Think, Ask, Act: The Intersectionality of Mental and Reproductive Health for Judicially-Involved Girls

Abstract

Danielle Smith, a 16-year-old African-American female newly detained at juvenile hall, presents for psychiatric evaluation. She describes a past history of sexual abuse by her foster father and two years of commercial sexual exploitation after running away at the age of 14. Scarcely more than 100 pounds, she endorses drug use, primarily marijuana, and also notes prior use of cocaine and methamphetamine, provided by her trafficker (described as her “boyfriend”). She has a timid smile and uses music and journaling as her refuge. Danielle is unclear about past psychiatric diagnoses, but does recall receiving medication from a psychiatrist while in foster care and expresses interest in resuming treatment.

Introduction

Girls in the juvenile justice system are a vulnerable population with overlapping substance use, reproductive and mental healthcare needs. The conceptual frame of “intersectionality” is a useful framework to better understand the multiplicity of biopsychosocial needs of justice-involved girls. Intersectionality is defined as “a theoretical framework for understanding how multiple social identities (i.e., race, gender, and sexual orientation) intersect at the micro level of individual experience to reflect systems of oppression (i.e., racism, sexism, classism) at the macro level”.¹ In this article, we propose the pragmatic application of the concept of intersectionality to better conceptualize the high unmet health needs of these youth. We conclude by providing recommendations for meeting their needs via the proposed “Think, Ask, Act” approach.

Background

Girls comprise an under-discussed, yet growing segment of the juvenile justice population, who experience a number of health challenges, with particularly high reproductive, substance use, and mental health needs.² More than 30% of incarcerated girls have been pregnant (compared with 4.3% among general-population adolescent girls), at least 10% have traded sex for money, and incarcerated girls have exceedingly high rates of prior child abuse.^3,4 Incarcerated girls also experience high rates of depression, bipolar disorder, post-traumatic stress disorder, mood disorders, substance use disorders, and suicidality.^5,6,7

Intersectionality and Integration of Care

The concept of “intersectionality,” coined by lawyer Kimberlé Crenshaw, is highly applicable to understanding the health needs of judicially-involved girls. Crenshaw developed the term intersectionality to better understand the unique experiences of marginalized groups, such as females of color, a group disproportionately overrepresented among judicially-involved girls.⁸ Crenshaw originally applied the concept of intersectionality to address the means through which individuals’ needs are compounded by their various identities, especially race and gender. Currently, the term has evolved to encompass a variety of dimensions that marginalize individuals, including socioeconomic background, religious affiliation, sexual orientation, gender identity, and educational background. Intersectionality underscores that, in particular, for females of color, their histories of racial and gender oppression have a direct impact on their health needs and the ways in which they engage with healthcare providers. Minorities often experience distrust of the medical community.⁹ For example, within the African American community, this distrust is rooted in a history of “racial discrimination, including slavery, post-emancipation persecution, and persistent racial discrimination.”¹⁰ This phenomenon is evidenced by studies that show a lower level of trust towards physicians among African American compared to Caucasian patients.¹⁰ Crenshaw’s principle suggests that the ability to positively impact a singular health issue is wholly dependent on the ability to combat other interrelated health issues. Applying this principle to the care of justice-involved girls underscores the need for mental health providers to adjust the lens through which they view patients. This involves incorporating their many dimensions of interdependent systems of oppression, vulnerability, and experiences of marginalization within our society.

To best serve judicially-involved girls, mental health providers must be attuned to the intersectionality of their health needs. Accordingly, we propose a, “Think, Ask, Act” approach as an integrated care model for mental health providers that care for judicially-involved girls (Figure 1). Justice involvement presents a unique opportunity to engage high-risk girls in treatment for these interconnected health issues. For many of these youth, detention is the first place where their health needs are identified and addressed.¹¹ Thus, multi-sector engagement amongst juvenile detention, child welfare, and community health centers is key to the success of an intersectional, integrated care approach. The “Think, Ask, Act” approach can facilitate mental health professionals’ ability to more comprehensively care for judicially-involved girls, by creating opportunities to form critical linkages between their intersecting mental and reproductive health needs.

Figure 1.

Think, Ask, Act Integrated Care Approach

“Think”

The case example of Danielle highlights the value of applying the principle of intersectionality when approaching the treatment needs of judicially-involved girls and emphasizes the need for an integrated and trauma-informed care approach. Danielle faces a number of challenges, including a history of sexual trauma, child welfare involvement and foster care placement, history of commercial sexual exploitation, substance use, and untreated mental health diagnoses. This is compounded by aspects of her identity as an African-American female. As illustrated in the case vignette, Danielle’s health challenges are inextricably linked. The intersectionality of Danielle’s marginalization and vulnerability likely contributed to her risk for commercial sexual exploitation and justice-involvement. These risks interplayed with a decreased access to reproductive healthcare services, lower quality of sexual health education, and less autonomy in sexual decision-making as a sexually exploited youth. These factors likely led to additional morbidity, including psychiatric morbidity, which in turn worsened her reproductive health outcomes, overall contributing to growing reproductive health disparities. As Danielle’s story illustrates, addressing the intersections between overlapping mental and reproductive health issues is critical. This is especially relevant when addressing the needs of marginalized populations who face many barriers to engaging in healthcare, such as judicially-involved girls. These barriers are exacerbated by the fact that judicially-involved girls frequently have a history of trauma exposure, running away, transient living, learning challenges, low educational attainment, and lack of trust in the judicial and healthcare system.

“Ask”

While primary care providers in detention routinely obtain reproductive health histories, we propose that mental health providers purposely inquire about aspects of the reproductive health history. Youths’ reproductive health histories often have a profound impact on behavioral health outcomes. These include gender identity, past history of sexual abuse, sexual trauma, past experiences with sexual health education and identified sources of information, experiences with pregnancy, and thoughts on contraception and pregnancy prevention. These are often elements that primary care providers and mental health professionals address, but not in sufficient depth. It is developmentally appropriate and critical that child and adolescent psychiatrists query adolescents about their sexual and reproductive histories, as these factors are often interconnected with other risk-taking areas.

“Act”

We provide a number of provider-specific and systems-level recommendations for an intersectional approach that can help mental health providers better address issues relevant to reproductive health (Figure 1). Provider recommendations begin with detailed screening for past and present reproductive health concerns, with an emphasis on direct linkage to reproductive health care both in detention and community settings. Cross-disciplinary communication amongst healthcare professionals (including primary care, reproductive, and mental health providers) probation staff, and education providers are essential to appropriately coordinate care. Systems-specific recommendations include the implementation of protocols for systematic screening of reproductive health needs during mental health assessments as well as interdisciplinary team meetings. Additionally, recognizing that juvenile detention facilities may be the primary location where many youth receive care and health education, we recommend providing sexual health education and mental health education in both a classroom and individualized setting. Attention to learning needs and academic attainment is also relevant, as the risks and treatment needs related to reproductive and behavioral health serve as risk factors for poor reproductive and mental health outcomes are often synergistic with low cognitive ability and low educational attainment. To circumvent stigma surrounding the receipt of mental healthcare services, we also recommend the co-location of mental and reproductive healthcare services as a means of effectively meeting the needs of this population. This model, which is similar to the integrated approach that is happening in primary care clinics nationally has been implemented at Planned Parenthood. At these clinics, mental health providers are available on-site to provide care to patients.¹² This allows for warm hand-offs between mental health and reproductive health providers (and vice versa), so that youth are able to receive care in one visit, in a familiar practice setting.

Conclusion

Youth such as Danielle illustrate that mental health and reproductive health are strongly intertwined for judicially-involved girls. The “Think, Ask, Act,” approach can help mental health professionals who come into contact with judicially-involved girls become better attuned to intersectionality. It can also improve provider’s fluency in facilitating open discussions about reproductive and sexual health needs so that they can provide appropriate and integrated care with this population. Akin to the bio-psychosocial framework, the intersectional framework allows us to disentangle the underlying trauma and interrelated substance use, mental and reproductive health needs of judicially-involved girls taking their histories of oppression, marginalization, and vulnerability in context. Ultimately, this approach is integral to our success in navigating their various health challenges, and may be a useful framework for the care of other at-risk adolescent populations. While we identified a need for an intersectional approach through working with judicially-involved girls, the utility of this model is likely generalizable to many, if not all, adolescent populations for which cross-communication between reproductive and mental healthcare providers is key.