Racial/ethnic and sexual orientation minorities and women historically have been relegated to social, legal, and economic disadvantage in the United States. Such disadvantage is thought to be one of the underlying factors responsible for mental health disparities.1,2 One of the most alarming disparities is the prevalence of violent victimization (eg, black male teenagers are more than 5 times as likely to die because of guns as their white peers). Blacks in urban communities are much more likely to be murdered, assaulted, or raped than their white counterparts.3,4
We review how culture and disadvantage interact in particular forms of violent victimization. General recommendations are given for competent intervention, because the psychiatrist often is in the best position to gain access to multisystem interventions that can prevent further violence and address the sequelae of trauma.
Violence against women
Men most often experience violence inflicted by other men who are strangers. Women are more likely to be assaulted, murdered, or raped by a current or ex-partner. In the United States, 21% of female victims of violent crime were assaulted by an intimate partner compared with 5% of men.5 In the case of sexual assault, 64% of women are assaulted by a current or ex-partner versus 16% of men. The World Health Organization studied 24 countries and found rates of partner abuse of women ranging from 20% to 50%. It is estimated that 1 in 4 women who seek psychiatric care has been battered. Similarly, 25% of women who attempt suicide have been victims of domestic violence. Nearly 12% of women who have been victims of domestic violence attempt to kill their abusing partner. Male partners are responsible for 50% of the homicides of battered women. Many battered women require emergency medical services. About 20% of women seen in primary care clinics report domestic abuse, and about 17% of pregnant women have been assaulted before or during pregnancy.
Many factors contribute to such high rates of abuse, including societal attitudes that devalue women and treat them like property, offenders who are emotionally dependent on their partners and have poor conflict resolution skills, and behaviors learned while growing up in a violent household. The consequences of abuse transcend physical harm and extend to psychological symptoms such as helplessness and hopelessness, low self-esteem, shame, and guilt. Victims may experience anxiety, depression, posttraumatic stress disorder, increased substance abuse, and suicidal ideation.
Identification of victims is often difficult because women may be afraid or ashamed to speak up. Routine screening is seldom done by physicians because they fear embarrassing their patients, they do not want to get involved in possible legal matters, or they do not know how to manage the problem if the patient does speak up.
Despite the importance of dealing with abused women, there are no validated studies of best-treatment approaches. However, understanding that the therapeutic alliance is a fundamental building block for healing, the therapist can begin by appreciating how hard it may be for victims to trust their therapist. The therapist must be patient as victims struggle to define better boundaries or even think of leaving their abuser. He or she must avoid approaches that blame the victim for choosing a bad partner or for provoking abuse. Women may also need specific help and advice concerning their safety. The therapist needs to be familiar with community resources that provide privacy and security.
Solutions to reduce violence against women are multifactorial. Psychiatrists can begin by advocating for societal changes. For example, young children should be taught to respect both sexes and to resolve conflict in healthy ways. Police need special skills in risk assessment and successful interventions. The court system needs to appreciate the difficulties women have in testifying against a partner. Governments should put more resources into shelters, as well as transitional and permanent housing. Governments should also support training and employment programs for women who are attempting to achieve independence.
Native American youth suicide
Native Americans have the same disorders as the general population but with greater prevalence and severity. For example, Native Americans experience 6 times the rate of alcoholism and tuberculosis, 3.5 times the rate of diabetes, and 3 times the rate of accidents, poverty, and depression. They also have a 2-fold increased risk of suicide and increased violence. Despite these risks, Native Americans generally have less access to treatment than those in the general population.
Compounding the lack of access is the cultural complexity of tribal or clan organization that may be disintegrating. Multiple agencies involved in behavioral health delivery to the Native American population often compete with one another instead of cooperating to provide needed services.
Nowhere is this more tragic than in the case of suicide. In the United States, more than 30,000 people die by suicide each year. Most (90%) of the people who die by suicide have a diagnosable mental illness and/or substance abuse disorder. Native Americans, and Native American youth in particular, have a 3- to 4-fold increased risk for suicide. Statistics from 2001 show that among the Native American youth aged 15 to 17 years, the death rate is 14 of every 100,000 persons, compared with 7.2 for white Americans. Clearly, suicide is a Native American crisis (Figure 1).
The school environment may be the first place where the warning signs of suicide are present and recognizable. Suicides and homicides at several reservations throughout the United States have highlighted the need for tribal crisis intervention teams. Cognitive therapies to teach adolescents how to cope with adversity and increase their repertoire of coping strategies have been successfully employed. Prevention programs (eg, substance use education) can significantly reduce risk factors known to increase suicide risk.6
1. Office of the Surgeon General. Mental Health: Culture, Race and Ethnicity. US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA); 2001. http://mentalhealth.samhsa.gov/cre/default.asp. Accessed October 2, 2008.
2. The Cultural Formulation, Appendix I. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Arlington, VA: American Psychiatric Association; 2000.
3. Oberg CN, Rinaldi M. Pediatric health disparities. Curr Probl Pediatr Adolesc Health Care. 2006;36:251-268.
4. Alim TN, Charney DS, Mellman TA. An overview of posttraumatic stress disorder in African Americans. J Clin Psychol. 2006;62:801-813.
5. US Department of Justice, Bureau of Justice Statistics. Criminal Victimization in the United States, Table 43a; 2006. http://www.ojp.gov/bjs/abstract/cvus/gender969.htm. Accessed October 2, 2008.
6. Suicide Prevention Resource Center. http://www.sprc.org/featured_resources/ebpp/ebpp_factsheets.asp. Accessed October 2, 2008.
7. Blue Corn Comics. www.bluecorncomics.com. Accessed October 2, 2008.
8. One Sky Center, the American Indian/Alaska Native National Resource Center for Substance Abuse and Mental Health Services. http://www.oneskycenter.org. Accessed October 2, 2008.
9. US Department of Justice—Federal Bureau of Investigation. Uniform Crime Reporting Program: Hate Crime Statistics, 2006. http://www.fbi.gov/ucr/hc2006/index.html. Accessed October 2, 2008.
10. Anti-Lesbian, Gay, Bisexual, and Transgender Violence in 2007. A report of the National Coalition of Anti-Violence Programs; 2008. http://www.ncavp.org/ common/document_files/Reports/2007HVReportFINAL.pdf. Accessed October 2, 2008.
11. US Dept of Justice, Bureau of Justice Statistics. Special Report: Hate Crimes Reported by Victims and Police; 2005. http://www.ojp.usdoj.gov/bjs/abstract/ hcrvp.htm. Accessed October 2, 2008.