The health of Black disabled boy children: an oversight for intersectionality?
by Zara Trafford
Institute for Life Course Health Research
Department of Global Health, Stellenbosch University, South Africa
Racialised structural discrimination is a global problem and in health services and systems specifically, racism is implicitly embedded in many of the practices and techniques at the root of biomedicine. This pattern has resulted in skewed diagnoses and documented poorer access to health services and wellbeing in the longer term (1). For example, the Diagnostic and Statistical Manual of Mental Disorders is widely used internationally, but when the criteria are applied uncritically, they result in “the disproportionate labeling of Black, Indigenous, and People of Color as violent or severely mentally ill” (2). In the United States where the relevant literature is most established, Black and Hispanic children are reportedly diagnosed with oppositional defiant disorder at dramatically higher rates than White children. In parallel, the same children often have missed diagnoses of Attention Deficit Hyperactivity Disorder (the diagnosis that their White peers more commonly receive when displaying similar behaviours) and do not get the appropriate level of support (3).
For researchers and practitioners working in Northern high-income settings, such considerations of marginalisation and racialised bias are often concerned with the experiences of “minority” groups within majority White countries. For those of us living and working in most of the world’s previously colonised countries, however, Indigenous and/or immigrant people of colour are the majority population. In these settings, oppressive segregationist policies enforced over centuries of minority rule have resulted in the social construct of race being conflated with socioeconomic class, an issue which is far from resolved and has far-reaching effects on children’s access to opportunities and resources from before birth and throughout their lifecourse. Examining contexts like South Africa more closely remind us that it is important to understand how features of an individual’s identity interact with their structural circumstances at a global level, certainly, but also to understand the specific contexts in which children in different parts of the world are born and raised.
For example, an intersectional identity that receives insufficient global attention is that of young Black boys and adolescents growing up in low-resource countries or communities, especially those also afflicted by high levels of violence. As a White, cisgender, South African woman with access to education and a relatively economically stable home, it has always been clear to me that gender is not the only metric that connotes susceptibility to violence. I have had damaging experiences that are due in part to my gender, but my life has nonetheless been dramatically easier than the vast majority of the Black boys and men in my country. This is because of the social, and often also economic, privileges associated with whiteness globally, despite White people being only 9% of the population in South Africa. For example, recent statistics demonstrate that globally and in South Africa, boys and young men are most at risk of violence, homicide, and accidental death (4). In South Africa, men have lower access to HIV testing and treatment, and poorer outcomes for retention in care (5). Both violence and HIV prevalence are concentrated in areas of lower resource.
Specifically for disabled children who are also growing up in circumstances of poverty, structural conditions have a profound and life-altering effect on their chances of access to the means for health, wellbeing, and a good life. Intellectual disability, autism, and other neurodevelopmental conditions can produce particular affects or behaviours that may frighten or confuse people who have not had sufficient exposure or opportunities for interaction. A recent video clip on a channel dedicated to sharing individual and family stories of disability, for example, featured a young Black man who is intellectually disabled and the adopted son of a White family living in an affluent neighbourhood in the United States. This young man had started a lawn-mowing service in his neighbourhood but an onlooker assumed he was trespassing and called the police. This particular pattern has not been sufficiently explored in an African setting, but it is not hard to see connections here between these neighbours’ fear of an unfamiliar young Black man in their area and deeply-rooted ideas of “dangerous” Black men (6), or of African men being inherently menacing (7) – see also the well-worn trope of the “angry” or “aggressive” Black woman.
During my own PhD research, I met and worked with the mother of an adolescent boy who was autistic. He was highly computer-literate, had strong high-level administrative skills, and was fluent in spoken and written English, which is unusual in his community. However, he did not speak much and had recently had a growth spurt, making him larger and stronger than many of the other children his age. Even though he lives in a majority Black country, his structural circumstances are such that, should he be arrested, he would likely be treated with insufficient understanding of and support for the specific needs associated with being on the autism spectrum. In a context where even the health services in South Africa are not disability-friendly (8–11), the police service and a massively overloaded criminal justice system are unlikely to provide disability-responsive and supportive care, especially in instances of neurodiversity which are even less well-understood (12–14). These issues worried this boy’s mother greatly but due to her structural circumstances, there was little she could do to moderate the issue without wider systemic changes.
The complex intersections between an individual’s gender identity, disability, and age, and their positioning within certain socioeconomic, geographical, and structural circumstances, can produce patterns that profoundly shape their access to the means for health and wellbeing. We will only be able to see these clearly, and act upon them appropriately, if we move away from generalised or universalising beliefs and work to further nuance our understanding of intersectional identities.
Based in Cape Town, Zara's work focuses on disability studies research, with a particular emphasis on health inequalities in South Africa and other Global South countries. She brings strong qualitative research skills and a methodical approach rooted in their Humanities training. With experience working across disciplines and effectively communicating with diverse audiences, they aim to contribute to critical interdisciplinary efforts in public health and disability from a Global South perspective.
References:
1. Yuen E, Daily S, Sadhu J, Baek J, Shapiro G, Pfeffer C, et al. Clinical Considerations in Working with Children and Adolescents of Color: Past, Present, and Future. Adolesc Psychiatry. 2024 Mar;14(1):3–8.
2. Riquino MR, Nguyen VL, Reese SE, Molloy J. Using a Transdiagnostic Perspective to Disrupt White Supremacist Applications of the DSM. Adv Soc Work. 2021 Sep 23;21(2/3):750–65.
3. Ballentine KL. Understanding Racial Differences in Diagnosing ODD Versus ADHD Using Critical Race Theory. Families in Society: The Journal of Contemporary Social Services. 2019 Jul 6;100(3):282–92.
4. Matzopoulos R, Prinsloo MR, Mhlongo S, Marineau L, Cornell M, Bowman B, et al. South Africa’s male homicide epidemic hiding in plain sight: Exploring sex differences and patterns in homicide risk in a retrospective descriptive study of postmortem investigations. PLOS Global Public Health. 2023 Nov 22;3(11):e0002595.
5. Cornell M, McIntyre J, Myer L. Men and antiretroviral therapy in Africa: our blind spot. Tropical Medicine & International Health. 2011;16(7):828–9.
6. Hutson TM, McGhee Hassrick E, Fernandes S, Walton J, Bouvier-Weinberg K, Radcliffe A, et al. “I’m just different–that’s all–I’m so sorry … ”: Black men, ASD and the urgent need for DisCrit Theory in police encounters. Policing: An International Journal. 2022 May 24;45(3):524–37.
7. Tsampiras C. From ‘Dark Country’ to ‘Dark Continent’: AIDS, ‘Race’, and Medical Research in the South African Medical Journal, 1980–1995. J South Afr Stud. 2015 Jul 4;41(4):773–96.
8. McKinney EL, McKinney V, Swartz L. Access to healthcare for people with disabilities in South Africa:
Bad at any time, worse during COVID-19? South African Family Practice . 2021;63(3).
9. Baloyi O, Jarvis MA, Chironda G, Mbeje P, Ngcobo SJ, Gqaleni T, et al. Experiences of families with children diagnosed with Autism Spectrum Disorder in World Health Organization Afro‐Regions: A scoping review. Nurs Health Sci. 2024 Jun;26(2).
10. Hanass-Hancock J, Alli F. Closing the gap: training for healthcare workers and people with disabilities on the interrelationship of HIV and disability. Disabil Rehabil. 2015 Oct 9;37(21):2012–21.
11. Kate S. Disability and rehabilitation: essential considerations for equitable, accessible and poverty-reducing health care in South Africa. S Afr Health Rev. 2014 Jan 1;2014/2015(1):89–99.
12. Bornman J, Bornman HG. Augmentative and alternative communication in the South African justice system: Potential and pitfalls. S Afr J Hum Rights. 2023 Oct 2;39(4):301–19.
13. Bornman J, White R, Johnson E, Nelson Bryen D. Identifying barriers in the South African Criminal Justice System: implications for individuals with severe communication disability. Acta Criminologica : African Journal of Criminology & Victimology. 2016 Jan 1;29(1):1–17.
14. Viljoen EM, Tonsing K, Bornman J. Challenges experienced by South African police officers when taking statements from victims with a communication disability: An exploratory study . South African Crime Quarterly. 2023;72:2–27.