Women all over the world endure constant pain, violence, and external control over their bodies, and their expressions of resistance and autonomy are easily labelled as mental illness by legal and medical, including psychiatric, discourses. Black women, in particular, are expected to hold the sharp end of the knife — as the Setswana expression, Mosadi o tshwara thipa ka bohaleng goes — and to do so quietly, without any articulation of historical and generational trauma. The racism inherent in modern western science was able to transform black women’s justifiable rage into a sign of non-rationality and ‘madness’.
Today’s psychiatry is not too far from the medical discourse that invented hysteria, a clear example of the obsessive quest for the “biological legitimacy” of a gendered framework in medicine and society. It also gave enough room for drapetomania, which considered an enslaved person’s desire or attempt to escape slavery a sign of mental illness — a predictable consequence of the hegemonic, straight, white, “masculine” and eurocentric science whose antiblack, misogynist, and colonialist theses defined “knowledge” about women, queer people and people of colour.
When the standard for logic and reasoning —and Science— is so deeply rooted in patriarchal white supremacy, blackness, queerness and femaleness are mental illness or irrationality simply by virtue of being the Other. The discourse and practice of medicine labels black women ‘crazy’; the law, medicine’s accomplice in this regard, labels them incompetent and “dangerous”. While mental illness can be used as a mitigating factor to reduce white men’s culpability in court, black mental illness is harshly surveilled and punished with prison, psychiatric institutions or other kinds of reclusion. Mental illness, therefore, is a flexible category that can fit everyone and no one, and is used to reinforce class, gender and race stereotypes. As Lauryn Hill said, “the view is that I’m, like, emotionally unstable which is reality—like you aren’t”.
Both medicine and the law rely on the family to report on women and to assume control over their lives and bodies. Surveillance and control over the bodies of women with disabilities is increased once they have been labeled as having mental illness, particularly when institutionalized. For example, forced sterilizations, forced contraception and forced abortions are the rule in institutions as a result of the double bind created by the ascription of either non-sexuality or hypersexuality to women with psychosocial and intellectual disabilities. Forced procedures are often recommended by doctors and authorized by a judge or a family member (or both).
Mainstream medicine also has the prescriptive power to label persons as non-compliant or non-adherent to treatment even though non-compliance is often a manifestation of power imbalances between systems and institutions on the one hand and “patients” on the other. Someone’s best choice (or only choice) might be “non-compliance” because of poverty, trauma, fear of violence or repercussion, lack of transportation, or any of the numerous barriers and tasks required by institutional structures for allowing access to services. As the Special Rapporteur (SR) on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health said in a report on social and underlying determinants of mental health, “the burden of managing and coping with the systemic damage caused by ignoring the determinants of health has fallen on individuals. These individuals then turn to a mental health-care sector that often lacks adequate resources and appropriate approaches to cope with collective failures.”
Human rights as a tool for scrutiny, accountability and change
Despite the SR’s report, it is uncommon to find in human rights systems a recognition of the importance of social and underlying determinants of mental health. It is also extremely rare to find serious scrutiny of mental health and psychiatry or their paradigms. An exception, the UN Convention on the Rights of Persons with Disabilities, that was created with strong participation of persons with disabilities, has helped recognize the structural oppression and human rights violations against women with disabilities, including women with psychosocial disabilities.
During the 43rd session of the Human Rights Council, in March 2020, Brazil and Portugal brought forward a resolution addressing some of the main concerns raised by the SR’s report. This approach to mental health can be powerful if it addresses the ways in which structural factors impact mental health. However, the first draft of the resolution had no gender analysis, no mention of trauma and, ultimately, no substance on how patriarchy, ableism and racism predetermine how equipped we are, in terms of power, resources and support, to manage our psychosocial wellbeing.
Engaging with the text of the resolution could lead to the trap of advocating to be objects of psychiatry and mental health, which have shown themselves to be hostile to a range of othered individuals and groups. However, although the human rights discourse and system are plagued with issues of legitimacy and representation, they can and must be used to address some aspects of the power hierarchies of institutional structures and social relations, in order to help crack open power negotiations in physical, mental, and sexual health.
At the Sexual Rights Initiative, we decided to continue engaging with the resolution to highlight social determinants of health, including poverty, violence, racism and xenophobia, and linking them to public health systems. We also sought to reaffirm the concept of bodily autonomy by ensuring that the text rejected any possibility of coercive medical interventions, including through third party authorization. The final result is far from satisfactory for us, though the SR has considered this resolution to be a step forward in negotiated documents.
We hope the progress made in this resolution can provide a platform for demanding effective access to health goods and services. We look forward to actors of the mental health sector, including multinational corporations, facing greater scrutiny and being held accountable for unethical research practices, violations and abuses of the rights of women and girls with disabilities. We must demand and invest in public funded healthcare systems that address gender inequality, poverty, racism and xenophobia so that we can have accessible community-based services that will support everyone’s full wellbeing and bodily autonomy.