Philip A. Bialer, MD

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.

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.

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.

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.

 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 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 (

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.

Native Americans historically have benefited from close tribal social support. While strained and at times fragmented, this can be a great source of strength and prevention. There needs to be an increased community awareness and access to hotlines or other help resources to buttress the tribal social support. Culturally sensitive approaches to prevention and treatment include talking circles, smudging, storytelling, traditional healers, the medicine person, use of herbal remedies, and traditional ceremonies (such as the sweat lodge). For example, members of the tribes of First Nations in Canada have benefited from outreach programs to Native American youth that use native-focused comic books with native heroes and legends promoting mental health and general physical health messages.

 Although the Native American population presents particular challenges, it has innate strengths that can be used to prevent the rising tide of Native American youth suicide and violence.

Domestic violence among South Asians: an example of a community response

Domestic violence is a spectrum of abuse that includes physical, psychological, economic, and sexual harm with the intent to control another person’s behavior. It is a persistent pattern of behavior that can occur at any point during the life cycle. Domestic violence is perpetrated all over the world-and 90% to 95% of the violence is committed by men against women.

In the United States, more than 3 million women are victims of physical abuse each year. No large studies have sampled the prevalence of partner abuse among Asian Americans in the United States. However, Asians made up only 17.5% of the population in Santa Clara County, California, but they accounted for 35% of women killed in domestic violence–related deaths between 1994 and 1997.

Throughout the United States, Asian Americans have responded to domestic abuse in their own communities by establishing various programs and organizations for survivors of domestic violence. Apna Ghar (Our Home), established in 1990, is the longest-running shelter for South Asian battered women in the Midwest. This shelter helps battered women become safe and self-sufficient. It also aims to increase community awareness about domestic violence by targeting social change through education and outreach. It is the first shelter and social service agency in the nation founded specifically to provide culturally appropriate services for victims of domestic violence from the South Asian countries of India, Pakistan, Bangladesh, Nepal, Bhutan, and Sri Lanka. Over the years, expertise and services have expanded to include immigrant women from regions such as the Middle East and other parts of Asia. Apna Ghar has served more than 5200 women and children in the past 17 years.

Current programs and services at Apna Ghar include a 24-hour crisis line, a shelter staffed around the clock, counseling services, legal advocacy, children’s advocacy, transitional housing, supervised child visitation, an economic empowerment program, outreach programs, and 40 hours of domestic violence training. The accomplishments are numerous, and every year a significant number of community organizations join Apna Ghar in the fight against domestic violence.

Violence against lesbian, gay, bisexual, and transgender persons

The true prevalence of lesbian, gay, bisexual, and transgender (LGBT) hate crimes is difficult to determine. The main sources of information come from the Hate Crime Statistics Reports and the National Coalition of Anti-Violence Projects (NCAVP) annual reports from the Federal Bureau of Investigation (FBI).

In 2006, there were 1415 hate crime offenses based on sexual orientation that involved 1472 victims; this category comprised 15.5% of all reported hate crimes (

 Although more than 12,000 agencies representing 85% of the population participated in this survey, hate crimes based on sexual orientation were reported by only 2000 agencies. The NCAVP report for the same year states that there were 1393 incidents of hate crime based on sexual orientation that affected 1672 victims.

These statistics were based on reporting from only 12 agencies representing 27% of the population. However, these statistics included 11 homicides, whereas there were no homicides reported by the FBI, and 15% of the crimes in the NCAVP report were against transgender individuals, a category which was not included in the FBI report.

Interestingly, a special report from the Bureau of Justice, based on bi-annual interviews of 77,600 people from 2000 through 2003 indicates that the number of LGBT hate crimes and victims was more in the range of 30,000 annually.

 This large discrepancy may be due to the reluctance of the LGBT population to report hate crimes or the reluctance of law enforcement agencies to classify these crimes as hate crimes.

Adolescents and young adults may be at particular risk for the mental health consequences of anti-gay harassment and violence. Some studies indicate that being a victim of anti-gay violence was associated with low self-esteem and a 2-fold increase in suicidal ideation. A survey in California of middle and high school students revealed that victims of sexual orientation bias–related incidents had the highest rates of negative behaviors, including lower grades and drug and alcohol use. Larger studies of the LGBT population have also shown hate crime victimization to be associated with depression, anxiety, distress, anger, less belief in the benevolence of others, greater perceived vulnerability, and lower self-mastery.

What can be done? First, for the victim, the psychiatrist must provide an environment that respects the trauma that has been inflicted and provides safety for the healing that must occur. The victim may need specific advice to help find a safe haven in the community (

Beyond the treatment of the individual patient, psychiatrists should be advocating for legislation that better protects the rights of all citizens. Neither sexual orientation nor gender identity is included in hate crime laws in 18 states. On the federal level, although the Matthew Shepard Act, which included both sexual orientation and gender identity in its definition of hate crimes, was passed by Congress in 2007, the bill was later vetoed by President Bush.

Better epidemiological studies are needed to accurately determine the prevalence of anti-LGBT violence. In addition, educational programs are needed for law enforcement personnel and mental health care providers. A better understanding of the mental health sequelae of anti-LGBT violence will allow for improved evidence-based treatment.

The disadvantaged racial/ethnic and sexual orientation minorities and women have disproportionately experienced suicide and homicide in the United States. The complex history of each group, its language, attitudes, values, and behaviors, which interact with those of the majority culture, produce unique patterns of violence. Regardless of a victim’s background, a psychiatric approach that begins with an assessment of the cultural identity of the victim gives each victim the best chance of becoming a survivor. This approach recognizes the assets available in the victim’s community of support and provides a safe haven for learning adaptive and proactive behaviors. Finally, psychiatrists are encouraged to advocate for broader social changes that will prevent future victimization and provide greater opportunities for recovery.


				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. 

. Accessed October 2, 2008.
				8. One Sky Center, the American Indian/Alaska Native National Resource Center for Substance Abuse and Mental Health Services. 

. Accessed October 2, 2008.
				9. US Department of Justice-Federal Bureau of Investigation. Uniform Crime Reporting Program: Hate Crime Statistics, 2006. 

. 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

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Racial/ethnic and sexual orientation minorities and women historically have been relegated to social, legal, and economic disadvantage in the United States.

Philip A. Bialer, MD

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