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"WE ARE SEXUAL BEINGS" BRINGING SEXUALITY TO THE FOREFRONT IN MENTAL HEALTH PROGRAMMES: In Conversation with Ratnaboli Ray.

ARROW speaks with Ratnaboli Ray, the 2016 Recipient of Human Rights Watch's Alison Des Forges Award for Extraordinary Activism, and the cofounder and Managing Trustee of the Anjali Mental Health Rights Organisation. Anjali works to ensure the human rights of people with psychosocial disability in India. (1,2)

In your years of working in this field, has the terrain of mental health changed in any way?

Until ten years ago, nobody thought of using the human rights lens in the mental health discourse; mental health was seen as a watertight medical compartment.

The second change that has happened is the affordability, availability, and accessibility of mental health services. Mental health services have begun to shift away from institutions and have started to make it to communities. However, it needs to be noted that many of these programmes are largely run by NGOs and civil society. The government is in the process of launching a district mental health programme covering all districts of India. But while the government's intention is fantastic, there are some implementation challenges, including a big gap between the demand and the supply of psychiatrists and mental health professionals in the country. This is why the training of lay professionals or barefoot workers is a large component of a successful community mental health programme.

The third change is the emergence of alternative setups like group homes, assistive living, and supported living, beyond institutions and community-based health service delivery. While these are in the nascent stages, such outfits were unthinkable ten years ago.

The fourth change is the improvement in the quality of services, whether in institutions or in the community. The fifth change is the enactment of the new Mental Healthcare Act 2017 which stresses on the rights of persons with mental illness, amongst other progressive clauses.

Over the years, have you seen changes in the way that society views accessing mental health services? How is this tied to stigma and discrimination?

This is a very contentious area. One of the things that Anjali is doing with our community health programme--and also others like Banyan and Sangath-is consciously increasing the help-seeking behaviour of people. For example, we have seen an increase in the help-seeking behaviour of young adolescents even with severe mental health issues.

However, increasing the mental health help-seeking behaviour of women, including housewives, remains extremely challenging. This is beyond stigma and has to do with barriers related to mobility, with disparity in the time clinics are open and the time women are free, and with women not having enough funds to access services.

Could you expand more on the gender dimensions of mental health? Are the causes and the impact of it different across genders (women, men, transgender people)? In what way?

Certain diagnoses--such as bipolar disorder-are slapped more often on women than on men. This happens both globally and in India. Furthermore, in terms of the infrastructure of mental health establishments in India, spaces for women are more cramped and have much less light and ventilation, as opposed to those for men. The impact of certain medication is also gendered as they may affect women and men in different ways.

The mental health fraternity has been the moral and medical gatekeeper, and has pathologised sexuality. For example, a trans person who is transitioning from male to female is treated differently by mental health professionals, compared to a person transitioning from female to male. There is a huge lacuna within the system; since there are no rights-based guidelines, there is a lot of arbitrariness in how mental health professionals deal with sexual minorities. It often depends on how empathetic they will be.

The framing of the mental health establishment, in general, is patriarchal, with the diagnostic criteria based on a male, white, heterosexual bias, and this is also true even in the Indian context. Anything other than that is viewed as a disorder or pathology. It is thus important to consider who is at the centre of psychiatry--it is certainly not a woman, nor a woman of colour, nor a woman of colour who is poor and illiterate, nor a poor, illiterate woman of colour living in a rural area, and most certainly not a poor, illiterate woman of colour living in rural area who is a bisexual or a lesbian. Although homosexuality has been removed from diagnostic nomenclature, attitudes haven't changed.

Can you explain the two different frames: mental health and psychosocial disability? What are the advantages of talking in one frame versus the other?

Whether someone has a psychosocial disability or not is a choice of that individual. I may be suffering from serious mental illness--which could be depression, bipolar disorder, schizophrenia, or any other illness--but whether I identify as someone with a psychosocial disability depends on my own politics and my own choice. Using the psychosocial disability frame also means taking the focus away from the medical identity of the illness, to the social factors related to the illness, as disability is largely a product of the social milieu we live in. Using this frame will also extend the coverage of programmes and schemes for persons with disability to people with psychosocial disability.

What are the key issues related to sexuality and SRHR of people with psychosocial disabilities?

People with psychosocial disabilities do not have access to information and services and to privacy, and they experience barriers related to expressing their desires and having relationships.

However, when we say that persons with psychosocial disabilities are asexual, it is not that people in mental health institutions do not have sexual desires, ideation, and wishes. Asexuality is imposed on them because if they are not asexual, then they are pathological. On the other hand, the perception that people with psychosocial disabilities are hypersexual is a myth. In my 25-year career, I have not seen someone who is "sexually hyperactive." Most people who come to us cannot practice affirmative sexuality because they do not have access to information, contraception, or places where they can build relationships. A lot of them are unemployed (since their mobility is often curtailed), and because most of them are poor, they live in cramped spaces where there is no privacy, not even for self-pleasure.

We also have to remember that mental health institutions are patriarchal and oppressive. Even after recovery, if women are found to be self-pleasuring, they are labelled as ill and are recommitted to mental health institutions.

Even reproductive health becomes very stressful, because the moment you take medication, your whole reproductive cycle goes awry. There is so much anxiety amongst women around whether they can become pregnant or not, particularly given how important motherhood is considered in South Asia. On the other hand, when they have given birth, the babies are often snatched away from them. I once saw a woman who gave birth in the psych ward whose baby was taken away and given for adoption. The woman was beaten up because the nurses thought she had some illicit love affair since she was found wandering out of the house, but who are they to even ask and judge?

Psychosocial disability is experienced throughout the woman's life cycle, especially in relation to reproductive health, such as post-partum depression. Please share your thoughts.

It's true. Post-partum depression is so common, and yet it goes completely unrecognised. Sadness is normalised in our society, and sadness is so gendered--women will cry--so it goes unrecognised. Society tells you that now that you have a baby, what are you being sad about? You have to suppress your sadness because giving birth is a joyous occasion; that is the construct.

Where can people with psychosocial disability access information on sexuality and sexual and reproductive health and rights? Is it offered in mental health institutions?

Generally, peers are the sources of information, and therefore these are all half-baked; then there is pornography, which can also be unreal.

Sexuality education is not offered in institutions because people with psychosocial disabilities are perceived as low-risk. There is a lot of curtailment and careful separation between male and female wards. There is no sexual policy for patients in institutions. In fact, one of our long-term objectives of working with the sexuality lens is to get the government to come out with such a policy-where patients have the right to privacy, where they can have space for self-pleasure if they want, for example.

Given the status of sexual and reproductive health of people with psychosocial disabilities, what are some of your recommendations?

Even if we are working with the recovery care model (which espouses that people exercise choices), we need to talk about the sexuality of people with psychosocial disabilities. We can't just choose to talk about housing, livelihood, to be symptom-free, and not talk about relationships, intimacy, romance, and pleasure. That's totally contradictory.

The UN should commit to enabling better access to information and knowledge on the interlinkages of sexuality and sexual and reproductive health and rights with mental health and psychosocial disability, and support the building capacity of disability and mental health organisations on these. Even the UN Convention on the Rights of Persons with Disabilities (UNCRPD) only talks about sexuality in the framework of marriage and family. It's therefore up to us civil society to bring this issue to the forefront for the UN to act upon.

What makes you passionate about this work? Who are or what is your inspiration?

I have witnessed mental health issues from very, very close quarters. Two of my aunts were diagnosed with schizophrenia and were locked away from public gaze in institutions. I also grew up in an extremely liberal family committed to social work. I have always interacted with so-called marginalised people; my best friends were from informal settlements.

Any final thoughts?

Let us not invisibilise people who are different from us, who have a history of mental illness. Let us embrace them, and let us live.

Ratnaboli Ray can be contacted at ratnaboli@anjalimhro. org.

Interview conducted by Maria Melinda (Malyn) Ando

Email: malyn.ando@gmail.com

Notes & References

(1.) Find out more about Anjali at http://www.anjalimentalhealth.org/founder.php.

(2.) While intellectual disability and psychosocial disability may be two different things, sometimes they get confused with each other. Intellectual disability is a condition related to a person's mental abilities not being developed. On the other hand, psychosocial disability has to do with mental illness. You will never see a child born with a psychosocial disability; it is something that occurs through the life cycle; it is something that we have socially constructed. On the other hand, people are born with intellectual problems.

(3.) Read more about the Banyan here: http://www.thebanyan.org/.

(4.) Read more about Sangath here: http://www.sangath.in/.
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Title Annotation:voices from the global south
Author:Ando, Maria Melinda (Malyn)
Publication:Arrows For Change
Article Type:Interview
Geographic Code:9INDI
Date:Dec 1, 2017
Words:1790
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