Disparities in quality of life by race, gender, and sexual orientation: An intersectional analysis of population-representative data in Gauteng, South Africa

Background: South Africa's history of apartheid has led to persistent inequalities. While progress has been made since 1994, disparities in quality of life (QoL) remain, particularly along racial lines. This study examines how race, gender, and sexual orientation intersect to influence QoL in Gauteng - South Africa's most populous and economically vibrant province. Methods: Using data from the Gauteng City-Region Observatory's QoL 6 (2020/2021) Survey, we analyzed a sample of 10,760 respondents. We employed inverse probability weighting with regression adjustment (IPWRA) to estimate the Average Treatment Effect (ATE) of race, gender, and sexual minority status on QoL, while controlling for socioeconomic factors. Results: Significant QoL disparities were observed across intersecting identities. White heterosexual men had the highest QoL scores, while Black sexual minority women had the lowest. After adjusting for covariates, all Black groups exhibited significantly lower QoL scores compared to their White counterparts. The largest gap was between White sexual minority women and Black sexual minority men (ATE: -14.47; 95%CI: -17.18,-11.76). Within the Black population, heterosexual men had significantly higher QoL than heterosexual women (ATE: -0.98; 95%CI: -1.54, -0.42). Conclusions: Despite progress since apartheid, substantial QoL disparities persist in Gauteng, primarily along racial lines, particularly in access to services and socio-economic opportunities. The intersectionality of race, gender, and sexual orientation creates distinct vulnerabilities, particularly for Black sexual minority women. These findings suggest that current policies aimed at improving equity may be insufficient. Addressing these disparities requires a multifaceted approach that considers the complex interplay of race, gender, and sexual orientation in shaping QoL.