Intersectionality and Addressing Disparities

Introductory Paragraph

This is the second in a pair of related articles on health equity and disproportionality. The first article titled, “Apply a Health Equity Lens,” focused on resources associated with building health equity. This requires an active commitment to remove obstacles for groups that are more impacted by inequity, and the material below centers on strategies in the field of substance use which are associated with marginalized populations.

Key Information

Addressing disparities begins by acknowledging that we are all unique and that a community look through multiple identity lenses. Likewise, as members of different groups within our communities, we experience differences in the screening, diagnosis, treatment, and recovery supports. This is particularly relevant in the historical context of substance use, because some groups have been more marginalized than others. For example, in looking at recent overall statistics, there is positive news — a 14.5% decline in national overdose deaths for the 12-month period ending June 2024. However, examining these gains through a disparities lens, it becomes apparent that the recent decrease in the opioid overdose rate is not uniformly distributed. Positive trends predominantly benefit White people.

Increased awareness of disproportionality impacts the way communities can address substance use in relation to the specific needs of youth, military-connected families, LGBTQI+ individuals, people with disabilities, those with low socio-economic status, and pregnant people. For example, the majority of pregnant substance-using people who do receive appropriate care and intervention are older and white with private health insurance. They are less likely to be reported to social services, creating significant disparities. People who use substances while pregnant have a great fear and mistrust of medical and treatment providers because of the risk of reporting, prosecution, and infant displacement. Those who are marginalized and do seek treatment have little success, as their honesty often leads to criminal reporting or they are unable to find available and affordable treatment programs. See SAFE Solution article titled, "Expand Perinatal Treatment and Support for People with SUDs" for more information.

The Drug Policy Alliance reports that the US has lost over one million lives to drug overdose during this crisis — yet, even though people of all races and ethnicities use drugs at similar rates, racial and ethnic disparities are evident:

• Black people do not use cocaine at higher rates than other groups, yet the cocaine-related overdose for Blacks is triple that of Whites. Clear racial differentials exist in access to harm reduction programs and medicated-assisted treatment (MAT).
• Native Americans overdose death rates, between 2021 and 2022, increased by 15% while they decreased for Whites. While national overdose rates in 2020 were comparable for Whites and Native Americans, most recent data reflect Native American rates are almost double the rate for Whites. Some of this difference is attributable to limited resources on tribal lands. A large component is associated with variability in overdose interventions associated with methamphetamines, versus opioids. In 2022, the national Native American overdose death rate associated with methamphetamines was more than double the rate for Whites.
• Latinx overdose rates doubled between 2018 and 2022, in large part to the proliferation of Fentanyl. Linguistic barriers which reduce access to prevention and harm reduction programs and compounded by disparities associated with documentation status.

Intersectionality

Intersectionality is a complex topic that warrants a full understanding by anyone engaged in social change work. Intersectionality runs deeper than and should not be confused with the type of inter-sectoral work found in promoting environmental justice by both environmentalists and social justice activists. Intersectionality describes a method for defining the mix of social identities with more accuracy than single identity formulations allow. For example, everyone is a blend of gender, race, class, and ability categories as opposed to being a type of member in different categories. Intersectionality has become associated with social and political correlations with privilege and marginalization. The term, intersectionality, was coined by Kimberlé Williams Crenshaw in three legal cases in 1989. Although each of the cases were lost, her position has been adopted widely in the social justice community and is often linked with its formative roots in Critical Race Theory. Crenshaw made a case in law suits for black women that this newly defined form of discrimination transcended racial and gender discrimination, because black women were being judged in the legal system separately both as women and as members of a minority rather than as black women. In the decades since then, the term has become politically controversial, because it has moved outside of the generally agreed upon descriptive nature of discriminatory patterns to a prescriptive call to action to address sources of structural power differentials. It has been critiqued both for the scope of change for which intersectional advocates calls and for the difficulty in measuring success in conditions which are inherently multi-variable.

Coalition Responsibilities

Coalitions have a responsibility to work to protect everyone in our communities. The first step in implementing this responsibility is to recognize that history points to long-term patterns of inequity. The next step is to realize the scope and diversity within health inequity. This includes incorporating people with lived experience in the decision making process and implementing trauma-informed approaches. Specific recommendations for practicing cultural competence and humility and for applying a health equity lens in strategy planning are detailed in the section titled “Building Capacity for Health Equity” within the SAFE Solution article on Health Equity.

In addition to the statistics on racial and ethnic disparities detailed above, there are several constituencies within communities for which substance use statistics are less documented. For example, collection of data on the transgender and questioning members of the LGBTQ+ has been more difficult to collect, particularly for youth. However, limited data have been collected by SAMHSA in its annual surveys on people who identify as lesbian, gay, or bisexual. These data point to double or triple use rates by LGB respondents, for all substances. When a coalition examines the membership of its community, it should look at not only the specific needs of racial, ethnic, and LGBTQ+ communities, but also evaluate the concerns of military-connected people, individuals with disabilities, and those with low socio-economic status.

One example might help to humanize what may seem to be abstract demographic characteristics. This points to the complexity of systems which are faced in one specific case. Someone named Chris has just been released from prison and is returning home. Chris is fortunate enough to have been supported in developing a recovery plan which includes medication-assisted treatment. However, Chris’s parole officer maintains that Chris cannot use any substances, MAT or otherwise. Instead Chris is required to do x, y, and z, none of which are in the recovery plan. A lack of re-entry services and laws in Chris’s state precluded applying for Medicaid in advance. Chris left jail with three days of medication but cannot see a doctor for a week. Chris is unable to find recovery housing with nearby transportation who will accept someone with a criminal background, so has not yet found employment. Without a job and without prescription coverage, Chris cannot afford to get more medication. The doctor wants to prescribe medications which the parole officer will not allow. If coalition members understand how their local systems are not working together and are working against people, then they can begin to see how difficult daily life might be for undocumented people or LGBTQ+ youth who are ready but uncertain as to how to access substance use services.

Relevant Research

• This article addresses disparities in treatment and access to treatment, regarding economic status and race/ethnicity.

• The Boston University Center for Antiracist Research is a collaborative research and education effort which includes Racial Data Lab, a national online database of racial inequality, and a qualitative (narrative) archive.

• O'Neill Institute for National and Global Health Law published "The Context: Racial and other Disparities in the Opioid Crisis."

Available Tools and Resources

• SAMHSA. This text includes a chapter allocated to behavioral health treatment for major racial and ethnic groups. SAMHSA also manages the Prevention Technology Transfer Center Network (PTTC) and this presentation covers by the Southwest PTTC covers unique challenges faced by marginalized communities in accessing substance use prevention resources and effective strategies for engaging and empowering all communities.

• SAFE Project has published “Resources for Diverse Populations” which provides links to a suite of resources for a variety of populations. Typically, it will take a combination of several strategies to reduce disparity. Therefore, it is important that there be as much input as possible when considering what needs to be done in a given community.

• United Nations. The UN Partnership on the Rights of Persons with Disabilities and UN Women have published “Intersectionality Resource Guide and Toolkit: An Intersectional Approach to Leave No One Behind." It was developed to help both organizations and individual practitioners address intersectionality in policies and in programs. It aims to contribute to an understanding of intersectionality that bridges the gap between theory and practice.

• JUSTICE SQUARED (Just Leaders for a Just Health System) is a collective which is supported by the Robert Wood Johnson Foundation. It aims to create practical, impactful, structural change to advance health equity and racial justice.

• The Hawai’i Department of Health manages the ‘Ohana Center of Excellence, which provides training and technical assistance for those working in substance use, behavioral, and mental health to better serve the needs of the Asian American, Native Hawaiian, and Pacific Islander (AANHPI) communities through culturally responsive care. Their website provides access to a variety of workshops and research articles.

• "How to Be an AntiRacist" is a best-selling book by Ibram X. Kendi. Since racism is often what is being left unsaid in addressing disproportionality, this book, while not directly about health inequity, provides a broad understanding of racism and other “-ism’s” and includes recommendations for building a more just society.

• The Drug Policy Alliance has published three facts sheets on the impact of the overdose crisis on Black, Native American, and Latinx communities.

Promising Practices

• Arkansas. This project aims to reduce alcohol use among black men by providing screening and brief interventions in a barbershop.