Embracing Black heterogeneity: the importance of intersectionality in research on anti-Black racism and health care equity in Canada

• Accumulating evidence shows that anti-Black racism negatively affects the health and well-being of Black populations in Canada.

• The heterogeneity of experiences of anti-Black racism in health care in Canada remains underinvestigated.

• Just as the everyday experience of being Black is not homogeneous, neither are perceptions and experiences of anti-Black racism.

• Intersectionality theory provides a valuable theoretical lens for considering the heterogeneous experiences of anti-Black racism in health care.

• Consideration of diversity within Canada’s Black communities and associated differences in perceptions and experiences of anti-Black racism in health care may facilitate the development of more equitable health systems.

Anti-Black racism produces and sustains health inequities through social and structural determinants of health such as reduced access to employment and material resources, or by increased exposure to various risk factors like overpolicing.1^–4 Since racism is a psychological stressor, it may also affect Black people’s health through negative psychological and physiologic stress responses.5 Although most research on this topic has been conducted in the United States, accumulating evidence shows that anti-Black racism negatively affects the health and well-being of Black populations in Canada as well, rooted in colonial racial codes and discriminatory conventions. 2^,6 Still, the heterogeneity of experiences of racism within Black communities in Canada is often overlooked in health care research. Ignoring the diverse identities and social positions of Black people can lead to overgeneralized findings that fail to recognize nuanced intersections with anti-Black racism that drive inequities in health and health care. We consider heterogeneity within Black communities in Canada and argue for the importance of acknowledging this heterogeneity in research and planning processes to address manifestations of anti-Black racism in health care systems more effectively.

Almost 1.5 million people in Canada reported being Black in the 2021 Canadian census, representing more than 4% of the national population and diverse ethnocultural groups (https://www150.statcan.gc.ca/n1/daily-quotidien/221026/dq221026b-eng.htm). In 2021, the Black population reported more than 300 ethnic or cultural origins, 450 first languages, and varying religions and experiences of immigration. Although around 40% of respondents reported Canada as their country of birth, almost one-third were born in Africa and 21% were born in the Caribbean. Black people in Canada also differ with regard to their educational attainment, employment, income, and family structures, among other factors. For example, in 2016, around 18% of Canadian-born Black men held a bachelor’s degree or higher, compared with around 31% of Canadian-born Black women (https://www150.statcan.gc.ca/n1/pub/89-657-x/89-657-x2020002-eng.htm).

The heterogeneity of Black communities in Canada is further emphasized when considering the various ethnic and racial labels that Black people employ for self-identification. These may include, for example, Black, Black Nova Scotian, Canadian, Caribbean, or West Indian (or references to a specific country in the Caribbean), as well as Africentric labels that make reference to African heritage (such as African, African Canadian, or Afro-Caribbean, or references to a specific country in Africa). George Elliot Clarke’s notion of African-Canadianité also references the heterogeneity of Black communities in Canada by highlighting the role that ethnicity plays in the formation of racial identities.7 These diverse backgrounds embody a spectrum of world views that influence how Black people experience and confront perceived racism, as well as how they navigate their health care needs.

Other sociodemographic characteristics — like gender, sexuality, class, skin tone, language, religion, and so on — interact with race in complex ways and are especially influential in shaping experiences of Blackness and racism. Intersecting marginalization linked to any or all of these characteristics introduces further complexity into how Black people understand their social position and construe meaning from interpersonal encounters.8 In this regard, intersectionality theory provides a helpful approach for considering heterogeneity and its effects and highlights how complex social categorizations (such as race, gender, and disability) interact with interdependent, compounding systems of discrimination to drive oppression, disadvantage, and privilege.9^,10 For instance, gendered racism (that is, intersectional experiences of sexism and racism) may lead to markedly different manifestations of anti-Black racism that draw from the unique stereotypes and prejudicial ideas that Black men and Black women face in relation to their race, sex, and gender.11 Although findings are mixed, age (or generation) has also been shown to affect experiences and reports of discrimination; sociopolitical climates and related racial dialogues create a kind of cohort effect that affects discrimination reporting. 8 For example, racialized minorities who lived through periods of high racial tension, such as in the civil rights era, may report greater accumulative experiences of racial discrimination than their younger counterparts.8

A recent Canadian study reported several social determinants that may increase the likelihood of experiencing anti-Black racism, including identifying as lesbian, gay, bisexual, transgender, questioning, or other sexualities, having higher education, and being older, employed, or Canadian-born.12 The authors noted that Black people were more likely to experience or report instances of racism as they gained socioeconomic or class status, suggesting that social mobility does not preclude the reality of anti-Black racism. These findings are key in portraying the nuanced and pervasive manner in which anti-Black racism manifests in the Canadian context. Consider, for example, how the everyday interactions of an older Black woman who recently immigrated to Canada from Nigeria may differ considerably from those of a younger Black man born in Canada, given their distinctive social positions and the cultural norms that shape their perceptions and experiences. Further, expectations linked to characteristics such as age, gender, and immigration status (particularly if accents are present) may also affect the way in which Black people are perceived, resulting in different experiences of racism linked to distinct prejudicial ideas and stereotypes. Further complicating an understanding of racism is evidence that the likelihood of identifying, reacting to, or reporting on anti-Black racism is greater among people who were born in race-conscious societies like Canada than those born abroad.13 For example, Black immigrants to Canada may be more likely to attribute instances of racism to their status as newcomers rather than their race if they originate from a context in which Blackness is not commonly used to define identity. Other intersections such as first language (and associated language barriers) and religious identities or faiths (and associated othering) may further shape expectations and perceptions of racism. As the everyday experience of being Black is not homogeneous, it follows that neither experiences nor perceptions of anti-Black racism are homogeneous.

These nuanced understandings of population heterogeneity and its linkages with perceptions and experiences of anti-Black racism in Canada have important implications for health research, health care equity, and health system design and management. For example, in the case of health equity research, intersectionality offers useful language to better understand and articulate the structural origin of health inequities and the mechanisms that work together to sustain them. As an analytical frame, intersectionality has relevance at various stages of the research cycle, provoking attention to researcher–participant situatedness and the interconnectedness of social identities and structural forces that affect how diverse Black people perceive, experience, and recount exposures to racism in health care. Importantly, the collection of unambiguous racial data across Canada’s health systems that clearly specifies what groups are included within “Black” research categories is key to this endeavour,14 as is the ability to link additional sociodemographic data that capture the diversity of Black communities and their health care experiences. The acknowledgement of intersectionality and the heterogeneity it engenders would also affect the interpretation of data and who is invited to participate in research processes.

Intersectionality is similarly important when it comes to the development of nuanced approaches to strengthening equitable health systems, such as new and effective clinical and management strategies aimed at reducing instances of anti-Black racism, as well as improving access and use of care services. In-depth examinations of the unique pathways through which various sociodemographic and cultural factors may influence anti-Black racism in health care contexts may advance understandings of the relationship that diverse Black people have with Canadian health care systems. Of particular concern are barriers to quality and timely care, and potential systemic factors underlying the health disparities experienced by Black people. For example, a targeted universalist approach that acknowledges both commonalities and differences in experiences of anti-Black racism may improve the effectiveness of health promotion initiatives, such as those aimed at increasing rates of vaccination or health screening within Black communities. This approach would also encourage health care providers to consider the social–structural factors that influence health and health care beyond the level of the individual, allowing for a more holistic assessment of patient needs and contexts, and enabling greater quality of care and improved health outcomes for Black patients. Finally, it would encourage health systems and medical curricula to avoid reductive strategies and lessons that generalize across Black communities. Without acknowledging the within-group diversity of Canada’s Black communities, health care policies and interventions aimed at addressing anti-Black racism are unlikely to make much of a difference.