The coyote in the mirror: Embracing intersectionality to improve human-wildlife interactions.

Christine E. Wilkinson is the winner of the third annual Rising Black Scientists Award for a graduate/postdoctoral scholar in the physical, data, earth, and environmental sciences. For this award, we asked emerging Black scientists to tell us about their scientific vision and goals, experiences that sparked their interest in science, how they want to contribute to a more inclusive scientific community, and how these all fit together on their journey. This is her story.

The need for an intersectionality framework in precision medicine research.

Precision medicine research has seen growing efforts to increase participation of communities that have been historically underrepresented in biomedical research. Marginalized racial and ethnic communities have received particular attention, toward the goal of improving the generalizability of scientific knowledge and promoting health equity. Against this backdrop, research has highlighted three key issues that could impede the promise of precision medicine research: issues surrounding (dis)trust and representation, challenges in translational efforts to improve health outcomes, and the need for responsive community engagement. Existing efforts to address these challenges have predominantly centered on single-dimensional demographic criteria such as race, ethnicity, or sex, while overlooking how these and additional variables, such as disability, gender identity, and socioeconomic factors, can confound and jointly impact research participation. We argue that increasing cohort diversity and the responsiveness of precision medicine research studies to community needs requires an approach that transcends conventional boundaries and embraces a more nuanced, multi-layered, and intersectional framework for data collection, analyses, and implementation. We draw attention to gaps in existing work, highlight how overlapping layers of marginalization might shape and substantiate one another and affect the precision-medicine research cycle, and put forth strategies to facilitate equitable advantages from precision-medicine research to diverse participants and internally heterogeneous communities.

Intersectionality within the racial justice movement in the summer of 2020.

In an environment that is high in racial justice saliency, how do identities inform motivation for supporting specific issues in the crowd? This study examines the role that intersectionality played in mobilizing participants to join the mass demonstrations sparked by the murder of George Floyd. Building on recent studies that show how protest participants connect issue-based concerns with their identities to boost support for movements, we analyze data collected through surveys with a random sample of activists participating in the protests after George Floyd's death in Washington, DC, in 2020. We find that intersectional motivations played a significant role in mobilizing protest participants. Analysis of these factors helps explain the diversity of the crowd and provides insights into how the movement may contribute to greater success for racial justice and the degree to which the movement has staying power.

Considering intersectionality and interacting levels of early intervention on early brain development-a commentary on Nelson et al. (2023).

It has long been recognized that an individual's experiences can metaphorically 'get under the skin' and become biologically embedded, thus affecting behavior and life outcomes (Hertzman, 2012). While this term is most often used to describe how adverse experiences influence biological process, it is rarely discussed how the same can be said of positive experiences, such as intervention to prevent or treat negative outcomes. In their annual review, Nelson et al. (2023) provide a timely and comprehensive review of how early intervention capitalizes on the neuroplasticity of the postnatal years, turning periods of 'vulnerability' to ones of 'opportunity'. Drawing on decades of expertise, they discuss the neurobiological mechanisms of intervention in two contexts: caregiving interventions for children growing up in disadvantaged environments, and therapeutic interventions for children at elevated risk of neurodevelopmental disorders such as Autism. They thought-provokingly describe both how early intervention operates through mechanisms of neural plasticity and how this can and should inform policy decisions to provide the greatest benefit to children. Here, I aim to underscore the importance of this review by addressing the intersection of these topics; specifically, I muse on how the scientific discovery of biological processes and the ethical imperative to support vulnerable children's development are intimately intertwined, and how this highlights both critical lines of future inquiry as well as policy implications.

Systems Connected to Inequities in Access to Kidney Transplantation and the Value of Intersectionality.

Patients from minoritized backgrounds based on race/ethnicity, gender, sexuality, and other social identities are more likely to experience inequities in access in kidney transplantation. Although these inequities have been reported over the decades, limited research focuses on the experiences of patients with intersecting minoritized social statuses and the mechanisms that contribute to their reduced access to transplantation. Intersectionality, a framework for understanding the ways in which multiple social identities represent interacting systems of oppression and privilege, offers a nuanced approach for understanding the experiences of patients diagnosed with end-stage organ disease with intersecting social identities. This article outlines complex systems that perpetuate inequities by highlighting the value of intersectionality in studying disparate outcomes to transplant and providing recommendations for the transplant community. This article aligns with the ESOT call for action to promote equity in transplantation worldwide.

Incorporating an intersectional gender approach to improve access to maternal and child health screening services.

BACKGROUND: In the Americas, the Pan American Health Organization (PAHO) has promoted initiatives that aim at the elimination of mother-to-child transmitted diseases for over two decades. Although Guatemala has assumed the commitment to improve access and coverage of reproductive and perinatal services, the goals have not yet been reached. Often, the implementation of these efforts is hampered by complexities rooted in social, cultural, and environmental intersections. The objective of this work is to share our experience applying gender intersectionality as a methodological and analytical tool in a participatory research project that aims to improve access to maternal and child health screening services. The study shows the novel strategy that incorporates intersectionality contributing to evidence on how it can be applied to strengthen public health efforts around the implementation of the EMTCT Plus (Elimination of mother-to-child transmission of HIV, Syphilis, Hepatitis B, and Chagas disease) framework, in the mostly rural municipality of Comapa, in Guatemala. METHODS: We applied a participatory methodology, integrating theoretical and methodological frameworks to have an intersectional understanding of health services delivered by both, midwives, and the public health institution, for the prevention, diagnosis, treatment, and follow-up of HIV, Syphilis, Hepatitis B, and Chagas. The data was collected by conducting interviews, focus groups, workshops, and reviewing laboratory databases, guided by five strategies from a cultural appropriateness framework. RESULTS: The intersectional analysis shed light on the synergies and gaps of the current efforts and protocols implemented by both the midwives and the Ministry of Health. The services offered for the four diseases were often delivered independently from each other, and a comprehensive educational and communication material strategy was absent. However, our findings will be used to inform consistent, locally relevant, and culturally appropriate educational content for the local population, also following the national policy guidelines. CONCLUSIONS: Using intersectionality as a method and as an analytical tool allowed us to understand the (1) interrelation of diverse social, cultural, and environmental determinants which influence the delivery of health services, as well as (2) the dynamics between the traditional and institutional health systems. (3) Community engagement and the participation of different stakeholders in a consultative process have been fundamental for the conceptual and methodological tenets of this research. (4) Finally, giving a more prominent role to midwives can strengthen sustainability and cultural appropriateness, which is complementary to the delivery of institutional health services.

RESUMEN: ANTECEDENTES: La Organización Panamericana de la Salud (OPS) ha impulsado iniciativas que buscan la eliminación de las enfermedades de transmisión materno infantil en las Américas desde hace más de dos décadas. Si bien Guatemala ha asumido el compromiso de mejorar el acceso y la cobertura de los servicios reproductivos y perinatales, las metas aún no se han alcanzado. Muchas veces, la implementación de estos esfuerzos se ve obstaculizada por complejidades arraigadas en intersecciones sociales, culturales y ambientales. Este estudio muestra una estrategia novedosa que incorpora la interseccionalidad como un componente metodológico y analítico. Esto contribuye a evidenciar la manera en que la interseccionalidad y la participación comunitaria pueden ser aplicadas para fortalecer los esfuerzos de salud pública en torno a la implementación de la estrategia ETMI Plus (Eliminación de la transmisión materno infantil del VIH, sífilis, hepatitis B y enfermedad de Chagas), en el municipio de Comapa, en Guatemala, el cual es mayoritariamente rural. MéTODOS: Implementamos una metodología participativa, integrando marcos teóricos y metodológicos para comprender la prestación de servicios de salud, tanto por parte de comadronas como de la institución de salud pública, desde una perspectiva interseccional para la prevención, diagnóstico, tratamiento y seguimiento de VIH, sífilis, hepatitis B y Chagas. Los datos fueron recolectados a través de entrevistas, grupos focales, talleres y tras la revisión de bases de datos de laboratorio, y nos guiamos por cinco estrategias propuestas en un marco para pertinencia cultural. RESULTADOS: El análisis interseccional permitió entender las sinergias y brechas de los esfuerzos y los protocolos que se implementan actualmente, tanto por parte de las comadronas como por el Ministerio de Salud. Encontramos que los servicios que actualmente se prestan para las cuatro enfermedades son en su mayoría independientes entre sí, y no se contaba con una estrategia integral de material educativo y de comunicación. Sin embargo, nuestros resultados se utilizarán como base para una estrategia de comunicación que sea coherente, localmente relevante y culturalmente apropiada para la población local, y también siga las regulaciones de las políticas nacionales. CONCLUSIONES: El uso de la interseccionalidad como método y como herramienta analítica nos permitió comprender (1) la interrelación de diversos determinantes sociales, culturales y ambientales que influyen en la prestación de servicios de salud, así como (2) la dinámica entre los sistemas de salud tradicional e institucional. (3) El compromiso de la comunidad y la participación de las diferentes partes interesadas en un proceso consultivo han sido fundamentales para los principios conceptuales y metodológicos de esta investigación. (4) Por último, otorgar un papel más destacado a las matronas puede reforzar la sostenibilidad y la adecuación cultural, que es complementaria a la prestación de servicios de salud institucionales.

Intersectionality of demographic characteristics in self-reported anorexia nervosa, bulimia nervosa, and probable eating disorders among college students.

OBJECTIVE: To investigate associations between identity intersectionality, with a primary focus on minority identity, and probable eating disorders (EDs) within the US college student population. METHOD: Data consisting of n = 414,299 college students' responses to the American College Health Association's National College Health Assessment between fall 2015 and spring 2019 were utilized for this study. Overall and stratified adjusted odds ratios (aORs) were used to assess the association between different facets of identity (i.e., race/ethnicity, gender identity, and sexual orientation) and probable EDs. RESULTS: Among all, in our analytic sample, 7.15% reported a probable ED. Interactions between all three identity variables were significant, and thus stratified odds ratios were evaluated. Transgender men were significantly more likely to report probable ED than cisgender male peers within the following racial/ethnic groups: non-Hispanic White (aOR: 3.33; 95% CI: 2.79, 3.96; p < .0001), non-Hispanic Black (aOR: 3.29; 95% CI: 1.72, 6.28; p = .0003), Hispanic (aOR: 2.31; 95% CI: 1.55, 3.43; p < .0001), Asian or Pacific Islander (aOR: 2.19; 95% CI: 1.45, 3.30; p = .0002), Biracial or Multicultural (aOR: 3.36; 95% CI: 2.17, 5.22; p < .0001), and other (aOR: 4.19; 95% CI: 2.25, 7.79; p < .0001). CONCLUSIONS: This study underscores the importance of increasing our understanding of interactions between marginalized identities and the ways in which minority identity informs ED risk. PUBLIC SIGNIFICANCE: The impact of multiple marginalized identities on ED outcomes is not well understood. Our study expands on previous ACHA-NCHA studies by addressing identity intersectionality, looking at more than one identity at a time (i.e., specifically race/ethnicity, gender identity, and sexual orientation). Our results contribute unique risk profiles for students who identify with multiple marginalized groups. Further, they indicate that that these associations vary based on the compounded effect of the demographic factors considered.

Intersecting gender identity and racial/ethnic inequities in eating disorder risk factors, symptoms, and diagnosis among U.S. college students: An intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy.

INTRODUCTION: There are documented inequities in eating disorders (EDs) by gender and race/ethnicity, yet, little is known about population-level prevalence of ED risk factors, symptoms, and diagnosis at the intersection of diverse gender and racial/ethnic identities. METHODS: Data from the Healthy Minds Study 2015-2019 (N = 251,310 U.S. university students) were used in a multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA). Participants were nested in 35 intersectional strata given by all combinations of 5 gender and 7 racial/ethnic categories. Multilevel logistic models with participants at level 1 and intersectional strata at level 2 were used to estimate stratum-specific predicted prevalence estimates for self-reported thin-ideal internalization, ED symptoms, and ED diagnosis. The variance partition coefficient (VPC) was calculated to quantify the contextual effect of the strata. RESULTS: There was considerable heterogeneity in the predicted prevalence of our ED outcomes across the strata (e.g., .3%-18.3% for ED diagnoses). There were large disparities in all three outcomes, with transgender participants of color having a higher predicted prevalence than expected based on the additive effects of gender and race/ethnicity. Moderation by race/ethnicity was also apparent, such that racial/ethnic disparities were wider within the cisgender groups relative to the transgender groups. VPCs indicated that ~10% of the total variance in ED outcomes was due to intersectionality between gender and race/ethnicity, over and above variance due to individual-level differences. CONCLUSION: Findings suggest that gender and racial/ethnic disparities in EDs are interrelated, underscoring the need to develop preventive interventions centering health equity. PUBLIC SIGNIFICANCE: Despite evidence that sexism, racism, and cissexism (i.e., anti-transgender prejudice) can impact EDs risk, little research examines the social patterning of EDs at the intersection of diverse gender and racial/ethnic identities. Using data from a sample of 250,000 U.S. university students, this study found that gender and racial/ethnic disparities in eating disorder risk are interrelated, highlighting the need to develop health equity centered preventive interventions.

Housing insecurity among black women surviving intimate partner violence during the COVID-19 pandemic: an intersectional qualitative approach.

BACKGROUND: Housing instability is highly prevalent among intimate partner violence (IPV) survivors, and the coupling consequences of structural racism, sexism, classism, and the COVID-19 pandemic, may create more barriers to safe and adequate housing, specifically for Black women IPV survivors. In particular, the consequences of the COVID-19 pandemic had the potential to amplify disadvantages for Black women IPV survivors, yet very little research has acknowledged it. Therefore, the current study sought to assess the experiences of housing insecurity among Black women experiencing intimate partner violence (IPV) while navigating racism, sexism, and classism during the COVID-19 pandemic. METHODS: From January to April 2021, we conducted in-depth interviews with 50 Black women experiencing IPV in the United States. Guided by intersectionality, a hybrid thematic and interpretive phenomenological analytic approach was used to identify sociostructural factors shaping housing insecurity. RESULTS: Our findings demonstrate the various ways in which the COVID-19 pandemic shaped Black women IPV survivors' ability to obtain and sustain safe housing. We derived five themes to capture factors contributing to housing experiences: challenges with separate and unequal neighborhoods; pandemic-related economic inequalities; economic abuse limitations; and strategies to maintain housing. CONCLUSIONS: Obtaining and maintaining safe housing during the COVID-19 pandemic was difficult for Black women IPV survivors who were also navigating racism, sexism, and socioeconomic position. Interventions are needed to reduce the impact of these intersecting systems of oppression and power to facilitate the resources necessary for Black women IPV survivors to identify safe housing.

Intersectional analysis of social disparities in type 2 diabetes risk among adults in Germany: results from a nationwide population-based survey.

BACKGROUND: Differences in type 2 diabetes risk have been reported for several sociodemographic determinants including sex/gender or socioeconomic status. From an intersectional perspective, it is important to not only consider the role of social dimensions individually, but also their intersections. This allows for a deeper understanding of diabetes risk and preventive needs among diverse population groups. METHODS: As an intersectionality-informed approach, multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) was used in a population-based sample of adults without known diabetes in Germany from the cross-sectional survey "Disease knowledge and information needs- Diabetes mellitus (2017)". Diabetes risk was assessed by the German Diabetes Risk Score (GDRS, range 0-122 points), estimating the individual risk of developing type 2 diabetes within the next 5 years based on established self-reported risk factors. Nesting individuals in 12 intersectional strata defined by combining sex/gender, educational level, and history of migration, we calculated measures to quantify the extent to which individual differences in diabetes risk were explained at strata level, and how much this was due to additive or multiplicative intersectional effects of social determinants. RESULTS: Drawing on data of 2,253 participants, we found good discriminatory accuracy of intersectional strata (variance partition coefficient = 14.00% in the simple intersectional model). Model-predicted GDRS means varied between 29.97 (corresponding to a "low risk" of < 2%) in women with high educational level and a history of migration, and 52.73 ("still low risk" of 2-5%) in men with low educational level without a history of migration. Variance in GDRS between strata was mainly explained by additive effects of social determinants (proportional change in variance to intersectional interaction model = 77.95%) with being male and having low educational level being associated with higher GDRS. There was no evidence of multiplicative effects in individual strata. CONCLUSIONS: Type 2 diabetes risk differed between intersectional strata and can to some extent be explained at strata level. The role of intersectional effects was minor and needs to be further investigated. Findings suggest a need for specific preventive measures targeted at large groups with increased diabetes risk, such as men and persons with low educational level.

A Scoping Review of Risk Factors of Hypertensive Disorders of Pregnancy in Black Women Living in High-Income Countries: An Intersectional Approach.

BACKGROUND: Hypertensive disorders of pregnancy (HDP) are maternity-related increases in blood pressure (eg, gestational hypertension, preeclampsia, and eclampsia). Compared with women of other races in high-income countries, Black women have a comparatively higher risk of an HDP. Intersectionality helps to provide a deeper understanding of the multifactorial identities that affect health outcomes in this high-risk population. OBJECTIVE: In this review, we sought to explore the literature on HDP risk factors in Black women living in high-income countries and to assess the interaction of these risk factors using the conceptual framework of intersectionality. METHODS: We conducted this review using the Arksey and O'Malley methodology with enhancements from Levac and colleagues. Published articles in English on HDP risk factors with a sample of not less than 10% of Black women in high-income countries were included. Six databases, theses, and dissertations were searched from January 2000 to July 2021. A thematic analysis was used to summarize the results. RESULTS: A final total of 36 studies were included from the 15 480 studies retrieved; 4 key themes of HDP risks were identified: (1) biological; (2) individual traditional; (3) race and ethnicity, geographical location, and immigration status; and (4) gender related. These intersectional HDP risk factors intersect to increase the risk of HDP among Black women living in high-income countries. CONCLUSION: Upstream approaches are recommended to lower the risks of HDP in this population.

Intersectional Effect of Gender, Race, and Socioeconomic Status in Mental Health Service Utilization: Evidence from the Canadian Community Health Survey 2015-2016.

This study examined the intersectional effects of gender, race, and socioeconomic status (SES) on mental health service utilization (MHSU) employing the intersectionality framework. Data was extracted from Canadian Community Health Survey 2015-2016 with a total of 85,619 sample. Covariate adjusted prevalence ratio (aPR) and the predicted probability of MHSU from intersectional analyses were estimated using Poisson regression with robust variance. The prevalence of MHSU was 15.04% overall, 19.61% among women, 10.27% among men, 21.56% among white women and 11.12% among white men. The study observed overall significant intersectional effect of SES by gender and race on MHSU. For instance, white men with the lowest income were more likely to have MHSU compared to their counterparts. Similarly, the predicted probability of MHSU decreased with the increase of SES that varied by gender and race. Two-way and three-way interactions also confirmed statistical significance (p-interaction < 0.05) of intersectional effect of gender, race, and SES. The observed socioeconomic differences in MHSU across gender and racial groups can be explained by intersectionality.

Intersectionality and Its Relevance in the Context of Aboriginal People with Brain Injury in Australia.

In this article, we explore the benefits of recognizing the impact of intersectionality on access to, and provision of, brain injury care in a First Nations context. While disadvantage and discrimination are often associated with the intersection of culture, gender, disability, and socioeconomic disadvantage, it is only when these factors are explored together that clinicians can really understand what people need to recover and thrive following acquired brain injury. In this article, we challenge speech-language pathologists to examine their own practices, to look beyond Western models of health and constraints of many current institutional models of care and ways of framing research, to acknowledge historical and ongoing colonizing influences, and to engage with community-led solutions. We provide a model of Aboriginal-led care, where intersection of discrimination and marginalization is minimized and the multiple components of the individual, carers/communication partners, and the environment become empowering factors instead.

The Intersectionality of Climate Change and Post-Stroke Aphasia.

Persons with communication disabilities including persons with post-stroke aphasia (PWAs) possess a vulnerability to climate change as a result of their communication impairments. The disproportionate effects of climate change are likely to exacerbate preexisting inequities in social determinants of health. Communication disability intersecting with other characteristics subject to discrimination (e.g., race, age, sex, income) may lead to inequities in climate-related adaptive capacity. This article echoes earlier concerns related to climate change and further educates healthcare professionals about the impact of climate change on the global human population, with particular consideration of PWAs. The aims of this article are the following: (1) to broaden the understanding of aphasiologists and clinicians caring for PWAs about climate change and the contributions of human activity (anthropogenic) to this crisis; (2) to describe climate change and its impact on health; (3) to detail the intersectionality of climate and health; (4) to explore climate change and its potential effects on PWAs; and (5) to offer hope through emissions reduction, adaptation, resilience, and immediate change.

The Intersection of Social Determinants of Health and Post-stroke Aphasia Outcomes: A Need for Intersectional Analysis.

Aphasia is a disorder that results from damage to portions of the brain that are responsible for language and can vary significantly by type and severity. Differences in aphasia outcomes are influenced by the social determinants of health (SDOH). The SDOH are structural, environmental, and personal determinants that influence health outcomes. Intersectionality, or how one's social and political identities interact to influence individual life outcomes and/or advantage in our society, provides a way to examine the varying levels of the SDOH. However, intersectionality is complex, difficult to measure, and has not yet been explored in post-stroke aphasia outcomes. This article reviews the relationship of race and aphasia outcomes and the SDOH and aphasia outcomes. Additionally, we provide a novel current approach to examine the SDOH and aphasia outcomes. Lastly, we discuss the need for evaluation of intersectionality in aphasia and aim to provide a leveled social-ecological framework to examine aphasia-related outcomes. With notable individual differences among aphasia outcomes, we present a framework to support optimizing research and clinical aphasia care in speech-language pathology.

Redefining global cardiac surgery through an intersectionality lens.

Although cardiovascular diseases are the leading cause of morbidity and mortality worldwide, six billion people lack access to safe, timely and affordable cardiac surgical care when needed. The burden of cardiovascular disease and disparities in access to care vary widely based on sociodemographic characteristics, including but not limited to geography, sex, gender, race, ethnicity, indigeneity, socioeconomic status and age. To date, the majority of cardiovascular, global health and global surgical research has lacked intersectionality lenses and methodologies to better understand access to care at the intersection of multiple identities and traditions. As such, global (cardiac) surgical definitions and health system interventions have been rooted in reductionism, focusing, at most, on singular sociodemographic characteristics. In this article, we evaluate barriers in global access to cardiac surgery based on existing intersectionality themes and literature. We further examine intersectionality methodologies to study access to cardiovascular care and cardiac surgery and seek to redefine the definition of 'global cardiac surgery' through an intersectionality lens.

How does intersectionality impact the quality of healthcare services for Black women living with HIV?

Women with HIV are affected more than men by intersecting discriminations. For Black women, additional discrimination can have a detrimental effect on their HIV care. An extended literature review of primary research studies was undertaken to explore the issues and the impact of intersectionality on Black women with HIV. Electronic databases were searched for studies published since antiretroviral treatment became recognised to be effective, and eight studies met detailed inclusion and exclusion criteria. Critical appraisal led to the identification of three themes: discrimination; stigmatisation; and racism. The findings suggest that while Black women with HIV reported barriers to health care because of intersectionality, older women who felt confident in their self-identity were more able to cope with issues around this. Knowledge of the factors affecting these women will enable health professionals to deliver person-centred care.

The Intersectionality of Food Insecurity, Job Insecurity, Healthcare Insecurity, and Mental Health Challenges in NYC Households During Covid-19.

Our intersectional research explored food insecurity and job insecurity as predictors of healthcare insecurity and mental health challenges among households living in economic instability since the COVID19 pandemic began. The New York City COVID19 Research Team adapted a validated, web based, anonymous survey questionnaire using a Social Determinants of Health Framework. The study oversampled underserved populations with a total of 2,099 participants. We report strong associations between food insecurity and job insecurity among healthcare insecure households, and significant mental health challenges among food insecure and healthcare insecure households. This underscores the need for integrated social policies to protect underserved urban populations.

The Mouth as a Site of Compound Injustices: A Structural Intersectionality Approach to the Oral Health of Working-Age US Adults.

Knowledge of and practice around health inequities have been limited by scarce investigations on intersecting forms of structural oppression, including the extent to which their effects are more severe among multiply marginalized groups. We addressed these insufficiencies by adopting a structural intersectionality approach to the study of edentulism (i.e., complete tooth loss), the dental equivalent of mortality. While individual information was gathered from approximately 200,000 adult (ages 18-64 years) respondents to the 2010 US Behavioral Risk Factor Surveillance System survey, state-level data for 2000 and 2010 were obtained from a 2021 study by Homan et al. (J Health Soc Behav. 2021;62(3):350-370) and the US Census. These 3 sources provided information on edentulism, race, sex, structural racism, structural sexism, and income inequality, in addition to multiple covariates. Analyses showed that the intersections between structural sexism and state-level income inequality and structural racism were associated with 1.4 (95% confidence interval: 1.1, 1.9) and 1.5 (95% confidence interval: 1.1, 2.2) times' increased odds of complete tooth loss, respectively. The frequency of edentulism was highest among non-Hispanic Black men residing in states with high structural racism, high structural sexism, and high economic inequality. Based on these and other findings, we highlight the importance of a structural intersectionality approach to research and policy related to health inequities in the United States and elsewhere.

Exploring the intersectionality of race/ethnicity with rurality on breast cancer outcomes: SEER analysis, 2000-2016.

PURPOSE: Disparities in breast cancer survival have been observed within marginalized racial/ethnic groups and within the rural-urban continuum for decades. We examined whether there were differences among the intersectionality of race/ethnicity and rural residence on breast cancer outcomes. METHODS: We performed a retrospective analysis among 739,448 breast cancer patients using Surveillance Epidemiology and End Results (SEER) 18 registries years 2000 through 2016. We conducted multilevel logistic-regression and Cox proportional hazards models to estimate adjusted odds ratios (AORs) and hazard ratios (AHRs), respectively, for breast cancer outcomes including surgical treatment, radiation therapy, chemotherapy, late-stage disease, and risk of breast cancer death. Rural was defined as 2013 Rural-Urban Continuum Codes (RUCC) of 4 or greater. RESULTS: Compared with non-Hispanic white-urban (NH-white-U) women, NH-black-U, NH-black-rural (R), Hispanic-U, and Hispanic-R women, respectively, were at increased odds of no receipt of surgical treatment (NH-black-U, AOR = 1.98, 95% CI 1.91-2.05; NH-black-R, AOR = 1.72, 95% CI 1.52-1.94; Hispanic-U, AOR = 1.58, 95% CI 1.52-1.65; and Hispanic-R, AOR = 1.40, 95% CI 1.18-1.67), late-stage diagnosis (NH-black-U, AOR = 1.32, 95% CI 1.29-1.34; NH-black-R, AOR = 1.29, 95% CI 1.22-1.36; Hispanic-U, AOR = 1.25, 95% CI 1.23-1.27; and Hispanic-R, AOR = 1.17, 95% CI 1.08-1.27), and increased risks for breast cancer death (NH-black-U, AHR = 1.46, 95% CI 1.43-1.50; NH-black-R, AHR = 1.42, 95% CI 1.32-1.53; and Hispanic-U, AHR = 1.10, 95% CI 1.07-1.13). CONCLUSION: Regardless of rurality, NH-black and Hispanic women had significantly increased odds of late-stage diagnosis, no receipt of treatment, and risk of breast cancer death.