Following on from this article on the problems with neurodivergent research in the global south, we're now looking at the five main reasons that people can't access therapy services.  While many of these barriers are not unique to this population group, the cumulative effect of multiple intersectional identities can make it effectively impossible for these individuals to access even frontline mental health support, let alone psychosexual therapy.

These barriers can be grouped into five main themes:

1. Access to culturally appropriate diagnostic services and assessment tools 
2. Accessibility barriers to general therapeutic services 
3. Communication problems with mental health professionals
4. Lack of social awareness and community support
5. Social isolation, shame, and stigma

1. Access to culturally appropriate diagnostic services and assessment tools 

There is a consistent and widely acknowledged male bias in neurodevelopmental disorders, particularly in autism (Santos et al., 2022). The putative gender ratios are 3:1 for autism and 2.3:1 for ADHD (Loomes, 2017). Moreover, for ADHD, a girl's first consultation occurs at an older age and takes more clinical visits than for a boy (Klefsjö et al., 2020).

Autism is significantly underdiagnosed, misdiagnosed, and late-diagnosed in non-white communities. For example, even in the US, Latino children typically receive a diagnosis 2.5 years later than white non-Latino children, with white children typically receiving their diagnosis around 6 years old, compared with 7.9 years for black children (Zukerman et al., 2015). White children also tend to enter the mental health system at least a year younger, and even after adjusting for age, sex, and time eligible for Medicaid, black children require more time in treatment before receiving their diagnosis. 

How about the tools used? The two ‘gold standard’ autism assessment tools are the Autism Diagnostic Observation Schedule, Second Edition (ADOS-2) and Autism Diagnostic Interview-Revised (ADI-R). However, my non-exhaustive search only found translations of the ADOS-2 in Afrikaans, Korean, and European and Scandinavian languages. Evidently, it is crucial that this be addressed, “especially in rural and underserved areas, through increased funding and the availability of trained mental health professionals specialised in…diagnosis and treatment” (Olatunji et al., 2023, 4939). Plainly, there is a noticeable shortfall in access to diagnostic services, as well as culturally and linguistically appropriate diagnostic tools. 

2. Accessibility barriers to general therapeutic services 

Globally, therapy is expensive to access, whether that’s through public health services funded by high taxes or paid for privately. Socioeconomic factors like poverty, lack of access to education and healthcare, and gender inequality can make it even harder to access therapeutic services.

Psychosexual therapy, in particular, is a secondary mental health service, if provided at all by the state. Therefore, it’s usually accessed privately or for a very limited number of sessions for a limited range of issues. Many neurodivergent adults, particularly those with co-presentations of learning difficulties, can struggle to obtain or maintain employment, meaning they have less disposable income for ‘luxuries’ like therapy. 

Another accessibility barrier may be how therapeutic services are booked. For example, many neurodivergent adults have a strong aversion to talking on the phone, but this may be the only way to book. Those with ADHD are more likely to struggle to remember when their appointments are and arrive at them on time. Most therapy services don’t take this into account, and if someone misses a session or is repeatedly late, they are discharged from the service. Thus, even if the person is able to navigate signing up for sex therapy, it can be hard for them to stay in therapy. 

3. Communication problems with mental health professionals

Even in this supposedly post-colonial era, many national mental health services persist in using colonial rather than indigenous languages, which can be a significant barrier to individuals accessing professional support. This elitist gatekeeping prevents many people from even knowing how to access mental health services. It can also force people to try to express deeply personal experiences in their second, third, or fourth language. The hangover of the medicalised approach to mental health can also dismiss or criticise individuals’ experiences, leaving them feeling undermined and discredited.  

 When writing about ADHD in the Middle East and North Africa (MENA) region, one study highlights how it’s often perceived as a childhood condition, yet most diagnosed children continue to meet the criteria as adults. As children, these individuals may have a parent or caregiver to advocate for them and communicate with mental health professionals (Safiri et al., 2023). Once adults, these people are likely to struggle to engage and communicate with mental health services without that additional support. 

Even on a linguistic level, how neurodivergence is understood and described can vary significantly between languages and cultures. While ADD and ADHD are typically the same or very similar in most languages, autism, however, is not. For example, “In Mainland China, the Mandarin term 'gūdúzhèng' (孤独症), literally translates into 'loneliness disease,' whereas in other Chinese-speaking countries, 'zìbìzhèng' (自闭症) – 'closed-self disease' is more commonly used” (Chinese Autism). These terms become all the more powerful within the context of Chinese cultures that tend to emphasise conformity and not bringing shame on the family. The Japanese term, “自閉症" (jihei-shō), is similar to the Chinese term in highlighting the element of social isolation. In Hindi, "ऑटिज़्म" (autism) is used and tends to describe a broader developmental condition affecting social interaction, communication, and behaviour. In contrast, in Spanish and French, “Autismo” and “Autisme” respectively, are linked to a psychological condition, akin to what we call “Autistic Spectrum Disorder” (ASD) in English. Thus, being autistic is no longer an illness or handicap to fix or mend, but rather an atypical way of thinking and being in the world. 

4. Lack of social awareness and community support 

Moving from the linguistic framing to the cultural context, for people like Priya’s parents, their belief system encourages them to favour a faith healer over a psychiatrist (Kudi et al., 2023). In many countries, social awareness of neurodivergence is very low. For example, in a survey on autism awareness, only 13% of participants in India had heard of autism, compared to 100% in the USA (Kapoor, 2019).

In many Latin American countries, in which many social issues are dealt with at the family level, being neurodivergent is often perceived as not living up to heteronormative gender stereotypes (Zukerman, 2015). Added to this, autistic people are typically perceived as less ‘likeable’ and trustworthy and more awkward, making it harder to date (Milton et al., 2022). Put together, it’s clear that there is a lack of social awareness about neurodivergence in terms of what it is and what may help support the neurodivergent individual. 

When considering community support, the absence of neurotype-based activity groups can also make it hard for people to find neuro-affirming communities. This is especially important for autistic people, as research suggests two key contributing factors to self-harm and suicidal episodes among autistic people are that individuals feel a sense of not belonging and of being burdensome (Costa et al., 2020; Pelton et al., 2023). Lack of social and community understanding, let alone support, is likely to further exacerbate these negative feelings. 

5. Social isolation, shame, and stigma

Neurodivergence, like any social divergence, tends to be viewed as failing to live up to normative societal benchmarks and/or gender and cultural stereotypes. For example, what might be called ‘gifted & talented’ in children in one population group may be labelled ‘disruptive’ in another, depending on what is deemed acceptable and aspirational. Many parents worldwide refuse to get their child diagnosed for fear of social stigma and live an isolated life from society.

Some forms of neurodivergence, such as Tourette’s, can be more visible and socially disruptive, further increasing the chances of social stigma. In a Chinese study of parents of autistic children, 70% felt neglected by society and discriminated against, as Chinese cultures tend to emphasise conformity and not bringing shame on the family (Chinese Autism). Children with autism, especially those who are high-functioning (i.e., without significant cognitive and language impairments), usually fail to receive the education they need (Baimbridge-Sutton, 2020). 

For a more hopeful perspective on how neurodivergent communities are creating their own spaces for connection, healing, and self-expression, you might also enjoy Neurodivergent Content Creators Redefining Sex, Sexuality, and Relationships.

If you're looking for a more personal and empowering next step, you’re warmly invited to join us for Neurodivergent Me, a free, self-paced, 4-week online course designed to help neurodivergent adults explore and better understand their unique sensory needs and preferences. Sign up here - we’d love to welcome you.