Sexism and Health: Advancing Knowledge Through Structural and Intersectional Approaches

During the first decade of the twenty-first century, research on the social determinants of health proliferated rapidly, with growing attention to factors such as neighborhood conditions, housing, employment, transportation, and education. Since then, researchers have increasingly turned their focus even further upstream to examine more macrolevel structural determinants of health (e.g., welfare state policy, globalization, income inequality, and structural racism). This trend reflects increasing awareness of how systemic inequity can be built into the fundamental social, economic, cultural, political, and legal institutions that shape individuals’ daily living conditions, medical care, and, ultimately, health.¹

Yet, one structural determinant in particular has received comparatively little attention in public health until recently: sexism. In fact, the word “sexism” rarely appears in the pages of leading public health journals. There are, however, substantial bodies of research examining sexual harassment, sexual violence, women’s health, and physician bias. These existing lines of research examine important types of direct, interpersonal gender-based mistreatment, but they do not capture more systemic, institutionalized forms of sexism. The inequitable gendered distribution of power, status, resources, rights, roles, exposures, and opportunities that characterizes a society’s gender structure has the potential to profoundly shape the health of its members. Thus, an emerging line of structural sexism and health research has begun to explore the health consequences of systematic gender inequality between men and women in power and resources, as manifest in institutions, interactions, and individuals.² Higher levels of structural sexism in state-level political, economic, and cultural institutions have been linked to more chronic conditions, worse self-rated health, and worse physical functioning in US men and women.²

The article by Rapp et al. in this issue of AJPH (p. 1796) builds on this nascent line of research by examining the relationship between structural sexism and health care access across the United States. I highlight the key contributions made by Rapp et al. and outline how the field can proceed to build a more robust knowledge of sexism and health using structural and intersectional perspectives.

EXPLORING PATHWAYS OF EMBODIMENT

Structural sexism is theorized to become embodied and shape population health through numerous pathways, including economic deprivation; reduced subjective social status and psychosocial resources (e.g., self-esteem and autonomy); exposure to violence, harassment, and unsafe living or working conditions; and inadequate health care.^1,2 Rapp et al. make a major contribution to knowledge of structural sexism by being among the first to examine how it affects barriers to health care among women. They find that greater exposure to state-level sexism is associated with more barriers to health care access (particularly affordability barriers such as the cost of medical bills, health insurance, prescriptions, and tests) among Black and Hispanic women in the United States. In their analysis, the authors control for Medicaid expansion under the Affordable Care Act, as it is not central to their argument, but there is clearly a need for future scholarship that more closely analyzes the connections between structural sexism and specific health care policies.

The findings of Rapp et al. also suggest that in addition to health care policy, any policies promoting gender equity are also likely to improve health care access among women of color. Health care is only one pathway through which sexism can harm health; therefore, much more research is needed to investigate the other social factors that function as mechanisms in this relationship. Future research exploring the social mechanisms will allow the development of other social policy interventions that can reduce gender inequity and shape social determinants in ways that improve population health.³

EXPANDING STRUCTURAL SEXISM MEASUREMENT

Another vital contribution made by Rapp et al. is their addition of new measures to capture state-level structural sexism. Previous research measured structural sexism with indicators that included women’s state legislative representation, the gender wage gap, the gender gap in labor force participation, the feminization of poverty, the prevalence of conservative religion, and the proportion of women who live in a county without an abortion provider. Rapp et al. identify two new measures of structural sexism in the social policy and legal domains that they add to their composite index: the absence of a paid family and medical leave policy and the absence of a state law restricting gun ownership for domestic violence offenders. Future work on structural sexism can incorporate these new measures and develop additional indicators reflecting different dimensions of structural sexism, such as gender-based job segregation; the underrepresentation of women in powerful business, professional, media, and governmental positions; and the curtailment of women’s bodily autonomy through cultural and legal issues of reproductive freedom and sexual violence.

Furthermore, although US states play a unique role as institutional actors shaping health,⁴ it is important to examine structural sexism in other social contexts. A more complete picture of structural sexism and health requires additional research examining structural sexism in other settings, such as religious institutions, neighborhoods, community organizations, schools, occupations, workplaces, and health care facilities.

STRUCTURAL SEXISM AND INTERSECTIONALITY

The final key contribution made by Rapp et al. is the application of an intersectional approach to structural sexism and health research. Rapp et al. are to my knowledge the first to identify the unique effects of state-level structural sexism on Black and Hispanic women. Their approach recognizes that sexism and racism do not operate entirely independently of one another but instead combine to jointly shape individual life experiences and health. The study by Rapp et al. takes the first important steps in this direction by incorporating an intersectional lens, but their approach to intersectionality is limited to the individual level by accounting for race and racism with individual racial identification categories.

Scholars can build on this work by using a structural intersectionality approach to population health.^5,6 A structural intersectionality approach would (1) measure structural sexism and structural racism (and other systems of oppression such as classism, heterosexism, cissexism, ageism, ableism, and nativism) in a given social context and explore how they relate to one another, and (2) examine how these structural inequalities jointly shape the health of various population groups defined by specific constellations of individual-level statuses (e.g., race, gender, class, sexuality, nativity, and disability).⁶ For example, future research can examine how structural racism, classism, and cissexism combine to shape the health of Black trans women. Although no single study can account for the myriad of intersecting identities and axes of oppression, a synthesis of structural and intersectional approaches is a promising avenue for future research.

CONCLUSIONS

As sociologists and epidemiologists increasingly turn upstream to understand the larger social forces driving population health, the study by Rapp et al. points to the importance of structural sexism. Rapp et al. provide vital new evidence of the relationship between systematic gender inequality and women’s health care access in the United States. Nevertheless, structural sexism research remains in a very early stage of development, and a great deal more work is needed to build the body of evidence documenting its associations with health and health care. Structural and intersectional perspectives like those employed by Rapp et al. are needed to further advance this emerging line of healthy equity research and to ultimately work toward a more just and healthier society.