Adopting an intersectionality framework to address power and equity in medicine

Responses to police brutality and the disproportionate effects of COVID-19 among ethnic minority populations have widened realisations about racism, and social and health inequities.¹ Typically, medical institutions such as the Association of American Medical Colleges outline their position against racism¹ separately from their mission for achieving gender equity.² However, in western settings, the downstream effects of medical education on doctors and patients is shaped by patriarchal and colonial histories and values.3, 4 Patriarchal cultures in medicine constrain women doctors’ career choices and progression internationally.⁵ Medical textbooks reinforce norms based on Whiteness by under-representing racial and ethnic minorities—eg, different presentations and clinical signs for patients with darker skin tones.⁶ Exporting western biomedical knowledge to other global settings reinforces inequality.³ Dismantling the power structures in medicine, however, requires complex thinking that goes beyond focusing on one dimension at a time—eg, patriarchy or racism. This requirement is also relevant to the decolonising global health movement.

Medical institutions need to turn their lens towards intersectionality—the inextricable way that factors such as race, class, gender, disability, and sexuality intersect to shape each other within broader structures and processes of power.⁷ Intersectionality has its roots in Black feminist scholarship⁸ and its transformative potential has been recognised in the context of global health⁷ and in medicine.⁴ However, as Sharma has argued: “to be truly transformative, any intersectional approach must grapple with the issue of power and privilege within medicine itself”.⁴ There is a need to scrutinise how medical institutions, which are increasingly working abroad in global health activities as well as at home, constrain or enable the critique of power structures and whether individuals working within those spaces analyse their own privileges, practices, and pedagogy to advance social justice.⁴

Recognition of systemic, intersecting inequities in professional medical culture begins by examining exclusion and discrimination in medical education, training, and workplace experiences. Western medicine is embedded with power structures³ that favour those racialised as White⁹ and cisgender and heterosexual men.4, 10 But experiences of marginalisation cannot be dissected, one social category at a time. For example, a White woman may experience relative advantage over a Black man during medical selection and training, despite the prevailing gender inequity in medicine. But it is also true that neither White women nor Black men are homogeneous in their experiences of advantage or disadvantage. Intersectionality points to other factors that shape inequities within groups—eg, disability, socioeconomic status, migration status, or sexuality. Challenging medical cultural norms and the system inequities they produce and reproduce starts with rejecting the idea that one system of inequality is more important than any other. Different inequities are intertwined and experienced simultaneously.

During medical training, implicit and explicit biases based on social stereotyping shape the identification, cultivation, and selection of individuals chosen for programmes and internships.¹¹ However few studies have examined the role of such biases on the relative lack of diversity in medicine, or how they operate through medical culture.¹⁰ Unconscious bias can contribute to systematic underestimation of the capabilities of qualified women and ethnic minority and internationally trained applicants. Importantly, medical education requires learning associations contingent on schemas (knowledge based on patterns) and can inadvertently teach stereotypes relating to social identity categories.¹⁰ Unconscious bias training will not address discrimination that results from explicit and intentional bias, but can increase awareness of how inequities are reproduced, without deliberate action challenging the broader structures and systemic practices that go beyond individuals.¹¹ Social diversity in medical recruitment panels and faculty composition can promote inclusion for historically marginalised individuals¹⁰ and lead to rethinking the skills and competencies of medical professionals. Recruiting from under-represented groups can help reduce health disparities in these communities.¹⁰ Key actors within institutions must engage in practices of cultural humility,¹⁰ including qualitatively examining experiences of marginalisation to recognise and address inequities. Visual audits of building and room names and the images in workplaces and websites can indicate the institutional messages about power and privilege being signalled to patients and doctors.

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The reinforcement of Whiteness norms and patriarchal practices in medicine should be recognised and challenged, from the medical simulation manikins used in teaching⁵ to the clinical handbooks used in practice.⁶ Including examples of patients’ intersectionality in medical curricula educates students on how experiences are shaped by the intersection of race, gender, class, and disability, which can create health inequities that are amplified by medical care.¹² The use of an intersectionality framework can improve diagnostic accuracy and protect against systematic biases that disproportionately affect marginalised patients.¹³ Biological and racial essentialism are embedded in medical research and education but are not rooted in scientific evidence5, 9 and can be challenged through use of an intersectionality framework. Importantly, intersectionality education and reflexivity skills training for medical students and doctors can make them aware of how their own social positions, values, and experiences shape their professional identities and approaches to patient care.¹² Positioning intersectionality into medical curricula signals institutional legitimisation of this approach and empowers individuals by recognising and confronting marginalisation. Intersectionality can also inform multilevel analysis of inequality outcomes— eg, generating more precise information about medical recruitment, retention, and doctors’ career progression.⁷ Such analysis identifies how inclusionary and exclusionary practices in medical culture shape individuals’ lives and at which intersections. Such fine-grained evidence will demonstrate each institution's commitment to dismantling intersecting power structures that impede the achievement of equity.