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Social, Cultural, and Economic Determinants Related to Suicide, Panel 3

The third and final panel in the session on social, cultural, and economic determinants related to suicide was moderated by Rajeev Ramchand and featured presentations on two groups within the general veteran population: sexual and gender minority populations, and Black/African American men. John Blosnich (University of Southern California and the Center for Health Equity Research and Promotion at the Pittsburgh VA) described some of the disparities in suicide risk and prevention among lesbian, gay, bisexual, and transgender individuals as seen through the lens of social determinants of health. Sean Joe (Washington University in St. Louis) spoke on the social determinants of suicide that impact Black American men, focusing in particular on factors that contribute to “provider role strain” that, in turn, can be a factor for suicide risk. Like the other panelists in this second session, Blosnich and Joe look at how data about specific populations might interact with research done on suicide prevention more generally and “introduce a slight detour in those conversations,” as Blosnich put it.

LGBTQ+ VETERANS

Blosnich presented on sexual and gender minority (SGM) populations within the veteran population, focusing on the health equity implications for LGBTQ+ people as seen in suicide prevention. He opened his presentation by highlighting some common terms of gender identity, pointing to the United States Transgender Survey, which shows many “evolving terms” related to gender identity in the United States. He stressed that gender identity is distinct from sexual orientation, which includes self-identification, sexual attractions, and sexual behavior; and that gender identity does not depend on medical interventions or medical therapies. Citing data from the Behavior Risk Factor Surveillance System (BRFSS) (2016) conducted by the Centers for Disease Control and Prevention (CDC), Blosnich noted that many people who identified their gender identity as transgender identified their sexual orientation as heterosexual. He also observed that the BRFSS introduced an optional module for sexual orientation and gender identity in 2014, which allows for probability-based samples rather than convenience-based samples that were (and are) more common in research about LBGT populations. Blosnich noted that a 2021 Gallup survey found that 5.6 percent of Americans identify as LGBT, and found that it is much more common for people in younger generations to identify as LGBT than those in older generations (Jones, 2021).

Blosnich noted that research on suicidal ideation and attempt consistently shows much higher rates among sexual and gender minority populations than those of the general population or their cisgender and heterosexual counterparts. He noted that these disparities for these sexual minorities can be seen in one meta-analysis of studies conducted by Hottes et al. (2016), Lifetime Prevalence of Suicide Attempts Among Sexual Minority Adults by Study Sampling Strategies: A Systematic Review and Meta-Analysis. This review found that 4 percent of people identified as heterosexual had considered or attempted suicide over their lifetime, compared

with 17 percent of people identified as a sexual minority. Blosnich also mentioned his own scoping review of reviews from 1990–2022, of 32 review studies that covered 1,148 studies, all of which supported the finding that “the prevalence of suicide morbidity is much higher” in this population.

Blosnich then turned to suicide research among sexual and gender minority veterans. He noted that doing research on this population is challenging because self-identified sexual orientation and gender identity data are currently “not represented in administrative data” at the VA. In a 2021 study, Boyer et al. using VA records had to “mine through data to find indicators that would suggest that a patient was a sexual minority.” In a different study about transgender veterans, they used International Classification of Diseases (ICD) coding to help identify a subset of veterans “who we would think are transgender.” This study revealed that while suicide was the tenth leading cause of death for cisgender veterans in the United States, it was the fourth for transgender veterans. Similarly, the rate of suicide was the fifth leading cause of death for LGB veterans, compared with the tenth leading cause for non-LGB veterans and also the U.S. population. Blosnich noted that these sampled were “probably underestimated.”

Blosnich then considered some specific social determinants that might explain these disparities in the rates of suicide morbidity. He pointed to the concept of minority stress found in the work of Virginia Brooks and further developed by Ilan Meyer as a way of understanding how stigma drives health disparities experienced by sexual and gender minority people. Blosnich noted that this model is predicated on distal and proximal stressors. The former, he explained, includes processes outside the person, including structural discrimination, laws, and policies. The latter describes intra-personal conditions, of, for example, “someone . . . internalizing the stigma that is leveled against them by society.” All of these features of minority stress impact the mental and physical health of the individual, Blosnich said. They also produce societal strains that lead to adverse social determinants, he noted. Blosnich pointed to two examples of how stigma drives social determinants, found in the VA study of transgender veterans. There, a universal screen for MST and housing instability showed that transgender veterans are “much more likely” to screen positive for both MST and housing instability compared with their cisgender peers. Similarly, Blosnich reported that data from the BRFSS show a high prevalence of nearly all adverse childhood experiences in the LGB population.

Blosnich then briefly gestured to research that seeks to quantify how larger societal elements like policies and legislation can become associated with mental and physical health outcomes for sexual and gender minority populations, including studies that show how “social environmental factors supportive of sexual and gender minorities have protective associations against suicide ideation [and] attempt.” He also pointed to family determi-

nants (i.e., how supportive the family is) as a risk or protective factor that might differ for LGBT populations. For that group, Blosnich commented, the family might be a source of rejection and distress rather than support; conversely, he noted, a study by Russell et al. (2018) shows that one indicator associated with lower depressive symptoms and lower prevalence of suicidal ideation and suicidal attempt for a transgender young person is the family’s acceptance and use of a chosen name that affirms the child’s gender identity.

Blosnich then elaborated on two examples where traditional suicide prevention interventions might be reconsidered in light of data showing how social determinants might affect LGBTQ+ veterans differently than the general veteran population or civilian population. These areas are religion/religiosity and firearms. Blosnich noted that the National Strategy for Suicide Prevention emphasizes faith-based partnerships, based on research that having a religious identity is usually a protective factor against suicide. He reported that his own study of 20,000 young adults and the importance of religious or spiritual beliefs to personal identity shows this, revealing that among people who identify as heterosexual, those who said religion was important to them had lower odds of reporting suicide ideation. For bisexual participants, there were no significant associations between religiosity and suicidal ideation, but for lesbian, gay, or questioning participants, there was an opposite association; those in that population who said they were more religious were more likely to say they had suicidal ideation in the past year. He observed that this difference “challenges us to think about how we can work with faith-based partners to make sure that a health equity lens is brought to suicide prevention” and, more broadly, to make sure that all partners in the work of suicide prevention are helping to understand where these disparities are coming from.

The second example Blosnich gave in using data to rethink traditional prevention approaches is firearms as a determinant for death by suicide. He reports that BRFSS data from California and Texas reveals that in both states, “sexual minorities are significantly less likely to report having a firearm in their household compared to their heterosexual peers.” While these communities had high prevalence in other known risk factors for suicide (including previous attempts, previously thinking about suicide, and actively thinking about suicide), the lower prevalence of this particular determinant was “a good sign,” Blosnich observed, and wondered if “less access to firearms could be a protective feature that we just do not really fully understand yet in this population.” Access to firearms is still a significant factor in suicide deaths for transgender veterans, he continued, but less so for this group than for the cisgender veteran population. At the same time, the rate of suicide death by poisoning is much higher for transgender veterans than their cisgender peers. Blosnich observes that these differ-

ences should, again, prompt reflection about how prevention interventions affect specific subgroups as well as the entire population. “If we devote a lot of resources into gun safety, which is important for all populations, is it still going to have as big an effect for this sample, transgender veterans, as opposed to looking into more prevention for death by self-poisoning, for example?”

Blosnich closed his presentation by discussing the absence of mortality data for LGBT people. This lack of representation in administrative datasets means that research showing that LGBT people are more likely to have risk factors for suicide but cannot be connected to mortality outcomes to determine if rates of suicide death are elevated. He observes, “We cannot get to these ultimate outcomes and that absolutely puts the brakes on prevention because we cannot adequately measure the burdens of disease.” Because of this, too, he notes, resources cannot be directed toward prevention interventions; and similarly, evaluation of public health and clinical interventions is not possible. “If our outcome is to reduce death by suicide for this population, that question is automatically off the table [for this population] because we do not include sexual orientation and gender identity in administrative datasets like we do for other populations.” He noted that this affects even community-based interventions and urged making administrative datasets inclusive. The discussion at the end of this panel briefly returned to the absence of mortality data for sexual and gender minority veterans; there, Blosnich said, to rectify this, “we are currently trying to train death investigators to gather information about sexual orientation and gender identity;” he also said that while the National Violent Death Reporting System at the CDC does have fields for sexual orientation and gender identity, these fields are left blank about 80 percent of the time.

BLACK AMERICAN MEN AND PROVIDER ROLE STRAIN

Joe presented on social determinants of health as they affect rates of suicide among young Black American men; he focused particularly on the effects of normative cultural expectations of men to play the role of provider. He began by reviewing data showing a marked increase in suicide morbidity among in young Black men in the United States. He then defined

provider role strain and discussed its significance as a social determinant of suicide risk for younger Black American men in particular. He closed the paper with a discussion of how this data might be used to reduce risk of suicide in the Black veteran population.

Joe reiterated that different ethnic groups can face different and higher risks for suicide. Such differences, he noted, suggest the need for different strategies for intervention and prevention. As an example, he highlighted differences between Black Americans and White Americans in the general population, noting that for White Americans, the risk of suicide increases with age while for Black Americans, risk of suicide peaks by age 35 and then declines with age.

Zeroing in on the suicide rates for Black Americans, Joe pointed to data that show that young Black men are disproportionately at risk, with firearms as the primary method used for all ages. These data include rates of suicide by sex, which are significantly higher for men than women between the ages of 10 and 84 within the Black population (Centers for Disease Control, Web-based Injury Statistics Query and Reporting System, 2021, 2022). It also includes rates of suicide by age; suicide is one of the top 10 causes of death for Black Americans (of both sexes) from ages 5–34. Within that young age group, firearms are the primary method (Centers for Disease Control, Web-based Injury Statistics Query and Reporting System, 2021).

This pattern, Joe noted, has “great social consequences” and should be considered when thinking about how to prevent suicide. He observed that this loss of the “very young” has different consequences than suicide among White Americans, which trends older and results in the loss of past generations. “Among Black Americans, we are losing future generations”—“future contributors to society.” Joe cites one response to this phenomenon, Ring the Alarm: The Crisis of Black Youth Suicide in America (2019), a report from the Congressional Black Caucus Emergency Taskforce on Black Youth Suicide and Mental Health made in an effort to draw attention to this situation. This report draws on data from trend analysis and shows that for most age groups, from 2001–2015, the rate of suicide for White Americans was higher than for Black Americans, with one exception, Joe explained; in the 12 and under age group, the rate of suicide for Black children was higher than that for White children (Bridge et al., 2018). The suicide rate for Black children increased 86 percent, and for Hispanic children by 3 percent, while the rate for their White counterparts decreased 32 percent (Bridge et al., 2015). Joe noted that recent data show the continuation of this increase in rates of suicide among Black children, up 123 percent from 2010 to 2022 (Centers for Disease Control, Web-based Injury Statistics Query and Reporting System, 2022).

Joe then turned to factors that might be contributing to this: “What is it about being Black and male that increases their risk for suicide?” He

pointed to the concept of “role strain,” defined as “the objective difficulty, and cognitive appraisals of such difficulty, that people in highly valued life roles . . . experience” (Bowman, 2006, p. 120) in meeting “the social and cultural standards” set out for a particular social role. Provider role strain is one variation of this, Joe continues. “For Black men, the inability to fulfill the roles of the patriarch and economic provider . . . has an impact on their perception of their inability to meet the social and cultural standards of what it means to be a man.” Joe noted that within the Black community, these include the ability to provide, procreate, and protect. While such normative ideas of masculinity are tied to basic notions of the American Dream, attempts by Black males to adhere to these roles are complicated by racial discrimination, he observed. He stated that Black men tend to blame themselves as individuals, rather than systemic bias and racial discrimination, for any failure to fulfill roles that are often defined by cultural expectations.

There is very little research on masculinity and how the inability to fulfill expected roles might impact suicidal behaviors, Joe points out, but provider role strain might be considered a social determinant whose indicators also point to increased risk of suicide. Drawing on data from the National Survey of American Life (NSAL), a national household probability sample of 5,181 Black respondents aged 18 years and older, conducted between February 2001 and June 2003 (Jackson et al., 2004), Joe identified some variables to measure provider role strain that might, in turn, function as predictors for an increased risk for suicide ideation and suicide attempts among Black men. These variables include food insufficiency (i.e., regularly not having enough to eat), material hardship (i.e., not meeting basic needs, including housing and utilities), and work status (including not just unemployment, but employed and not earning enough), Joe clarified. He explained, food insufficiency indicated that the individual was twice as likely to think about suicide; similarly, those not in the labor force were twice as prone to suicidal ideation. Odds ratio analysis showed that the lower the level of material hardship, the lower the level of risk for suicide, but not significantly so. Similarly, when predicting suicide attempts, material hardship and food insufficiency did not show statistical significance. However, Joe pointed out, in the area of work status, being unemployed or not in the labor force did elevate risk for suicide attempts within this sample of Black American males by at least four times. These data show how “social determinants are playing a role in the Black male’s risk for suicide.”

Using the data in the NSAL sample, Joe also made what he called the American Dream Index, a subset of the group who was beginning to achieve homeownership and other achievements tied to normative sociocultural expectations of the male role as provider, patriarch, and protector. He reported that analysis here showed that the lower the mean score, the

less likely the individual is to achieve the American Dream and more likely to either consider or attempt suicide.

Joe noted that, as a whole, these data reveal social determinants of health for Black Americans that must be considered when working with veteran populations. One example he points to is the high rate of firearms use in suicide among both Black and veteran populations.

Joe also emphasizes veterans’ vulnerability to factors associated with provider role strain in the period of transition from active duty to nonactive duty and out of the armed services. This shift away from a sense of “great belonging” and relatively straightforward access to assistance has the potential, he noted, to leave veterans feeling “disconnected, uncertain, and without purpose.” These feelings are also associated with provider role strain, Joe noted, as veterans figure out a new role and job. He speaks of “the importance of matching career and opportunity once [veterans] leave that very skilled setting of armed services.” More generally, Joe said, “this combination of factors” that contribute to provider role strain and also are present in the moment of veterans’ transition out of active duty “must be considered for any community-level suicide prevention strategy particularly for Black Americans.”

DISCUSSION

The discussion, moderated by Ramchand, covered questions of data, the impact of military culture on expectations for Black males, discrimination as a social determinant, and why Black American children seem to be at increasingly higher risk for suicide.

Joe addressed the possibility that hyper masculine military culture might intensify self-perceived expectations about what the role of a man should for Black men more than White men; he commented, “I would expect to see a hardening of the adherence to . . . normative expectations among those entering the military.” Joe continued that he would not suggest that there are differences between ethnic groups (including Black and White men) in terms of how this role intensifies in the military; but, he said, younger generations of Black Americans are adhering to broader American cultural norms, and “now we are beginning to see a rise [of suicide] particularly among younger Blacks.” So, he reiterated, entering into the military would harden normative expectations and pressure to meet them.

Discussion of these two presentations also engaged with the theme of discrimination as a social determinant. Acknowledging that addressing discrimination from a policy position is a “long game,” Ramchand observed that in the short term at the individual and community levels, “we can address the stressors that discrimination causes. But how can we, in the short term, address from the social determinants’ perspective, some of

these discriminatory practices?” Blosnich mentioned very recent discriminatory legislation passed in Florida, the so-called “Don’t Say Gay” bill, and pointed to the importance of mobilizing communities and helping people to find movements that work against this sort of legislation. Blosnich commented that in addition to fighting for change in and of itself, being a part of such communities can also be a way of “processing how society currently is, and feeling you can do something.” Joe observed that “we know [discrimination] is a social determinant” and so it is important to understand how it impact an individual’s experience. He added that policies and practices that “make people feel of less value” will “exacerbate the stress response” and increase risk of factors that lead to suicide or serving as a “precipitating trigger” that confirms a self-perception of not mattering. Joe specified that addressing this at the individual level means helping others navigate discrimination, while efforts at the community level should “try to eliminate that experience.”

The final topic of the question-and-answer session was possible reasons behind the increase in suicide risk among Black youth. Joe explored one reason within the “multifactorial explanation:” changing cultural expectations. He noted that Black children are subject to cultural expectations that are not so different than White children, “so why would they not be at risk” in the same way (i.e., at higher risk)? These cultural expectations may put younger generations of Black Americans at risk in ways that are different than earlier generations, who were not subject to the same cultural expectations. “There has been a change in cultural expectations between the generations,” and so now we are seeing a corresponding increase in rates of suicide morbidity, Joe suggested. He added that some protective factors have waned “or are no longer as protective.” As Black individuals become subject to cultural expectations around individual achievement and the American Dream—“I should be able to achieve as much as everyone else”—Joe said, they may encounter obstacles that are not the result of individual factors but social determinants, but not see these obstacles as such. As a result, individuals internalize a sense of personal responsibility for outcomes that are actually largely structurally determined. This mismatch can put individuals at higher risk for suicide morbidity; “I think that is what is happening with Black children nowadays,” Joe concludes.

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