Psychiatrists and mental health professionals are steadily
learning—and placing into practice—that preventing youth suicide
among minority populations means understanding the social context in which
members of those groups often live. Society discriminates doubly against
African Americans and homosexuals, for example, both for whom they are and for
any mental illness they may have, a combination that can increase the risk of
suicide, two speakers said at the Suicide Prevention Action Network meeting in
Washington, D.C., in July.
A century ago, it was a common belief in psychiatry that African Americans
were too "unsophisticated" to get depressed or commit suicide, a
characteristic attributed as well to other marginalized ethnic groups such as
Chinese or Eastern European immigrants, said Sherry Davis Molock, Ph.D.,
M.Div., an associate professor of psychology at George Washington University.
Some of that bias remains, predisposing clinicians to errors in diagnosis and
treatment, she added.
While suicide rates among African-American youth were once lower than for
whites, those rates have increased sharply over the last 30 years, especially
between 1980 and 1995. Today, suicide ranks as the third leading cause of
death among African Americans aged 15 to 24, after homicide and accidents.
Clinicians should take extra care in evaluating potential suicidality among
these youths. Conventional suicidal symptoms may not be obvious at first in
some minority groups, said Molock. For many cultural and social reasons,
African Americans are more likely than whites to signal suicidality as
behavioral or somatic complaints than as the classic sadness of depression,
For example, because of cultural or religious stigma attached to suicide,
some black youth may engineer their own deaths by "victim-precipitated
homicide," by confronting police or others who will use deadly force to
respond to the provocation.FIG1
Sherry Davis Molock, Ph.D., M.Div., tells attendees at a Suicide
Prevention Action Network meeting in Washington, D.C., that outdated and
clichéd views of racial or cultural minorities can distort diagnosis or
treatment of conditions that increase risk of suicide.
Credit: Aaron Levin
Also, more young African-American men die of drowning than any other ethnic
group studied. That may be partly a measure of not knowing how to swim but it
may also indicate unrecorded suicidality, since medical examiners may not be
thinking suicide when listing the cause of death.
"Blacks will express little suicidal intent, even when asked,"
she said. She recalled the case of one of her patients, a student who
swallowed crushed glass but told doctors in the emergency room that it was an"
accident," and was promptly discharged home.
"If it looks like a suicide, it probably is," she
Mental-illness stigma in the African-American community is frequently
expressed as denial, she said. When a whole community is stigmatized, its
members don't want to make it worse by admitting a "failure" such
as committing suicide. With her divinity degree, Molock, who is black, has
been able to speak the language of church leaders, who play an important
leadership role in the black community, urging them to take a less-rigid view
of suicide and its causes.
Condemnation of suicide is based more in cultural tradition than theology,
she said. While respecting the clergy's religious teachings, she also tries to
explain how denunciations of mental illness and suicide are hurtful and can
dissuade listeners from seeking treatment. She also notes that churches can
provide troubled young people with a sense of community, a chance to help each
other, and a place for group activities.
Other barriers—such as lack of insurance coverage or access to health
facilities—have to come down, she added. And, she noted, there are too
few psychiatrists in underserved neighborhoods to meet the demand for
treatment, so primary care clinicians must shoulder the burden of care.
Higher rates of depression, suicidal ideation, suicide attempts, and
completed suicides are also present among young members of sexual minorities,
reflecting not only the general travails of adolescence but the added stigma
of being gay, lesbian, bisexual, or transgendered, Effie Malley, M.P.A.,
senior prevention specialist with the Suicide Prevention Resource Center in
Newton, Mass., told the group.
"The time of disclosure [of their sexual orientation] is a really
vulnerable period for kids, and it's happening at younger and younger
ages," she said.
Epidemiological studies report that 47 percent of gay or bisexual boys and
73 percent of gay or bisexual girls have thought about suicide, compared with
35 percent of heterosexual males and 53 percent of heterosexual females in
their peer group, she pointed out. Young gays or lesbians are three to seven
times more likely to attempt suicide than their heterosexual peers, but
empirical data linking completed suicide to sexual orientation are sparse.
"Gender nonconformity" is itself a risk factor for suicidality,
she said. "It is especially pronounced when a young person comes out too
early or not at all," experiences internal conflicts about his or her
sexual orientation, is involved in family conflicts over sexual orientation,
or is bullied and victimized at school.
Clinicians need to be cautious about use of language, even when
inadvertent, that might turn off young people who are in the midst of
grappling with their sexual orientation, she noted. Asking a young man if he
has a "girlfriend" can signal that a doctor or counselor is
unwilling to face the boy's true feelings of sexuality.
However, protective factors such as family connectedness, having a caring
adult or positive role model in their lives, or going to school in a safe and
supportive environment can mitigate some of the factors than can increase
Both racial and sexual minorities at risk for suicide can benefit from
culturally competent programs that address known risk and protective factors,
said Malley. ▪