Micro-Level Analysis
At the individual level, refugee women may define themselves in ways that reflect
their heritage and recognize, to divergent grades, their race, ethnicity, class, gender,
age, language, education, citizenship status, biology, and genetics (Heise, 1998). The
intersections of these dimensions, explains Guruge and Khanlou (2004), “create differences
both within and between groups of women” (p. 38). Rather than focusing
solely on gender that views all women as the same, intersectionality assumes dynamic
variability and looks to other aspects of individuality—such as economics, ability, and
geography—that more aptly illustrate the unique situation for each individual woman.
An intersectional analysis recognizes that a refugee Sudanese woman, who was
previously a teacher in her home country, partly English speaking, but now unemployed
and alone in a new country, will experience different alterations in identity
formation than an immigrant woman from the United Kingdom who is employed at
a day care. Although they may experience some of the same transitions in adaptation
to a new country, the woman whose experience is shaped by her loss in income,
language disparity, and lack of social support may have significant challenges that not
only affect her health in the present but also may have persistent effects over time.
Intersectionality scholars understand that each woman’s experience is unique and
affected by the changes in context that shift the meaning of various social identities
to give rise to new ones (Samuels & Ross-Sheriff, 2008). This approach is particularly
relevant for refugee women who are displaced for fear of threats often related to
race, ethnicity, religion, or political affiliation. This displacement frequently involves
disruption in geography, resources, social supports and networks, and socioeconomic
status leading to both loss and adaptation. The new identities often occur
in the context of constrained resources, disruptive transitions, unfamiliar settings,
and impose additional stressors that in turn impact the health (and well-being) of
refugee women. Not only is their individual health compromised but also the new
identities—for example, the imposition or uptake of the identity of refugee status,
HIV status, social assistance status, health insurance status, and so forth—come
to act as pathways by which systems of inequality place women at a disadvantage,
and in turn influence their health outcomes (Weber & Parra-Medina, 2003).
Intersectionality asserts that numerous influences are always at play, affecting
the physical, mental, and spiritual health experiences of women (Hankivsky &
Christoffersen, 2008). An intersectionality framework assists nurses to take a closer
look at the individual circumstances, beliefs, culture, education, class, citizenship,
and age of individual women to better understand both their individual needs and
the situations of disadvantage, disparity, or advantage that may be impacting their
health and well-being (Hankivsky & Christoffersen, 2008). For example, Settles
(2006) found that although Black women hold other identities that may impact their
daily lives, their unique experiences may lead them to be especially conscious of
their racial and gender associations. Along the same lines, Cummings and Jackson
(2008)—in their study of the race, gender, and socioeconomic status disparities in
self-assessed health—found that Black women rated their health as much worse
than their White counterparts. Similarly, it is important to consider how new social
identities—based on refugee status, HIV status, socioeconomic status, and so on—
affect and shape the experiences of women in the context of pregnancy. It is also
important to consider the interactions between these different identities to better
understand these experiences and their multiplicative effects on health (and wellbeing)
and access to health care during pregnancy.
With reference to pregnant refugee women, an intersectional analysis would
encourage nurses not only to be aware of the life transition of pregnancy and its
influence on identity but also to expand that analysis to other influential processes.
This would include premigration experiences, which may include trauma or torture,
and postmigration experiences that often affect the identity of the woman because
of changes in employment and socioeconomic status (Guruge & Khanlou, 2004). In
both premigration and postmigration contexts, women will experience HIV-related
stigma. However, the dynamics between stigma and other factors such as culture,
race, gender, citizenship status, class, and socioeconomic status (just to name a
few) will translate differently in the lives of women (Reidpath & Chan, 2005). In both
contexts, HIV-related stigma will be amplified in the context of pregnancy (Barroso
& Powell-Cope, 2000; Ingram & Hutchinson, 2000). However, how that stigma may
be manifested in the life of each particular woman will vary depending on that
woman’s beliefs, social norms, social roles, community influences, and practices. As
a result, women may experience HIV-related stigma in multiple ways ranging from
shame, alienation, exclusion, marginalization to poor access to health care, human
rights violation, and violence: all of which will affect their health and well-being.
An intersectional analysis recognizes that an immigrant woman from the United
Kingdom who was diagnosed with HIV and linked to care in her home country, with
three children who are HIV negative, and is well underway with her fourth pregnancy
will experience different alterations in identity formation than a Congolese woman
who was diagnosed upon arrival to the host country and is expecting her first baby.
By rejecting any linear or singular entitlement to any one social identity, intersectionality
proposes that what is created at that intersection of gender, refugeeness,
HIV, and pregnancy is a completely “new” identity. This “new” identity cannot be
simplistically evaluated based on the sum of its individual parts. Rather, it is important
to consider the various influences that intersect at any one particular point in
time. This tells us that intersecting influences may produce an entirely new social
identity for HIV-positive refugee women who experience pregnancy in postmigration
context. However, the ways in which women identify themselves and are identified
in the context of pregnancy will vary based on refugee status, citizenship status,
socioeconomic status, and HIV status in conjunction with other individual factors
such as race, ethnicity, age, language, education, and previous life experience