“The way we imagine discrimination or disempowerment often is more complicated for people who are subjected to multiple forms of exclusion. The good news is that intersectionality provides us a way to see it.” Prof Kimberlé Williams Crenshaw
Defining disability
Given the overall sensitivity of disability policy in the UK, there are various ways of defining what a ‘disability status’ is[1].
For practical purposes, one definition is provided by the Equality Act (2010)[2], but there are very many other theoretical formulations including individuals with vulnerabilities which require support[3]. In one (neoliberal) formulation linked to each citizen being a ‘productive’ member of the society, Gary Becker (1962) treated the individual and collective resources possessed by individuals, such as their abilities, education, knowledge, skills and training, as a reservoir of “human capital”[4]. Such a view is rather out of place with an alternative framing that everyone has a part to play in an inclusive culture, and is actually quite out of date now. There is currently a workforce crisis in the NHS[5], so in theory disabled doctors should be in great demand. It is essential that we are focused on all the ways disabled doctors can be disadvantaged, not merely on account of being disabled. Disabled doctors can also have other protected characteristics – and this is important for how they are treated in and recruited into the NHS workforce.
The current equality legislation, to prevent individuals with protected characteristics from being discriminated to their detriment, is deniably critical in public policy. Simply enforcing this legislation, and there is a long way to go there, is, however, insufficient to address more pervasive systemic injustices.
In pursuit of all disabled doctors being ‘valued and welcomed’[6] in the NHS, according to the official clinical regulator, many researchers in medical education have aimed to explain processes of domination, oppression, inequality and discrimination within existent power structures of the NHS[7]. Recognition of systemic, intersecting inequities in professional medical culture begins by examining exclusion and discrimination in workplace experiences[8] [9].
Intersectionality
Medical institutions arguably need now to acknowledge the construct of intersectionality—the way that factors such as race, class, gender, disability, and sexuality intersect to shape each other within broader structures and processes of power. Many factors clearly interlink to produce barriers, opportunities and enablers at every stage of the education training that produces considerable potential for inequity[10]. A crucial matter concerns when protected characteristics in combination produce a disempowering effect. Intersectionality, a term in increasingly common usage from political scientists, sociologists, anthropologists and lawyers, is admittedly a highly abstract concept, and began life in the outstanding socio-legal critique from Prof. Kimberlé Crenshaw[11], resulting from the US courts’ ignorance of discrimination against Black Women specifically. The field has grown to be an important symbol of social justice.
Much is now discussed in relation to intersectionality, but it is worth noting that the original analysis was narrow-in-scope and a straightforward comment on jurisprudence. Crenshaw’s original paper centres on three legal cases that dealt with the issues of both racial discrimination and sex discrimination, including DeGraffenreid where the claimants challenged a collective redundancy scheme resulting in dismissing all Black Women on grounds of indirect discrimination. The court refused to recognise Black Women in the US jurisdiction as a category of relevance and did not find any discrimination because the scheme did not impact disproportionally on White women or Black men. Similar jurisprudence issues have subsequently occurred in EU law, for example the Parris case involved older homosexual men[12]. Intersectionality has therefore occupied an important space in law, social justice and public policy.
The intersectional approach differs markedly both from unitary analyses which focus on protected characteristics separately; multiple approach analyses posit the existence of multi-layered discrimination[13]. In 2020, the BMA disability report in 2020[14] had mentioned that,
“there are likely to be differences of experience within these two broad groupings and that further research is needed to understand how disability and ethnicity may lead to multiple disadvantages and intersectional discrimination.”
Crenshaw (1991) in fact has delineated three types of intersectionality: structural, how people are marginalised within systems that fail to recognise the position they occupy at the intersections of different layers of oppression; representational, how marginalised groups are depicted visually and discursively; and political, how the issues and interests of particular groups are marginalised within political agendas and social movements[15]. Structural solutions that address the factors underpinning interlocking systems of oppression are needed to affect long-term, systemic change and prevent intersectional stigma from moving forward. As example, the Manas por Manas study also advocates for and supports transgender women to step into positions of power, visibility, and influence within universities, clinics, and communities[16]. Discrimination against disabled doctors can take various forms, some quite subtle. Disrespectful behaviour can include inappropriate demeaning or abusive words, shaming, unjustified negative comments and complaints, not wishing to work collaboratively, and so on[17].
Lived Experience of (Black, Asian and minority ethnic) BAME population
Isolated personal accounts of the lived experience do exist, for example one author writes very elegantly about specific problems faced by BAME women in Scotland in the COVID-19 pandemic[18]. People who are BAME with disabilities would be expected to experience discrimination qualitatively different from the separate discriminations, and this is rarely discussed. Yet often our legal and cultural institutions have been reluctant to acknowledge the intersectional experience, preferring instead to understand people by a singular trait like their race, gender, or disability[19].
Concluding thoughts
Laws and how they are applied may be barriers. Furthermore, a related phenomenon called epistemic violence can be understood as individuals’ attempts to deny the unique experiences offered by those who live at the margins of society such as BAME disabled doctors. Epistemic violence plays a key role in power systems such as sexism, racism and ableism, among others[20]. In some cases, attempts to silence those marginalised voices are entirely intentional, whereby those in power limit a given group’s ability to speak and be heard on topics of concern[21]. Put simply, institutions can facilitate oppression of vulnerable employees. While awareness about the socio-cultural factors that underlie a patient’s health beliefs grows, in parallel with an urgent need for physicians to be competent to provide adequate care to patients of different cultures and backgrounds, the quality of patient–doctor interactions will improve for marginalised patient groups, including for disabled patients[22]. It is an easy logical step therefore to concede that we need many more disabled doctors, and certainly some as top role models in medical leadership. There are currently very few with visible disabilities. My own personal opinion is that, although a desire to remain free from political controversy and acrimony has often prevented medical schools, hospitals, medical leaders, Governmental bodies, Royal Colleges and other professional societies from “speaking out” on issues of social justice, it should be noted that silence, especially on matters that impact health and wellbeing regarding disability, is a political statement in and of itself[23].
[1] Gilleard C, Higgs P. Frailty, disability and old age: a re-appraisal. Health (London). 2011 Sep;15(5):475-90. doi: 10.1177/1363459310383595. Epub 2010 Dec 15. PMID: 21169203.
[2] https://www.gov.uk/definition-of-disability-under-equality-act-2010 (accessed 9 February 2024).
[3] Gilleard C, Higgs P. Frailty, disability and old age: a re-appraisal. Health (London). 2011 Sep;15(5):475-90. doi: 10.1177/1363459310383595. Epub 2010 Dec 15. PMID: 21169203.
[4] Becker, G. S. “Investment in Human Capital: A Theoretical Analysis.” Journal of Political Economy, vol. 70, no. 5, 1962, pp. 9–49. JSTOR, http://www.jstor.org/stable/1829103. Accessed 9 Feb. 2024.
[5][5] https://www.kingsfund.org.uk/insight-and-analysis/data-and-charts/nhs-workforce-nutshell#:~:text=A%20Flourish%20chart-,Vacancy%20rates,enough%20staff%20to%20keep%20up.
[6] https://www.gmc-uk.org/-/media/documents/dc11872-pol-welcomed-and-valued_pdf-78449815.pdf
[7] Medical Schools Council (2021). Active inclusion: challenging exclusions in medical education, https://www.medschools.ac.uk/media/2918/active-inclusion-challenging-exclusions-in-medical-education.pdf. (accessed 28 March 2024)
[8] Samra R, Hankivsky O. Adopting an intersectionality framework to address power and equity in medicine. Lancet. 2021 Mar 6;397(10277):857-859. doi: 10.1016/S0140-6736(20)32513-7. Epub 2020 Dec 23. PMID: 33357466; PMCID: PMC9752210.
[9] Weßel M, Gerhards SM. “Discrimination is always intersectional” – understanding structural racism and teaching intersectionality in medical education in Germany. BMC Med Educ. 2023 Jun 2;23(1):399. doi: 10.1186/s12909-023-04386-y. PMID: 37268929; PMCID: PMC10236740.
[10] Crampton PES, Afzali Y. Professional identity formation, intersectionality and equity in medical education. Med Educ. 2021 Feb;55(2):140-142. doi: 10.1111/medu.14415. Epub 2020 Nov 30. PMID: 33179338.
[11] https://www.law.columbia.edu/faculty/kimberle-w-crenshaw (accessed 9 February 2024).
[12] Schiek, D., “On Uses, Mis-Uses and Non-Uses of Intersectionality before the Court of Justice (EU),” International Journal of Discrimination and the Law 18, no. 2-3 (June September 2018): 82-103.
[13] Keshet Y, Popper-Giveon A, Liberman I. Intersectionality and underrepresentation among health care workforce: the case of Arab physicians in Israel. Isr J Health Policy Res. 2015 Apr 15;4:18. doi: 10.1186/s13584-015-0004-0. PMID: 25878770; PMCID: PMC4397687.
[14] BMA. Disability in the medical profession, Survey findings 2020. https://www.bma.org.uk/advice-and-support/equality-and-diversity-guidance/disability-equality-in-medicine/disability-in-the-medical-profession (accessed 9 February 2024).
[14] Schiek, D., “On Uses, Mis-Uses and Non-Uses of Intersectionality before the Court of Justice
[15] Crenshaw, K. W. (1991) Mapping the margins: Intersectionality, identity politics and violence against women of color. Stanford Law Review, 43, 1241–1299.
[16] Sievwright KM, Stangl AL, Nyblade L, Lippman SA, Logie CH, Veras MASM, Zamudio-Haas S, Poteat T, Rao D, Pachankis JE, Kumi Smith M, Weiser SD, Brooks RA, Sevelius JM. An Expanded Definition of Intersectional Stigma for Public Health Research and Praxis. Am J Public Health. 2022 Jun;112(S4):S356-S361. doi: 10.2105/AJPH.2022.306718. PMID: 35763723; PMCID: PMC9241457.
[17] Gouger DH, Sankaran Raval M, Hussain RS, Bastien A. Examining intersectionality in anesthesiology training, academics, and practice. Curr Opin Anaesthesiol. 2022 Apr 1;35(2):201-207. doi: 10.1097/ACO.0000000000001108. PMID: 35165234.
[18] Blogpost, “Why Intersectionality Matters: BAME Women in Leadership Roles”, https://www.wrc.org.uk/blog/why-intersectionality-matters-bame-women-in-leadership-roles (accessed 28 March 2024).
[19] Abrokwa,A, “When They Enter , We All Enter”: Opening the Door to Intersectional Discrimination Claims Based on Race and Disability, 24 MICH. J. RACE & L. 15 (2018).
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[19] Schiek, D., “On Uses, Mis-Uses and Non-Uses of Intersectionality before the Court of Justice
[20] Bennett, K. (2007). Epistemicide! The tale of a predatory discourse. The Translator. Studies in Intercultural Communication, 13(2), 151–169.
[21] Wyatt TR, Johnson M, Zaidi Z. Intersectionality: a means for centering power and oppression in research. Adv Health Sci Educ Theory Pract. 2022 Aug;27(3):863-875. doi: 10.1007/s10459-022-10110-0. Epub 2022 Apr 2. PMID: 35366113.
[22] Muntinga ME, Krajenbrink VQ, Peerdeman SM, Croiset G, Verdonk P. Toward diversity-responsive medical education: taking an intersectionality-based approach to a curriculum evaluation. Adv Health Sci Educ Theory Pract. 2016 Aug;21(3):541-59. doi: 10.1007/s10459-015-9650-9. Epub 2015 Nov 24. PMID: 26603884; PMCID: PMC4923090.
[23] Kingsley, J., Berkman, E.R., Derrington, S.F. (2021) The disruptive power of intersectionality, The American Journal of Bioethics, 21:9, 28-30, DOI: 10.1080/15265161.2021.1952346.
Author
Prof. Shibley Rahman
Prof. Shibley Rahman is the specialist advisor on disability for the NHS Practitioner Health. He trained in medicine at Cambridge and London, completed his Ph.D. at Cambridge, and also holds postgraduate degrees in business management and law from London. He is currently a honorary research fellow for University College London (UCL), and an honorary visiting professor for the Centre for Ageing and the Life Course, University of Liverpool. He has published widely books and papers on the frailty syndromes, and is the convenor for the specialist interest group for neurodelirium for the American Delirium Society.
Declaration of interests
I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.