Coining the term, Intersectionality, Kimberle Crenshaw aimed to encourage people to consider the ways in which social determinants such as racism, classism, ageism, sexism, etc. form interlocking systems of oppression that shape the experiences and life chances of individuals as a consequence of multi-dimensional social identities (Green, Evans, Subramanian 2017). Although coining the term to describe biases and violence against African American women, it has become more widely used for other issues as it is used as a lens through which one can see where power comes and collides and where it interlocks and intersects.
To understand Intersectionality is to understand that it is not just a matter of a race, gender, or LGBTQ issues, rather a matter of how these identities shape experiences, interactions, symptoms, treatment, etc. and how they overlap. Although Intersectionality is a move toward creating common ground through discussing differences, while individuals encompass multifaceted identities, individuals still share values and experiences.
As it is human nature to categorize as a way of understanding, social identities are often utilized as a source of social empowerment and reconstruction (Green, et. al 2017).
Identities and Related Positions in Society
Sebastian Lopez, a thirty-year-old Hispanic male is molded through various identities and positions in society. He migrated to the United States from Guatemala at age nine with his mother and sister where he was then reunited with his father after a five-year separation. Sebastian was raised in the Roman Catholic faith, where he attended church, with a primarily Hispanic congregation, twice a week in the community.
Sebastian stopped practicing at the age of eighteen but reports still believing in God. Sebastian has identified himself as an individual in the LGBTQ community, as well as an individual who struggles with substance abuse and who has previously been diagnosed with the human immunodeficiency virus (HIV). Sebastian has a history of clinical depression due to disclosing his sexuality. Due to Sebastians sexuality, his father does not speak to him with the exception of holidays and his mother and sister keep in touch. Sebastian has not introduced his significant other of two years to his family with whom he spends much of his time volunteering with the LGBTQ community. Sebastian began using alcohol and cannabis as a young teen and experimented with methamphetamine at age twenty-one. At age twenty-one he began presenting with promiscuous behavior and at age twenty-five he was diagnosed with HIV but currently denies symptoms of AIDs. Sebastian is able-bodied, credentialed and young. Identifying as Hispanic, LGBTQ, and as an individual who struggles with illicit substances, Sebastian is marginalized. It appears that Sebastian does not have a positive support system. These intersections between axes create complex social locations that are more central to the nature of social experiences than any of the axes considered singly.
The previous dedication to the Roman Catholic faith for this client reinforced the idea that individuals who practice this religion shall not engage in same-sex attractions. Traditionally, religious contexts have been understood as a protective for psychosocial health outcomes but those who identify as LGBTQ are questioned due to denominational teachings (Dahl, Galliher 2012). A study that involved eight adolescents (15-17 years) and eleven young adults (19-24 years) who identify as LGBTQ raised in Christian religious affiliations and two participants raised Catholic participated in individual in-depth interviews, journal writings, and focus groups to provide greater insight into the lived experiences of LGBTQ individuals (Dahl, Galliher 2012). With that, young adults shared feelings of inadequacy and feelings of religious-related guilt. The construct of internalized homophobia has been associated with depression and feelings of worthlessness (Dahl, Galliher 2012) as Sebastian experienced as a teenager due to coming out. Participants experienced suicidal ideation and it was found that depression is more common among lesbian, gay and bi-sexual individuals raised in a Catholic environment (Dahl, Galliher 2012). Moreover, adolescents tended to describe more social difficulty with family members when identifying as LGBTQ. Disengaging from his religious beliefs, identifying as an individual part of the LGBTQ community has marginalized and pressured Sebastian. It is reported that due to the socio-cultural or customs and lifestyles of Sebastians he was not supported through this stage of his life, which reinforced feelings of heightened frustration, confusion and worthlessness. Such feelings led Sebastian to a purposeful overdose and psychiatric hospitalization. With prominent beliefs and attitudes from family, Sebastian was convinced by his mother to stop seeing a social worker for psychotherapy because she thought it was pointless and felt he should spend more time with his teen church group.
Furthermore, as previously mentioned Sebastian began experimenting with alcohol and cannabis as a teen and began using methamphetamines frequently. The socio-cultural of using illicit substances led to recurrent unprotected intercourse with strangers and after being diagnosed with HIV at age twenty-five, Sebastian entered an outpatient substance use rehabilitation center and discontinued his use of stimulants and alcohol.
Impact on Help-seeking/Access to Care/Engagement in Treatment
In identifying Sebastians substance history, one describes this as part of his identity. In regard to Sebastians history of substance abuse, this could impact help-seeking in particular. Stigmatizing attitudes toward people with a drug addiction have detrimental effects on the lives of these people (Sattler, Escande, Racine, Goritz 2017). Drug addiction being one of the most stigmatized conditions in society, even in comparison with other stigmatized mental illnesses has led individuals to become shameful and fearful of seeking help. Individuals of this population are often oppressed by the negative attitudes and behaviors toward them. Public stigma has been a recurrent boundary for those in desperation of treatment. Such stigma presents as a barrier to personal aspiration and life opportunities and often interferes with the ability to seek housing, obtain employment, get insurance, and receive treatment (Sattler, et. al 2017). The internal fear of anticipated stigma can cause treatment avoidance and long delays before an individual presents himself or herself for care (Thornicroft, 2008). Not only does this stigma present itself in people in the community but it can also present in health care providers. For those who chose to seek help and are receiving suboptimal care due to negative attitudes toward substance misuse and cultural insensitivity can heighten feelings of shame and guilt for the individual (van Boekel, Brouwers, Weeghel, Garretsen 2013).
Further, Sebastian has identified himself as part of the LGBTQ community, which can have a severe impact on help seeking, access to care and engaging in treatment especially when intersected with substance abuse and his current diagnosis of HIV. Sebastian appeared to have very minimal family support during the process of sharing his sexual orientation and still does not speak with his father. For Sebastian, this led to feelings and thoughts of not being accepted and feeling worthless, which led him down a dangerous path of depression, substance abuse, and risky sexual behaviors. Studies have shown that individuals of this community often have a social fear of being othered or not feeling like they belong and have shared concerns about the lack of culturally diverse workers (Rivera, 2015). Individuals who identify as lesbian, gay, bisexual, transgender, and queer experience unique mental health disparities. Although the acronym LGBTQ is utilized as an umbrella term and the needs of this community are often grouped together, each of these represents a distinct population with its own mental health concerns (Rivera, 2015). Sebastian has an overlap of concerns that could impact help-seeking, such as identifying as gay, struggling with addiction, having a history of depression, and being diagnosed with HIV. Also leaving Sebastian at a disadvantage is his difficulty to maintain full-time employment and as a result he is insured under the Affordable Care Act. Although a major concern and human rights concern, these stigmatized populations have been the subjects of relatively little mental health research. Moreover, other factors such as Sebastian being in denial of his substance use and HIV, not having immediate family support, and having no external support other than his significant other and the meetings he stopped going to has a significant impact on whether Sebastian may choose to seek help, engage in treatment, or have access to care. Sebastian enjoyed engaging in activities for others, such as volunteering his time in the LGBTQ community, but appeared to be neglecting himself. It also appears that he is not very much open and or willing to let anyone in other than his significant other who was not aware of much prior to the month of Sebastian ceasing treatment.
From a strengths-based perspective, Sebastian is credentialed as he successfully completed his high school career and later completed a two-year program for computer programming at a professional trade school. Fortunately, Sebastian is able-bodied and young, therefore enabling him to work, take care of himself, etc. Sebastian also appears to be aware of the resources available to him as he has a history of previous substance use and mental health treatment. Although Sebastian does not receive support from his family, he does receive the support of his significant other. Moreover, Sebastian is aware of the history of unknown mental illness from maternal aunt, which serves as a strength.
When exploring how the clients social identities could impact the experience of diagnosis and treatment it is important to consider each possible aspect such as the concepts of countertransference or the transference the client might be experiencing. It is important to understand that the client might feel alienated because of previous experiences of being rejected, socially isolated, and judged by his family. Keeping Sebastian in context, one might want to first explore the symptoms that have appeared due to client terminating biomedical medications. It would be beneficial for Sebastian to seek treatment from a physician that specializes in HIV to better understand how his behaviors, feelings, thoughts, etc. have been exacerbated due to incompliance with his medications. It appears that Sebastian has become emotionally unstable as evidenced by being disoriented a month prior and engaging in promiscuous behavior with strangers. It is important to explore the idea that Sebastian may be in possible denial considering even after being informed of mental health history with his aunt he still refused cognitive testing. There is potential for a possible mental health diagnosis based on current symptoms and criteria presented in the DSM-5. In a social justice context, without proper care to address biomedical, substance abuse and emotional state, Sebastian can continue to self medicate, where medical conditions may worsen and or emotional status can evolve and become severe. Sebastian would be doing himself, others that he supports in the community, job and significant other a disservice. He might not be viewed as a reliable, credible human being and can be viewed and or treated as a liability or high risk.
One will find that being and or practicing self-awareness is fundamental to a clients treatment. To understand our own biases and work on them is to better understand clients and to better treat and engage with them. Being aware of our own biases, values, stereotypical beliefs, and assumptions helps us to better serve culturally diverse clients (Oden, Holden, Balkin 2009).
Further, practicing self-awareness enables workers to better understand the differences between his or her own lived experiences and the clients lived experiences. To better engage a client it is beneficial to allow them to educate the worker on their experiences, culture, perceptions, etc. Self-awareness will allow the worker to be more open, receptive and willing to engage in this process. Moreover, being empathetic to the clients feelings and lived experiences is important. Potential biases or the understanding and outlook on the world could create a disservice to the client if the worker is not sensitive to the clients experiences and allowing our biases to get in the way. It is imperative for workers to become aware of these biases before they negatively impact a clients treatment and utilize supervision to unpack those biases and work on them.
Dahl, A. L., & Galliher, R. V. (2012). LGBTQ adolescents and young adults raised within a Christian religious context: Positive and negative outcomes. Journal of Adolescence, 35(6), 1611-1618. doi:10.1016/j.adolescence.2012.07.003
Green, M. A., Evans, C. R., & Subramanian, S. (2017). Can intersectionality theory enrich population health research? Social Science & Medicine, 178, 214-216. doi:10.1016/j.socscimed.2017.02.029
Oden, K.A., Miner-Holden, J., Balkin, R.S. (2009). Required counseling for mental health professional trainees: Its perceived effect on self-awareness and other potential benefits. Journal of Mental Health, 18(5), 441-448. doi:10.3109/09638230902968217
Rivera, A. (2016). ProQuest. Perceived Stigma and Discrimination as Barriers to Practice for LGBTQ Mental Health Clinicians: A Minority Stress Perspective, 1-56. doi:10193625Sattler, S., Escande, A., Racine, E., & G?ritz, A. S. (2017). Public Stigma Toward People With Drug Addiction: A Factorial Survey. Journal of Studies on Alcohol and Drugs, 78(3), 415-425. doi:10.15288/jsad.2017.78.415
Thornicroft, G. (2008). Stigma and discrimination limit access to mental health care. Epidemiologia e Psichiatria Sociale, 17, 1419. doi:10.1017/S1121189X00002621
van Boekel, L. C., Brouwers, E. P. M., van Weeghel, J., & Garretsen, H. F. L. (2013). Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: Systematic review. Drug and Alcohol Dependence, 131, 2335. doi:10.1016/j.drugalcdep.2013.02.018
Aspect Identity/ identities Does this identity give the client a position of privilege or marginalization?
Race (e.g., black, white, biracial) Hispanic Marginalized (considered a minority)
Ethnicity (e.g., Korean, Italian, Guyanese, Native American, Columbian) Guatemalan Marginalizes him as he migrated to the U.S at age.
Biological sex (e.g., male, female, intersex) Sebastian identifies as Male This puts the client in a position of privilege.
Gender identity/expression (e.g., women, men, transgender) Men Privilege (sexism/androcentrism)
Sexual orientation (e.g., lesbian, gay, heterosexual, bisexual) Sebastian identifies as Gay. Marginalized (seen as less than dominant
Religion Raised in Roman Catholic Faith Marginalizes Sebastian as the faith is not similar to his beliefs and sexuality.
Socio-economic class (e.g., lower, middle, upper class) Lower class (difficulty obtaining full-time employment, works as a freelance computer programmer)
Sebastian is credentialed though. Marginalization. May be at a disadvantage in access to services.
Dis/ability (e.g., able-bodied, disabled) Able-bodied Privilege (able-ism)
Citizenship Permanent resident of the United States. Privilege.