Inequity in psychiatry cannot be addressed without first embracing intersectionality

To the Editor

Over the past year, the RANZCP has released multiple statements emphasising the college’s commitment – and our need as practitioners and professionals – to working towards culturally safe and humble practice with a diverse range of minority groups (Position Statements: 105 – Cultural Safety, 76 – Partnering with carers in mental healthcare, 62 – Partnering with people with a lived experience, 83 – Recognising the mental health needs of the lesbian, gay, bisexual, transgender, intersex, or questioning (LGBTIQ+) population and 104 – Whanau Ora). This is inclusive of those from indigenous communities, minority ethnic groups, the LGBTQ+ community and those with trans and gender diverse (TGD) identities and those with intersex variations.

These statements are critically important in building a roadmap to addressing the inequitable outcomes – and additional burden of illness – that these groups face. Within the recommendations they incorporate, they include guidance as to how these might be implemented in practice. However, there is no recognition that inequality is a problem within the RANZCP, nor a commitment to apply these principles internally and to our own governance structures.

We have taken great steps in releasing these statements, but without also holding our organisation to the same standards, this is merely virtue signalling. It is changing the colour-scheme of the college logo to match the indigenous, pride, or trans flag at the appropriate time of year in a display of tokenism without associated meaningful change. The power lies not in our statements but in actions taken following their release.

I congratulate the college on the recent review on gender equity in the college, but emphasise the need for an approach based on intersectionality in doing so (Crenshaw, 1989). The questionnaire underpinning this effectively erased the identities of TGD members of the college by providing only options for ‘male’ and ‘female’ and relegating all others to ‘undisclosed’. This is a categorisation which has been repeated on college registration forms – including on our in-train system – and consistently on conference and congress registrations.

In doing so, we enact cisgenderism, ciscentrism (Ansara, 2012) and transnormativity (Riggs et al., 2018) by signalling that ours is an organisation which never considered even the possibility of gender diversity within our membership. We push a collective unconscious belief that gender-diverse individuals could not possibly reach the standard required to be admitted to our college. It is therefore unsurprising that this group frequently feel unsafe to be open about their identity and their experience within our profession. Their voices are silenced and we, and the communities we serve, are poorer for losing the wisdom of their lived experience. We cannot hope to rectify this while actively maintaining a space which denies the possibility of their existence.

Experiences of this nature are not unique to gender-diverse members of the college; nor are they the first to experience them. Female, indigenous, ethnic minority and sexually diverse members of the college (and recently trainees) have reported similar struggles at different times during our history. These are neither different fights nor different issues. Instead, they reflect different faces of the spectre of colonialism at the heart of New Zealand and Australian culture, and within the RANZCP by extension. The solution is not to address this through incrementalism (or by having minorities fight among themselves for focus in the so-called ‘Oppression Olympics’ (Yuval-Davis, 2012)) but instead to adopt an approach based on intersectionality.

By considering gender inequality as unrelated to other forms of marginalisation and prejudice, we cannot hope to achieve gender equality for those to who exist within the intersections of those issues. While upon successfully completing this process, the issue may be seen as resolved for those women who are lucky enough to be white, non-indigenous, cisgender, able-bodied and fellows (etc), those who experience multiple forms of marginalisation will continue to fall through the cracks. With the momentum lost, they must wait for the spotlight to once again fall on gender as the issue of the moment, albeit with far fewer voices with which to draw attention.

Alternatively, we can co-design a solution alongside women and gender minority individuals with a diverse range of intersectionally marginalised traits. Only in doing can we truly hope to ‘not diminish from the important aim for inclusion, diverse representation and equity for all including Aboriginal and Torres Strait Islander people, Māori, Culturally and Linguistically Diverse, those with disabilities, and the LGBTQIA+ community’ (RANZCP, 2022) and find a resolution which is also applicable in their reality. Historically attempted solutions in wider society have ignored this issue, often by instead enacting privilege through declaring them ‘too complicated’, ‘too hard’ or ‘unrelated’ and leaving them at the wayside. By instead accepting these issues as interconnected and embracing intersectionality by empowering and including these voices, we can find a solution which addresses the underlying issues once and for all. Our alternative is to spend decades repeating the process turn-wise providing half-measures to each marginalised group within our college.