Keywords

Rates of suicide are often elevated in racial and ethnic minority youth, with increasing rates for Hispanic, Black, and Asian or Pacific Islander youth and a decreasing rate for White youth between 2018 and 2019 (Ramchand et al., 2021). Further, LGBTQ+ youth are at high risk for suicidality, with some research suggesting this population is three times more at risk than their heterosexual and cisgender peers (Hatchel et al., 2021; see Rubin et al., Chap. 13, this volume). These higher suicide rates among racial, ethnic, gender, and sexual minority youth align with some findings that these populations have higher rates of suicide ideation and behaviors, in comparison to their non-minority counterparts (Kann et al., 2016; King et al., 2008). Research has shown that cultural factors play a significant role in predicting and explaining suicidal behavior in racial and ethnic minority youth (Goldston et al., 2008). However, current research has not created recommendations that incorporate cultural considerations for youth, making it difficult for practice and policy to integrate these factors (Polanco-Roman & Miranda, 2021). For this reason, the current chapter presents the Cultural Theory and Model of Suicide for Youth, to provide guidelines for integrating cultural differences into suicide practice, policy, and research.

The Cultural Theory and Model of Suicide for Youth

The original Cultural Theory and Model of Suicide synthesized research from 1991 to 2011 via an extensive literature review of articles regarding culturally specific suicide risk and protective factors into theoretical principles across four major cultural factors (cultural sanctions, idioms of distress, minority stress, and social discord). The model was originally developed for use across the life span; however, this chapter examines specific use of the model with cultural minority youth, presented in Fig. 11.1 (Chu et al., 2010). The Cultural Theory and Model of Suicide for Youth addresses the four overarching cultural factors that have been shown in research as particularly salient or more strongly related to suicide behaviors for various ethnic minority and LGBTQ+ youth. Because of this cultural factor rather than group-specific approach, individual minority groups are often discussed together (e.g., as “cultural minority youth”) in this chapter.

Fig. 11.1
A flowchart. Four factors affect three theoretical principles. Cultural Sanctions link to Cultural Meanings; Idioms of distress are linked to culture affects expressions, and minority stress and social discord are linked to culture affecting Stressors. Each factor has sub-sections like LGBTQ+ minority stress, family conflict, or ethnical or racial minority stress.

The cultural theory and model of suicide for youth. Author’s own creation. (Note: * Indicates additional subdomains added for youth)

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Cultural Sanctions

Cultural sanctions are the messages of approval or acceptability supported by one’s culture. The literature suggests that two types of cultural sanctions, including the unacceptability and shame associated with life events and the acceptability of suicide as an option, influence the developmental pathways to suicide. Notably, cultural sanctions can moderate the relationship between one’s exposure to stressful life events and suicidal distress (Chu et al., 2020). For instance, while academic difficulties augment suicide risk for all youth, academic stress is a particularly salient suicide risk factor for Asian American youth due to cultural demands for academic excellence and shame associated with academic failure (Wong et al., 2011).

Second, the perception of suicide as an “acceptable” action increases suicide risk for ethnic and sexual minority youth. For example, some Asian American youth view suicide as a rational (even honorable) way of handling stressful situations that might bring dishonor to their families (Thapa et al., 2015), and lesbian, gay, and bisexual youth have been found to view suicide as more acceptable than their heterosexual counterparts (Canetto et al., 2021). In contrast, religions with negative attitudes toward suicide may protect ethnic minority youth from suicide risk (Cole-Lewis et al., 2016).

Idioms of Distress

A second major way in which culture interfaces with suicide risk is through variations in youth’s expression of suicidal distress – called “idioms of suicidal distress.” Chu et al. (2010) suggested that minoritized individuals vary in whether or not they express suicidal thoughts and behaviors, the manner of expression, and specific methods of attempting suicide. Ethnic minority youth, for example, appear to be less likely to reveal their suicidal ideation and behaviors (Anderson et al., 2015). Externalizing behaviors as an effort to guard themselves against victimization may be particularly related to suicide expression among Black youth (Congressional Black Caucus Emergency Taskforce on Black Youth Suicide and Mental Health, 2019). As another example, Latinx youth tend to express their suicidality through risk-taking behaviors, irritability, and substance use (Olshen et al., 2007).

Minority Stress

Minority stress includes elevated stress levels stemming from experiences of discrimination and social inequities for youth of minority status (Meyer, 2003). Such stress results in increased depression, substance use, and suicidal thoughts or behaviors. For Black youth, discrimination, racism, low socioeconomic status, and neighborhood disadvantage are associated with higher risk of suicidal thoughts and behaviors (Opara et al., 2020). Among Asian American youth, experiences of perceived discrimination have been linked to increased lifetime suicidal ideation and attempts (Kuroki & Tilley, 2012). Likewise, experiences of victimization and prejudice among transgender individuals (particularly for ages below 25) are related to high levels of suicidality (Johns et al., 2019). Research has also shown that acculturative stress from both family and society is positively associated with suicidal thoughts and behaviors in Latinx, Asian American, and Black youth (Gomez et al., 2011).

Social Discord

Family discord, conflict, perceived burdensomeness, and lack of positive relationships are strong predictors of suicide risk for Hispanic, Asian American, and Black youth (Garza & Pettit, 2010; Joe et al., 2007; Kuroki & Tilley, 2012). Intergenerational cultural conflict (ICC) is a unique construct associated with family discord, which refers to the gaps between levels of acculturation and cultural values between youth and their parents. This conflict is shown to be a stronger contributing factor to Latinx and Asian American youth’s suicide behaviors in comparison to their White counterparts (Fortuna et al., 2007; Lau et al., 2002). Additionally, family alienation and invalidating familial discourse are related to increased suicidal thoughts and behaviors for LGBTQ+ youth (McBee-Strayer & Rogers, 2002).

Peer rejection, victimization, and bullying are also strongly associated with an increased risk of suicidal behaviors among LGBTQ+ youth with ethnic minority identities (Hatchel et al., 2019a, b). The relationship between peer victimization/bullying and suicidal ideation is mediated by increased feelings of alienation and a reduced sense of school belonging (Lardier et al., 2020).

Three Theoretical Principles for Cultural Suicide Factors

Past research indicates that the four cultural suicide factors - cultural sanctions, idioms of distress, minority stress, and social discord - operate according to the following three theoretical principles. First, culture affects the types of stressors that are related to increased suicidal ideation and behaviors for youth. Second, the cultural meanings (i.e., cultural sanctions) associated with life stressors and suicide affect the development of suicide risk, one’s threshold of tolerance for psychological pain, and potential for suicidal behavior. Third, culture affects how suicidal thoughts and behaviors are expressed. In particular, culture can impact how one expresses their suicidality, such as their choice to disclose or hide their thoughts, as well as what methods they use to make attempts.

Implications

Practice Implications

Given the myriad of ways that suicidal distress can be expressed across cultures, cultural idioms of suicidal distress should be integrated into screening and assessment for symptoms of suicidal ideation, intent, plan, and means. For example, the Cultural Assessment of Risk for Suicide (CARS; Chu et al., 2013) was developed to assess culturally specific suicide risk factors among adults, which is now adapted, but not yet psychometrically validated, for use with adolescents as CARS-A (Khoury, 2020). Furthermore, how youth symptoms are assessed (e.g., interview and self-report), what questions are asked and in what sequence, and how confidentiality concerns and psychoeducation are provided should be carefully considered. Providers need to account for internalized stigma, trust with healthcare systems, different reporting styles, willingness to disclose risk, and unique idioms or expressions of suicidal distress for ethnic, gender, and sexual minority youth. Moreover, risk and protective factors related to minority stress and social discord should be integrated into comprehensive assessment protocols to determine the ultimate suicide risk level for clients, with cultural sanctions/meanings of suicide about stressors and suicide as influential factors that modulate such risk. Together, these factors and principles are important for facilitating recovery through culturally tailored safety plans and treatments with youth and their families.

Research Implications

The four factors and three principles of the Cultural Theory and Model of Suicide for Youth can serve as grounding principles for research across diverse populations. It is important to use evidence-based tools and assessments to ensure consistency across the field and that all individuals are screened appropriately. Studies are needed to further develop and validate culturally adapted suicide risk screening and assessment measures for adolescents, as well as to infuse these cultural factors into adaptations of existing evidence-based protocols. There is also a growing need to validate, adapt, or create suicide prevention programs that are specifically tailored to these factors. Future research is needed to deepen our understanding of the ways in which the cultural factors and principles are experienced in specific cultural groups. This research has particular relevance for cultural minority subgroups who have elevated rates and/or risk for suicide, suicidal ideation, or attempts (e.g., Latinx, Black, Native American/Alaskan Native, and LGBTQ+ youth).

Policy Implications

Suicide prevention strategic plans and safety protocols at the school, county, state, and national level should incorporate culture and diversity (including the four factors and three principles of the Cultural Theory and Model of Suicide for Youth identified in this chapter) as a priority when aiming to reduce youth suicide. For example, policies outlining best practices for suicide prevention efforts should include targeted outreach to specific groups of minoritized youth experiencing family rejection and/or academic stress. Prevention and postvention services in schools should also incorporate minority-specific resources (e.g., The Trevor Project for LGBTQ+ youth). Furthermore, resources that include suicide warning signs should highlight cultural factors (e.g., idioms of distress such as risk-taking behaviors, irritability, or displays of aggression, or minority stress such as feeling targeted or bullied as a minority individual) to promote awareness of specific cues for minority youth suicide risk.

Training and education policies would also benefit from integration with the Cultural Theory and Model of Suicide for Youth. For example, policymakers and administrators should place a strong value on cultural factors as they prioritize suicide-related competencies in mental health graduate education, and state-level licensing requirements that require continuing education in suicide. Otherwise, well-meaning efforts may fall short of meeting the needs of some of our most vulnerable youth and families. Finally, local and national guidelines for suicide safety and treatment should be re-examined from a cultural lens taking into account the factors highlighted throughout this chapter and a willingness to revise or recreate programs.

Conclusions

Evidence, although limited, suggests that a downward extension of the Cultural Theory and Model of Suicide is appropriate for ethnic, gender, and sexual minority youth, with considerations of specific risk factors that may increase their vulnerability to suicidal behaviors. A better understanding about how risk factors such as academic stress, ICC, and peer rejection influence suicide risk can have implications for practice, research, and policy. Routine integration of these cultural risk and protective factors of suicide will help promote cultural responsivity in youth suicide prevention and postvention efforts. Recent efforts to attend to the need for cultural infusion into suicide prevention efforts are evident in printed resources such as the Suicide Prevention Resource Center’s Guidelines for Culturally and Linguistically Responsive Media & Resource Materials or Guidance for Culturally Adapting Gatekeeper Trainings (SPRC, 2017, 2020); however, progress is nascent and in need of dedicated commitment and resources in the field. There is an urgent need to provide additional support for practitioners, researchers, and policymakers to further integrate culture into the valuable work of mitigating youth suicidality.