Intersectional Analyses of Religion, Culture, Ethics and Nursing

S. Reimer-Kirkham, S. Sharma

Please do not cite or circulate (manuscript in progress)

Today’s global migration has resulted in societies with unprecedented diversity along multiple lines. Global cities are becoming increasingly cosmopolitan, as exemplified in

Canada’s largest cities reported to have “visible minority” populations nearing the majority

(Stats Canada 2010 release/Canadian Broadcasting Coorporation, March 9, 2010). At the same time, the global distribution of wealth is increasingly held in fewer hands (Raphael) with the result that poverty (ranging from homelessness to working poor) is as widespread as ever. Other lines of social classification include (dis)abilities, sexual orientation and, as the focus in this volume, religion/spirituality. The landscape of religious/spiritual affiliation is a complex one with global trends and local specificities. Global migration is resulting in diverse religious profiles in many countries. Even those countries considered most secular (e.g. Europe; Berger,

Davie & Fokas, 2008) are renewing attention to religion as a demographic feature with implications for public policy and social cohesion. Importantly, increased interest in the sacred is also occurring outside institutional religion with the postmodern age marked by personalized explorations of spirituality. Our thesis in this chapter is that in the context of this unprecedented diversity, religion and spirituality need to be understood as intertwined with other social categories such as gender, ethnicity, and class. Referred to as intersectionality, these interrelationships shape how identities are lived out and how social disadvantage and oppression operate in collective ways. The intersectionality of religion/spirituality with other social classifications has, we suggest, not been adequately accounted for in the fields of nursing and nursing ethics. At the level of social ethics, religion/spirituality are implicated in the intersecting

1 social determinants of health and health inequities. In the realm of clinical nursing ethics, a lens of intersectionality gives insight into the complexities of moral agency, ethical decision-making, and relational practice.

We begin by providing an overview of intersectional theory. We argue that intersectional theorizing as it is typically employed today needs to be expanded to more intentionally incorporate religion and spirituality. Equally important, religion and spirituality must be understood as intersecting with other social classifications rather than studied as though they operate in isolation. That is, people rarely identify themselves by just religious affiliation or spiritual disposition, but rather understand their religious/spiritual selves in relation to gender, class, ethnicity, and so forth, and may well foreground different dimensions of these identities, depending on circumstance. Because religion and spirituality have been understudied in intersectional theorizing, their place as sites that exacerbate or mitigate disadvantage that ultimately lead to health inequities is not well understood.

A discussion of intersectionality itself illuminates the complex and varied ways in which the constructs of religion and spirituality are taken up (Reimer-Kirkham & Sharma, in press). As highlighted in this volume, considerable energy across the years has been put to defining both religion and spirituality, often with the aim of differentiating the two and distancing spirituality from religion. Spirituality, especially in the nursing literature, is commonly portrayed as the internal experience of things of immanent and transcendent nature, and religion as the external social organized pursuit of transcendence (whether named as God, Allah, or another ascription to deity). Rather than landing on a particular definition, an intersectional approach has us (for reasons we develop below) incorporating internal and external, immanent and transcendent dimensions in our conceptualization of religion and spirituality. Although spiritual experience is

2 often intensely private, we caution against viewing it apart from social context (e.g., as purely transcendent), for, even though current discourse constructs spirituality as whatever an individual deems as “special” (Taves, 2009), a point we agree with, the influence of the social world on this individual construction, though not always recognized, is ultimately the interest of intersectionality. Also, in the spirit of intersectionality, less emphasis is put on defining the social constructs of interest (e.g., gender, race, class, sexuality, dis/ability, and—in this discussion—religion and spirituality) as to pin down the very essence of what one is examining, an endeavour that risks essentialism. Rather, these constructs are seen as loose abstractions to which people ascribe various meaning, and that are laced with social significance and relations of power. In the case of religion/spirituality, the constellation of meaning hinges loosely on the sacred. A further factor that complicates attempts to define religion and spirituality and that also stands as a call for intersectional approaches to the topic, is that of the power of religion and spirituality for inclusion and exclusion. Intersectionality prompts investigation of multiple axes of disadvantage, and the challenge in the case of religion and spirituality is to avoid essentialist constructions that would have them as only oppressor or oppressed.

A Précis of Intersectionality

Intersectional theorizing is not new, but has gained considerable profile in recent years

(e.g. McCall, 2005; Yuval-Davis, 2006), popularized by Black feminists such as Kimberlé

Crenshaw (1991) and Patricia Hill Collins (1990). Crenshaw, a legal scholar, used the image of a road intersection where vehicles coming from different streets collide with a hapless victim.

Fault cannot be easily attributed in this situation. By analogy, neither racism nor sexism (as vehicles) are ever held fully accountable for the harm they cause. Crenshaw lamented that the struggles of women of colour “fell between the cracks of both feminist and anti-racist

3 scholarship” (Davis, 2008, p. 68). Similarly, Collins argued that black women are uniquely situated at a focal point where two exceptionally powerful and prevalent systems of oppression come together: race and gender. With this foundation, she elucidated how matrices of domination operate; “oppression cannot be reduced to one fundamental type” (Collins, 2000, p.

18) but rather structural and interpersonal domains of power re-appear in spaces of crosscutting interests. Importantly, intersectionality does not “trump” any one category of oppression over another, but rather understands them as a mutually constitutive matrix (Collins, 1990; Yuval-

Davis, 2006). In fact, intersectionality’s main contributions are fuller and more complex understandings of people’s (a) identity formation, especially with an eye to multiple identities; and (b) experiences of oppression, and the structural forces that perpetuate these oppressions.

There are material consequences in people’s lives from these intersecting categories.

Intersectionality is premised on the conviction that understanding the social position occupied by black women compels us to see, and look for, other spaces where systems of inequality come together. By understanding the simultaneity and complexity of identities, advantage, and disadvantage (enmeshed in a broad spectrum of structural oppressions), solidarity is achieved, not in an essentialized view of “women’s experience” but rather at strategic points in a “politics of solidarity” (Carastathis). Hence, intersectionality has, since its inception, been not only an analytic tool but also a political strategy to deconstruct social relations and promote more just alternatives (Luft & Ward, 2009).

Intersectionality, Religion, and Spirituality

There is a mutual corrective that is much needed in bringing religion/spirituality more overtly and intentionally into intersectionality discourse and praxis. On the one hand, scholars studying and practitioners practicing in relation to religion/spirituality desperately need to

4 complicate their purview. Too often religion/spirituality (particularly in nursing and related health fields) are considered in isolation from the social contexts that unquestionably qualify how religion/spirituality are lived out. On the other hand, our contention is that religion/spirituality are often not taken seriously in intersectional analyses, resulting in incomplete analyses that leave invisible pathways to social inclusion and exclusion.

Complicating conceptions of religion/spirituality with intersectional analyses

Increasingly, the emphasis on single categories of identity is seen as inadequate to represent the complexity of social life; for this reason, intersectionality counters one and two dimensional approaches (Hankivsky & Cormier, 2009). Drawing on exemplars from a recent study on the negotiation of religious and spiritual plurality in healthcare1, we have elsewhere

(Reimer-Kirkham & Sharma, in press) made a case for enriching the study of religion/spirituality in healthcare with intersectional analyses. We argued that “more nuanced readings of religion and spirituality are needed to account for how they are lived out in gendered, racialized, and classed ways” (Reimer-Kirkham & Sharma, in press, n.p.). Until very recently, religion and spirituality have been typically portrayed as “stand alone” phenomena or social categories, studied in isolation from ethnicity, race, gender, and class. This is particularly so in nursing.

Nursing literature has tended to promote acontextual interpretations of spirituality and religion that holds spirituality as a highly personalized phenomenon that is either so transcendent that it is not contaminated with “earthly” realities such as race, class, and gender, or so immanent that it is everywhere and everything, making other social categories essentially meaningless. As for religion, many nursing texts, for example, subsume religion under culture or spirituality. When deemed a subcategory of culture, religion is essentialized as a set of static cultural practices.

1 SPIRIT: The Negotiation of Religious and Spiritual Plurality in Health Care (Primary Investigator: Sheryl Reimer- Kirkham with Barbara Pesut, Rick Sawatzky, Heather Meyerhoff, Sonya Sharma, Marie Cochrane). Funded by Canada’s Social Sciences and Humanities Research Council 2006-2009. See: insert url for report

5 When subsumed within spirituality, religion is often made invisible. In contrast, intersectional analyses foreground social operations of power, making acontextual interpretations of religion and spirituality improbable. By illuminating the complexity of multiple social locations influencing identity, intersectional theorizing guards against reifying or essentializing religion and spirituality. Intersectionality also contends that social categories matter equally, with the relationship between categories open to empirical investigation (specific to each situation)

(Hancock, 2007). For such reasons, we contend that intersectional frameworks are needed to enrich the study of religion and spirituality in nursing and nursing ethics.

Nursing literature has shown some consideration of feminist interpretations of spirituality

(including how gender and spirituality are mutually constitutive), indicative of an interest in intersecting social classifications (see chapter in this volume). However, one could well imagine that the Black feminists who so convincingly argued for intersectional analyses—in part as a mechanism to bring the experience of women of colour to the attention of the predominantly

White feminist discourse—would offer a heavy critique to feminist studies of spirituality and religion that do not take into account race and class. Indeed, Rosemary Radford Reuther (Nov

2009), noted feminist theologian, observed the criticism in the 1970s and 80s by Women of

Colour of the racial tendencies in an effort to create an ‘essential’ woman within feminism more broadly, and feminist theology in particular.

Religion and spirituality as more than “etc.”

From another angle, we observe that intersectional analyses have often been deficient in accounting for religion/spirituality as intersecting categories. Shifting trends in regard to religion and spirituality, with the accompanying recognition of the widespread relevance of “lived religion,” religion as embodied and experienced in everyday life for many individuals (McGuire

6 2008; Orsi 2003), as well as the relations of power mobilized through religion and spirituality have led us to make a case for the inclusion of religion and spirituality more routinely in intersectional analyses (Reimer-Kirkham & Sharma, in press). While acknowledging that many scholars have been wary of conservative religion that has sought to colonize political and social organizations and perpetuate patriarchy, there is a need to account for how religion and spirituality are an intricate part of many people’s lives, complicating intersections of gender, race, and class (Klassen, 2003). In short, religion and spirituality need more than a perfunctory nod in the position of “etc.” at the end of a string of “race, class, and gender”.

Sojourner Truth’s widely cited speech punctuated with the question “And ain’t I a woman?” is described by Brah and Pheonix (2004) as deconstructing

every single major truth-claim about gender in a patriarchal slave social formation….the

discourse offers a devastating critique of socio-political, economic and cultural

processes of ‘othering’ while drawing attention to the simultaneous importance of

subjectivity—of subjective pain and violence that the inflictors do not often wish to hear

about or acknowledge”.

Sojourner Truth’s words drive to the heart of her spiritual beliefs: “I have borne children and seen most of them sold into slavery, and when I cried out with a mother’s grief, none but Jesus heard me. And ain’t I a woman?” Pheonix and Brah acknowledge the foregrounding of the importance of spirituality to this type of activism. Patricia Hill Collins, a contemporary Black feminist, often noted as one of the originators of intersectionality, observes that African

Americans have long relied on religion and faith-based sources as sites of resistance to racism

(2006, p.84). She compares the use of religion by immigrant groups as an avenue to maintain group identity to African Americans for whom their religion (Christianity in particular) evolved

7 in response to their suffering under American historical slavery and ongoing racism. Collins points out that African American spirituality can take on recursive secular or sacred dimensions, contributing powerfully to ethnic identity. From these excerpts, we see that Sojourner Truth and

Patricia Hill Collins clearly understand religion and spirituality as integral aspects of identity and resistance, signaling them as integral to intersectional analyses.

Religion and spirituality thus need to be understood as powerful social forces for inclusion and exclusion, particularly as they intersect with other social influences. Because of the intersection with other social influences, inclusion and exclusion however do not operate as binaries, but often overlap, creating a tension between the two. For example, in recent interviews conducted with women about their experiences of church life (Sharma 2007), a Black Nigerian woman named Faraa spoke about an experience she had at her church. One day her son was asked to do a Bible reading. After this, people from the congregation whom she identified as

White English remarked on how well he read. They went on to say that they could understand her son, but not her husband when he preached. Her husband’s position as a university lecturer and a deacon at their church, a mark of esteem and social status, did not alter their viewpoint.

Faraa explained that they understood her child because he was raised with an English accent, but when they heard her husband they heard Africa. In North America and Western Europe,

Christianity and Whiteness are intimately linked and generate social norms and expectations

(Joshi 2006). Racializing religions such as Christianity, Hinduism or Sikhism, “results in essentialism; it reduces people to one aspect of their identity and thereby presents a homogeneous, undifferentiated, and static view of an ethnoreligious community” (Joshi 2006:

212). Faraa later said that she disliked being critical of her church because it was a place of belonging and she had close friends there. Her religiosity gave her a place where she

8 experienced a sense of inclusion. However, when religion is overlapped onto culture, ethnicity, and race, it can invoke colonial images of the racialized other, positioning those who are not

White Christians or whom do not ‘fit’ the host society’s perceptions on the margins, thereby re- inscribing longstanding patterns of exclusion and inclusion (Reimer-Kirkham & Sharma, in press). Faraa’s story demonstrates the contradictions that abound in her church–Christianity seeks universal membership, but can enforce partial norms–and the underlying intersections between religion, race, class and power.

In summary, intersectional analyses are needed to move beyond singular analyses of religion/spirituality that risk essentialism and/or incomplete analyses. Regardless of methodology or theoretical framework, our goal as scholars is to understand phenomena accurately.

Intersectionality can offer a theoretical grid toward this end. While scholars employing intersectional analyses have tended to shy away from religion/spirituality, examples from Black feminists, immigrant and indigenous scholars demonstrate how lived experiences of oppression and resistance are often intertwined with religious/spiritual meanings, practices, and structures

(Bilge, 2010; Dossa, 2009; Kuokkanen, 2008; Williams, 2008). In the next section, we focus on a particular dimension of nursing—that of nursing ethics—with the aim of elucidating how intersectional analyses that intentionally incorporate religion and spirituality enhance ethical nursing practice.

Intersectional Applications to Nursing Ethics

Intersectionality in general has not been widely taken up in nursing to-date, although it is emerging as a very helpful analytic framework for nurse scholars working in the field of population health and health disparities (see Varcoe, Hankivsky, & Morrow, 2007;.Guruge &

Khanlou 2004). Our discussion here articulates with this emerging discourse, focusing on the

9 nexus of religion and spirituality with other intersecting social differences that contribute to the social determinants of health and health disparities, and nursing ethics. Intersectionality, as a method of inquiry and praxis with its focus on matters of identity and intersecting oppressions, brings particular angles of investigation to the field of nursing ethics, especially with the incorporation of religion and spirituality. We focus on several interrelated domains in which this type of inquiry can especially enrich nursing ethics: social justice and health inequities; and identity and moral agency. In these interdependent domains, intersectionality reminds us of the embeddedness of ethics in the everyday—of “lived ethics” as not only a system of formal theory, but also the mutual shaping of ideas and real life (Peterson).

Social pathways to health inequities

At the heart of intersectional theorizing is concern for oppression, or those social relations that systematically disadvantage groups of people and act as social pathways to economic, social, and health inequities. Hankivsky (2010) explains: “those who engage in intersectionality research or policy are committed to social justice and seek significant shifts in power. Because intersectionality recognizes relational constructs of social inequality, it is an effective tool for examining how power and power relations are maintained and reproduced”.

The moral end (or social good), then, of intersectional praxis is social justice, and for nursing ethics specifically, this end involves addressing social determinants of health and eradicating health inequities. Importantly, here we follow Margaret Whitehead’s (1991) conception of health inequities as “differences in health which are not only unnecessary and avoidable, but in addition are considered unfair and unjust” (p.220). At this point in time, little research has been conducted that uncovers how religion intersects with other social categories as a determinant of health and health inequities, however as scholars increasingly document the racializing of religion (Dunn et

10 al.., 2009; Joshi, 2006), and as we understand more about racialization as a determinant of health inequities (Tang & Browne, 2008; Weber & Fore, 2007), this social pathway of intersecting oppressions merits attention. Experts in population health have gathered convincing evidence from studies that repeatedly demonstrate health inequities along the lines of race/ethnicity and gender, although there is still some debate about the exact mechanisms of this differentiation

(Krieger, 2003; Nazroo, 2003; Paradies, 2006; Williams & Mohammed, 2009). Here we focus on racialized religion and religious patriarchy as two illustrations of how religion and spirituality can intersect with other social categories to contribute to health inequities.

First, racialization results in essentialism; it reduces people to one aspect of their identity and thereby presents a homogeneous, undifferentiated, and static view of an ethnoreligious community (Joshi, 2006). For example, by phenotypical and cultural markers, South Asian adherents of religions such as Islam, Hinduism, and Sikhism are deemed “other” in societies such as Canada, the USA, Australia, and Britain where Whiteness and Christianity continue to be normative. Joshi points out that the racialization of religion locates certain religious populations within lower social strata of these societies by applying ideological forces in conjunction with social and political relations of domination. In studying the effects of racialization of religion,

Joshi found that while South Asians tend to be lumped together as “other”, religious identities are also racialized in particular ways. She noted that in the current sociopolitical and cultural context, Hinduism tends to be exoticized, Islam demonized, and Sikhism vilified. The sense of danger historically associated with the West’s post-Crusades view of the Muslim world, again heightened after terrorist attacks in the U.S. and Europe, feeds into ideological notions of the other that result in systematic oppression. For example, cleanliness before prayers and eating is very important to practicing Sikhs. Yet, the significance of these practices can be sometimes

11 overlooked within systems of care, whether due to workload of healthcare professionals or a lack of knowledge about religious rituals within different ethnic communities. It may also be the case however that when race and religion are conflated in association with certain ethnic groups, religious practices important to specific communities are ignored, deemed different, resulting in the racialization of religion, and the treatment of health and wellbeing as it relates to the religion and/or spirituality of particular groups as inequitable.

Secondly, by another angle of analysis, religion as an identity category can lead to further discrimination of women (Sticker, 2008) and thus exacerbate social and health inequities. In many societies, religion, operating as one of the major social institutions of control by which women and men are treated differently (see Johnson, Greaves, & Repta. 2009), affects worldviews on women’s roles and is an element of patriarchal systems (Klassen 2003).

Patriarchal systems of doctrine and practice carry a range of effects, from perpetuating gendered domestic roles to systematically disadvantaging life opportunities (such as education, adequate housing, and income) and negatively and directly impacting health outcomes for women (e.g., in regard to reproductive rights). With the rise of fundamental, politicized forms of religion, and rising global awareness of women’s human rights, more attention is being given to oppressive conditions at the intersection of religion and gender. Okin observes: “It has become clear, from evidence from many parts of the world and many religions, that fundamentalism of various kinds

—many of which are clearly growing in power—is harsh on women and imposes rules irreconcilable with women’s rights (Okin, 1998). For example, within contemporary East Asian

Confucian cultures, women have progressed and evolved with modernization and globalization.

However, as Nyitray (2007) contends, a parallel and digressive fundamentalism is occurring within these societies, resulting in oppression and resistance to women’s changing identities and

12 increased opportunities. As such, for many women in fundamentalist contexts, including those in the West, there is a tension between oppression and liberation, accommodation and resistance.

Even as women recognize the ways in which fundamentalism can limit their roles, there are many elements within fundamentalist contexts that they negotiate and embrace (Sharma and

Young, 2007).

We have highlighted these two examples—racialized religion and religious patriarchy— pertaining to how religion may operate within a “matrix of domination” (Collins, 2000) to differentially impact health outcomes. However important these oppressions are as determinants of health and health inequities, they are never fully determinate of that experience (Sherwin,

1999, p.3). Resistance to oppression—at social and individual levels—are expressions of moral agency, often rooted in, taking strength from, or coalescing around the multiple dimensions of identities also made visible through intersectional theory. The personal and the social are intertwined, and in the realm of ethics where moral decisions carry personal consequences, these touch points must be kept in mind.

Identity and Moral Agency

Nursing ethics are increasingly taking an expanded view of moral agency, moving beyond traditional conceptions of agency that emphasize rationality and deliberate choice to contextual views that understand agency as “enacted through relationships and in particular contexts” (Rodney, Brown & Liaschenko, 2004, p. 155). Moral agency is then “inclusive of rational and self-expressive choice, notions of identity, social and historical relational influences, autonomous action, and embodied engagement” (Rodney et al., p.157). In these ways, we understand moral agency as situated, and inevitably shaped by multiple intersecting sources of

13 social identity constituted by race, class, gender, religion/spirituality and other contextually relevant social classifications (Appelbaum, 2002).

As with intersecting forms of oppression that demand the attention of nursing ethics, so too do intersecting formations of identity. Taking an intersectional approach to identity provides an invaluable guard against essentialist and oversimplified interpretations of moral agency and

“lived ethics”. Inhorn (2006), in her exemplary summation of ethnographic research on women’s health, points out that moral decisions are inextricably linked to women’s health experiences, and that women are “moral pioneers” who negotiate between their own religious belief systems and the moral possibilities arising from the worlds of science, technology, and biomedicine. When shifting identities are recognized, multiple avenues arise whereby to make the connections between individuals characteristic of relational ethics. Relational ethics

(Bergum & Dossetor, 2005) are grounded in commitment to each other and hence are expressed through intersubjective or human-to-human connection. In our empirical work we have witnessed how religious/spiritual identities may provide these avenues for connection— sometimes via shared views, other times not the shared beliefs per se, but rather a shared valuing of religious/spiritual dimensions (Reimer Kirkham et al., 2004; Pesut & Reimer-Kirkham, 2010).

With an emphasis on the multiple dimensions of self, health care providers become more reflexive about their own religiously/spiritually-informed values and beliefs that might well shape their views on various ethical issues (Pesut & Reimer-Kirkham, 2010) and their propensity to engage (or not engage) with patients and families deemed “other”. The same connections through multiple identities can also provide the foundation for strategic alliances. Patricia Hill

Collins underscores the importance of situated knowledge for the formation of coalitions:

14 Each group speaks from its own standpoint and shares its own partial, situated

knowledge. But because each group perceives its own truth as partial, its knowledge is

unfinished. Each group becomes better able to consider other groups' standpoints

without relinquishing the uniqueness of its own standpoint or suppressing other groups'

partial perspectives (Collins 2000: 270).

Relational ethics, thus, benefit from an intersectional approach, in making visible how the specific social location of individuals can affect their moral agency (Sherwin, 1999), creating intentional opportunities for connections through various facets of identity, and leveraging these same types of connections for strategic alliances. In these ways, intersectionality elucidates the interplay of identity, morality, and relationality which, in turn, influence health and health inequities and thus provide the stage for approaches that begin to shift those nursing practices and healthcare services that re-inscribe advantage and disadvantage.

Concluding Comments and Cautions

Bringing an intersectional approach to ethics—one that incorporates religion/spirituality with intentionality—is not straightforward. Sherwin (2008) observes that bioethics has tended to focus on “modest, familiar [problems] with a well-defined scope” (p.8) when more complex approaches are needed to address the nature of problems facing humanity. A challenge, then, is that of countering dominant circumscribed ethical approaches. Yet, the complexity of intersectional analyses can pose challenges to the scientific integrity (e.g., rigour) of one’s work

—there are limits to how many “variables” one considers concurrently (Warner, 2008).

Although a fundamental principle of intersectional theorizing is that no single category is pre- eminent, the tendency is to focus on “master categories” such as gender or race rather than

“emergent categories” such as Dossa’s (2009) work on disabled immigrant Muslim women.

15 Another disincentive to intersectional approaches is that of our propensity—particularly in the study of religion and spirituality—to focus on either individual or social levels. In the realm of the individual, one finds a focus on spirituality with its internal personalized, privatized dimensions anchored in intersectionality’s study of identify formation (multiple identities). At the social level, emphases on religion—with its affiliations with patriarchy, colonization, and other structures of power that result in oppression and disadvantage for some, and dominance/privilege for others—too often lack linkages to “lived religion” (McGuire, 2008;

Orsi, 2003).

Despite these cautions, we call for nursing ethics to embrace integrative, interdisciplinary, and intersectional approaches, bringing the individual and social together for the most effective way of making visible pathways to social inclusion and exclusion. As we understand intersectional influences on moral agency (for all stakeholders involved in healthcare) and relational ethics, we gain increased explanatory capacity in our analyses, and greater compassion and social justice in enacting ethical practice. Intersectionality applies to everyone. Where the social level may infer that intersectionality is most relevant to those

“marginalized” within society’s matrices of domination, the individual level (multiple identities) reminds us that all are implicated in one way or another in the social relations that result in health inequities, and conversely, in creating opportunities for human flourishing.

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