United States.”Annals of Epidemiology26(2):106–14.
8.
BaileyZinzi D.KriegerNancyAgénorMadinaGravesJasmineLinosNataliaBassettMary T.2017. “Structural Racism and Health Inequities in the USA: Evidence and Interventions.”The Lancet389(10077):1453–63.
9.
BoenCourtneyKeisterLisaAronsonBrian. 2020. “Beyond Net Worth: Racial Differences in Wealth Portfolios and Black–White Health Inequality across the Life Course.”Journal of Health and Social Behavior61(2):153–69.
10.
BowlegLisa. 2012. “The Problem with the Phrase Women and Minorities: Intersectionality—An Important Theoretical Framework for Public Health.”American Journal of Public Health102(7):1267–73.
11.
BravemanPaulaGottliebLaura. 2014. “The Social Determinants of Health: It’s Time to Consider the Causes of the Causes.”Public Health Reports129(Suppl. 2):19–31.
12.
BrownTyson H.2018. “Racial Stratification, Immigration, and Health Inequality: A Life Course–Intersectional Approach.”Social Forces96(4):1507–40.
13.
BrownTyson H.HargroveTaylor W.2018. “Psychosocial Mechanisms Underlying Older Black Men’s Health.”Journals of Gerontology, Series B: Psychological Sciences and Social Sciences73(2):188–97.
14.
BrownTyson H.RichardsonLiana J.HargroveTaylor W.ThomasCourtney S.2016. “Using Multiple-Hierarchy Stratification Approaches to Understand Health Inequalities: The Intersecting Consequences of Race, Gender, SES and Age.”Journal of Health and Social Behavior57(2):200–22.
15.
ChaeDavid H.CloustonSeanMartzConnor D.HatzenbuehlerMark L.CooperHannah L. F.TurpinRodmanStephens-DavidowitzSethKramerMichael R.2018. “Area Racism and Birth Outcomes among Blacks in the United States.”Social Science & Medicine199(2018):49–55.
16.
ChandolaTaraniJenkinsonCrispin. 2000. “Validating Self-Rated Health in Different Ethnic Groups.”Ethnicity & Health5(2):151–59.
17.
ChenYing-YehSubramanianS. V.Acevedo-GarciaDolorosKawachiIchiro. 2005. “Women’s Status and Depressive Symptoms: A Multilevel Analysis.”Social Science & Medicine60(1):49–60.
18.
ChoSumiCrenshawKimberlé WilliamsMcCallLeslie. 2013. “Toward a Field of Intersectionality Studies: Theory, Applications, and Praxis.”Signs: Journal of Women in Culture and Society38(4):785–810.
19.
ChooHae YeonFerreeMyra Marx. 2010. “Practicing Intersectionality in Sociological Research: A Critical Analysis of Inclusions, Interactions and Institutions in the Study of Inequalities.”Sociological Theory28(2):147–67.
20.
CohenPhilip N.1998. “Black Concentration Effects on Black-White and Gender Inequality: Multilevel Analysis for U.S. Metropolitan Areas.”Social Forces23:208–28.
21.
ColenCynthia G.2011. “Addressing Racial Disparities in Health Using Life Course Perspectives: Toward a Constructive Criticism.”Du Bois Review: Social Science Research on Race8(1):79–94. doi:10.1017/S1742058X11000075.
22.
ColenCynthia G.KruegerPatrick M.BoettnerBethany L.2018. “Do Rising Tides Lift All Boats? Racial Disparities in Health across the Lifecourse among Middle-Class African Americans and Whites.”SSM – Population Health35(6):125–35.
23.
CollinsJames W.DavidRichard J.2009. “Racial Disparity in Low Birth Weight and Infant Mortality.”Clinics in Perinatology36(1):63–73.
24.
CollinsPatricia H.2000. Black Feminist Thought: Knowledge, Consciousness, and the Politics of Empowerment. New York, NY: Routledge.
CotterDavid A.HermsenJoan M.VannemanReeve. 1999. “Systems of Gender, Race, and Class Inequality: Multilevel Analyses.”Social Forces78(2):433–60.
27.
CrenshawKimberle. 1991. “Mapping the Margins: Identity Politics, Intersectionality, and Violence against Women.”Stanford Law Review43(6):1241–99.
28.
CummingsJason L.JacksonPamela Braboy. 2008. “Race, Gender, and SES Disparities in Self-Assessed Health, 1974–2004.”Research on Aging30(2):137–67.
29.
DavisKathy. 2008. “Intersectionality as Buzzword: A Sociology of Science Perspective on What Makes a Feminist Theory Successful.”Feminist Theory9(1):67–85.
30.
DillBonnie T.ZambranaRuth E.2009. “Critical Thinking about Inequality: An Emerging Lens.” Pp. 1–21 in Emerging Intersections: Race, Class, and Gender in Theory, Policy, and Practice, edited by DillB T.ZambranaR. E.Piscataway, NJ: Rutgers University Press.
31.
FrankMark W.2014“A New State-Level Panel of Annual Inequality Measures over the Period 1916–2005.”Journal of Business Strategies31(1):241–63.
32.
GeeGilbert C.FordChandra L.2011. “Structural Racism and Health Inequities.”Du Bois Review: Social Science Research on Race8(1):115–32.
33.
GkioulekaAnnaHuijtsTimBeckfieldJasonBambraClare. 2018. “Understanding the Micro and Macro Politics of Health: Inequalities, Intersectionality and Institutions—A Research Agenda.”Social Science & Medicine200 (2018):92–98.
34.
GlennEvelyn Nakano. 1992. “From Servitude to Service Work; Historical Continuities in the Racial Division of Paid Reproductive Labor.”Signs: Journal of Women in Culture and Society18(1):1–43.
35.
GreenMark A.EvansClare R.SubramanianS. V.2017. “Can Intersectionality Theory Enrich Population Health Research?”Social Science & Medicine178(2017):214–16.
36.
GrollmanEric Anthony. 2012. “Multiple Forms of Perceived Discrimination and Health among Adolescents and Young Adults.”Journal of Health and Social Behavior53(2):199–214.
37.
GrollmanEric Anthony. 2014. “Multiple Disadvantaged Statuses and Health: The Role of Multiple Forms of Discrimination.”Journal of Health and Social Behavior55(1):3–19.
38.
GroosMayaWallaceMaeveHardemanRachelTheallKatherine P.2018. “Measuring Inequity: A Systematic Review of Methods Used to Quantify Structural Racism.”Journal of Health Disparities Research and Practice11(2):190–206.
39.
HargroveTaylor W.2018. “Intersecting Social Inequalities and Body Mass Index Trajectories from Adolescence to Early Adulthood.”Journal of Health and Social Behavior59(1):56–73.
40.
HarnoisCatherine ELuiz BastosJoãoKeithVernaCampbellMary. 2019. “Measuring Perceived Mistreatment across Diverse Social Groups: An Evaluation of the Everyday Discrimination Scale.”Social Science & Medicine232(2019):298–306.
41.
HarnoisCatherine E.BastosJoão LuizShariff-MarcoSalma. 2020. “Intersectionality, Contextual Specificity and Everyday Discrimination: Assessing the Difficulty Associated with Identifying a Main Reason for Discrimination among Racial-Ethnic Minority Respondents.”Sociological Methods & Research. doi:10.1177/0049124120914929.
42.
HartChloe GraceSapersteinAliyaMagliozziDevonWestbrookLaurel. 2019. “Gender and Health: Beyond Binary Categorical Measurement.”Journal of Health and Social Behavior60(1):101–18.
43.
HatzenbuehlerMark L.McLaughlinKatie A.KeyesKatherine M.HasinDeborah S.2010. “The Impact of Institutional Discrimination on Psychiatric Disorders in Lesbian, Gay, and Bisexual Populations: A Prospective Study.”American Journal of Public Health100(3):452–59.
HillTerrence D.JorgensonAndrew. 2018. “Bring out Your Dead!: A Study of Income Inequality and Life Expectancy in the United States, 2000–2010.”Health & Place49(2018):1–6.
46.
HomanPatricia. 2019. “Structural Sexism and Health in the United States: A New Perspective on Health Inequality and the Gender System.”American Sociological Review84(3):486–516.
47.
hooksbell. 1984. Black Women Shaping Feminist Theory. ProQuest Information and Learning.
48.
HudsonDarrell L.PutermanEliBibbins-DomingoKirstenMatthewsKaren A.AdlerNancy E.2013. “Race, Life Course Socioeconomic Position, Racial Discrimination, Depressive Symptoms and Self-Rated Health.”Social Science & Medicine97(2013):7–14.
49.
IdlerEllen L.BenyaminiYael. 1997. “Self-Rated Health and Mortality: A Review of Twenty-Seven Community Studies.”Journal of Health and Social Behavior38(1):21–37.
50.
IdlerEllenCartwrightKate. 2018. “What Do We Rate When We Rate Our Health? Decomposing Age-Related Contributions to Self-Rated Health.”Journal of Health and Social Behavior59(1):74–93. doi:10.1177/0022146517750137.
51.
JacksonPamela BraboyWilliamsDavid R.2006. “The Intersection of Race, Gender, and SES: Health Paradoxes.” Pp. 131–62 in Gender, Race, Class, & Health: Intersectional Approaches, edited by SchulzA. J.MullingsL.New York: Jossey-Bass/Wiley.
52.
JacobySara F.DongBeidiBeardJessica H.WiebeDouglas J.MorrisonChristopher N.2018. “The Enduring Impact of Historical and Structural Racism on Urban Violence in Philadelphia.”Social Science and Medicine199(2018):87–95.
53.
JylhäMarjaGuralnikJack M.FerrucciLuigiJokelaJukkaHeikkinenEino. 1998. “Is Self-Rated Health Comparable across Cultures and Genders?”Journals of Gerontology Series B: Psychological Sciences and Social Sciences53(3):S144–52.
54.
KavanaghShane A.ShelleyJulia M.StevensonChristopher. 2017. “Does Gender Inequity Increase Men’s Mortality Risk in the United States? A Multilevel Analysis of Data from the National Longitudinal Mortality Study.”SSM – Population Health3(2017):358–65.
55.
KawachiIchiroKennedyBruce P.GuptaVanitaProthrow-StithDeborah. 1999. “Women’s Status and the Health of Women and Men: A View from the States.”Social Science & Medicine48(1):21–32.
56.
KingDeborah K.1988. “Multiple Jeopardy, Multiple Consciousness: The Context of a Black Feminist Ideology.”Signs: Journal of Women in Culture and Society14(1):42–72.
57.
KoenenKarestan C.LincolnAlisaAppletonAllison. 2006. “Women’s Status and Child Well-Being: A State-Level Analysis.”Social Science & Medicine63(12):2999–3012. doi:10.1016/j.socscimed.2006.07.013.
58.
KriegerNancy. 2014. “Discrimination and Health Inequities.”International Journal of Health Services44(4):643–710.
59.
KriegerNancy. 2020. “Measures of Racism, Sexism, Heterosexism, and Gender Binarism for Health Equity Research: From Structural Injustice to Embodied Harm—An Ecosocial Analysis.”Annual Review of Public Health41:37–62.
60.
LichterDaniel T.ParisiDomenicoTaquinoMichael C.2015. “America’s Segregated States.” Pp. 30–36 in Pathways: Poverty and Inequality Report 2015, edited by GruskyD.VarnerC.MattinglyM.Palo Alto, CA: Stanford Center on Poverty and Inequality.
61.
PhelanJo C.LinkBruce G.. 2015. “Is Racism a Fundamental Cause of Inequalities in Health?”Annual Review of Sociology41:311–30.
62.
LucasSamuel Roundfield. 2013. Just Who Loses?Philadelphia, PA: Temple University Press.
63.
LukachkoAliciaHatzenbuehlerMark L.KeyesKatherine M.2014. “Structural Racism and Myocardial Infarction in the United States.”Social Science & Medicine103(2014):42–50.
64.
MasseyDouglas S.DentonNancy A.1993. American Apartheid: Segregation and the Making of the Underclass. Cambridge, MA: Harvard University Press.
65.
McCallLeslie. 2005. “The Complexity of Intersectionality.”Signs: Journal of Women in Culture and Society30(3):1771–800.
66.
McGeeDaniel L.LiaoYoulianCaoGuichanCooperRichard S.1999. “Self-Reported Health Status and Mortality in a Multiethnic US Cohort.”American Journal of Epidemiology149(1):41–46.
67.
MesicAldinaFranklinLydiaCanseverAlevPotterFionaSharmaAnikaKnopovAnitaSiegelMichael. 2018. “The Relationship between Structural Racism and Black-White Disparities in Fatal Police Shootings at the State Level.”Journal of the National Medical Association110(2):106–16.
68.
MetzlJonathan. 2019. Dying of Whiteness: How the Politics of Racial Resentment Is Killing America’s Heartland. New York: Basic Books.
69.
MontezJennifer KarasHaywardMark D.WolfDouglas A.2017. “Do U.S. States’ Socioeconomic and Policy Contexts Shape Adult Disability?”Social Science & Medicine178(2017):115–26.
70.
MontezJennifer KarasHaywardMark D.ZajacovaAnna. 2019. “Educational Disparities in Adult Health: U.S. States as Institutional Actors on the Association.”Socius: Sociological Research for a Dynamic World 5. doi:10.1177/2378023119835345
71.
MontezJennifer KarasZajacovaAnnaHaywardMark D.2016. “Explaining Inequalities in Women’s Mortality between U.S. States.”SSM – Population Health2(2016):561–71.
72.
MullerChristopherWildemanChristopher. 2016. “Geographic Variation in the Cumulative Risk of Imprisonment and Parental Imprisonment in the United States.”Demography53(5):1499–509.
73.
PearsonJay A.2008. “Can’t Buy Me Whiteness: New Lessons from the Titanic on Race, Ethnicity, and Health.”Du Bois Review: Social Science Research on Race5(1):27–47.
74.
PickettKate E.WilkinsonRichard G.2015. “Income Inequality and Health: A Causal Review.”Social Science & Medicine128(2015):316–26.
75.
PirtleWhitney N. LasterWrightTashelle. 2021. “Structural Gendered Racism Revealed in Pandemic Times: Intersectional Approaches to Understanding Race and Gender Inequalities in COVID-19.”Gender & Society35(2):168–79. doi:10.1177/08912432211001302.
76.
RaginCharles C.FissPeer C.2017. Intersectional Inequality: Race, Class, Test Scores, and Poverty. Illustrated ed. Chicago, IL: University of Chicago Press.
77.
RaginCharles C.FissPeer C.2020. “The Logic of Intersectionality.” Paper Presented at the Annual Meeting of the American Sociological Association, August10, virtual conference.
78.
ReskinBarbara.2012. “The Race Discrimination System.”Annual Review of Sociology 38:17–35. doi:10.1146/annurev-soc-071811-145508.
79.
RichardsonLiana J.BrownTyson H.2016. “(En)gendering Racial Disparities in Health Trajectories: A Life Course and Intersectional Analysis.” Social Science & Medicine: Population Health2(2016):425–35.
80.
RobertsHelen. 1997. “Socioeconomic Determinants of Health: Children, Inequalities, and Health.”BMJ314(7087):1122–25.
81.
SchulzAmy J.MullingsLeith, eds. 2006. Gender, Race, Class, and Health: Intersectional Approaches. San Francisco, CA: Jossey-Bass.
82.
SewellAbigail A.2016. “The Racism–Race Reification Process: A Mesolevel Political Economic Framework for Understanding Racial Health Disparities.”Sociology of Race and Ethnicity2(4):402–32.
83.
SzymanskiAlbert. 1976. “Racial Discrimination and White Gain.”American Sociological Review41(3):403–14.
84.
TaylorCatherine J.2019. “Health Consequences of Laws and Public Policies that Target, or Protect, Marginalized Populations.”Sociology Compass14(2):1–13. doi:10.1111/soc4.12753.
85.
TurnerR. JayBrownTony N.HaleWilliam B.. 2017. “Race, Socioeconomic Position, and Physical Health: A Descriptive Analysis.”Journal of Health and Social Behavior58(1):23–36.
WallaceMaeveCrear-PerryJoiaRichardsonLisaTarverMeshawnTheallKatherine. 2017. “Separate and Unequal: Structural Racism and Infant Mortality in the US.”Health & Place45(2017):140–44.
88.
WeberLynn. 2010. Race, Class, Gender, and Sexuality: A Conceptual Framework. New York: Oxford University Press.
89.
WeberMax. [1922] 1946. “Class, Status, Party.” Pp. 180–95 in From Max Weber: Essays in Sociology, edited by GerthH. H.MillsC. W. Reprint, New York: Oxford University Press.
90.
WarnerDavid F.BrownTyson H.2011. “Understanding How Race-Ethnicity and Gender Define Age-Trajectories of Disability: An Intersectionality Approach.”Social Science & Medicine72(8):1236–48.
91.
WhitfieldKeith E.AllaireJasonBelueRhondaEdwardsChristopher L.2008. “Are Comparisons the Answer to Understanding Behavioral Aspects of Aging in Racial and Ethnic Groups?”Journals of Gerontology, Series B: Psychological Sciences and Social Sciences 63B(5):P301–308.
92.
WilkinsonRichard G.PickettKate E.2009. “Income Inequality and Social Dysfunction.”Annual Review of Sociology35:493–511.
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