Intersectionality and Women’s Health: Sexual Orientation, Race/Ethnicity, and Cervical Cancer Screening with Madina Agénor

Over the last few years, there has been a significant increase in public health literature that employs an intersectional approach. Intersectionality is an analytical tool that allows us to more accurately describe how human experience is shaped by multiple forms of social inequality that act in diverse and mutually reinforcing ways. This week’s WAPPP seminar featured Madina Agénor, Assistant Professor of Social and Behavioral Sciences at the Harvard T.H. Chan School of Public Health. Professor Agénor presented her research on how sexual orientation and race/ethnicity simultaneously affect disparities in cervical cancer screening among U.S. women.

Professor Agénor presented the results of three studies to demonstrate how intersectionality matters for population health and health equity. The first study examines how sexual orientation affects cervical cancer screenings without using an intersectional approach, and the second does the same for race/ethnicity. The third study employs an intersectional approach to illuminate how sexual orientation and race/ethnicity interact to produce discrepancies in cervical cancer screening.

Sexual orientation and cervical cancer screenings 
Lesbian and bisexual women (collectively referred to here as “sexual minority women”) are less likely to receive cervical cancer screenings and routine gynecological care than heterosexual women. Women with female sexual partners may also be more susceptible to cervical cancer because of higher rates of smoking and HPV. In addition, sexual minority women face a number of barriers to healthcare, including lower average income, lack of access to regular care and health insurance, and discrimination in society and in the healthcare system.

However, sexual minority women’s health is an understudied area, and there are significant gaps in research, including overreliance on convenience samples of mostly white, college-educated women; problems with measurement of sexual orientation (some studies conflate sexual orientation identity with sexual behavior); lack of appropriate comparison groups; and limited attention to potential drivers of sexual orientation disparities in pap testing.

Professor Agénor’s research uses a national probability sample of U.S. women, operationalizes sexual attraction, sexual orientation identity, and sexual behavior as different components of sexual orientation, uses appropriate comparison groups for each component of sexual orientation, and assesses whether healthcare factors (including access to insurance, receiving contraception, and STI services use) contribute to sexual orientation disparities in pap testing.

Lesbian-identified women exhibited significantly lower pap test use compared to heterosexual women (43% versus 69%), as did women with only female sexual partners compared to women with only male sexual partners (46% versus 71%). These disparities persisted even after controlling for age, household income, and other similar factors. Interestingly, differences in healthcare factors – access to health insurance, contraception, and STI services use – completely attenuated this disparity. According to the results of this study, focusing on only sexual orientation without an intersectional lens, healthcare factors may explain the discrepancy in cervical cancer screening among sexual minority women.

Race/Ethnicity and cervical cancer
In 2012, incidence of cervical cancer was highest among black and Latinx women, and cervical cancer mortality was three times higher among black women than white women. However, there has only been one subnational population-based study on sexual orientation, race/ethnicity, and pap test use, and this study also lacked appropriate comparison groups and didn’t seek out the drivers of disparities. Again using a national probability sample, Professor Agénor examined sexuality, race/ethnicity, and healthcare factors across racial and ethnic groups within sexual minority groups.

Professor Agénor found a lower prevalence of pap test use among women with only female sexual partners for black and white women, with the greatest disparity in pap test use between white women with only female partners and white women with only male partners. There was no difference in pap test use among Latinx women, regardless of whether they had male or female sexual partners. Importantly, the results of this study indicate that healthcare factors completely attenuated the disparity between women with female sexual partners and women with male sexual partners for white women only.

The magnitude and mechanisms of sexual orientation disparities in pap testing vary by race, which we wouldn’t have known without employing an intersectional approach. The crucial implications of this study are that addressing healthcare access barriers may mitigate disparities for some but not all women, and that we should be wary of “one-size-fits-all” interventions.

Qualitative Intersectional Study 
In order to better understand the mechanism of these effects on black sexual minority women, Professor Agénor held focus group discussions that centered around four key themes: healthcare provider communication style, heteronormative healthcare provider assumptions, heterosexism, racism, and classism, and healthcare provider background.

• Participants preferred healthcare providers who took time to build relationships, were knowledgeable about sexual minority women’s health, and provided them with relevant sexual health information. 
• Many participants reported that their healthcare providers assumed heterosexuality, and therefore provided patients with limited relevant sexual health information. Similarly, many participants reported both a fear of disclosing their sexual orientation to healthcare providers and negative experiences when they did so. 
• Many participants reported that their healthcare providers made social class assumptions based on their race/ethnicity. Some healthcare providers made further assumptions based on perceived social class about their patients’ ability to understand health information, which affected both how they communicated with them and how they involved them in decision making. 
• Participants reported negative experiences with OB/GYNs and expressed a preference for nurses and physician assistants, who provided more individualized attention. Finally, respondents reported a preference for healthcare providers with similar lived experiences, particularly for black sexual minority women healthcare providers. 

The results of this study indicate that patient-provider communication may be an important contributor to sexual orientation disparities in pap test use among black women. Sexual orientation and race influence black sexual minority women’s pap testing experiences and outcomes by shaping their exposure to multiple forms of discrimination and their access to and rapport with healthcare providers. Interventions designed for black sexual minority women should address multiple forms of discrimination and will have to look different than interventions designed for white sexual minority women.

Whether or not we employ an intersectional approach can be critical for designing appropriate interventions to promote health. Intersectionality matters for population health and health equity.

The responsibilities of being a "Token" minority

Lauren Lyons, a Masters in Public Policy alumna of the Harvard Kennedy School, is a rocket scientist (literally, she used to work at NASA's Jet Propulsion Lab) and a space and technology policy expert. An engineering graduate of Princeton university, Lauren serves on the UN's Space Generation Advisory Council, and conducts Space exploration public outreach.

She just wrote an absolutely stunning blog post about being a Black woman in elite academic and professional situations in America. Being even a minority in a room is a major step towards breaking glass ceilings; accordingly it can come with certain responsibilities---but also pain and frustrations.

Lauren was kind enough to let us feature that brilliant piece here. Please read the whole thing...

The Curious Conundrum of the Code-Switching Tokenized Teacher

A student raises her hand in a political science lecture, and confidently proclaims: “If people are to be treated equally under the law, then policies that single out minorities for special advantages are not only unfair and unnecessary, but are unconstitutional. President Obama is evidence that class is what determines your success in America, not race.”

People of color who have attended elite academic institutions might be able to identify with the following, oft reflexed, 3-step stream of consciousness:

Step 1: Jaw drops reactively in forming of the classic “WTF?” face.

Step 2: Calm down. Quickly straighten out the “WTF?” face, and try to appear nonplussed.

Step 3: Decision point:

a) Sit quietly and allow this person—and whomever in this room of 150 students agrees with her—to graduate from here actually believing this, be elected into Congress (because at this school, it really is a possibility), and then pass laws that curtail civil rights legislation, all while disappointing my ancestors who would have given anything for such a teaching moment on inequality and social justice, or 

 b) Take on the responsibility yet again, as the lone voice of color, to explain the “minority perspective,” subject myself to repeated Q&A, speak on behalf of every Black, Hispanic, and Native American kid who knows for certain that this country is in no way post-racial, deal with the fallout of receiving emails from classmates wanting to discuss it further a.k.a. try to prove me wrong and deny my experience, and risk now being forever marginalized at the resident thought leader on the Black experience even though my field of study is Science and Technology Policy.

Phew.

No, this is not an exaggeration. And as you can probably imagine, this thought process – although it occurs in the mere blink of an eye – is mentally, emotionally, and spiritually exhausting. And it seems that the more I find myself within elite academic, business, and social arenas where minority perspectives are vastly underrepresented, the more I find myself facing the Curious Conundrum of the Code-Switching Token Teacher. Allow me to unpack that a little bit... 

To continue reading the full article, please visit Lauren's blog: http://www.laurly.com/post/60174788163/the-curious-conundrum-of-the-code-switching-tokenized

Diversity to a Deadline: Delivering Everyone's London

The research is growing: for those of us concerned about diversity and the incorporation of traditionally excluded groups' members and voices into realms ranging from politics and boardrooms, to cubicles and community functions, there is probably a report or an experiment to which we can turn. We can examine the resilience of diverse groups, the challenges they face, and the styles of leadership that guide them best. 

Reports and experiments are valuable, but when an entity embraces a goal to integrate diversity and inclusion throughout all functional areas, what does this actually look like?

Stephen Frost, WAPPP Fellow and former Head of Diversity & Inclusion for the London Organizing Committee of the Olympic Games and Paralympic Games, was faced with this challenge. He spoke yesterday not as an academic, but as a practitioner. Before we begin, watch this fun video for a quick recap of the history of the modern Olympic Games and how this factors into the need for an intentional focus on diversity and inclusion.

Frost approached the task before him with an important guiding principle: it doesn't just happen. Diversity and inclusion (D&I) could not be taken for granted as a given in international games, nor could it be seen as a extra little side program.  Rather, D&I needed to be a commitment integrated into all functions and decisions. The question "had to become not why would you do the program, but why wouldn't you?"

The D&I process for the London Olympic Games had three components: understand, lead, and deliver.  London's vision was to use the power of the games to inspire change. The bid to the Olympic Committee highlighted diversity - of age, ethnicity, ability, gender identity, sexual orientation, and social status. A wonderful goal, to bring the experience of the Olympics more in line with the myriad of lives gathered in the audience, serving as volunteers, or employed as staff, but how?

Leadership is the key. Frost brought in Desmond Tutu to inspire the board and agency managers. Nearly all at the upper and mid-management level signed the diversity leadership pledge. There were no quotas for hiring; instead, information was monitored and frequently shared. No department wanted to rank at the bottom of this shared list, creating an internally competitive dynamic to meet and exceed all targets. The media caught word of this process, and unfortunately mocked it with headlines like, "Will Britain Take Gold for the Most PC Olympics Ever?"

The proof, however, was in the pudding. This process was not about being politically correct.  It was about showing that a commitment to diversity and inclusion could be realized to exceed expectations in a large organization - and that these were, indeed, the people's games.  The final part of the D&I process, delivery, illustrated its success. Frost highlighted the D&I efforts in workforce, procurement (supply chain/contractors), and service delivery.  Specialized programs reached out to traditionally excluded groups for the workforce, no contract over £20,000 could be awarded unless the contractor met certain D&I standards and was approved by the Diversity Team, and the various needs of different groups were taken into account while designing details such as counter heights and entrances. 

Frost challenges practitioners to reframe their perspectives on diversity and inclusion.  While a commitment is necessary, there need not be additional programs or requirements - creating a more inclusive workplace need not be a burden.  The key is removing barriers to entry, and accepting diversity and inclusion as critical aspects of every day business.



Valerie Kane is an MPP Candidate at the Harvard Kennedy School.

Race in Your Face

This will be uncomfortable, so try to relax. Examining our own race and gender stereotypes can be as pleasant as sitting in the dentist’s chair. But for Kerri L. Johnson, Assistant Professor of Communication Studies at UCLA, discovering awkward truths about people’s biases is an occupational hazard. Dr. Johnson investigates how people use physical cues to categorize other people.  Sometimes she even gets hate mail and coverage by Rush Limbaugh.

At the Social Communication Lab at UCLA, Dr. Johnson and her social psychologist colleagues do things like asking students to decide whether a point-light display figure is a man or woman and to categorize faces of different races as male, female, gay or straight. They even have a program that analyzes the relative femininity or masculinity of a person’s face.  Despite the ill-informed hate mail, the researchers persist, because understanding how biases are formed is the first step to combating unfair stereotypes and discrimination. 

In one study, Dr. Johnson demonstrated that race is gendered. For example, in the United States, there is overlap in stereotypes of Asians and women (soft-spoken, shy, family-oriented), while the stereotypes about Blacks overlap with stereotypes about men (dominant, athletic, competitive). The same pattern surfaced when the researchers measured whether respondents were more likely to misidentify the Asian men’s faces as female and Black women’s faces as male. The faces in question were digitally created so that only the race varied (see above). Sure enough, subjects more quickly and more correctly identified the Black men and Asian women than the other way around, and the respondents’ own race or gender did not seem to make a difference.   

The Social Communication Lab runs dozens of similar experiments, finding, for example, that even when information was limited to just photos of faces, subjects were better than chance at categorizing the person as “gay” or “straight.” And, as another angry-letter-provoking study demonstrated, categorizing someone, whether by race, gender or sexual orientation, has implications for how we will interact with that person given our own baggage and biases.

Yet it was a study of politicians and gender that achieved notoriety and misrepresentation by both Samantha Bee at the New York Times and Rush Limbaugh. The conclusions of the study were that Republican women in Congress had more stereotypical feminine facial features than did their Democratic counterparts; and that uninformed observers were more likely to identify the highly feminine women’s faces as Republican and the less feminine ones as Democratic.

You can take a moment to learn about the methods used in this unexpectedly controversial study, and even start another uncomfortable discussion in the comments section here. Please, just go easy on the hate mail.

Anya Malkov is an MPP candidate at the Harvard Kennedy School, a WAPPP Cultural Bridge Fellow, and an alumna of From Harvard Square to the Oval Office.

Professors Are Biased Too

An ordinary e-mail once caught the eye of Modupe Akinola,Assistant Professor of Management at Columbia Business School. It was from a prospective Ph.D. student, an African-American woman, asking for a meeting.

Dr. Akinola wondered: “Would I have reacted differently if this was from a man? Would it make a difference if the request was for today and not next week?” She joined with colleagues Katherine Milkman and DollyChugh to turn these questions into research questions in a field experiment measuring discrimination in academia.

The creative and elaborate experiment started with putting together a representative sample of over 6,500 faculty members from 260 universities. The team used publicly available demographic information on professors to ensure a good sample. The researchers then created a few prospective Ph.D. students. The names of these imaginary students were tested and proved to be easily recognizable as either male or female and as Caucasian, Black, Hispanic, Indian or Chinese.

At 8:00 am on a Monday, e-mails from Brad Andersons, Latoya Browns and 18 others went out to unsuspecting subjects, asking to meet “today” in half the cases and “next Monday” in the other half. The research team was impressed by how quickly most faculty wrote back and how often they agreed to meet, but when and with whom they agreed to meet was more interesting.

One would think academia, with its affirmative action and enlightened world views, might be a post-racial, post-gender sphere. As it turns out – not so much, especially not when there is time to think about it.

In the now condition, Akinola, Milkman and Chugh found no significant difference between number of responses to white males and to others, but when the request was for later, white men received both more responses and more meeting acceptances than any other prospective students. The white men fared better than all other racial categories across almost all disciplines. The effect remained even when the race or gender of faculty and student matched.

According to construal level theory (CLT) immediate events demand concrete reasoning focused on feasibility, whereas decisions about distant events trigger abstract thinking and a focus on desirability of the event. Thus, future events create more room for unconscious stereotypes and biases to enter the decision-making process. In this study, for instance, the responses received to the “now” requests systematically displayed a focus on “how,” whereas the “later” e-mails were more likely to be answered with a request for credentials or more information – a “why” response.

The point of this experiment and other studies that spotlight the influence of stereotypes and biases on consequential decisions is not to call people racist or sexist. The point is to come up with ways to address the biases and to improve minority outcomes. For instance, referring all prospective students to the Ph.D. program coordinator would take the burden off individual professors and ensure that all students get their questions answered. This is just one option that an experiment like this might bring up for discussion.

Unfortunately, some faculty did not take kindly to the experiment. When debriefed and told that they had been used in a study of bias, many expressed outrage and demanded to speak with the Institutional Review Board.

To me, their reaction suggests the thorny subjects of race and gender are not studied enough in academia. Perhaps academia, more so than other spheres, makes it taboo to have biases, but shaming does not make biases go away! Nobody wants to be called a racist or sexist, not even a little bit, but simply feeling guilty is not productive. We can structure decision-making in ways that level the playing field, and we need creative researchers like Akinola, Milkman and Chugh to make that happen.

Anya Malkov is an MPP2 at the Harvard Kennedy School, a WAPPP Cultural Bridge Fellow, and an alumna of From Harvard Square to the Oval Office.