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Critical Public Health

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Intersectionality and the determinants

of health: a Canadian perspective
a b
Olena Hankivsky & Ashlee Christoffersen
a
Public Policy Program and Institute for Critical Studies in Gender
and Health, Simon Fraser University , Vancouver, Canada
b
Institute for Critical Studies in Gender and Health, Simon Fraser
University , Vancouver, Canada
Published online: 30 Sep 2008.

To cite this article: Olena Hankivsky & Ashlee Christoffersen (2008) Intersectionality and the
determinants of health: a Canadian perspective, Critical Public Health, 18:3, 271-283, DOI:
10.1080/09581590802294296

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 Critical Public Health
Vol. 18, No. 3, September 2008, 271–283

Intersectionality and the determinants of health: a Canadian perspective

Olena Hankivskya* and Ashlee Christoffersenb
a
Public Policy Program and Institute for Critical Studies in Gender and Health, Simon Fraser
University, Vancouver, Canada; bInstitute for Critical Studies in Gender and Health,
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Simon Fraser University, Vancouver, Canada

(Received 13 January 2008; final version received 12 June 2008)

Despite Canada’s leadership in the field of population health, there have been few
successes in reducing the country’s health inequities. There is an increasing
recognition that regardless of the progress made to date, significant gaps remain
in comprehending fully the root causes of inequities, including the complex ways
in which the determinants of health relate, intersect and mutually reinforce one
another. Calls are being made to draw on the theoretical insights of critical social
science perspectives to rethink the current framing of health determinants.
The aim of this paper is to contribute to the theoretical project of population
health by exploring the innovative paradigm of intersectionality to better
understand and respond to the ‘foundational’ causes of illness and disease,
which the health determinants perspective seeks to identify and address. While
intersectionality has taken hold among health researchers in the United States,
the United Kingdom and Canada, the transformative potential of this approach
in the context of health determinants is largely unexamined.
Keywords: intersectionality; feminism; health inequalities; healthy public policy

Introduction
Canada has been a world leader in research related to the determinants of health; many see
this as directly related to its commitment to social justice, universal health care and
equality. Despite the interest, activity, and resources being deployed in this area of research
and policy, significant inequities in health persist, and Canada is losing its reputation as
a innovator in the field. Calls are being made to rethink existing approaches and in
particular to explore alternative paradigms for framing health determinants. The aim of this
paper is to contribute to the theoretical project of population health by offering
a conceptual framework to understand and respond to the ‘foundational’ causes of illness
and disease, which the health determinants perspective seeks to identify and address.
The paper begins with a brief overview and analysis of the health determinants
framework in Canada. Using gender as an example, the problematic way in which
determinants are typically conceptualized and applied in research and policy is revealed.
In particular, the inadequate methods of constructing determinants, capturing their
relationships, and understanding the wider context of structural inequities in which they
are embedded are highlighted. This analysis signals the limitations of current approaches

*Corresponding author. Email: oah@sfu.ca

ISSN 0958–1596 print/ISSN 1469–3682 online

ß 2008 Taylor & Francis
DOI: 10.1080/09581590802294296
http://www.informaworld.com
 272 O. Hankivsky and A. Christoffersen

and the need for theoretical innovation that can improve the knowledge base of health
determinants. The final section of the paper profiles some recent conceptual developments
in Canada, highlighting work on intersectionality. The intersectional paradigm provides
a normative framework that captures the complexity of lived experiences and concomitant,
interacting factors of social inequity, which in turn are key to understanding health
inequities. Key defining features of intersectionality, including its explicit attention to
power, are illustrated to explore the ways in which this perspective can inform a more
complete and nuanced understanding of health determinants and in the process inform
and re-establish Canada’s leadership efforts in the field.
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Reflections on the status quo

Since the 1990s, the health determinants approach has been recognized in health policy
and has gained ground among health researchers (Benoit and Shumka 2007). In terms of
the recognized determinants,1 specific questions and concerns have been raised. First, is
this list comprehensive? Second, what determinants of health are more important than
others? Third, critiques have also been raised regarding how each determinant of health
is interpreted and measured in both research and policy. Related to this is the more
general problem of conceptualizing determinants of health as single reducible categories,
so often reflected in biomedical and epidemiological approaches, rather than seeing them
as ‘complex social locations that shape the experience of health in important ways’
(Hedwig 2007, p. 1). Despite the assertion of the Public Health Agency of Canada that its
population health model ‘recognizes the complex interplay between the determinants of
health’ (PHAC 2007), typical approaches do not systematically incorporate analyses that
capture mutually enforcing effects of various social locations and experiences of
domination and oppression. As will be further elaborated in the analysis of gender in
the following section, there is a need for careful interrogation of how each determinant of
health is valued, conceptualized and viewed in terms of other determinants, including
‘the broader structures and circumstances that produce particular relationships between
factors’ that affect health (Coburn et al. 2003, p. 393).

Observations of gender as a health determinant

The inclusion of gender as a health determinant was thought to be a crucial step in
questioning previously unquestioned social norms and structures that influence gendered
experiences of health, which affect vulnerabilities to illness, health status, access to
preventative and curative measures, burdens of ill-health, and quality of care (Wuest
et al. 2002). Ideally, as Benoit and Shumka argue elsewhere, ‘a health determinants
approach that incorporates gender [should] allow us to first, investigate variations in
how women experience and recount different aspects of their health and then,
secondly, link these accounts to socio-structural forces and within particular socio-
cultural contexts’ (2007, p. 16). At this juncture, this is rarely realized in either research
or policy. Although government agencies recognize gender as a key health determinant,
not all researchers or policy-makers in the field explicitly acknowledge the importance
of gender. For example, in 2002 a major national conference, The Social Determinants
of Health Across the Lifespan, failed to incorporate gender in its list of determinants to
be considered. Not surprisingly, the Canadian Institutes of Health Research (CIHR)
recently decided that there was a pressing need to develop a gender and sex-based
 Critical Public Health 273

analysis guide for health research, ‘designed to help peer reviewers and applicants
consider when and how sex and gender are implicated in proposed research projects’
(CIHR 2006).
At the same time, when gender is taken into account, its complexity and interaction
with other determinants is inadequately investigated and understood. This is largely
because of the dominance of a gender-based analysis (GBA) in the Canadian health
context. GBA is concerned with identifying and clarifying the differences between
women and men, boys and girls, and demonstrating how these differences affect health
status, access to, and interaction with, the health care system (Health Canada 2003).
While some attempts have been made to expand on this analysis and introduce a gender-
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and sex-based analysis (CIHR 2006), gender and sex as separate determinants/variables
are often confused. Moreover, despite GBA’s commitment to both women and men
and boys and girls, gender is seen as primarily affecting women. While aspects of the
emergent ‘men’s health movement’ have been criticized as ‘backlash politics’, the fact is
that in the Canadian context, most discussion of men’s health amongst feminist health
researchers is viewed as an unjustifiable detraction from the agenda of the women’s
health movement. However, men and masculinities need to be examined as there are health
consequences that flow from adhering to stereotypical roles and expectations for both men
and women. Indeed, ‘masculinity needs to be explored in terms of how it is played
out under different social circumstances by different groups or categories of men’
(White 2002, p. 273).
Further, even though gender’s interaction with other variables such as racialization,
class, and sexual orientation is recognized within the GBA framework, the primacy of
gender is consistently maintained. As a result, the importance of diversity is acknowledged,
but unlike gender, it is not a central focus of analysis. For instance, among many women’s
health researchers in Canada, differences between women are merely paid lip service, and
a good number of leading experts resist moving forward, in a meaningful way, on the issue
of intersecting axes of oppression that affect health. The lack of attention to how gender
interacts with or is modified by other determinants of health or in fact may be less relevant
than other factors wrongly essentializes the experiences of women, reifies existing
inequities among different groups of women and arguably leads to the production of faulty
and incomplete knowledge (for further analysis see Hankivsky 2007, Hankivsky et al.
2007). Persistent and increasing inequities within the group ‘women’ are challenging
Canadian researchers to move beyond GBA and to engage in broader frameworks of
analysis that moves beyond the assumed norm of the ‘white, middle-class heterosexual
woman’. A starting place for this work is the design and development of tools and methods
that begin with the social locations of marginalized and vulnerable women (Jackson et al.
2005, Hankivsky 2007, Reid et al. 2007, Varcoe et al. 2007).
Moreover, in literature that explicitly deals with gender as an important determinant,
the extent to which public policy affects health is rarely acknowledged. Current Canadian
governmental efforts to purportedly improve health inequities occur in a paradoxical
policy context of neoliberalism and economic globalization, characterized by drives
toward privatization, deregulation, and trade liberalization. In health policy circles, the
effects of a range of neoliberal government policies on the Canadian welfare state have
been documented, but have not been systematically linked to growing social disparities
and their gendered effects on health. These trends raise a number of important questions
put forward by Raphael: ‘Is the creation of healthy public policy primarily about health?
Or is healthy public policy primarily about politics?’ (2006, p. 132).
 274 O. Hankivsky and A. Christoffersen

Toward a better understanding of the determinants of health

The examination of gender underscores a myriad of limitations with the current
approaches to health determinants and how such dominant approaches may contribute
to maintaining the status quo and re-entrenching a range of social, political, and economic
hierarchies that influence health. At the moment, considerable efforts are being made to
critically analyse the state of health and specifically social determinants in Canada
(Raphael et al. 2006). For example, in August 2006, the government of Canada announced
funding for a $4 million National Collaborating Centre for Determinants of Health aimed
at identifying factors that determine health and to develop a pan-Canadian public health
strategy. Renewed attention to social determinants of health has not been limited to
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Canada. In 2005, The World Health Organization established a Commission on Social

Determinants of Health charged with recommending interventions and policies to improve
health and health inequalities through action on social determinants.
Alongside these developments are calls for theoretical innovation in the area of
population health and health determinants (Potvin et al. 2005, Raphael 2006). In many
ways, social epidemiologists are at the forefront of these efforts although other noteworthy
approaches, especially in the Canadian milieu, are emerging within sociology, political
economy and human rights discourse (Raphael 2006). In Canada and abroad, however,
‘the theoretical project of population health is still in very early infancy and sadly, is still
quite marginal to the main emphasis of most publications in the field’ (Dunn 2006, p. 572).
One of the key conclusions of The Canadian Women’s Health Surveillance project was that:
‘There is a need for coherent theoretical frameworks that help to explain the dynamic
interrelationships among the social and biological determinants of health, including
processes of human resilience and vulnerabilities, causal pathways and cumulative effects
of circumstances and risks over the life cycle’ (Tudiver et al. 2004, p. 12). Similarly,
Raphael has argued that ‘one of the shortcomings in the work on social determinants of
health is the failure to consider ‘‘a master conceptual scheme’’ that illuminates the
political, economic, and social processes by which the quality of social determinants of
health is shaped. Hence, much of the work lacks what is usually termed as ‘‘critical social
science perspective’’ (Raphael 2006, p. 654).

Social inclusion/exclusion
In Canada, some conceptual work along critical social science lines is in progress. As one
example, the potential of social inclusion/exclusion for clustering the social determinants
of health is being examined (Raphael 2003, O’Hara 2006). Considering how certain
populations are excluded from social and economic benefits based on their gender, race,
ethnicity, disability, and class starts to get at the complexity of the relationship between
determinants, which is one of the key challenges to adopting a health determinants
perspective (Benoit and Shumka 2007). As Oxman-Martinez and Hanley elaborate, ‘health
disparities must be understood within a context of intersecting domains of inclusion,
exclusion and inequality’ (2005, p. 4). And yet, the very concept of exclusion/inclusion
presupposes a certain ‘standard’ or ‘norm’ from which the ‘excluded’ deviate. The very
articulation of an excluded ‘other’ ‘implies the marking of differences, whose explicit or
implicit devaluation demands rectification’ (Burman 2004, p. 294). This way of thinking
does little to disrupt certain privileged reference points and in essence does little to
challenge existing structural and systemic barriers and relationships of power. Labonte
similarly questions: ‘How does one go about including individuals and groups in a set of
 Critical Public Health 275

structured social relationships responsible for excluding them in the first place?’
(2004, p. 117). Although the conceptual shift provided by an inclusion/exclusion lens
represents an important change in thinking about social forces that drive health
determinants, it does not go far enough in terms of challenging power or the inequities
that go beyond material resources to relations of domination and subordination. To this
end, a more promising theoretical resource is that of intersectionality.

Intersectionality
Although the rich history of intersectionality is not always accurately documented, the
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concept became popularized in the late 1960s largely in response to the limitations of
second wave feminist theorizing that privileged gender as an identity category. The term
itself is credited as emerging from the seminal works of critical social science and
humanities researchers such as bell hooks (1990), Patricia Hill Collins (1990, 2000), and in
particular Kimberlé Crenshaw (2000) and Crenshaw et al. (1995). Intersectionality is
a theory of knowledge that strives to elucidate and interpret multiple and intersecting
systems of oppression and privilege. It seeks to disrupt linear thinking that prioritizes any
one category of social identity. Instead, it strives to understand what is created and
experienced at the intersection of two or more axes of oppression (e.g. race/ethnicity, class,
and gender) on the basis that it is precisely at the intersection that a completely new status,
that is more than simply the sum of its individual parts, is formed (Jackson 2003). While
sharing certain similarities with the work of Bourdieu (1990a, 1990b, 1994) and Bourdieu
and Wacquant (1992), especially in terms of Bourdieu’s theory of social relations and
insights into the effects of broader socio-cultural structures and circumstances and the role
of power (Faber 2005, Lynam and Cowley 2007), this perspective extends beyond
Bourdieu’s focus on the hidden injuries of class to consider a range of identities and
inequities.
Intersectionality is extending beyond its emergent theoretical roots and is now being
applied to multiple areas of research and policy. For example, this perspective has been
taken up in the US by a range of health researchers (e.g. Kohn and Hudson 2002, Krieger
et al. 2003, Weber and Parra-Medina 2003, Weber 2005, Bredström 2006, Schulz and
Mullings 2006). In the Canadian context, intersectionality has been drawn on to inform
diversity analysis and mainstreaming efforts intended to deal with the conceptual inertia
surrounding gender within research and policy (Hankivsky 2005, 2006, 2007, Jackson et al.
2005, Spitzer 2005). Despite making inroads into some areas of health research and policy,
including health determinants literature, intersectionality remains largely uninvestigated.

Intersectionality as a transformative paradigm for health determinants

Because of its unique approach to interrogating the meaning and relationship between
different social categories and ability to reveal the dynamics of power, the intersectional
tradition, as Weber and Parra-Medina argue, ‘has great potential to provide new
knowledge that can more effectively guide actions toward eliminating health disparities
across race and ethnicity but also across gender, sexual orientation, social class and
socioeconomic status, and other critical dimensions of social inequality’ (2003, p. 183).
And to explore how it may further the project of health determinants, its defining features
need to be identified and analysed. Firstly, in recognizing the importance of multiple
categories of social identity, intersectionality does not presume – a priori – the importance
 276 O. Hankivsky and A. Christoffersen

of one category over another. In terms of a health determinants framework, examinations

of health inequities that are reduced to any one single determinant or marker of difference
would be viewed as inadequate for understanding the various dimensions that are always
at play in shaping and influencing social positions and power relations. In their recent
review of the state of women’s health in Canada, Varcoe et al. describe in detail the
dangers for example, of focusing exclusively on gender: ‘[the] . . . sole attention to gender
carries the risk of treating all women the same . . . overlooking the fluid and changing
nature of gender; overlooking the ways in which economics, race, ability, geography,
ability, sexuality and other influences shape and intersect with gender; and diverting
attention away from differences among women’ (2007, p. 18).
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Secondly, intersectionality moves beyond the assumption that health outcomes may be
caused by a number of contributing causes by asserting that numerous factors are always
at play. Intersectionality encourages a contextual analysis that probes beneath single
identities, experiences and social locations to consider a range of axes of difference to
better understand any situation of disadvantage (Yuval-Davis 2006). In Canada, moving
towards this innovative approach to social locations and inequities in the context of
health determinants is extremely pressing and timely. It is estimated that by 2017, one
in five Canadians will belong to a visible minority group (Statistics Canada 2005).
Oxman-Martinez and Hanley argue that this demographic shift makes necessary in
research ‘an integrated approach that addresses the multiple and intersecting areas of
gender, ethnicity and socio-economic inequality’ (2005, p. 20). In a similar vein, Hankivsky
has argued that what is needed in Canadian health policy transformation is the
introduction of a method that captures the numerous variables that interact and produce
synergies that impact on health (2007). Failure to do so can lead to ‘analyses that are less
policy relevant and analytically sound than would otherwise be the case’ (Phoenix and
Pattynama 2006, p. 189).
Thirdly, an intersectional perspective does not simply add social categories to one
another in an attempt to understand diverse experiences. Instead, the methodology for an
intersectional paradigm seeks to uncover the convergence of experiences, including
multiple forms of discrimination and oppression. And it does so without assuming these
relations are predetermined (Hancock 2007). In other words, it strives to illuminates the
significance of the interacting consequences of many different, but interdependent and
reinforcing social identities and systems. Paying attention to how axes of oppression affect
one another and how various experiences of oppressions are simultaneous gives new
insights into social locations and experiences of identity (Risman 2004). Clearly, it
may be impossible to take into account all relevant differences in any given moment
(Ludvig 2006). Further, it is also challenging to determine whether all possible
intersections might be relevant at all times, or when some of them might be most salient
(Verloo 2006). Nevertheless, intersectionality challenges dominant analyses of health
determinants by revealing how to better conceptualize the cumulative, interlocking
dynamics that affect human experiences, including human health. It has the potential to
inform the complex interplay of determinants that the Public Health Agency of Canada
seeks to bring to its work on population health.
And, because identities are seen to occur in interactions, within category diversity
becomes important and the essentialization or homogenization of social categories is
rejected. In concrete terms for example, Canadian researchers and policy makers
concerned with eliminating health disparities between the Aboriginal and non-
Aboriginal populations would be challenged to reject the often used practice of
homogenizing the Aboriginal community and drawing on static conceptualizations
 Critical Public Health 277

of culture. Instead, the starting place for such an analysis would be an explicit recognition
that there is no common Aboriginal experience and that there is wide diversity within this
community. Indeed the Aboriginal community encompasses First Nations, Inuit and
Métis. Moreover, within this population there are wide within-group power and health
differentials. There is no doubt that ‘Aboriginal health is the rich diversity of social,
economical and political circumstances that give rise to a variation of health problems and
healing strategies in Aboriginal communities’ (Waldram et al. 2006, pp. 258–259). The fact
that there are no simple binaries between Aboriginal and non-Aboriginal communities is
not, however, consistently apparent in the literature that explores the determinants of
Aboriginal health in Canada.
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Beyond seeing the integrated and fluid nature of social categories of experience,
intersectionality approaches these as part of a broad framework of macro and micro
relations, institutions, and processes that are involved in the social construction of
inequity. Because capitalism and material resources are key to understanding health it is
not surprising that much of the determinants of health research focuses on socioeconomic
status. To illustrate: income is often seen as an especially important determinant ‘as it
serves as a marker of different experiences with many social determinants of health’
(Raphael 2006, p. 118). At the same time, however, income, material conditions and the
distribution of various resources are not the only factors to consider. They do not fully
explain the complexity of power relations in society. From an intersectional perspective
a key question is: ‘Who has power and control over whom?’ (Weber and Parra-Medina
2003). In terms of understanding power dynamics, it is critical, for instance, to examine the
effects of policy decisions on differentially situated citizens. As one example, reforms to the
welfare state or health care system may be seen as resulting in financial efficiencies for
government. In reality, however, these policy decisions also create relational inequities in
which some individuals and groups in society benefit and others experience further
marginalization and oppression. The link between policy and its role in strengthening or
weakening the relationships between the determinants of health is largely uninvestigated
(Raphael 2006).
Not only does intersectionality take into account ‘the multiple and interconnecting
impacts of policies and practices on different groups . . . it [also] acknowledges the
historically situated and always emergent nature of power structures’ (Lee 2005, p. 6).
This allows for both a retrospective and prospective analysis often absent from health
determinants discussions which can lead researchers to capture the extent to which social,
political and economic divisions are particular to a certain time and place. Similarly,
Risman explains: ‘We cannot . . . only study inequalities’ intersection and ignore the
historical and contextual specificity that distinguishes the mechanisms that produce
inequality by different categorical divisions’ (2004, p. 443). For instance, because gender
differences and inequities in any particular time and place combine with the effects of other
forms of social division such as class and ethnicity, not all women or all men experience
gender or gender-related health problems or issues in the same way. Accordingly, an
intersectional approach directs attention to variation which ‘helps to identify the
distinctive features (and perhaps the causes) of particular national constellations of
social structure, perhaps linking such structures to particular historic trajectories’
(Weldon 2006, p. 244).
This line of interrogations leads to an explicit focus on power which is not yet
front-and-centre in health determinants analyses. In Canada, societal norms are shaped by
those who have power and have typically been characterized by Euro-centric values of
White, able-bodied, heterosexual, middle class men and so ‘white culture is the hidden
 278 O. Hankivsky and A. Christoffersen

norm against which all other groups are measured’ (Roman 1993, p. 71). These norms are
embedded in Canada’s colonial history. For Aboriginal populations, the impacts on health
of this history are multifaceted and profound (Adelson 2003, Waldram et al. 2006).
Traditional societal norms also influence the experience and health of ethno-racial
minority populations, whose health is often worse than other Canadians because of
historic and contemporary structural patterns of discrimination both within and outside
the health care system (Oxman-Martinez and Hanley 2005). Moreover, mainstream norms
also inform the authoritative positions taken by some health experts in research with
marginalized populations. In the process of maintaining their ‘expertise’ they do not
systematically reflect on how their positions of power may reify systems of racism,
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homophobia, sexism and classism. By properly contextualizing systems of oppression, an

intersectional paradigm provides the tools with which to challenge accepted and idealized
norms as well as established binaries and cultural differences that fail to recognize or
challenge power dynamics.
Part of disrupting established norms and ‘expertise’ requires taking the perspective of
those populations whose social and health realities remain at the margins of health
inequities research. McCall (2005) refers to this methodological approach as ‘personal
narratives’ which can take on many different forms: literary, historical, discursive or
autobiographical. Similarly, Valentine has argued that it is important to develop ‘a new
body of empirically grounded research into the lived experience of intersectionality’
(2007, p. 18). Narratives provide insights into ‘current self-positioning in time and place’
(Ludvig 2006, p. 251). Yuval-Davis cautions, however, that although ‘The differential
positionings of the participants in such a dialogue from which they gaze at the situation
should be acknowledged . . . they should not be considered representative of any fixed
social grouping’ (2006, p. 20). Nevertheless, there is no doubt that the ways in which
individuals see themselves in relation to the world has a significant influence on health
(Hedwig 2007). And despite the often fluid, dynamic and unstable nature of group
identification, at certain points in time it may be possible to identify cross-cutting
categories of experience and oppression, such as poverty, for political and policy action.
Through narratives it may also be possible to recognize how individuals shape their own
existence, especially the ways in which people ‘both individually and collectively, act to
improve their health’ (Coburn et al., p. 393). This is certainly an area of health
determinants research that has been identified as requiring more attention in Canada
(Coburn et al. 2003).
Finally, what makes intersectionality so relevant in the context of health determinants
is its commitment to social justice. Pursuing social justice in health entails ‘reducing excess
of burden of ill health among groups most harmed by social inequalities in health, thereby
minimizing social inequalities in health and improving average levels of health overall’
(Krieger 2001, p. 698). Significantly, the explicit focus on power, which is so central in an
intersectional paradigm is essential to the pursuit of social justice in health because as
Ludvig argues elsewhere, it is dependent on revealing and interrogating ‘Who defines when,
where, which, and why particular differences are given recognition while others are not’
(emphasis in original, 2006, p. 247). Even though social justice initiatives cannot always
take every group into account, transformative and strategic coalitions and alliances can be
formed to work towards social change that more effectively addresses complex
intersectionalities (Burgess-Proctor 2006, Bishkawarma et al. 2007).
Perhaps the greatest challenge at this point in time in realizing the full potential of
intersectionality is that while some progress has been made to capture the multi-
dimensional nature of health inequities, discussions of how to apply intersectionality have
 Critical Public Health 279

been limited (McCall 2005). For example, there is little empirical work that examines
intersectional differences between multiple social categories, and models and methods that
are able to measure and simultaneously investigate multiple intersectionalities are only
beginning to be developed (Carter et al. 2002, Weber 2005, Hankivsky et al. 2007,
Parken and Young 2007). In the work to date, qualitative methods are being used for
a variety of investigations as they are seen as lending themselves to the micro-level
complexities of individual lives (McCall 2005, Schulz and Mullings 2006). Researchers are
also investigating quantitative methods that focus on macro-level population data and
which are able to be designed to capture complex statistical intersections (Weber and
Parra-Medina 2003, Burgess Proctor 2006). Arguably mixed methods approaches are
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considered the most suited to the intersectionality paradigm because they can produce
both macro and micro level data and provide the opportunity to examine their concurrent
production (Burgess-Proctor 2006, Hancock 2007, Hankivsky et al. 2007). Overall,
however, much more attention needs to be paid to evaluating the potential of current
methods and developing new approaches for producing an intersectional analysis.
Similarly, the integration of intersectionality into health policy is in its nascent stages.
There is some evidence from other fields that this perspective is gaining ground with
policy makers and practitioners and that models and guides for the application of
intersectionality are staring to be developed.2 Two especially noteworthy examples include
the multi-strand project emerging out of Wales (Parken and Young 2007). This project has
developed a method for public policy analysis that is designed to simultaneously integrate
numerous factors such as age, disability, gender, race and ethnicity, religion and belief and
sexual orientation. The second example is found in the work of Bishkwakarma et al. (2007)
in which the authors strive to integrate intersectionality into a typical policy cycle, using
the case study of education in Nepal. In both instances, the key message is that
intersectional approaches are essential to developing policies that respond to the
multiplicity of social locations and lived experiences. And as Hankivsky has argued
elsewhere, policy decision-makers may be persuaded to incorporate these methods into
their work if they understand that they have the potential to lead to more effective,
responsive and therefore efficient policy decisions (Hankivsky 2005).

Conclusion
In a recent article by Potvin et al., the authors state ‘we believe that the knowledge base of
public health should be situated more coherently within a theoretical perspective that seeks
to understand and guide our contemporary world’ (2005, p. 594). An intersectional
paradigm offers such a theoretical perspective by posing new questions and charting a path
to rethinking understandings of the determinants of health. Without doubt, this
framework complicates everything. Its intellectual and applied demands are very high
because this approach requires moving beyond singular categories of identity to the
complexity of diverse influences that shape and affect lives. However, ‘it is very much in
keeping with the trend in public health policy away from a biologically-based causal
model, to a more nuanced and complex understanding of how health and illness are
influenced by multiple determinants’ (AIHW in La Masurier and Lumby 2005, p. 3).
In the final analysis, intersectionality embraces rather than avoids the complexities that
are essential to understanding social inequities, which in turn manifest in health inequities.
It therefore has the potential to create more accurate and inclusive knowledge of human
lives and health needs which can inform the development of systematically responsive and
 280 O. Hankivsky and A. Christoffersen

socially just health systems and policy. As a leader in the field, Canada and its health
researchers should recognize the indispensability of an intersectional approach for
challenging and transforming dominant approaches to health determinants.

Notes
1. The Public Health Agency of Canada recognizes the following as key determinants of health:
income and social status; social support networks; education and literacy; employment/working
conditions; social environments; physical environments; personal health practices and coping
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skills; healthy child development; biology and genetic endowment; health services; gender; and
culture (PHAC 2007).
2. For some recent examples, please see CRIAW (2007) and Bishwarkarma et al. (2007).

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