Unequal Access to Mental Health Care; an Intersectional fight

“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. Therefore, the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.” (World Health Organisation 1946).

We cannot ignore that healthcare accessibility is unequal. Depending on someone’s gender, sexuality, race, and socioeconomic status, challenges add up in accessing  the necessary healthcare due to misdiagnosing, stereotypes, or financial difficulties. The struggle intensifies when dealing with Mental Health. It is important to stress that unequal access to mental health care is a systemic issue. Minorities face various social disadvantages that members of the socially dominant group do not, increasing the likelihood of psychological problems (Keith & Brown: 131).

Access to Mental Health Care and Gender Identities:

Gender categories act as a coordinating mechanism for social relations and are based on socially constructed beliefs which assume  differences in characteristics and behaviours depending on people’s  gender. According to this common belief, someone labelled as female is expected to behave differently from someone labelled as male (Ridgeway 2011: 44). As a result of centuries of social and institutional inequality, members of both groups are led to believe that one group deserves to be more respected, worthy of prestige, and is considered more skilled in some way than the other. In this situation, males are seen as the dominant  group (Idem: 45). Unfortunately, doctors are affected by the social construction of gender categories and often treat female patients differently from male patients. Researchers in the 80’s have shown that while therapists described men as independent, mature, healthy, and socially competent adults, women were described as more submissive, less adventurous, easily influenced, less competitive, being more emotional and less objective (Pope et al. 1985: 152). This reflects the social conceptualisation of masculinity and femininity that still persist nowadays. As a result, on the one hand, women seeking mental health care were more likely to receive treatment in order to become responsible adults and on the other hand, a female having the features of a “healthy adult”, may be seen pathologically as missing the characteristics of a healthy woman (ibid). This illustrates how attributes perceived as female are not what is expected of an adult. 

In fact, feminist academics have highlighted the existence of epistemic authority, which focuses on who gets to do science and to have a neutral point of view and who is denied a neutral point of view, in a world where neutrality is a sign of power (Harding, 2004; Anderson, 2017). Yet everyone produces knowledge from a specific standpoint linked to their personal experiences (ibid.). Hence , what has been considered neutral for a long time is, in fact, the standpoint of the dominant social group; white, upper-class, cisgender, heterosexual men (ibid.). Consequently, the world has been built over white men’s experiences, and so has the medical field. This means, for example, that women are less likely to be diagnosed with ADHD or autism from a young age because the scientifically recognised symptoms are symptoms experienced by men (Russell et al. 2021: 674). This is not only because women are experiencing different symptoms but also because they are better at masking them as they learn from a young age to stay calm and polite (often less expected from young boys) resulting in late diagnosis, and making it harder to succeed in school, work, relationships and other aspects of life (Mandy et al., 2022). 

Gender-based inequalities lead to mental health inequality which creates additional barriers for women in patriarchal societies. The only option for women and gender-nonconforming persons to access fundamental rights is to change the underlying social structure that denies such rights. It is crucial to understand how the white-male standpoint shapes our knowledge of science and how it affects women’s and gender-nonconforming people’s access to adequate Mental Health Care. 

Access to Mental Health Care and Trans Identity:

Sex and gender are too often understood as binary and non-changeable. This is problematic for transgender people whose self-identifications are generally complex and hard to pin down (Bettcher 2014: 389). Bettcher, a transwoman academic, identifies four mechanisms of reality enforcement used to invalidate transgender experiences and often used by medical practitioners (idem: 392). The first mechanism is identity invalidation. This refers to categorising someone through the mistaken gender identity (ibid). The second is the appearance-reality contrast which is using the appearance of someone to justify identity invalidation (ibid). This is linked to either passing as non-trans and risking to deceive other people or being openly trans and risking transphobia and violence (ibid). Lastly, genital verification can be used to erase someone’s gender identity (ibid). Due to these struggles related to self-identification and social recognition, transgender people are more largely exposed to mental health issues such as depression. For example, a survey in the US showed that 41% of the transgender community had attempted suicide (Herman et al., 2019). 

Trans people make decisions about their gender identity and expression under the patriarchal and binary society (Koyama 2003: 247). Trans women especially are often forced to adopt traditional characteristics of femininity in order to be recognised by the healthcare system, which has positioned itself as the judge of who is genuinely a woman and who is not. In order to be acknowledged as women, trans women are then required to prove their womanhood by accepting gender stereotypes (ibid). A psychologist’s lack of awareness of the experience of being trans and identity invalidation can lead to misunderstanding and therefore being unable to give appropriate treatment. A transgender adolescent sent to a hospital for suicide attempts and self-harm injuries, for example, was misgendered and discharged from the hospital early by medical staff. He then committed suicide (Mirza & Rooney, 2018).  

Access to Mental Health Care and sexuality:

Heteronormativity not only affects gender minorities’ access to mental health care but also sexual minorities’. Heteronormativity is the idea that normative sexuality, here heterosexuality, has been represented as normal or appropriate, while same-sex forms of sexual practice, along with other sexualities and forms of gender expression, have been viewed as abnormal and deviant, usually with serious consequences for minorities (Lind 2013: 189).

 In this case, being considered deviant has two significant consequences for queer people. Firstly, much like trans individuals, those with a different sexuality than heterosexuality are more likely to face individual discrimination and marginalisation, worsening their exposure to mental disorders and distress (Mirza & Rooney, 2018). Secondly, mental health care practitioners are usually uneducated in the particular requirements of these persons and fail to provide adequate care (ibid.). LGBTQ+ people are more likely to be denied treatment and to be verbally or physically abused by mental health practitioners (ibid.), without even mentioning countries where LGBTQ+ people face conversion therapy and are totally denied access to mental health care.

Even within marginalised groups there are imbalances: gay men commonly get more access to health care than lesbians and bisexual women. This is due to the fact that the healthcare system started to care about sexual minorities during the AIDS crisis, focusing on white gay men’s experiences. This illustrates how LGBT women and racial minorities encounter additional challenges.

Access to Mental Health Care and Race/ Ethnicity:

Gender and sexual identities are not the only barriers to accessing mental health care. Systemic racism reinforces myths and unfounded beliefs around race and ethnicity, impacting all institutions, including those that provide mental health treatment. While it is increasingly recognised that genders are socially constructed, it is less frequent to hear that classifications like white and black were historically developed and maintained too (Nakano Glenn 2000: 4). Yet it was, resulting in countless stereotypes and abuse.  Generations of medical research on predominantly white male bodies not only harmed women but also people of colour. Unequal treatment and misdiagnosis are caused by circumstances beyond geography, education, or socioeconomic class for patients of colour, but they are also driven by medical practitioners’ biases (Epstein 2022). As a result, race and ethnicity play an essential role in access to mental health care. Compared to white people, racial minorities have far less mental health support, as they are less likely to receive adequate care and are more likely to receive low-quality care (McGuire & Miranda 2008: 3). Research has shown that people of colour are more likely to be diagnosed with severe mental illnesses such as schizophrenia than white people and, therefore, more likely to be sent to psychiatric hospitals (idem: 4). 

The psychologist’s lack of cultural sensitivity and possibly negative perceptions associated with racism all have an influence on the administration of mental health treatments in the Black community (ibid). The fact that minority women are exposed to several forms of oppression, and institutional expectations based on non-intersectional settings affects and limits chances for meaningful intervention on their cause (idem: 30). Intersectional studies acknowledge that cultural necessities are described primarily as distinct from other social experiences centered  on class, gender, racism, or sexuality (idem: 25). This means that a group identified as culturally different is assumed to be internally homogeneous when this is not the case (ibid). However, in the case of women of colour, the impacts of gender and class oppression are intensified by the racist and discriminatory behaviours that they frequently face (Crenshaw 1991). As a result, it is important to consider someone’s multiple identities, which intersect and provide various experiences and requirements. 

According to Kimberle Crenshaw, Black representatives were opposed to publishing a study on domestic violence because they feared that the statistics would unjustly portray Black communities as incredibly aggressive, thereby perpetuating stereotypes (ibid.). This may apply on an individual basis in terms of mental health treatment since ethnic minorities may be afraid to seek help in order to avoid reinforcing preconceptions about their mental health and illnesses.(Ashley 2014). For example, symptoms presented by Black women during mental health treatment may support stereotypes of angry black women as aggressive, tempered, irrational, confrontational, and uneducated without justification. Black women may then be hesitant to seek mental health care, afraid of perpetuating this stigma (idem: 29). Furthermore, if they do get mental health care, psychologists who are unfamiliar with the angry Black woman narrative may misunderstand symptoms, leading to misdiagnosis and inadequate treatment (ibid.).

Access to Mental Health Care and social class:

In many countries, mental health care is expensive, making it harder for lower social classes to access care when needed. In addition to economic disparity, LGBTQ+, women, ethnic and racial minorities and disabled people are overrepresented in lower classes (Badgett et al. 2019) because they face discrimination and employment inequalities. However, they are also the populations that are the most exposed to mental health disorders (The Scottish Public Health Observatory, 2022).

In countries where mental health care is accessible for free, it is often necessary to be referred by a general practitioner. In this case, if as stated above, the practitioner misdiagnoses, refuses to provide adequate care, or does not recognise their patients’ symptoms, the latter will not have access to free mental health care. Therefore, they will have to either give up due to financial difficulties; or wait longer to access the necessary care. Research suggests that being in poverty, living in inequality, and being in low-income situations are related to a wide range of health-related problems. For instance, these individuals tend to use health care services less frequently and receive poorer-quality care (McGlynn et al., 2006).

Additionally, inadequate mental health can affect someone’s ability to work, handle finance etc. Therefore, if a lower-class person loses their job due to untreated alcoholism, ADHD or depression, they might easily enter a vicious circle. 

Where systems of racial, gendered, and classist dominance intersect, intervention techniques based mainly on the experiences of women who do not have the same class or racial backgrounds will be of little assistance to women who encounter distinct challenges due to race and class (Crenshaw 1991: 1282). Women are more likely to be exposed to unemployment, violence and abuse. LGBTQ+ people are more likely to experience loneliness, family conflict, low self-esteem, injustice and discrimination. Ethnic and racial minorities are more likely to experience difficulties in communicating, low income and poverty, injustice and discrimination. All these factors are adverse factors for mental health (World Health Organization 2012), yet these populations face the most difficulties in accessing mental health care. Using an intersectional approach to mental health care recognizes that these populations are not only facing social inequalities due to their social identity but also medical inequalities

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