Women's experiences of discrimination and the impact on health: research

Part 3 – In-depth interviews with women aged 16-25

This section of the report presents the justification and process leading to focusing on young women in this research phase. It then describes the methods taken and the findings from the study.

Why focus on young women?

Adolescence and young adulthood are critical times in the life course for investigating health and social inequalities. Experiences starting at this age can impact on an individual for the rest of their lives, resulting in health outcomes later in life.^[41] There is also good reason to focus on young people within public health research where we are taking a prevention perspective. There is broad recognition and support for prevention action to address health outcomes and inequalities within Scotland, as outlined in a discussion paper from Public Health Scotland.^[42] One way of doing that is focusing on individuals earlier in the life course. This prevention approach has been used specifically in relation to women's health in a report by the Royal College of Obstetricians and Gynecologists,^[43] based on the life course approach and the understanding that women experience multiple challenges starting in early life.

The gap in women's health inequalities related to young women prompted the decision to have one of the preliminary focus groups (Part 2) aimed at young women aged 16-25 years. Some participants in the ethnic minority focus group and the chronic illness focus group were also within this age range. The experiences and perspectives of the young women in the focus group sample were identified as particularly relevant to the intersectional investigation of discrimination and health. For instance, much of the self-advocacy work described in Theme 4 in of the focus group findings was done by young people, who highlighted their intersectional position of their age and gender as a specific barrier to healthcare access. Further, this group talked about mental health issues where the other groups did not. As mental health is a key priority for Scotland, with a new Mental Health and Wellbeing Strategy being launched in 2023,^[44] and there are gendered inequalities in mental health, focusing on young women provided a potential opportunity to understand discrimination in relation to both physical and mental health in greater detail. Finally, the young people included in the focus groups displayed examples of discrimination that were distinctly intersectional with other dimensions of inequality such as race/ethnicity, disability/chronic illness and gender identity. Therefore, narrowing the age range to young people would still allow the use of an intersectional framework, which had been tested in the focus groups and was applied to recruitment, data collection and analysis of the interview phase.

Therefore, we decided to focus on young women given: (1) the importance of the age group for health inequalities, (2) being an under-researched population within women's health and inequalities ( (3) the findings from the focus groups highlighting some areas specifically relevant to young women that warranted in-depth exploration, and (5) the ability to maintain an intersectional framework within the age group.

Current evidence on discrimination and young women

In addition to the evidence review presented in Part 1, we conducted a more focused literature search for evidence related to adolescent and young adult women as well as any studies that use intersectionality within young people.

Data in UK and Scotland shows mental wellbeing has decreased over time among children and young adults.^[45] The percentage of children with emotional and behavioural problems has increased, an overall trend driven by a change among girls.^[46] Survey data from 2022 by the Department of Health and Social Care finds that while the rates of a probable mental disorder in England are similar in boys and girls aged 11 to 16 years old, 17 to 24 year old women were almost three times more likely to experience an emotional disorder than young men of the same age (31.2%/13.3%) – a 10% increase from the rate in girls aged 11–16.^[47] This follows research from other countries that finds girls and adolescent young women are likely to display greater prevalence of mental health issues such as anxiety and depression.^[48][49][50]

The Office for National Statistics (ONS) data has shown that since 2012 suicides among females aged 10 to 24 have increased significantly.^[51] Young women in particular have been recently identified as a high-risk group, with over a quarter (26%) experiencing a common mental disorder—such as anxiety or depression—compared to 9.1% of young men.

This concerning trend has become exacerbated by the Covid-19 pandemic. Recent data shows young adults, women, people with physical and/or mental health conditions, and people in a lower socio-economic group are more likely to report experiencing poor mental health.^[52] While UK evidence from the pandemic suggests that most children and young people had broadly coped well, girls and young women were more likely to report difficulties with mental health and wellbeing.^[52] In October 2020, 27.2% of young women in Scotland aged 17–22 years in comparison with 13.3% of young men identified as having a probable mental disorder.^[53] Recent data from the Health and Wellbeing Census (2021-2021) also shows that overall, girls in Scotland report worse physical and mental health. Girls have less positive perceptions than boys across a range of mental health and wellbeing measures.^[54]

Discrimination has the potential to have a significant impact on young people, particularly those at positions of multiple disadvantage. Emerging adults who are in higher education may have more access to health care compared to those who are not, although much research on health during this developmental stage focuses on university student samples.^[55]

Further, there is a lack of research on adolescent girls' experiences of discrimination and the effects on their health. Researchers have overwhelmingly focused on discrimination among adults. This is surprising given that adolescence ushers in cognitive and psychological advancements that render discrimination more discernable and more personally relevant.^[56] Children begin to develop an awareness of discrimination by age five.^[57] Early life experiences with discrimination may affect one's health in adulthood, and are associated with poorer mental and physical health.^[58] Given that adolescence is a sensitive period in which mental health difficulties are at their peak for many young women in Scotland,^[59] it seems reasonable to expect that more regular experiences with gender discrimination are likely to precipitate emotional and psychological difficulties for girls and young women.

Research finds that discrimination based on race/ethnicity, sexual minority status, and gender is associated with higher rates of drinking, drug use and risky sexual behaviour during adolescence.^[60] However, not all young people who experience discrimination report higher levels of health risk behaviours. While reducing discrimination is important for addressing the consequences of discrimination for health outcomes, better understanding the factors that exacerbate or attenuate the link between discrimination and health risk behaviours is necessary for developing more effective interventions for vulnerable young people currently experiencing discrimination.^[60] Moreover, a more comprehensive assessment of young people's experiences with discrimination may improve our understanding of the discrimination-health relationship in adulthood.

Health condition-specific literature

It is important to note that in both fieldwork phases of this project, researchers had a broad topic guide that asked women about experiences of discrimination both within and outside the health system. Many of the examples and two of the themes (Theme II: Mental Health and Theme III: Contraception) focus on specific areas of health. These areas were not the focus of the topic guide, but were what participants brought up. They serve as examples of ways in which women experienced discrimination and how that impacted on their physical and mental health. For this reason, we did not do an extensive preceding literature review on areas such as mental health and contraception. Throughout the report there are some reflections on previous literature and evidence on these areas and how it relates to what we found.

Methods

Aims

The aim of the second phase of this research was to explore young women's experiences and perspectives of discrimination, with two underlying objectives:

• To understand young women's experiences of discrimination and the ways (and extent to which) those experiences impact on their physical and/or mental health
• To adopt an intersectional approach to understand the complexity of multiple and interconnected forms of discrimination

Research design and recruitment

The study design was a semi-structured qualitative interview project. The ALLIANCE's and the Scottish Government's networks and social media was used to advertise the project. Interested people emailed the researchers and were sent the consent form, participant and privacy information and a demographics survey. The survey meant researchers could assess eligibility and manage recruitment to ensure there was a good spread of experiences, of women from different backgrounds. An interview was arranged via email with those eligible.

Data collection

A topic guide was developed following the focus group phase and discussion with the research advisory group. The topic guide was adapted to be more suitable to one-to-one interaction and remain semi-structured to allow for more in-depth probing about certain topic areas. The following were used to create the topic guide: the core priorities of the Women's Health Plan; discussions with a lived experience group and other interested stakeholders; literature and evidence on young people, intersectionality, discrimination, and women's health. The topic guide was reviewed by the same Research Advisory Group as for Phase 1. The topic guide was tested through an interview with a young woman in England.

Participants were offered a telephone, online video call or face-to-face interview if location and availability allowed. Each interview started with a reminder of the consent form points and obtaining verbal consent. The researcher then worked through the topic guide and used additional questions based on what the participant said. Each interview lasted approximately 45 minutes. Following the interview, everyone was emailed a thank you voucher and a document containing signposting information.

Data analysis

The data analysis process was very similar to the focus group phase. Audio recordings were transcribed by an external company. Transcripts were then analysed thematically using NVivo 1.6.1 software^[61] by the two researchers on this project. A three-stage analysis approach was used: (1) open coding, (2) axial coding and (3) theme generation. Open coding involved researchers reading through the transcripts and assigning one-word or short phrase codes to sections of text. Researchers then revisited the transcripts and codes with similar meanings were grouped together and relationships identified between them (axial coding). The researchers met regularly to compare codes and develop a set of themes. This iterative process resulted in a set of four themes, which are outlined here with quotes from the data to support the findings. Participants are referred to by their participant number: '[Participant 14], [Participant 10]' and so on.

Limitations

The findings from this project are limited in a similar way to Phase 1. Even though we spoke to more women in this phase, qualitative research is not generalisable to the wider population of Scotland and should be interpreted with this in mind.

The title of the project 'Discrimination and Health' likely attracted participants who had an interest in the topic or who had significant experience in the topic area. It is possible that this is the reason why we spoke to several young people with chronic physical or mental health conditions.

There were some groups of women within the age bracket we did not speak to. For instance, we did not interview mothers under 25, young women from certain ethnic communities such as the gypsy traveller community and we only spoke to one gender non-conforming person. The sample had considerable ethnic diversity as well as women from urban/rural areas and a range of socioeconomic advantage, so the findings contain experiences and perspectives from a number of, often marginalised, positions. Again, as the findings are not representative and generalisable of the population of women in Scotland, these qualitative findings are intended to explore ways in which discrimination may impact on health using examples from a sample of women's lived experience.

The same limitation related to the intersectionality approach described in the focus groups phase applies here.

Findings

This section reports the findings from the second phase of the project, organised thematically. Each section outlines the researchers' interpretation of the themes, using excerpts of data to exemplify and evidence the finding. Each theme includes a brief reflection on how the findings relate to evidence and literature in the field that the findings either support or challenge.

Participant characteristics

The sample comprised 28 young women aged 16-25 residing in Scotland. The sample captured a range of diverse and intersectional identities. Most identified as women (n=27). One participant was currently questioning their gender identity.

The mean age of the sample was 20 years old, with half the sample aged 21-25 (n=14) and the other half aged 16-20 (n=14) at the time of interview. Just over half the sample had a long-term physical or mental health condition (n=15). Almost half the sample were White (n=15), with 13 participants belonging to an ethnic minority background. Ethnic groups represented in this sub-sample included Indian, Pakistani, Arab, African, Chinese, and Mixed Race. Just under half of the sample did not practice a religion (n=13) with the remainder identifying as either Muslim, Church of Scotland, Catholic, Sikh and other Christian.

Participants represented each quintile on the Scottish Index of Multiple Deprivation (SIMD),^[62] with 12 participants residing in the two most deprived quintiles. Most of the sample were working as an employee or self-employed (n=17), and eight participants were studying. Just over half of the sample identified as Straight/Heterosexual and nine identified as bisexual.

Theme 1 – Ageist Sexism

The sample were all aged between 16 and 25 years and considered adolescents or young adults. Several participants claimed that their young age meant that assumptions were made by healthcare professionals that they were "fit and well" [Participant 28] and would not have "anything wrong with them" [Participant 12]. While it is true that adolescence and young adulthood for the majority is the healthiest time of life, participants in this sample spoke of how these assumptions made it a challenge to be "taken seriously" [Participant 23, Participant 12] about a range of physical and mental health complaints:

I think that some people make assumptions when they see you, that your health is good. It often felt very much like, "Oh, that is going to be okay. That'll be fine." Well actually, now I have a literal metal ankle [Participant 1]

I don't know whether that's because I'm a young girl and they have this assumption that all young children, or people in high school are really fit and healthy, and they have no problems whatsoever, and it's only if you're older that you have these problems [Participant 12]

I think young people's health problems can sometimes be, maybe, viewed as lesser because we presume that younger people are healthier than older people, which isn't necessarily the case [Participant 2].

The first time I went, she was like, "Oh, I don't think it's anything like that, like bad, but I'm prescribe you this." Even though it was concerning to me, because I was now coughing up blood and things [Participant 12].

Some young people in this sample also discussed how there were further assumptions based on stereotypes of young people being undeserving and "delinquents" [Participant 26]:

And age is a big part of it. I think there is a thought among some that, "You're young, you're in your 20s, you don't really know what you're talking about." [Participant 22]

She [healthcare professional] was suggesting it would be unfair to give it to me [partially sighted registration] when there could be someone else who needed it more who was older, when I was 18 [Participant 13]

I think, if you're young, it doesn't matter if you're a boy or girl, you'll still be discriminated against, just in different ways [Participant 16]

Several participants saw these assumptions as resulting in age discrimination within in healthcare. As visualized in the network above with the strong connection between age and gender, most participants described how this discrimination was intersectional with being a woman, producing a specific experience for young women. Sometimes, participants found it a challenge to talk about sexism or ageism as separate things, with many participants claiming their experience of discrimination was likely elements of both. This intersectional experience of being a young women led to similar feelings expressed in the focus groups of "not being listened to" [Participant 26] or "taken seriously" [Participant 14] and being "patronised" [Participant 5], both within healthcare settings (e.g. primary care) but also with school, college and work environments:

They are often thinking, "You're a stupid wee girl" or, "She doesn't know what she's talking about." And actually we do, at times women's health issues are just dismissed [Participant 22]

I think gender was a big one, as well, that worked closely in age because it wasn't just, "Oh, you're young and you're dumb." At the same time is was, "Oh, you're a woman and you're blonde so you may not understand." [Participant 24]

It was probably a combination of both because I was so young, I was only 14 and I kind of came in by myself and I'm like, "This is what I want to say." I feel like gender played a part in it as well, it's just like a balance between the two. [Participant 25]

That was one of those ones where I was just a bit like, "I wonder if I had been an 18-, 19-, 20-year-old, athletic boy who needed to go and play football or whatever, if someone would've cared more." [Participant 1]

I've never told anybody my age and if I do tell them, I say I'm over 25…Whether you've been to university, or whether you've worked in a law firm, or whether you've done whatever, nobody will take a female seriously at a young age. [Participant 10]

Further, participants spoke of assumptions that they had issues with "body image" [Participant 11] or "daddy issues" [Participant 21], while others said they were made to feel as though young women are "naïve" [Participant 27], "overdramatic" [Participant 16], "don't know about the world" [Participant 3], "stupid" [Participant 23], "hormonal" [Participant 17] and "irrational" [Participant 21]. Some of these assumptions could be seen as sexist stereotypes experienced by women of any age, others were expressed by participants as amplified because of their young age.

While for some participants their young age was seen to exaggerate the sexism participants were feeling, for others, these experiences of discrimination were expected to carry on as they got older. Some participants found strategies to navigate this. Those in the sample over 20 years talked about "learning how to communicate" [Participant 1] and "being prepared" [Participant 23] when going into healthcare consultations.

Some participants who had more serious, complex or chronic conditions decided to "go private" [Participant 23] as they were not getting the support they wanted from the NHS:

We had to pay for a shower stool and medications, we also have to pay to get a prescription, consultancy, tests. I think I'm quite lucky we can afford that [Participant 16]

At that stage, I decided to go private because I had no other choice [Participant 21]

The participants who mentioned accessing private healthcare were residing in less disadvantaged areas of Scotland using the SIMD (quintiles 3 and above). This begins to highlight the impact of socioeconomic deprivation on these young women's health, which will be covered later in Theme IV.

While some participants developed methods of self-advocacy as was mentioned in the focus groups (e.g. being prepared, persistent and assertive) or were able to afford private healthcare, many expressed that the sexism and ageism they had experienced had meant they were "put off wanting to go to the doctor" [Participant 2] or "less likely to go [to the doctor]" [Participant 25] when they need it:

I think in terms of maybe going and getting reassessed by someone else, it's put me off, like, asking to do that, because of how, like- it's just, like, "Oh you are, but I'm not going to." It's put me off going back to do that [Participant 13]

I was like, "There's no point in even going to the doctors, because they clearly don't care about the health and about this problem that I keep bringing to them. If I've been twice or three times already, then you should take it more seriously, but here you were just pushing it away like it's just a minor thing." [Participant 12]

Despite little evidence on discrimination among younger populations, as described earlier in this report, there is a scoping review (2021) that highlights some evidence relevant to this theme that is worth reflecting on. The review explored perceptions of young people and age discrimination within and outside healthcare settings. For instance, studies in the review found that respondents across various countries tended to share similar assumptions about age groups, including that adolescents are impulsive, rebellious and undisciplined.^[63] Further, another study in the review pointed to younger people regularly feeling patronised by older adults. Finally, within health and social care settings, one US study in the review found that children and adolescents were regularly viewed negatively by nurses when treating them as patients.

This theme reveals these young women's specific experiences of ageism and sexism within the health system. The intersection of age/gender has been explored through qualitative intersectional analysis previously, but this has often been done in relation to older women's experience. However, there are parallels to this study worth mentioning. For example, Riach and Jack (2021)^[64] conducted a study in Australia of menopausal women's experience in the workplace and found that women experience a 'constellation of aged, gendered and ableist dynamics and normative parameters', which relates to the finding in this report that experiences of discrimination could rarely be separated.

This theme also echoes findings from The Status of Young Women in Scotland survey conducted by The Young Women's Movement research team. Based on a survey of 900 young women and people of marginalized genders aged 16-30 (2022-2023), they find that most of their respondents felt strongly that their negative experiences accessing healthcare were because they were young (55%) and because of their gender (62%).^[65] Our results highlight how these experiences of ageism and sexism are difficult to separate, showing the importance of recognizing that identities and backgrounds such as age, social class and disability traverse gender lines and shape young women's unique lived experiences.

The forms of self-advocacy discussed in this theme (e.g. being prepared, persistent and assertive) have also been documented in previous research. As noted in the focus group findings, for some women, being assertive can at times result in further gender stereotyping. We further find age and previous experience using healthcare to play a key role in these women's attempts of self-advocacy, with only older participants in our sample discussing strategies to navigate discrimination. This is an area that would benefit from further investigation, especially since the Status of Young Women in Scotland survey also found that many women in their sample described feeling exhausted by having to advocate for themselves in healthcare settings to get the support, treatment or follow-up care that they need.

Theme II: Mental Health

Impacts of intersectional discrimination on mental health

Almost all participants in the sample explained how discrimination had affected their mental health or wellbeing. For example, being discriminated against increased their levels of stress and anxiety and negatively impacted their relationships with themselves and others. Participant 16 outlined how ableism, combined with gendered stereotypes, negatively impacted on her mental health and wellbeing:

There will always be people staring, which is stressful, it tires me out… they might see me using a wheelchair, and I'm a teenage girl, they are a bit dubious to begin with, but I then move my legs. Then they obviously think I'm pretending or putting it on, I'm just a spoilt brat. That itself is also stressful, knowing that people are judging me because I'm using a mobility aid [Participant 16].

Racism was also a common thread through which some participants conveyed the links between discrimination and mental health. This experience was often intersectional with gender, migrant status, language, nationality and religion:

My teacher [in college] was a bit racist… like maybe because I'm I'm Arab or from a different country, I don't know… but she was treating me very bad… And you're over-thinking and you don't eat because of that [Participant 6]

If you were a girl [at school in Scotland], and you wear a hijab, you will certainly get bullied, even more if you do not have English. Sometimes boys take a different view of hijab girls. They think they can't do anything, that she can't talk to anybody, that she has to be alone [Participant 8]

These intersecting stereotypes, for these young women, created a sense of exclusion and isolation that had a negative impact on their mental wellbeing. For these participants, the "bad feeling" was mostly described through their behaviours such as "not eating" [Participant 6], "staying off school" [Participant 7] as opposed to using mental health diagnostic terms such as anxiety and depression, which we found to be terms more commonly used by White participants.

Young women from minority ethnic backgrounds also suggested there was a level of exhaustion in anticipating and expecting racism, even in the absence of any discriminatory acts. This anticipation often meant participants felt they needed to change themselves (e.g. their name [Participant 10], or accent [Participant 15]) or their behaviours (e.g. career choices [Participant 6] and avoiding certain spaces or settings [Participant 15]) to avoid being discriminated against. These expectations of discrimination were expressed across our sample and tied to a range of identities and background (gender, age, religion, race, disability, language):

…actually I am quite worried about my future, because I want to be a nurse and I will be wearing a hijab and the people in the hospital will then see you [Participant 6]

I go by an English name and I it makes me feel sad, because I can't use my birth name, because people will find it difficult to say. I change myself so I'm not discriminated [Participant 10]

Because of that discrimination that I had, I went to the airport four hours early. I did that to make sure that I didn't have to deal with this thing again. And in future I probably would, and try and see what the ethnic, the minority culture of a place is like before I go [Participant 15]

Further, discrimination led some participants to remove themselves from school and college when they experienced discrimination or racial bullying. For example, Participant 8 and Participant 6 share how the discrimination they faced in educational settings tied to their religious and ethnic backgrounds led to them temporarily or permanently discontinuing education:

I didn't go to school for a week or so…that was the worst week ever [Participant 8]

I didn't continue with the course, I couldn't really go on with it because I couldn't learn anything from her with the way she speaks to me [Participant 6]

These accounts highlight the emotional toll of navigating prejudice and the important consequences intersectional discrimination has on participants' mental health and wellbeing. As Participant 3 notes, "on the grand scale of things, when you're discriminated against for things that you can't change, it does start to have a bit of a knock-on effect, because you remember it." These experiences display not only the mental health impact of discrimination, but how these young women removed themselves from specific spaces and wider society.

Seeking Mental Health support

While the first sub-theme explored the impacts of discrimination on participants' mental health and wellbeing, this theme focuses on the experiences of participants who explicitly spoke about the process of getting mental health support or treatment. Almost half of the participants in the interviews sample (n=13) spoke about having mental health issues and their experiences seeking support. All the young women described struggling to get their mental health symptoms taken seriously. Dismissal was often grounded in participants not being believed or being told there is nothing wrong with them:

I told my friend that I was going to student support in school, and telling them how I was feeling. Basically she was, like, "Wait, no, don't do that. Because I know someone who went to them, and they did literally nothing for her." I went and spoke to the school anyway, my friend was pretty much right. It was downplayed, and they were saying things like, "People have it worse than you" [Participant 17]

I have in the past really struggled with my mental health I wasn't given the same support as a boy the same age… Even with just being stressed out, we're just kind of told by the school, 'Oh it's part of life, get over it.' [Participant 4]

Participants who gave examples of when they weren't being heard or taken seriously about their mental health were prompted by researchers to reflect on their identities (e.g. gender, age, sex, race, disability) in those situations (i.e. whether one felt more predominant or not). In all instances, participants identified their gender as predominantly shaping these experiences. They said this was due to their mental health symptoms often being dismissed as a natural part of being a young woman (described by 6 participants):

I did, sort of, see it at school, with, there'd be boys who were being a bit disruptive, who were then being taken to down to pupil support. But with the girls, we were more told that we were just hormonal, and stuff [Participant 17]

Girls will be seen as moaning, or we'll as like, "Oh, she just wants to add work on [for the NHS]. However, we know as women that we will only make fuss about something when it's needed to be fussed about. We don't just make something out of nothing [Participant 10]

Maybe sometimes women are a wee bit more open to talking about their emotions. So if you say to Uni, "Oh, I've had a rough couple of days, I've been really depressed, I need an extension" they're just like, "Och, you're fine." Whereas I know some of my guy pals have used that for evidence of why they can't hand stuff in. Sometimes it's taken a wee bit more seriously. So you don't know if sometimes it's just- and men are a wee bit more, "Oh, this actually might be a real problem" whereas as a girl they're like, "Och, well, she's just a bit emotional." [Participant 22]

Initial dismissal often meant participants would delay or avoid seeking further support and then their mental health would as a result deteriorate. Various participants expressed frustration at the expectation to "prove" that they need support:

When I had mental health issues, I couldn't say to others, like, "I'm struggling," without giving proof. It then got to a point where I felt like I had to cut myself to show to my work that I'm in pain, because I didn't have the proof that I'm going through something [Participant 10]

…especially for myself I know from a mental health point of view if they can't see it or if you can't prove it with a doctor's note that you've not been well, nobody takes you seriously. [Participant 22]

I think a lot of the time from my experience of being younger, I was really, kind of, just scared after being told no so many times. It just felt like I was, kind of, being judged or just not properly listened to. I just stopped for quite a long time, quite a few years…I don't think I ever went to the doctor's at all, just because I felt a bit scared about going or just felt like what I would be going for wasn't reason enough. It wasn't justified. Anything I had wasn't justified unless I was collapsing or having an infection or something. It's not real. [Participant 21]

While some participants described ways in which stigma around mental health is beginning to be broken down, participants highlighted that increased mental health awareness at times can actually work against young people and become a way of dismissing mental health concerns. While now there is a broad recognition that "there's a mental health crisis", there is a risk of dismissing young people "because it's easily explained by negative societal trends" [Participant 1].

Other participants highlighted how increasing awareness of mental health issues had resulted in a "tick box exercise", with everything "wrong" with young people being explained by mental health [Participant 16]. The awareness of the extent of poor mental health among young people (i.e. the mental health 'crisis'), meant that participants felt that it was so commonplace in their age group, with overstretched and limited resources, that it was hardly worth investigating. The attitude from multiple healthcare professionals many had seen was that it was something young people would eventually "get over" [Participant 17].

Health barriers resulting from gender stereotypes

The stereotypes about mental health, young people and women discussed previously not only resulted in barriers accessing support for mental health issues for these women, but difficulty getting treatment for physical health conditions. Several participants in the interview sample gave specific examples of when they were seeking healthcare support for physical symptoms, but they were told it was likely a mental health problem. Some participants reflected on the stereotype of the "anxious teenage girl" [Participant 1], when referring to instances when their physical health concerns were put "down to mental health" [Participant 11] and assumed to be psychological:

I used to get reoccurring UTIs a lot as a teenager. It would always happen at times when I was stressed or down. But, because it was so connected with being an anxious teenage girl, it would almost be treated like a phantom UTI [Participant 1].

The doctor had said anxiety and worrying all the time was the problem, but he also said that I probably have like [low] blood pressure… but even if it was anxiety or worrying, that couldn't last for years and years like this has, you know? I've been like this for two years now, but I don't think it's because it's anxiety [Participant 7].

Some of the young women in the sample were willing to entertain that a mental health diagnosis for their symptoms was a possibility, but described how the diagnosis was often given at a very early stage. Participants described how assumptions about their physical symptoms were made with "no tests" [Participant 11], "no investigations" [Participant 16] and very few "questions" [Participant 15] asked about their health complaint. As one participant explains:

The doctor presumed it was psychological, even though I had loads of physical symptoms and he never discussed it with me, at all. I felt like what he was saying was only to do with my age and me being a girl, it wasn't because of any tests he'd done [Participant 11].

When mental health issues were the suggested diagnosis for these participants, what followed was that little or no mental health support was offered. This left some participants feeling as though their pain was not "real" [Participant 23] and they should "get on with it" [Participant 9] or they were "written off" [Participant 16]. For example:

I went to them for my chronic issues and it was always dismissiveness of it, there was always the talk of it being anxiety and depression. It did also annoy me that they didn't even want to help me, like if it was anxiety and depression like they said, they just wanted to write it down, and write me off, and they weren't offering to help me [Participant 16].

Some of our participants were hesitant about disclosing mental health symptoms to healthcare professionals for fear that would become the focus of the consultation, further leading to their pain not being believed. Participants also felt that such symptoms might be a distraction and reinforce stereotypes as often "they [doctors] just boil it down to one single issue" [Participant 5]. For example, Participant 1 described how she was reluctant to "be honest" about her mental health in case it "automatically discredited" her physical symptoms:

I was concerned that physical symptoms weren't going to be explored properly because they can easily be put down to, "Oh, you've got a history of mental health issues." …it's only after about 9, 10 months that I've finally gone to her [doctor], "Maybe it is just really linked to my anxiety." But, even if I knew that, I wasn't really ready to be honest about that, because then it would be such an easy them to just go, "You just have to manage your anxiety and you'll be fine" [Participant 1].

Participants' intersectional experiences of having their physical symptoms dismissed as psychological (anxiety, stress, depression), and their mental health symptoms dismissed as a gender norm or female attribute further highlights an interplay of their identities, especially, age and gender.

This theme explores how (1) discrimination (e.g. ableism, sexism, racism) impacted on participants' mental health, (2) discrimination acted as a barrier to accessing mental health support and, (3) how assumptions and stereotypes about young women being inherently anxious made it a challenge for participants to access support for both mental health and physical health conditions.

Our findings contribute to growing evidence associating intersectional discrimination with poorer mental and physical health^[66] and highlight the important consequences discrimination had on our participants' mental health and wellbeing. Our findings also support recent results of the 'Women's Health – Let's talk about it' survey,^[67] based on nearly 100,000 responses from women in England. The majority of their respondents reported instances where they were not listened to by healthcare professionals when discussing symptoms, a number that increased for respondents with an existing health condition or disability (89%). They also found that women's symptoms were frequently dismissed as "a natural part of being a woman". Likewise, our participants reported not being listened to particularly around their mental health, a key area of dismissal also identified by respondents in the survey. This is particularly concerning as, despite evidence showing that stigma around mental health is beginning to be broken down and a greater prevalence of mental health issues among younger people, they further find younger respondents feel considerably less comfortable talking to healthcare professionals about their mental health than older respondents. Less than half of respondents in their survey aged 16-19 feel comfortable (41%), compared to those aged 80 or above (72%).

The Status of Young Women in Scotland survey (2022-2023)^[23] also found that when young women were presenting with any symptoms, mental or physical, medical professionals would suggest hormonal or menstrual issues were the likely cause. Our findings therefore contribute to growing evidence within Scotland highlighting specific health barriers experienced by young women resulting from intersecting age and gender stereotypes.

Theme III: Hormonal contraception

The intersection of gender and age discrimination becomes especially apparent in participants' experiences related to contraception. Fourteen participants recounted their "journey" [Participant 28] with reproductive technologies when asked to share an experience in which they felt discriminated within or outside a healthcare setting. There was a sense among the sample that hormonal contraceptives such as the pill were easily available, readily prescribed and often brought up by healthcare professionals when the participant was seeing them for something other than contraception. This prescription of the pill often occurred in early adolescence and was mentioned as the first (and in many instances, only) drug suggested for birth control. The perceived willingness at which doctors prescribed the pill to adolescent girls did not "sit well" [Participant 3] with a number of participants:

Birth control is actually a really big decision but I think it's treated quite lightly [Participant 2]

Whether it's relevant or not, doctors tend to always ask are you on any form of contraception?… I don't know if young women should be constantly, constantly encouraged to ingest these synthetic hormones from such a young age [Participant 3]

Some participants understood this ease at which the pill is prescribed as reflecting a public health priority for young women to "not get pregnant" [Participant 3]. This focus on pregnancy prevention through the pill left participants feeling they were not trusted or believed to practice safe sex or feeling solely responsible to prevent pregnancy:

I've just always felt I didn't have any control over that part of my health, because everyone's so bothered about me getting pregnant. It feels like young women aren't trusted to practice safe sex [Participant 1]

I feel like it is almost just unfair that we're constantly reminded, like it's only your responsibility as a young woman. That's a type of discrimination that women face very, very regularly and that does not really sit well with me [Participant 3]

Further, participants discussed experiences where the contraceptive pill was prescribed for issues beyond birth control, such as menstrual regulation or pain, and to treat endometriosis or polycystic ovarian syndrome (PCOS): "we're offered the pill to cure everything" [Participant 14]. The prescription of the pill as a type of medication meant that some participants' primary concern for which they were going to the GP was at times overshadowed by a focus on preventing pregnancy, despite it being irrelevant to their situation:

It doesn't necessarily matter to me as much if the birth control is the best contraception… we need to be using the best thing for actually solving the problem [Participant 2]

I think there are often too many things having to do with periods where we think birth control is an answer, which it is not. There was never enough questioning of whether pill they had given me as the solution was helping [Participant 1]

Participants who were prescribed the pill for any reason reflected on the lack of knowledge about potential side effects of the pill. These side-effects (e.g. "vomiting" [Participant 3], "hair loss", "mental health problems" [Participant 20], "weight change" [Participant 10], "bleeds" [Participant 9]), were often not "properly explained" [Participant 3] when prescribed, sometimes leaving participants feeling as though something else was wrong with them or that they had not "fully consented" [Participant 9] to the prescription:

I was on the pill for around four years and it was only doing me harm [Participant 10]

I've had a lot of issues with different contraceptives. Last year I got really unwell and I couldn't keep food down for several months. I lost about a stone in weight, it made me very, very depressed and it was just an awful time [Participant 3]

I only found out information about the pill after researching myself years after I started taking it [Participant 9]

Following prescription, some young women in the sample went on to experience mental and physical symptoms. Those that sought medical advice were met with resistance to investigate the side effects or consider changing methods. Several participants reported being told to "wait and see" [Participant 3], even after long periods of time, which left them feeling dismissed and like their "pain was undervalued" [Participant 2]. It was also apparent that mental health issues in particular were not considered valid reasons to change or come off contraception. While participants recognised that it may often take time to adjust to medication or contraception, from their perspective, they were speaking to their doctor about symptoms of concern to them, to which they were told to persevere through the mental and/or physical pain:

Instead of asking, "Are you alright?" they would be like, "Can we put you on more hormones? The worst thing that could happen is that you get pregnant" [Participant 1]

Some participants described their experiences over time with different forms of birth control as an unnecessarily long "journey" [Participant 5]. For those with a reproductive health condition, it took years to figure out how to best treat it or find a suitable form of contraception. Some participants expressed frustration at the length of time it took to find appropriate support and that there was rarely discussion beyond being told to "stick with it" [Participant 20].

I just had the same journey of going to the doctor, trying this one, and going back because it doesn't work for me. And then going back, trying a different one. There was no like trying to offer different things that might be better. And they were all very patronising. I know I was young, and I know I'm not a doctor, but I do know that this thing [the pill] just doesn't work for me, and they keep going, "No, just keep trying it" [Participant 5]

It's still frustrating for me that it took 18 months to get to that point [Participant 2]

One of the consequences of these experiences was that several participants "came off" [Participant 20] hormonal contraception. Some participants felt there was a breakdown in trust in the healthcare professionals due to the lack of information about side effects. The dismissal of suspected symptoms and limited discussion about the available options of contraception intensified that distrust and meant that a few young women we interviewed felt hesitant to engage with healthcare professionals about contraception again.

The dismissal and lack of appreciation of the side effects these women were reporting about their contraception mirrors the mental health theme. Contraception and mental health access are two examples of the healthcare system where young women in this sample describe a feeling dismissed and multiple points of discrimination, primarily related to their age and gender. We therefore interpreted these two themes as two examples of areas of the health system where discrimination manifests (rather than highlighting these areas as being of the greatest concern for policy in Scotland). It is unlikely that contraception and mental health support are isolated domains, but in this sample of young women they were the most discussed. Discrimination in the form of dismissal and disbelief of symptoms was also discussed by the focus group participants, related to different areas of health (e.g. surgery, chronic conditions), which illustrates our argument that discrimination is described by women as pervasive in many areas of the health system and wider society.

Many participants in our study brought up experiences with reproductive technologies, most notably the contraceptive pill, as instances when they felt discriminated. The findings in this theme therefore contribute to both the evidence base on discrimination, but also the literature on reproductive technologies. There is a lack of research exploring women's intersectional experiences of reproductive technologies. In 2018, 28% of women aged 15-49 years in the UK used the birth control pill as their main method of contraception.^[68] Data is however missing on the proportion of women taking the contraceptive pill in the UK or Scotland for issues beyond contraception, including menstrual regulation, lessening menstrual pain and flow and to treat endometriosis and premenstrual syndrome, all of which are primarily treated with the contraceptive pill. Data from the US finds 14% of pill users or 1.5 million women take the pill for non-contraceptive reasons.^[69]

Our findings also support evidence from The Health and Social Care Alliance's survey.^[70] Based on more than 400 responses from women in Scotland in 2020, they also found that some respondents felt that they were put on the oral contraceptive pill as a default, which masked symptoms of menstrual health issues such as endometriosis and delayed diagnosis. Similarly, they also found mentions from their respondents of the risks of treatment not being fully discussed before taking place. Evidence from the Women's Health Strategy^[71] in England also highlights the oral contraceptive pill and side effects as a key topic where respondents felt they were not listened to by healthcare professionals. Heavy periods and endometriosis, and pain related to menstruation and other gynaecological conditions are also among the top areas where their respondents felt dismissed, mirroring the areas brought up by participants in this study when discussing their experiences with reproductive technologies, especially when prescribed for health issues beyond contraception.

Theme IV: Racism, structural sexism and socioeconomic disadvantage

The way that young women experienced discrimination was often complex, usually intersectional and difficult to untangle. For example, one participant said discrimination was like "a bowl of spaghetti" [Participant 3] in this way. Participant 10's testimony exemplifies this intersectional experience of discrimination. Throughout the conversation, she drew on her racial identity ("people don't take you seriously sometimes with the colour of the skin"), gender ("females, we get seen as we complain a lot, we moan a lot, we just make a fuss out of something"), age ("Because you perceive them as a healthy group…They're not taking them seriously") and language ("you have to speak proper English…Because again, you are discriminated with your terminology").

In this theme, there is a focus on participants' testimonies of structural racism, structural sexism and socioeconomic inequality. While these experiences at times intersect with other forms of discrimination (for example, age, religion, language, disability), these were dominant descriptions and are the focus of this theme.

Thirteen participants in the sample were from minority ethnic backgrounds. These participants talked about experiences of racism within and outside the health system, using both structural and interpersonal examples of discrimination. One structural experience of discrimination related to participants feeling as though there was little knowledge or understanding about certain health conditions and how they present in people from their ethnic background. For example, one participant said "because I was a black, they didn't know much" [Participant 12]. A specific experience mentioned by a few participants related to skin conditions and how they "show up differently on different coloured skin" [Participant 14]:

My sister and I have eczema sometimes but when we go to the doctors a lot of the time they don't think that's what it is. I think you can notice the effects on White people more than you can on people of colour [Participant 20]

I think, maybe, things like how, in medical textbooks, skin rashes or cancer, are shown on white skin, and not brown skin or black skin. Or they show up differently on different coloured skin [Participant 14]

So, it will be hard to solve these problems when everything is based on White people [Participant 12]

These participants described how the lack of knowledge about non-White skin led to discriminatory experiences that resulted in "repetitive appointments" [Participant 12], delays in diagnosis, which for some participants worsened their condition. One participant incorporated her experience of cultural discrimination and stereotypes attached to the colour of her skin, within her testimony of the lack of research (structural discrimination). The racism this participant experienced at multiple levels, she felt, resulted in the health service being unable to treat her properly but also a lack of care about her as a person:

It felt like they weren't trying to solve the issue. I think that has something to do with the lack of research on Black skin, but I don't think they were probably weren't as bothered or cared as much about what happened to my skin [Participant 12].

Similar to not being "cared" about, some young women described how the systemic racism within the health system and wider society allowed "micro-aggressions" [Participant 12] or subtle types of interpersonal discrimination to occur. Examples included being spoken to "differently or impolitely" by healthcare professionals or administrative staff [Participant 10], having "several repeat appointments" [Participants 12] or "not being gotten back to" [Participant 14], "being ignored" [Participant 9] and being thought to "not speak English" [Participant 10]. While some of these experiences could be understood as resulting from the extreme pressure on the health system (as many participants acknowledged), these participants specifically expressed these as "racist" [Participant 19] experiences and felt that they would be treated differently if they were white. These experiences often related to other axes of discrimination such as language, migrant status, nationality, religion, gender and age, which at times interacted with ethnicity and acted as "additional barriers" [Participant 15] to being treated fairly:

Perhaps it's because I'm from a different country or maybe because I'm Muslim I don't know… but she was treating me really badly [Participant 6].

The fact that I never got the option to decide if I wanted a female or a male doctor when it came to my examining my skin was, I think, both discrimination against me being a young girl but also because I'm Black [Participant 12]

I'm not sure if it is a woman thing, or a woman of colour thing, or a people of colour thing to really have to exaggerate [symptoms], in order to be heard [Participant 9]

These experiences resulted in feelings of dismissal and frustration for these participants, similar to those explored in relation to age and gender in Theme I. Participant 10 gave a description of her experience of being diagnosed and subsequently managing Polycystic Ovary Syndrome (PCOS). This example shows how complex and connected intersectional structural discrimination, micro-aggressions (inter-personal discrimination) and stigma are for young women from ethnic minority backgrounds. The participant expressed her unique position as a young woman from an ethnic minority background with a 'women's health' condition and the difficulties that come with that:

So you might come from an ethnic minority background, you're more likely to have PCOS. Because women within ethnic minority communities are less likely to get medical advice about it, because of the stigma that comes with that, and then maybe that's why there's a lack of research or information and support to help that person [Participant 10]

As well as experiences of racism, participants across the sample described wider societal sexism. These experiences could be considered 'structural' as they were ways that women were restricted in their opportunities to be healthy aside from interpersonal experiences with healthcare professionals. There were parallels with young women from ethnic minority backgrounds in that many participants described how "women's health" [Participant 20] conditions were under-researched. Specifically, conditions such as PCOS and gynecological issues, with several participants being told there would be little support, treatment or medication for their condition.

A further example of structural sexism related to young women's public health, which some participants suggested limited how there were able to take part in health behaviours such as physical activity. These examples not only related to being a young woman, but also to location (rurality) and socioeconomic disadvantage. For example, some participants mentioned that decisions about exercising outside were inherently different for men and women, with personal safety being a key factor for women:

I always think about this with my partner. When he goes out on a run at night-time, I'm just, like, "Oh, that would be nice to feel safe enough to do that." [Participant 20]

When I live with my parents… they live in a lovely wee village and, that's absolutely fine, I don't feel any issues running at night, I feel safe. If I was to run in [town] at night, where it's quite badly lit, I wouldn't feel safe and there would be a risk there. So that, kind of, stops me being able to exercise how I like to exercise [Participant 24]

if it's really late at night I'm, like, I have to scoop out a wee bit more money and get an uber home rather than walk through because I know that the route that I'm going is not all perfectly lit or if I feel okay, I'm going to walk home [Participant 25]

It's more likely that I'll just do a 10-minute jog where the street lights are rather than a nice route that I would be used to because I get scared. [Participant 28]

These quotes reveal how structural sexism outside of the health system also have an impact on these young women's health and opportunities to be healthy. The experiences are related to location and socioeconomic disadvantage due to the links between how "safe" women feel in certain places, which in this sample appeared to change depending on how well lit an area was, the perceptions of safety of an area and how familiar they were with it. However, several participants took it as a given that women simply don't run alone at night.

Finally, socioeconomic disadvantage came into these experiences when income was mentioned as an enabler or barrier to safe exercise. Nine participants talked about the funds needed to have a gym membership. Some young women explicitly said they were unable to afford a gym membership. Although many saw the gym as a safer option to exercising outside, there were still safety concerns that related to being a young woman, particularly at cheaper and 24-hour gyms:

Financially, hugely, it's changed, the cost-of-living crisis… I used to go to the gym. I used to live right next to the gym so it wasn't an issue. That's also another thing, it was a 24-hour gym and I didn't feel comfortable going past the dark period at night. I didn't feel safe doing that… You hear stories of people being harassed in the gym [Participant 24].

Sometimes, I'm at the gym and I'm nervous. Like, "Oh, someone's looking at me," or I'm anxious like, "I want to do this exercise, but I'm worried how people will see me. I'll look weird." I don't want- I'm very anxious about people perceiving me- Sexualising me, or anything like that. [Participant 26].

There was someone, this guy. Do you know when you can just feel eyes on you? And it started making me feel uncomfortable about going at that time of night. So, I've started going in the morning but I feel like it's actually better for me now, to go in the morning. But yes, it's so weird because I actually did feel really comfortable there until that happened [Participant 20].

These quotes show one way that public health messages around exercise can be discriminatory, in a structural and intersectional way. Factors such as financial challenges, safety and general discomfort mean that young women and particularly those on lower incomes face unique challenges. Not only do some young women have to make economic decisions about their health in the current economic climate in Scotland, but they have the added consideration of whether the space is safe and what time they are able to visit. Particularly in Scotland, with the winter months and longer hours of darkness also being said to restrict young women's ability to engage in health behaviours. These challenges are embedded in wider structural discrimination such as gender-based harassment and income inequality.

There was also discussion in the interviews of socioeconomic advantages some young women may have aside from income to afford "private healthcare" [Participant 18], "gym membership" [Participant 28] and "healthy food" [Participant 8]. This related to access to non-monetary resources such as "knowledge" [Participant 12] and "information" [Participant 19] as well as a personal sense of "empowerment" [Participant 22], a sense of "entitlement" [Participant 15] and "confidence" [Participant 5]. These were described as "privileges" that were able to support women in either being healthy or receiving healthcare support. One example that displays this comes from Participant 21 who described her journey receiving an Attention Deficit Hyperactivity Disorder (ADHD) diagnosis in her young adulthood. She outlined her diagnosis as a "privilege" because she claimed she was only in a position to get it because of her increased access to knowledge about health through going to higher education in her early twenties. Being exposed to this new information gave her a sense of empowerment and the skills to navigate the process. She was expecting a level of sexism given that the condition is less well-understood in women, but she highlighted that her newfound education gave her resources to persevere:

It made me feel, like, you know, I was an irrational woman. And I also didn't feel comfortable always to say…. the only things that have got me through is this information I've got from doing my course, which is privileged. Most people don't know these things, you know? And being, like, "I know I'm entitled to a referral." So no matter what they say, I'm like, "I know I'm entitled,". Only through being given that language and almost being given- a point in the direction of how to approach things, was I able to, kind of- feel slightly empowered to try and do these things [Participant 21].

This theme presents some examples from the qualitative data which illustrate how structural discrimination (namely racism, sexism and socioeconomic disadvantage) interplay with interpersonal experiences with healthcare professionals and wider society.

There is a wealth of evidence related to structural and systemic racism and how that impacts on health, with the levels of discrimination described in the background of this report having been developed to understand racial health inequalities.¹⁴ The Covid-19 pandemic has not only shone a light on racial health inequalities but may have exacerbated them. Scholars have increasingly turned their attention to examining the significance of racism in producing adverse health outcomes among women specifically, as they are likely to experience a 'double jeopardy'. The focus group participants in the first phase of this project also highlighted the priority for many ethnic minority women in navigating everyday racism, over and above sexism and other discrimination. However, the interview data from this second phase provide evidence of racism and intersectional discrimination within the health system that these young women experienced as patients. A comparative qualitative study with UK ethnic minority women's experiences of maternity care during the pandemic reveals similar patterns.^[72] They revealed that ethnic minority women experienced racism at interpersonal and structural levels. This chimes with the findings in this report that highlights that experiences of racism, operating at these different levels of discrimination, are likely to have major impacts on ethnic minority women. These findings within this theme contribute to the knowledge base around the importance of intersectional analysis to 'help peel back the veil' that the pandemic has begun to reveal.^[73]

Socioeconomic health inequalities within the UK and Scotland are well-documented. Poverty is inherently gendered with the overall pay gap in Scotland currently sitting at 15%.^[74] These gendered economic inequalities were expressed through our participants testimonies about not being able to afford "safe" health resources like the gym. Barriers to physical activity for women and girls have been explored^[75] and continue to be a policy focus, given that women are less likely to meet physical activity guidelines in Scotland.^[76] Therefore, this project makes a timely contribution to literature and public health strategies by underscoring how key considerations for young women in Scotland in terms of their physical activity are safety and finances.

Conclusions

Conclusions for interview study findings

The findings from the young women in this sample extended those resulting from the focus groups. The participants in the interview study similarly describe how they felt discriminated against in multiple ways and through cultural, institutional and interpersonal levels. Participants revealed the unique challenges faced by young women in terms of discrimination and their health, within and outside healthcare settings. Stereotypes of the "anxious teenage girl" shaped the participants' experience of healthcare for a range of physical and mental symptoms. Such stereotypes manifested in interactions with healthcare professionals to the extent where participants felt discouraged to access healthcare due to the expectation of negative treatment because of their age and their gender. Particular areas of interest for this age group are mental health and contraception, as these were domains where the sample highlighted being dismissed, patronized and unsupported, leaving them feeling frustrated with the health system. Structural experiences of racism, sexism and socioeconomic disadvantage were also highlighted by our participants, indicating that it is not solely negative interactions with individuals that young women are concerned about in relation to their health.

ESRC Fellow reflections

I was brought into the Scottish Government as an ESRC Fellow to develop a package of research to support the Women's Health Plan. Here I reflect on what I see as the main contributions of this programme of work.

1. The challenge of building a robust evidence base for women's health inequalities

The aim was to 'build an evidence base on women's health inequalities, with specific focus on the impact of sexism, racism, ableism, and other forms of discrimination including homophobia and transphobia on women's health.' The evidence review drew upon various projects within the UK that begin to address women's health inequalities. The qualitative findings from the focus groups and interviews begin to give insight into how women experience discrimination in relation to their health,. However, there are still a wide range of gaps related to women's health condition data, ethnicity data and areas of discrimination we were not able to address within the scope of this work (e.g. transphobia, classism). Therefore, one major contribution of this research is highlighting potential avenues for research and policy to continue with the aim of building a robust evidence base.

2. Importance of an intersectional approach to research and policymaking

The findings would have not been as rich and relevant to the policy aims of the Women's Health Plan had an intersectional approach not been embedded within every stage of the research. Through 'thinking intersectionally' when designing the research project and incorporating that into the recruitment plan, we were able to speak to a diverse sample of women in these two projects. Recruitment was monitored throughout using a demographics survey upon registration, allowing researchers to visualize the 'missing' perspectives from the research and where efforts should be focused. For example, through engaging with third sector partners who work with young women who may be marginalised from the research.

Not only has this work highlighted the importance of intersectionality, but it provides a case study of how intersectionality can be operationalized in research for policymaking. My reflection on this is that there are three key actions we took that resulted in a successful intersectional analysis: (1) incorporating intersectional thinking early in the project development process, (2) being committed to intersectionality as a framework through recruitment, adjusting the recruitment strategy dependent on the developing sample of participants, and (3) structuring (and testing) questions that allow participants the space to reflect on their multiple and interconnected identities. These three steps mean that the data are already set-up for intersectional analysis. We found that there was little interpretation on our part and largely it was clear the different intersections participants were speaking about. Finally, it is important to recognise that there needs to be a starting point when using intersectionality for policymaking (for us, that starting point was women, and subsequently young women). Being comfortable with a certain level of complexity and 'messiness' helped us draw out useful examples of discrimination that should be useful for policy colleagues when it comes to designing strategies.

3. Qualitative research is essential for capturing knowledge for policymaking

This qualitative research project contributes to the evidence base on women's health inequalities and discrimination. While taking account of the limitations of qualitative research related to sample size and generalizability, these projects provide a range of intersectional examples of how some women in Scotland experience discrimination and how that impacts on their health. Without the space to discuss complex and difficult concepts and experiences, these insights would be lost. While survey and quantitative data highlight structural discrimination, what they don't show is how this structural discrimination plays out in women's lives, in often subtle ways. The qualitative approach allowed us to identify potential policy directions for future iterations of the Women's Health Plan, such as mental health and contraception. The added value of qualitative work here is that it demonstrates how those experiences are playing out for women in Scotland. Those in-depth accounts from women are needed to effectively design policies and interventions to improve their health. Therefore, I see the final contribution of this package of work is highlighting that qualitative research should remain a major part of health inequalities research for policymaking.