Understanding intersectionality in Psychology
Two years ago, I interned at a government affiliated Psychiatric facility in Assam. On my first day, I was told that the two other psychology interns and I were at the bottom of the food chain. I soon discovered that that was inaccurate- we were in the crater hidden under that bottom. Religiously, rounds to the wards would begin at a certain hour, vary in length depending on the Professor-in-charge, and end with me at the back end of the crowd. Streaming behind the psychiatric doctors, students pursuing their MD (Doctor of Medicine) would swerve to the front, followed by rotational MBBS interns (Bachelor of Medicine and Bachelor of Surgery), accompanied by the Clinical Psychologist, and the Psychiatric Social Worker. Clenching our notebooks behind the dozen fluttering white coats, the psychology interns would peep to get one look at the client. In the month-long internship, I learned some unfamiliar, unspoken conventions- like rising in respect for every superior that walks into the room. And the tacit implication of hierarchy. Needless to say, I was on my feet every half hour. For weeks, I made copious notes to compensate for the lack of affirmation. In retrospect, I realize that I was positioned at a strange juncture of multiple identities- determined by my education, socio-economic class, gender and residence. While not all of these social categories were disadvantageous, some were particularly limiting.
Let us latch on to that thought for a while and shine the light on the other end of the table- on our clients. What are the social categories that affect the way our clients view reality? Identity formation is a process guided by years of socialization comprising transmission of cultural norms, attitudes, and belief systems. Intertwined with these influences are significant transgenerational experiences including, but not limited to exclusion, trauma, discrimination and lack of representation. As I’ve mentioned before, not all social categories are necessarily detrimental to an individual’s mental health. For instance, as a north-east Indian woman with ‘understated Mongolian features’ (or as I’ve been told) and a satisfactory grasp over Hindi, I have not had to bear the burden of unwarranted scrutiny. That experience is an outcome of genetic latitude, economic class, and exposure to opportunities. While this outcome is not unique, it is not customary either.
In the initial stages of the Corona-virus pandemic, when the President of the United States was still addressing the virus as a ‘Chinese virus’, a despicable development resurfaced. Along with a rise in Anti-Asian racist incidents in the US, racism against north-east Indians came to the fore. Harrowing reports of individuals being spat on, called ‘Corona virus’, assaulted, humiliated and alienated frequented national bulletins. One could (incorrectly) argue that such events surfaced in the context of Corona-virus, and that ‘people were terrified and precarious’. But there is a need to understand the inequitable systems that allow presumptions so lopsided that accountability of action is diminished. North-east Indians often report facing minority stress, and feel pressurized to unduly represent their communities at all times.
These experiences are not limited to racism. Exclusion may manifest itself in various contexts, sexuality being one. In September 2018, the Supreme court of India read down the provisions of Article 377 of the Indian Penal Code and decriminalized consensual same sex relations. However, in a time when the word ‘homosexual’ barely qualifies as expressible within the four walls of most Indian households, more work needs to be done at the socio-cultural level. Individuals belonging to the LGBTQ+ community face undeserved stigma for merely asserting their right to be recognized. In addition to coming to terms with their reality in an inordinately hetero-normative society, there is the distress of having to come out to their families, and the fear of rejection or abandonment.
Contrary to the dominant discourse, it is not their sexuality that makes them vulnerable to trauma. It is the multiple narratives that sustain ignorance about sexuality to begin with. This includes homophobia in school corridors, bigoted representation in cinema, oversexualization of lesbian encounters parallel to complete dismissal of gay encounters, and normalized homophobic slurs that constitute lazy and outdated comedy. In the context of both gender and sexuality, with the Trans Act’19 taking away an individual’s right to self-determination, conversion therapy continues to be legal. And childhood giants continue to fall prey to their own dogmatism.
However, this is not to say that individuals will seek therapy only because of issues related to their intersectional identities. An example drawn from able-ism makes a good argument in this regard. Sometimes, discrimination is not served explicitly in the form of uninformed opposition but benevolence, subtle indiscretion or casual language. When it comes to persons with disabilities, a major issue is accessibility. From not having adequate reading material in braille, absence of subtitles in visual aid or sign language interpreters, and inaccessibility for wheelchairs, there is muted but consistent exclusion. With this, we have only explored a handful of crossroads of identities. There are, however, equally jarring systemic networks that determine identity formation, attitudes and access to mental health, and actual healthcare interactions.
An ethnographic study conducted by Sobin George in Meenkera village, Karnataka revealed that there are various ways in which caste manifests itself in the public health system. Infra-structurally, there are separate health centers for different social groups with the centers meant for Dalits having poor facilities. Most health officials in the village are also not Dalits. On the other hand, caste discrimination in medical interactions were more subtle. George noted that doctors and nurses would refrain from touching a Dalit patient during diagnosis, and interrupt them more often, allotting them lesser consultation time in comparison to non-Dalit patients. Surprisingly, most Dalit patients normalized the discriminatory behavior of service providers and did not attribute it to caste differences. This is despite a strong sense of Dalit consciousness in the village with 36% of the households belonging to the community. George attributes his findings to attitudes that the members hold about healthcare. They consider medical practice paternalistic where doctors have superior knowledge. Poor infrastructure is often considered ‘normal’ due to corruption and poor management.
However, what happens when a number of socially adverse categories intersect? For instance, when gender and caste intersect, the effects are dangerously compounded. Studies show that Dalit women are disproportionately exposed to violence. Beyond this, the conviction rate for rape cases against all women in India is a mere 25%, but when specifically looking at Dalit women the conviction rate drops to an abysmal 2%. This is not to say that caste discrimination itself doesn’t present as a major source of distress.
Despite the fact that the Government of India does not release caste-based information on the subject, historically disadvantaged castes typically overlap with low income communities. They have a 40% higher rate of depression than the national average. And 80% of India’s population belongs to historically disadvantaged castes and tribes or religious minorities.
Payal Tadvi, a Mumbai doctor from a tribal community, killed herself because of harassment by “high caste” seniors at her hospital. In January 2016, doctorate scholar Rohith Vemula, a Dalit, killed himself in his hostel room after the University of Hyderabad suspended him and stopped giving him his fellowship stipend. He had challenged casteism on campus. In his suicide note, Vemula wrote, “The value of a man was reduced to his immediate identity.” According to Amnesty International, 65% of hate crimes in India in 2018 were against Dalits, the lowest in a complex ladder of castes in Hinduism.
One overlapping network that consistently gets ignored is that of economic disadvantage and caste. Poor people are often deemed lazy and dependent. Their poverty is tied to their own ‘lack of initiative’ and ‘responsibility’. It is not unusual to find advantaged individuals pointing fingers at ‘able-bodied’ people on the road who could have miraculously grabbed opportunities to change their lives- studied under the streetlight, walked 300 kilometres to a local government school, topped the district, become a civil servant or a trillionaire by starting their own company in a garage.
What gets drowned in our need to glorify opulence is the practicality of random events and life itself. Behind our logically inaccurate correlation of personal struggle and prosperity, there is an assumption of access- to essentials, shelter, capital, opportunities and most of all, agency. What most individuals often fail to perceive is that lower-class often intersects with gender, sexuality, disability and caste to aggravate disbenefit. Economic stress itself can perpetuate a trans-generational cycle of limitation. For instance, if a family suffers from economic disadvantage and one of their children becomes a millionaire, that is an exception and not the rule. And this is not tied to their potential or capability to succeed, but the disequilibrium in opportunities that they have access to. This starts from having to support their families from a younger age, ability to pursue higher education, paying steep rental fees, taking up multiple jobs, and in general leading a stressful life. Lastly, even with higher levels of stress (psychological and somatic), let alone mental health, sometimes even physical healthcare can become a luxury.
When speaking of transgenerational disbenefit, it is not unusual to find trauma percolating multiple cohorts in conflict ridden areas, and victims of large-scale displacement. In May 2020, oil and natural gas began to gush out uncontrollably from the Baghjan oil field in Assam’s Tinsukia district in an event known as a blowout. Almost two months after the tragedy, conditions are no better than before. Displacement, life in relief camps, loss of property, livelihood, and the uncertainties of future rehabilitation continue to remain critical concerns. And the sound pollution, pollutants in their drinking water, poor air quality, periodic ground tremors, along with the ongoing pandemic have only worsened the situation. In the aftermath of the disaster, on July 18, a 45-year-old inhabitant from a village in Baghjan, died at the Assam Medical College Hospital in Dibrugarh district after consuming pesticide. But this is not unfamiliar to the residents of the Kashmir valley.
According to a recent study published by Doctors Without Borders (MSF) in the British Medical Journal, the estimated prevalence of mental distress in adults in the Kashmir Valley was 45%. Even before the government revoked article 370, in April 2017 a study reported a 49.81% prevalence of PTSD (Post-Traumatic Stress Disorder) symptoms. This number is seven times greater than the global lifetime average of PTSD.
The point of this article is not to criticize the very existence of society. In fact, writing this has been a painful intellectual exercise because the ‘people’ I am talking about includes me. The systems I am addressing have, at some point, been unknowingly perpetuated or even supported by me. No civilization is perfect and I do not believe that there will ever exist a ‘model’ of anything that one can completely lift, emulate and reach a personal optimum level of potency. This includes countries, disciplines, practices, sociocultural influences or even an individual lifestyle. The whole idea of intersectionality is to provide for a framework for examining how multiple social categories combine in systems and affect those who occupy the intersections of these social categories. And for that same reason, neither governance nor psychology in India can be a replica of any one model that has been successful in a different context.
For India’s 1.3 billion people, there are 9000 psychiatrists. There is no confirmatory, or consolidated information on this number, making information of available psychologists and psychiatric social workers even more indefinite. However, the government in 2018 stated that there are 898 psychologists against 20250 required in the country and 900 psychiatric social workers against the 37,000 needed.
At this point, you may ask- what can psychology even do? In itself, that question is as deflated and helpless as one can be. So, I will try to sincerely answer that question and hope that it floats. For starters, understand that our view of reality is contingent on what we consider the ‘norm’ in psychological research. In most cases, outliers are removed as exceptions or chance errors. And in almost all cases, the bell chimes toward one type of norm- upper socioeconomic strata, college-going students in urban localities, and binary gender identity. Right off the bat, this excludes a whole spectrum of economic classes, demographic populations, regions, and gender identities. While this may be conducive in studying certain ‘universal’ cognitive attributes, how universal is universal if it does not include a holistic view of subjective experiences? Secondly, a lot of psychological modules of intervention heavily emphasize on the importance of disengagement from others, reliance on ‘self’, and focus on independent identity. No matter what my personal opinions on the same are, that idea is neither culture fair nor may it be my client’s goal to become self-reliant. They may want to reconcile with a family who they believe, abandoned them. In such a case, it would be easier engage in eclectic practice of therapy- tailoring practice to meet the needs of each client. However, that handles the short-term problems of individual therapy, not the long-term goal of making psychology more intersectional. And from a systemic lens, it is more important to understand that not every analysis that is carefully cooked is necessary or correct. Not every transgender homosexual client that walks into the counselling room is there because of their gender or sexuality. Neither is every war-torn community we walk into completely riddled with trauma and grief. Every system that interlocks to create a social category is unique, and every individual that assumes that identity has their own resistance to both stress and change.
Perhaps, I will disappoint you and give you a simple answer to a hopeless question. As practitioners, the solution towards intersectionality begins with a clichéd, but underrated advice on being a decent human being- read the room and always re-read the stories you think cannot be questioned.