Mental Health at the Margins: The Need for an Intersectional Approach for Inclusive Mental Health Care in India

Human experiences are shaped by the complex interplay of multiple social identities, including gender, sexuality, caste, class, ethnicity, socioeconomic status, and religion, all of which are embedded within systems and structures of power. ¹ These intersecting factors, collectively known as social determinants, significantly influence healthcare outcomes, including the development of health issues, help-seeking behaviors, and service utilization, particularly in mental health, referred to as Social Determinants of Mental Health (SDMH). ² Despite its importance, research on SDMH is significantly limited. Existing studies have revealed that current interventions often overlook SDMH, which can compromise treatment outcomes and hinder effective care. ³ Mental health professionals must recognize the profound impact of SDMH on human experiences and mental well-being. ³ The concept of intersectionality offers a valuable framework for understanding how intersecting identities (such as race, gender, sexuality, class, and ability) converge to produce distinct experiences of discrimination or privilege, ultimately influencing mental health outcomes. This approach emphasizes that overlapping identities can intensify oppression or advantages rather than simply adding up as separate factors. ⁴

The term “intersectionality” was introduced by American critical race theorist and black feminist legal scholar Kimberlé Williams Crenshaw in 1989 within the context of Black feminism. ⁵ However, its roots extend into various social justice movements, including those for LGBTQIA+ rights, civil rights, disability rights, Indigenous rights, and post-colonial struggles. ⁶ In public health, intersectionality has been applied as a framework to understand, investigate, and analyze health inequalities. ⁷ By moving beyond traditional individual-level determinants, it considers interactions across macro (global and national), meso (regional and provincial), and micro (community and individual) levels.^4,8 A more comprehensive approach is necessary, as traditional methods primarily focus on the biomedical model. While this model is crucial for understanding the etiology of illnesses and developing individual-level interventions, it falls short of capturing the broader impact of illnesses on individuals and society. ⁹

Hancock described intersectionality as the most effective approach for diagnosis and crafting targeted interventions. ¹⁰ Intersectionality is particularly relevant in mental health, where social stigma and cultural factors tied to intersecting identities often require individualized, culturally sensitive care.^11,12 Research has consistently shown that the burden due to psychiatric disorders is significantly higher in racial/ethnic, gender, and sexual minorities. ¹³ India’s vast diversity in social determinants makes it a crucial context for exploring intersectionality, particularly in mental health. There is a significant research gap in this area within our country, and consequently, our professionals lack training in intersectional approaches. Understanding intersectional approaches will enable mental health professionals to provide holistic and wholesome patient care. This article aims to elucidate the significance of intersectionality as an essential component in understanding mental health and treatment outcomes within the Indian context.

A Case Scenario

Ms. X, a 26-year-old cisgender woman from a rural village in Kerala, belonging to a religious minority community, presented to a psychiatric clinic in a nearby town with a six-month history of persistent depressive symptoms. An unmarried teacher, Ms. X, initially sought help from a religious healer, accompanied by her family, who harbored concerns about seeking conventional mental health treatment due to stigma and financial constraints. Ms. X reported experiencing profound feelings of hopelessness, fatigue, and anxiety, which were particularly exacerbated by the pressure of meeting her family’s expectations regarding marriage and her role within the community. Furthermore, a recent incident of communal tension in her area had intensified her symptoms, leading to increased social isolation and withdrawal. Ms. X’s family and friends advised her to “be strong,” reinforcing her need to conceal emotional struggles. This pressure led to guilt and apprehension about seeking professional help, fearing it would be seen as a sign of weakness. Ms. X harbored self-doubt, wondering if she was “overthinking” her problems, which contributed to her ambivalence about seeking treatment. Moreover, her online research had fueled concerns about potential medication side effects, further exacerbating her hesitation to consider pharmacological interventions.

Ms. X felt a sense of comfort and reassurance knowing that her psychiatrist was not only a woman but also shared her cultural background, hoping this shared understanding would facilitate more effective treatment. However, the interview occurred in a formal, medicalized setting where she felt uneasy. She found the environment intimidating and struggled to open up and communicate. After a brief evaluation, the doctor promptly diagnosed Ms. X with Major Depressive Disorder (MDD) and recommended medication and psychotherapy. Though the doctor emphasized the need for treatment compliance and provided brief psychoeducation, the doctor did not explore Ms. X’s concerns, family dynamics, and cultural background, which might have provided a more comprehensive understanding of her situation. As someone raised in a community and family with a strict power hierarchy and already struggling with anxiety, Ms. X felt hesitant to express her concerns or clarify her doubts with the doctor, instead choosing to remain silent. Ms. X and her family persisted in their apprehensions regarding the medication’s potential side effects and the financial burden of traveling for psychotherapy sessions, which further complicated matters. Ultimately, Ms. X decided to discontinue her treatment and revert to magico-religious practices, failing to return for follow-up appointments.

Discussion

An Intersectional Analysis

According to Hancock, ¹⁴ there are three approaches to conceptualizing the case of Ms. X. A “unitary approach” focuses on the patient individually, resulting in psychobiological treatment, as seen in this case. The unitary approach means the doctor only sees a patient’s illness (like depression), overlooking how their gender, religion, culture, and social background affect their diagnosis and treatment. While this approach may provide some relief, it may fail to address the root causes and compounded stressors, leading to poor adherence, as seen in this case. Previous research highlights that factors like gender, race, immigration status, and family income significantly impact the development and treatment of depression, underscoring the limitations of the unitary approach in mental health care. ¹⁵

A “multiple approach” would consider her identities individually as influences on her mental health without recognizing their interaction. For instance, the doctor might address the stigma associated with her religion separately from her gender-related societal pressures and financial struggles. This may lead to fragmented interventions and only partial acknowledgment of the context of her symptoms. Different identities (like gender, race, and socioeconomic status) do not affect mental health in isolation but rather interact and compound each other. ¹⁶ Research shows that women, minorities, immigrants, and low-income individuals face more significant depression disparities with additive effects. Therefore, considering these factors together is crucial when planning mental health interventions. ¹⁵

In contrast, an “intersectional approach” considers how aspects of the patient’s identity, such as gender, religion, and socioeconomic status, interact to shape her unique experiences. This approach acknowledges her depression and compounded vulnerabilities arising from multiple marginalized identities. It would explore systemic factors that hinder her access to care, such as the availability of affordable and culturally sensitive mental health services in rural areas, the lack of mental health awareness within her community, and broader structural inequities affecting women in her situation. The doctor would adopt a collaborative approach, actively listening to Ms. X’s concerns and understanding her explanatory model of mental health. This might involve acknowledging her family’s reliance on magico-religious practices, addressing their concerns about medications, and incorporating psychoeducation tailored to their cultural and financial context. Treatment options may include psychoeducation, low-cost, accessible telepsychiatry, and collaborations with grassroots-level interventions like the District Mental Health Program.

An Intersectional Model

While many studies have examined mental health burdens across individual categories such as race, gender, or sexual orientation, the intersections of these identities reveal complex and often unexpected patterns.^12,17 In the hypothetical case above, gender, religion, socioeconomic status, and rural background intersect to influence her mental health and access to care. As a woman from a conservative community, she faces challenges such as societal expectations around marriage, family roles, and mental health stigma. Her family’s limited resources and reliance on magico-religious beliefs complicate her situation, while regional communal tensions exacerbate her vulnerability as a minority group member. She has access to the internet, but without adequate health education, she encounters incomplete or incorrect information, which adds to her anxiety and influences the course of her treatment. An unequal power dynamic shapes her interaction with the doctor. Thus, different factors collectively shape her unique mental health experiences (Figure 1). Had she been, for example, a transgender woman, an older woman, an uneducated woman, or disabled, each added identity layer would further compound her vulnerabilities. ¹⁸ Intersectional analysis highlights these nuances.

Figure 1.

Intersections of Various Factors Influencing Mental Health in the Hypothetical Case Scenario.

Identity concordance between patient and physician has been found to improve patient-clinician relationships and outcomes, as patients often feel more connected to a clinician with shared identities.^19,20 In this case, the doctor and patient share religious and gender identities. However, Ms. X’s additional vulnerabilities—such as her education level, socioeconomic status, and rural residence—differentiate their experiences. Her reluctance to question her doctor’s recommendation may stem from a deeply ingrained cultural respect for authority figures, common in collectivist societies like India. ²¹ The resulting power imbalance limits patient autonomy. ²² The doctor’s quick decision to prescribe antidepressants without addressing the complexities of the case shows a focus more on clinical decision-making than on the patient’s lived experience. Instances such as dismissing concerns about treatment, overlooking financial and logistical challenges, and exerting unintended authoritative pressure are examples of epistemic microaggressions. ²³ These types of microaggressions are everyday experiences for people with multiple marginalized identities. ²⁰ Intersectionality encourages an exploration of the patient’s intersecting identities and the clinician’s positions of power and privilege differences. ²⁴ For this case, it means understanding how different aspects of Ms. X’s identity converge to create her unique experiences, barriers, opinions, and preferences. It would also mean reflecting on the doctor’s privilege and potential gaps in understanding. This exploration could lead to individualized intervention plans that are feasible and culturally appropriate.

There has been a recent surge in interest in the applications of intersectionality in the mental health arena. Metzl and Hansen introduced structural competency training for mental health care to equip clinicians with the skills to recognize and address structural factors that shape mental health outcomes. ²⁵ Hankivsky et al. developed the Intersectionality-Based Policy Analysis (IBPA) framework, enabling the examination of health policies through an intersectional perspective. ²⁶ Intersectional approaches have been applied effectively in health policies addressing HIV and reproductive rights globally, demonstrating their practical value. ²⁷ However, there is a need for intersectional policies and plans adapted to the local context.

The Indian Context

Though intersectionality may serve as an essential framework in India’s complex mental health landscape, its implementation may be challenging. Holman et al. identified the complexity of intersectionality as a barrier to its practical application. ²⁸ Bowleg noted that while intersectionality provides a robust conceptual framework, tools for its methodological applications remain limited. ⁷ Furthermore, research in this area is lacking, particularly in large, high-quality datasets. ¹² A meta-narrative review found that medical education lacks sufficient training and literature on intersectionality.^29,30 Additionally, implementing intersectionality in psychiatry would require moving beyond traditional single-axis frameworks, and thus, the existing field dynamics may hinder its application. ²⁸

According to Holman et al., two significant limitations of health inequity policies are their tendency to focus on individual interventions rather than addressing upstream sociopolitical determinants of health and their emphasis on health inequities between groups defined by single axes of difference. ²⁸ The Mental Healthcare Act of 2017 (MHCA) exhibits both these limitations. Under the MHCA, Ms. X has the right to access care and protection from discrimination on all grounds. Additionally, the MHCA emphasizes confidentiality, patient autonomy, and informed consent. ³¹ However, the Act does not adequately address her membership in multiple minority groups or the other sociopolitical factors that form the context of her symptoms. An intersectional approach, in contrast, would address the structural and systemic factors underlying Ms. X’s situation. As Sen et al. argue, an intersectional approach to policymaking would function as a precise scalpel, allowing policies and programs to be tailored to different subgroups rather than the hatchet we now have. ³²

Conclusion

In a society like India, where diverse identities intersect and influence mental health in complex ways, intersectionality serves as a robust framework. An intersectional approach can strengthen existing mental health policies and support the development of new ones that address the unique needs of marginalized communities, reduce barriers to care, combat stigma, and ultimately improve mental health outcomes. However, implementing this approach is challenging due to the country’s vast and diverse population, limited resources, a shortage of mental health professionals, and the lack of awareness and research concerning indigenous groups. Addressing these challenges requires training mental health professionals and policymakers in the principles and application of intersectionality. Collaboration among various stakeholders—including mental health professionals, community leaders, policymakers, and others—is crucial to facilitating these efforts. Health policies must adopt an intersectional approach, acknowledging the interconnected nature of social identities and their impact on health outcomes. Moreover, prioritizing research on intersectionality and the social determinants of health is essential. In addition to systemic reform, mental health professionals must continuously self-reflect, acknowledge their biases, and understand how power dynamics can shape clinical interactions. Sensitivity to the diverse lived experiences of patients, active listening, and a commitment to ongoing education are crucial in delivering person-centered care. By taking these steps, we can build a more inclusive mental health system that better meets the needs of all individuals.