Abstract

Introduction

This article focuses on the analysis of experience reports of students’ mental health suffering/disorder from a Brazilian public university under the perspective of intersectionality. Throughout this exposure, we would like to demonstrate how this is a conceptual tool that may qualify the observation of social dynamic and its relation with health, highlighting relevant knowledge that might help in the construction of personal and/or institutional confrontation strategies.

The health phenomena, with its cross character, can be observed influencing many life areas and this is not different when it is about the university living experience. This observation becomes peculiar when these people have characteristics that make the health multidetermined aspect evident, as it is the case of students who are attended by Pró-Reitoria de Ações Afirmativas e Assistência Estudantil (PROAE). This is the responsible body at the Universidade Federal da Bahia (UFBA), to administrate actions of Plano Nacional de Assistência Estudantil (PNAES), that among ten planned activities areas, indicate attention to health. It is very common for students to search for PROAE to report questions about daily health and it is through these consultations, according to the welcoming principles of Política Nacional de Humanização (PNH)¹1 Brasil. Ministério da Saúde. Dicas em saúde: acolhimento. Brasília: Biblioteca Virtual em Saúde; 2008., that the student is oriented about the offer of actions and service available on the Rede de Atenção à Saúde from the county and the university that can attend their needs. The welcoming helps, through listening, to identify the health needs, preserving the singularity of each person, and the way they are noticed and reverberate over daily and academic life.

The Núcleo de Atenção à Saúde Integral do Estudante (NASIE), is a PROAE department responsible for this welcoming job of health care. The records of these consultations (between 2014 and 2017, being the temporal cut from our research) show an expressive number of mental suffering and/or disorder experience reports that create countless challenges for students to stay in the university. In 2016, 48% of students who attended for the first time presented this complaint, and in 2017, this number increased to 52%. These data also highlighted the overlap of social inequality and other oppressions on these students’ life stories, which became thought-provoking how these factors relate from the narrative of those who experience the issue.

Mental health, contemplated as a vast field of knowledge, is a multifaceted, multidetermined and complex phenomena. Authors as Jucá²2 Jucá VJS. Os sentidos da cura em saúde mental [tese]. Salvador: Universidade Federal da Bahia; 2003. e Nunes³3 Nunes MO. Interseções antropológicas na saúde mental: dos regimes de verdade naturalistas à espessura biopsicossociocultural do adoecimento mental. Interface (Botucatu). 2012; 16(43):903-915. Doi: https://doi.org/10.1590/S1414-32832012005000045.
https://doi.org/10.1590/S1414-3283201200... highlight its relation with people’s singularity and subjectivity and their way to be in the world, influenced by cultural aspects (symbolic values and expressions), social relations, political contexts, economic situations, and others. In this case, it does not belong to only one knowledge sphere, being the appreciation object of several disciplines, and besides being theoretical-scientific, it also includes the non-scientific knowledge, making sure that Amarante⁴4 Amarante P. Saúde mental e atenção psicossocial. Rio de Janeiro: Editora Fiocruz; 2007. highlights it as polysemy. In the course of history and the human interaction with the natural environment, it is socially (re)built, gaining nuances and comprehension shapes that involve life specificities and plots in historicity. Finally, away from intend to establish the ideal concept to analyze people’s mental health, recognizing as a considerable complex task, these reflections emphasize that this must be an activity in permanent discussion due to its level of importance in a society where, according to the World Health Organization, “mental health conditions affect millions of people in the world”. (p. 2).

Intersectionality: when axes of oppression change the context

Talking about intersectionality in the health field allows us to improve our view about how the social wefts relate to being healthy and, more specifically, to mental health, a fertilized field to the subjectivity. This concept acts as a tool that helps in the comprehension closeness of what mental health can be and how it unfolds in each one’s life. It instrumentalizes the reflections about who this individual really is, marked by the symbolic relations that are built, ratifying, and reifying over time, as long as he occupies (or vacates) spaces and social roles. The intersectional axes expose the subordination imposed on himself, able to influence how he sees himself and is seen. If we consider that subjectivity becomes unique in the way how an individual or a group notices and expresses values, feelings and preferences, it is essential the search for tools that help on the identification of thin lines that weave life wefts. The choice of the word “thin” does not intend to classify it as less important or fragile, but it has the intention to bring to the surface the fact that sometimes, the condition of inequality and oppression is not noticed, not even for the individual himself, in addition they are subtle in a way that can run through several structures, filling in personal and social gaps, taking root to the human constitution and becoming acceptable, despite perverse, and being recognized and validated as natural and inseparable.

The discussion about this concept stood out from the black feminist movement, at the end of 1970s, highlighting that the interlacement of axes of subordination potentiates the effects of the same individual occupying different inequality social spaces. Lopes affirms that “the intersectionality reveals what it is not seen when categories such as gender and race are regarded in a separated way”⁶6 López LC. A mobilização política das mulheres negras no Uruguai: considerações sobre interseccionalidade de raça, gênero e sexualidade. Sex Salud Soc (Rio J). 2013; (14):40-65. (p. 45), showing how its application expands the comprehension of the complexity of this plot that involves and dominates the subjects. The teacher Kimberlé Crenshaw, a North American black activist, presents intersectionality as “a conceptualization of a problem that tries to capture the structural and dynamic consequences of interaction between two or more axes of subordination”⁷7 Crenshaw K. Documento para o encontro de especialistas em aspectos da discriminação racial relativos ao gênero. Estud Fem. 2002; 10(1):171-188. (p. 177). She associates this term with the intersection of avenues.

Axes of social domination are not only parallel, because, at some point, as well as the avenues, they intercross and may produce new contexts, and the inequality expressions are not a static phenomenon and the more that this occurs with the same person, the more he can become disempowered from his life control. Pointing out that even being intersectional, these axes are not necessarily interdependent and the existence of one does not imply the mandatory presence of another. It may occur the non-perception of the presence of one or another inequality, or the molested individual shows greater capacity for confrontation and resistance.

Another important reflection is that, as Lorde affirms, “there is no hierarchy of oppression”⁸8 Lord A. There is no hierarchy of oppressions. In: Byrd RP, Cole JB, Guy-Sheftall B. I am your sister: collected and unpublished writings of Audre Lorde. New York: Oxford University; 2009. p. 219-220. (p. 6), so there is no oppression that should get emphasis over others, considering it more important and deserving of greater concentration of battles. Akotirene, based on studies of Patrícia Hill Collins, “recriminates competition arguments between the most excluded, the hierarchies between axes of oppression and violation considered less important”⁹9 Akotirene C. O que é interseccionalidade? Belo Horizonte: Letramento; 2018. (p. 33-4). Besides the classic oppression relations by class or gender, in contemporary relationships, emerged new oppression ways like fatphobia, transphobia, and ageism, which also need to be considered as sickening elements from the social relations so the individual social-historical analysis may be respectful to all ways of suffering.

In terms of articulation, the differences and inequalities do not overlap dividing the individual into several states that together would show his real condition. When trying to identify who this person is in the social structure, instead of reading through summation, for example: woman and poor and transsexual and deficient, you can qualify the reading with the following differential: poor, transsexual and deficient woman, because the conditions and suffering resulting this occur simultaneously and then it emerges a specific identity. Brah affirms that those oppression expressions “cannot be treated as ‘independent variables’, because the oppression of each is inscribed within the other– it is constituted by the other and is constitutive of it”¹⁰10 Brah A. Diferença, diversidade, diferenciação. Cad Pagu. 2006; 26:329-376. (p. 351).

Studies that do not consider this social life dynamic may incur superficial analyses, not representing the reality. Crenshaw advocates that planned interventions from a partial and out-of-focus comprehension from the real feminine condition (considering that his writings are related to the black woman condition in the society) “are, very likely, inefficient and perhaps even counterproductive”⁷7 Crenshaw K. Documento para o encontro de especialistas em aspectos da discriminação racial relativos ao gênero. Estud Fem. 2002; 10(1):171-188. (p. 177), being essential the detailed analyses of dynamics that are involved to produce effective interventions.

When the intersectionality expresses itself in the mental health field

The technology, industrial, scientific changes and others of modernity produced facilities and comforts to daily life, as an example the access to information in real-time, resulted in knowledge globalization and exploration of different cultures. However, as a part of the consequences of this progress, challenges emerged that might affect the people in their condition of being healthy in front of the new ways of dealing with life. To Wilkinson¹¹11 Wilkinson I. Anxiety in a risk society. London: Taylor & Francis e-Library; 2002., one of these results is the individualization that can occur when there is a rupture with social traditional references, and in search of new ways of organization, the individual sees himself isolated while he faces the burden of life, needing to assume several responsibilities at the same time.

Evaluating that the psychic suffering experience may be produced through social relations, as affirm Zanello et al.¹²12 Zanello V, Fiuza G, Costa HS. Saúde mental e gênero: facetas gendradas do sofrimento psíquico. Fractal Rev Psicol. 2015; 27(3):238-246., these modern life challenges alone can be anxiety triggers. Considering a society where the inequalities might mark these responsibilities, it is essential to observe the specific nuances of the context where each individual performs his tasks in order that analyses surely identify his real condition to others and himself. In this sense, the intersectionality perspective can contribute more positively to capture and expose the reality of the facts than an analysis that considers separately the multiple variables that produce and/or amplify suffering arising from social living. Thus, watching how many characteristics that compose the subject’s identity - some of them self-declared and others imposed - interact with each other (being black, poor, fat, gay, etc.) produces a closer look to the delicate sphere of mental health. Recognizing the nuances of crossing intersecting elements on the emotional condition and its ramifications about the psychic illness is not an easy task, but necessary according to the relevance of qualifying the study and the intervention on mental health.

It seems to be reasonable that the connection between intersectionality and mental health does not have universal patterns applicable to any individual. This condition may vary according to social, economic, cultural, political, and environmental context to which one is exposed, and it can be done with different readings to the same individual in different periods of life. Not every intersectionality is noticed by the individual, or by those who observe him, as a contributing factor to the reduction or increase of emotional suffering, because it must evaluate his capacity to apply necessary knowledge and protector behavior to the preservation and promotion of mental health. The perception of this relationship of influence between these two phenomena by the own individual is built through critical reflection of his social condition, that it can be harmed by his health state, but it can also be stimulated by the interaction with the different social actors that act directly or indirectly on their health. Listening by someone who is prepared to identify and articulate the different fields that make up the life of these individuals, including the subjective issues that encompass interests, biological and cultural characteristics, is a tool that allows us to overcome superficial and generalist analyses.

For being multidetermined, mental health is a fertile field for the use of concepts that help on the decoding of its structure. Studies such as those of Ramos and Gonzalez¹³13 Ramos CN, Gonzalez ZK. Interseccionalidade e saúde mental: um olhar para a raça e gênero [no Caps] pelos caminhos do pensamento descolonial. In: Anais do 11o Seminário Internacional Fazendo Gênero & 13th Women’s Worlds Congress; 2017; Florianópolis. Florianópolis: UFSC; 2017. p. 1-9. and Smolen¹⁴14 Smolen NJR. Raça/cor da pele, gênero e Transtornos Mentais Comuns na perspectiva da interseccionalidade [dissertação]. Feira de Santana (BA): Universidade Estadual de Feira de Santana; 2016. show this inseparable relation between intersectionality and mental health, talking about structuring elements of the individual’s identity as gender, race/color, economic and social condition. In terms of research, the interface of these studies has been increasingly studied, but, when it is about focusing on such a specific group as undergraduate students, the interlocution between those themes have not been explored.

In the academic field, would it be possible to affirm that a bisexual, black student, residing in a metropolitan region far from the university campuses, poor and fat suffers more or less than a transsexual, white student, from southeastern Brazil, poor and without healthy family ties? Not considering the different expressions of iniquity imbricated in the fact of being students and their respective reactions to those challenges, it could give in to the trend of establishing a simple and basic category, because both are undergraduate students. But, understanding that inside of their private universe, each person is affected in different intensities and frequencies, the thought arises that in addition to establishing subcategories to the student condition, different answers must be sought that adapt to the general rule to the concrete situation, increasing the possibility of produce an analyses and a more equitable university.

Based on Berth’s statements, a society (in this case, an empowered university) is an individuals’ product “with a high level of recovery of awareness of their social self, its implications and aggravating”¹⁵15 Berth J. O que é empoderamento? Belo Horizonte: Letramento; 2018. (p. 41), while it can lead more people to this state, because “the individual and public empowerment are two inseparable faces from the same process”¹⁵15 Berth J. O que é empoderamento? Belo Horizonte: Letramento; 2018. (p. 42).

Then, it can be proposed that there is a complex dynamic of mutual influence between mental health and intersectionality that requires cautious observation for evolving a chain of multidetermined themes.

Method

The original study, a dissertation to obtain a master’s degree, was of a qualitative and quantitative approach, and to this article, the objectives referring to the phenomena of intersectionality were selected, which includes the analyses of paradigmatic cases and the identification of its dynamic intersections, emphasizing the qualitative approach. After exclude the students who graduated, awaited graduation, completed the course, did not have an active enrollment in semesters 2018.2 and 2019.1, evaded or did not complete the general registration on PROAE (corresponds to the delivery of documentation and the conclusion of socio economic analyses), the research started with a population of 217 students that reported experience of mental suffering/disorder. This suppression was mainly due to the difficulty of contacting students who are not active at the university. The time frame comprises the period of October 2014 (the start of the nucleus activities) to December 2017. From 217, 27 did not conclude the PROAE general registration, and 16 documentation envelopes were not located in the records in the period that were requested. So, the final population was composed of 174 students.

The data collection was carried out in documents delivery for analyses of socioeconomic vulnerability, forms containing health information and other narratives presented in the consultations, activity reports and data sheets. Using the principles of descriptive statistics to organize, synthesize and present, the data was organized in sheets considering qualitative and quantitative variables. The grouping and counting of the data was made using the filter feature for later calculation of simple frequency and percentage of each variable, organized in sheets. The analysis and interpretation constituted the qualitative step, based on published material study equivalent to the target audience characteristics, creating information about socio demographic profile, showing phenomena pertaining to the population studied.

For the interviews, students who declared to live in an inequality and oppression condition were selected from understanding the intersectionality.

The sample for the interviews was 12 students. This intentional cut considered those who were with an updated contact, forms properly filled and that attended periodically for follow-up, for having a greater volume of recorded information, facilitating the identification of elements potentially generating discrimination. Care was taken to ensure that the sample included people with different combinations of intersecting inequality, highlighting the diversity that may come when this resource is pondered. Every student was invited via e-mail and reinforced by phone call or face-to-face contact. Seven answered positively and the individual interviews with a semi-structured script were recorded and transcribed between December 2018 and January 2019.

The participants received a fictitious identification extracted from the names of the Centros de Atenção Psicossocial (CAPS) in Salvador-BA. The method of analytical handling of the interviews material was the content analysis Bardin¹⁶16 Bardin L. Análise de conteúdo. São Paulo: Edições 70; 2011. and it was organized in three phases: pre-analysis, exploration and treatment/inference/interpretation. The pre-analysis was configured by the material organization aiming at its operationalization. The choice of the documents was due to their relevance and heterogeneity highlighted by the multiplicity of intersectional combinations of characteristics, producing greater diversity and enhancing the observation of their effects on the suffering experience. The exploration of the material configured an extensive phase culminating in the creation of a chart organized around three central categories: individual, social and programmatic vulnerability (since the original research included the health vulnerability phenomena, in addition to intersectionality and mental health). Essential parts of the interviews were collected and organized in the chart. The treatment, inference and interpretation of these data constituted the final phase of this process and it was based on critical and reflexive analysis in order to correspond with the general and specific objectives of the study.

The research was presented for consideration by the Research Ethics Committee and had opinion number 3.027.956 approved.

Intersectional perception of psychic suffering by university students

Notwithstanding this article deals centrally with the qualitative results of the original research, it is understood as valid to briefly expose the quantitative results as a way to enrich the situational perception of the public served by the NASIE.

The sociodemographic study showed an audience composed 70% by young, black and brown people (19-29 years old), with 89% coming from urban areas, with previous learning paths built in public schools (78,7%). About 57% of homes have exclusively a woman as the main maintainer in a poverty state. While they take care of their academic career and health, this public needs to manage by themselves the maintenance of their new homes without extra income, only accessing the benefits of the student assistance. This conjuncture and its inherent challenges point to the need of institutional intervention in order to provide support to qualify the permanence and conclusion of the course. For the interviews, the group was composed of four women and three men, three from the interior of the state and four from the capital. All of the interviewed participants recognized structures of oppression that mark their lives, generating specificities in their social identities. They also described that the complications referent to health were identified in a previous period to the university admission, three in childhood, two in adolescence and two in adulthood. However, their reports show that even having started at a previous stage, the occurrences of psychic suffering were accentuated in the relationships established in the academic context. All of them were in a economic vulnerability situation, with a per capita income less than one and a half minimum wage and depended economically on student assistance for permanence. A brief characterization follows for a better understanding of their life stories.

Nise declares herself a black, lesbian, one-person family, living in extreme poverty condition, with suicidal ideation and diagnoses of anxiety and panic. Nzinga is black, faces depression, has fragile family relations and a great difficulty of living in spaces where discrimination based on race and gender is more intense. Rosa lives with a partner in a region controlled by the drug trafficking, declares herself black, bisexual, fat, bulimic, with an often suicidal ideation, some suicide attempts and diagnoses of Borderline Personality Disorder, BPD and depression. Maria is from quilombo, black, victim of sexual violence during childhood and adolescence, intense low self-esteem, raised by grandparents due to fragility in the parental relationship. Eduardo is gay, psychoactive substance user, with Bipolar Affective Disorder, eating disorder, suicidal ideation. Aristides is brown, from a popular community, heterosexual, with Transtorno do Déficit de Atenção com Hiperatividade (ADHD), has an often practice of self-multilation. Franco declares himself white, fat, gay, psychoactive substance user, with Bipolar Affective Disorder, ADHD and personality disorder.

All of them reported that inequality and oppression conditions that they lived interfered negatively on their health state, six of them noticed that their academic performance was harmed when their health state was not favorable and one said that he did not always feel harmed in his academic routine as a result of the instability in his health situation. This data shows the relation between social iniquities and mental health and how this relation reverberates in the academic trajectory.

Watching the interception of intersectionality in mental health requires encouraging the individual to speak by himself, because it can be useless to try to identify the consequences of the pressure of social control structures based on the subjects’ mental condition, without considering the way that they learned to perceive and manage this reality. Facing a structure that produces invisibility by naturalizing the oppression, authenticating a place to speak up brings to light a complexity of factors as subjectivity, which makes each one to experiment similar challenges in different ways. In this specific group, some characteristics make them pairs: they are students from the same university, demonstrably in a state of financial deprivation and facing challenges such as disorders and/or emotional distress. In these terms, exploring superficially the context could incur unreal results, then, it stands out the value of legitimate listening through the interview.

The fragment reveals that the motivations for suffering are not always silent and even if not understood in all their magnitude and potential, when identified, allow their intersection with other life areas: racism, poverty, implication of academic development, qualified permanence, etc., as well exemplified as Crenshaw when treating axes of subordination as an intersection of avenues. It is interesting to notice that the student herself, occupying the oppressed position, can capture the relation between the different ways of domination that she carries in her identity and how it reverberates in her emotional state. It elucidates that the university environment is also a stage for the historical reproduction of contradictions of the dominant elite, which rises to the superior status when compared to groups that are not always minority, but are seen as inferior. The intersectional approach assists to evidence the cruelty of this system that classifies people based on their physical appearance, economic support, sexual orientation and other trivial phenomena.

Just like Nzinga, Maria and Franco also revealed how this intersection increases emotional suffering, creating fear, insecurities and difficulty when relating to people.

Therefore, it is appropriate to ask: Where is the empowerment in this? When feeling oppressed, some people look for new arrangements to continue belonging to certain spaces. Berth¹⁵15 Berth J. O que é empoderamento? Belo Horizonte: Letramento; 2018. affirms that, usually, because of being immersed in oppressive circumstances, the oppressed does not recognize this condition. It is also noticed that the behavior facing the challenges can validate oppression and ratify their place as excluded, and it is in this scenario that they adopt and reproduce the oppressive discourse as a way of life, without realizing it. Freire¹⁷17 Freire P. Pedagogia do oprimido. 17a ed. Rio de Janeiro: Paz e Terra; 1987. alleges it is impossible for the oppressed, who hosts the oppressor or keeps him as a shadow, to participate in a reflexive way in the conquest of his freedom, taking control of his historical destiny. This is a critical process that starts when the oppressed realizes that the oppressor, at some point, is also vulnerable, and it is in this phase that what he describes as undervalues (introjection of the oppressor’s negative message until the oppressed starts to believe that he really is inferior and that his oppressor holds superiority) starts to be questioned. The author affirms that this awakening is more likely to occur when the oppressed belong to groups engaged in the struggle for liberation that stimulate dialogue and reflection. This transformation to be perennial requires that, by expelling the domination of the oppressor from himself, the space left empty is immediately filled with the discourse of his autonomy. It can be reflected that the maintenance of the oppressed condition causes the intensification of suffering and makes the autonomy difficult to apply good health practices.

To the interviewees, mental health suffering/disorder was already noticed in a prior phase to entering the university and from this new phase, all of them expected to be able to complete the course already started, whether receiving support from the education entity, family, friends or through their own resources. In this construction, when faced with the social discrepancies affirmed in the structure of this new environment, while dealing with their health condition, there are many outcome possibilities, varying according to the subjectivity and resources of each one.

Talking about the domain that can be projected over the other, Nzinga reveals that:

At the same time that oppressions influence the emotional state and tend to discredit the value of the achievements achieved, the reflection of this interaction leads to the academic trajectory.

There are also those who, when faced with adverse situations, reveal skills that emphasize a positive approach and make them react differently. The resilience, according to Silva et al., “provides a promising perspective in terms of health and human development, especially with population living in unfavorable psychosocial conditions”¹⁸18 Silva MRS, Elsen I, Lacharite C. Resiliência: concepções, fatores associados e problemas relativos à construção do conhecimento na área. Paidéia (Ribeirão Preto). 2003; 13(26):147-156. (p. 151).

As presented before, these students experience similar situations, but the confrontation occurs in a different way. This is not intended to undertake a search for the best way to cross these barriers while living the student identity, but to emphasize the relevance of respect for the subjective condition when offering strategies to overcome such challenges.

The interviews expose the exclusion as a result of their social conditions in an environment they expected to be accepted and that this phenomena accentuates emotional suffering, when they are not able to belong to these spaces, even if this does not mean their empowerment, but only an adjustment of the behavior.

Final considerations

The exposure in this study highlighted the predicate of multidimensionality attributed to the phenomena of mental health. Its dimensions make it complex, causing its manifestation in people’s lives to be loaded with singularity, making it valid to use resources that allow it to reveal its nuances and unfoldings. In this way, the analysis took on the task of embracing the nexus between mental health and intersectionality.

In the midst of subjectivity that integrates the peculiar state of each one, the concept of intersectionality points as support the perception/revelation of the characteristics that compose one’s identity, being relevant to note that some of these characteristics are defined and imposed from the external context – from the social-historical relationships - to the interior, resonating with the way this individual recognizes himself, relates to others and experiences his well-being. The level of this influence varies for each one and it may also happen that, due to individual attributes and experiences, this confrontation does not produce concrete damage to health. In this research, the narratives pointed out the consequences of intersectional oppressions, with emphasis on gender prejudice, affective-sexual orientation, poverty, race/color and stigmas about their mental health conditions, making them more susceptible to suffering. These repercussions are heterogeneous, sometimes ratifying exclusion from passive behavior that displays disempowerment in the face of the force of discrepancy in social relations driven by the power of the ruling class, sometimes demonstrating overcoming by resorting to personal attributes such as resilience, or collective resources, as social support or militancy/activism groups. This perception of the intertwining of social-historical aspects of multi-discrimination, which colorize and label the individual, with the subjective experience of emotional suffering/disorder is best expressed through discourse, hence the importance of offering an adequate space for speaking and a welcoming and qualified listening.

It is also necessary to consider elements that potentially generate stress and enhance mental suffering, such as the specific characteristics of university life, as competition in search of the best academic spaces, the expectation of professional training that enables changes in the economic standard of students and overcoming teaching/learning deficiencies in high school.

Since education is a factor that acts upon health in a determining/conditioning way, it is of fundamental importance that the university advances in the discussions about its responsibility in this construction of the healthy being, in attention to the specificities of the public that receives periodically and in the recognition that many aspects of inequality rooted in contemporary society are also perceived and validated in its spaces, and therefore, efforts should be made to foster strategies for understanding these social dynamics and its confrontation.

References

Publication Dates

History