30 Suicide and attempted suicide among indigenous people

There are hundreds of indigenous groups and peoples around the world. Examples are the Australian Aborigines, the North American Indians (Native Americans) of the US and Canada, and the Maori of New Zealand. Such groups and peoples often have elevated suicide rates compared with the general population in their countries, and divergent epidemiological characteristics. Adoption of culture-specific prevention strategies in countries where indigenous peoples live is proposed and discussed.

There is no internationally accepted definition of ‘indigenous peoples’. However, Sims and Kuhnlein (2003) cite several key characteristics used (but not adopted) by United Nations' bodies and other agencies to distinguish indigenous peoples:

The hundreds of indigenous groups all over the world are often referred to by local and regional names. Examples are the Aborigines of Australia and the North American Indians (Native Americans and Canadians), or ‘first peoples’ and ‘first nations’ as they are also called, of the US and Canada. Although widely known as the world's ‘first peoples’, they nevertheless lack territorial, economic and political autonomy. Many people attribute this to colonization and ever accelerating modernization and cultural globalization (Ray 1996; Bartholomew 2004).

Indigenous people's physical and mental health and social indicators are often less favourable than those of other inhabitants of the same areas (Clelland et al. 2007). This may indicate a vulnerability to suicidal impulses. On the basis of data taken from the WHO, it was concluded that indigenous people are among the highest risk groups for suicide in the world today (WHO 2002; Leenars 2006).

Below, suicides and attempted suicides among selected indigenous groups around the world are reviewed. Risk and protective factors are described, as are the preventive measures being taken in these societies.

Indigenous people in various parts of Canada comprise of the ‘First Nations’ or ‘Inuits’. There were approximately 45,070 Inuits living in Canada in 2001. The majority live in remote communities spread across two provinces and two territories, in four distinct regions (Advisory Group on Suicide Prevention 2002):

As Figure 30.1 shows, Inuits from three distinctive regions had higher suicide rates than non-indigenous Canadians in 2002. Inuits from the Inuvialuit region were an exception, with a rate (18/100,000) that was very much lower than those of their counterparts in the other regions, and only slightly higher than that of non-indigenous Canadians (Advisory Group on Suicide Prevention 2002).

A study conducted by Chandler and Lalonde (1998) showed that suicide rates among Inuit tribes vary greatly. For some, suicide rates exceed 600/100,000; for others, it is as low as approximately 10/100,000. It may be useful to examine why some tribes have such extremely high suicide rates while others have rates as low as, or even lower than, Canada's mean national suicide rate.

Scant data on hospitalization due to self-inflicted harm in Inuit communities are reported. Statistics on emergency medical consultations in Alberta show that in the year 2000, the rate of hospitalization for attempted suicide among the First Nations was 6.74 times higher than that among other ethnic groups in the Canadian population (Alberta Centre for Injury Control and Research 2005).

Greenland has some of the highest suicide rates in the world (Leineweber et al. 2001). According to Leineweber (2000), people born in Greenland are regarded as ‘Inuit’ or ‘Natives’. Of the country's 56,000 inhabitants, 89 per cent were born there, i.e. Inuits make up the vast majority of Greenland's inhabitants (Bjerregaard and Curtis 2002).

Suicide rates vary widely from one region of Greenland to another (Henderson 2003). Although suicide attempts are not well documented in Greenland, a study conducted by Grove and Lynge (1979) showed that the rate of attempted suicide among the Greenland Inuits was approximately 100/100,000. This does not differ substantially from rates in, for example, Europe or North America.

Alaska has the highest percentage of indigenous people in the US (Barnhardt 2001). The ethnic group often referred to as ‘Alaska Natives’ includes the Inputiat, Yupik and Aluet people. Alaska Natives make up 16.4 per cent of the total Alaskan population; together, they and the American Indians account for 25 per cent (Barnhardt 2001).

Alaska Natives' suicide rates are some five to six times the overall US rate, and two to three times the Alaskan rate for all deaths by suicide. Although they make up only 16.4 per cent of the Alaskan population, Alaska Natives account for 39 per cent of suicides in the state (Alaska Injury Prevention Center 2006).

The regions in the north and west of Alaska—North Slope, Northwest Arctic, Nome and Yukon-Kuskokwim (Y-K) Delta—where the majority of the population are Inupiats (‘Eskimos’) have the state's highest suicide rates. In contrast, the south-eastern regions, with an Aleutian majority, have the lowest rates (Alaska Injury Prevention Center 2006).

This relationship seems, however, to be age-dependent. Perkins (2005) reported that there were fewer suicide attempts among Alaska Natives than Caucasians in 2001–2002. This is true of suicide attempters aged 19 and over who were hospitalized for attempted suicide in Alaska: 40 per cent were Natives and 50 per cent were Caucasians. On the other hand, the corresponding figures for adolescent suicide attempters (aged 18 and below) were 55 per cent Native and 40 per cent Caucasian. Other statistics show that in 1994–99 too, the rate of attempted suicide among Alaska Natives aged below 19 was, at 157/100,000, far higher than their white counterparts' rate, which was 38/100,000 (Alaska Department of Health and Social Service 2003).

There are currently over 560 federally recognized American Indian (Native American) tribes living in urban and rural communities around the US (Olson and Wahab 2006). American Indians and Alaska Natives, the largest indigenous groups in the US, have the highest mortality rates. In Alaska, the Natives' mortality rates were 60 per cent higher than those in the US white population in 1989–1998. Alaska Natives had significantly elevated mortality rates due to cancer, cerebrovascular disease, diabetes, chronic obstructive pulmonary disease and suicide (Day and Lanier 2003).

The suicide rate for American Indians and Alaska Natives combined is 31/100,000, which is twice the rate in the non-Hispanic white population (15/100,000) and more than three times the rates of African Americans and Hispanics (National Adolescent Health Information Center 2006).

Metha and Webb (1996) report wide variation among the various tribes' suicide rates, ranging from a low of 6/100,000 among Chippewa Indians (mostly located in Minnesota, Wisconsin and Michigan) to a high of 130/100,000 among the Blackfeet (who are nomadic and dispersed across the United States).

The Navajo are the largest American Indian tribe in the US, with the majority of the population residing in New Mexico and Arizona. The Comanche live in Oklahoma and Texas, and Athabascans are the largest group, with some 12,000 members in Alaska (American Indian Heritage Foundation 2005). These tribes show considerable differences in suicide rates. The Athabascans in Alaska, for example, have a suicide rate of 41.9/100,000, while the Navajos in Arizona have a rate of 16/100,000, and the Comanche living in Oklahoma have a rate 11.9/100,000. The overall American Indian rate is 73 per cent higher than the US as a whole (Indian Health Service 2004; American Indian Heritage Foundation 2005).

Approximately 6.2 per cent of American Indian youth between the ages of 12 and 17 attempt suicide, compared with 3.7 per cent of Hispanics, 3.4 per cent of Caucasians, and 2.4 per cent of African Americans. The incidence of suicidal ideation for these age groups is 8.6 per cent for American Indian youth, 6.3 per cent for Hispanics, 8.1 per cent for Caucasians and 4.8 per cent for African Americans respectively (Youth Violence Prevention Center 2003).

Indigenous people in Australia, known as ‘Aborigines’ (a term that includes both Aboriginal people and Torres Strait Islanders), make up 2.5 per cent of the country's population. Suicide was fairly rare in Aboriginal society until the late 1960s, and in the 1970s there was a noticeable increase in suicide and suicidal behaviour. Today, studies have shown that Aboriginals have a significantly higher rate of suicide and attempted suicide than non-Aboriginals in Australia (Elliot-Farrelly 2004).

The data demonstrate that suicide rates are much higher among Aboriginal males than non-Aboriginal males across all age groups, except 40–44 and 50–54. In the 40–44 age group, Aboriginal males have only half the suicide rate of non-Aboriginals, while the rate in the 50–54 age group is slightly lower than among non-Aboriginals. Aboriginal males aged 15–19 have a suicide rate some 4 times higher than non-Aboriginals (Harrison et al. 1997).

Data from the Australian Bureau of Statistic show that, in 1999–2003, there were twice as many suicides among Aboriginal males than among non-indigenous males in Australia, and the male rate was more than three times higher for the age groups below 34 years (Australian Institute for Health and Welfare 2005). Females below the age of 24 had a suicide rate 5 times higher than that of non-indigenous females. However, for those aged 35 years and over, Aboriginal females' rates were similar to, or even lower than, their non-indigenous female counterparts (Australian Institute for Health and Welfare 2005). One study showed that in the Northern Territory between 1981 and 2002, suicide rates rose in both the indigenous and the non-indigenous male population, by 800 per cent and 30 per cent, respectively (Measey et al. 2006).

Helps and Harrison (2006) report that, among males and females alike, suicide attempts are significantly more frequent among indigenous groups than among other Australians.

In 2001, Maori people made up nearly 15 per cent of the total New Zealand population (Ministry of Health 2006). Suicide rates among Maori aged 15–24 years had risen since 1957, reaching 35.2/100,000 for men and 6.0/100,000 for women in 1987–91. These high rates were similar to those of young non-Maori New Zealanders (Skegg et al. 1995).

Of the various ethnic groups, the Maori had the highest suicide rate for all ages, at 17.8 per 100,000, in the years 2000–2003. Other ethnic groups, such as European, Pacific and Asian, had rates of 13.1, 10.4 and 8.8 respectively during this period (Ministry of Health 2006).

Over a 24-year span, the frequency of suicide attempts among Maori people has been consistently higher than among their compatriots of European, Pacific and Asian origin. At the end of 2003, Maori people had an attempted-suicide rate of more than 200/100,000, whereas Asians had the lowest rate, approximately 60/100,000 (Ministry of Health 2006). One study showed that suicidal ideation was greater among Maori than non-Maori people, but after adjustment for sociodemographic variables Maori and non-Maori people were found to have similar rates of suicidal ideation (Beautrais et al. 2006).

Little is known about indigenous groups and suicide in remote and restricted areas in Brazil, Siberia and Taiwan, for example.

The indigenous peoples in the state of Mato Grosso do Sul in the south-west corner of Brazil are known as ‘Guaraní’. The Guaraní make up 2.6 per cent of the Mato Grosso do Sul's population (Coloma et al. 2006).

Coloma, Hoffman and Crosby (2006) conducted a longitudinal study on suicides in 2000–2005 among Guaraní clans in the state of Mato Grosso do Sul. Their findings showed that suicide rates among the Guaraní were 121.5/100,000 in 2000 and 113.2/100,000 in 2005 for males, and 63.7/100,000 and 59.1/100,000 respectively among females. In 2005 the overall suicide rate among the Guaraní was 86.3/100,000, which was approximately 10 times the overall rate in Mato Grosso do Sul and 19 times the Brazilian national rate. In the 20–29 age group in 2005, Guaraní suicide rates were 159.9/100,000, and people aged 30 years and under accounted for 85 per cent of the suicides.

Data on suicidal behaviour among the indigenous groups residing in Siberia are also somewhat limited. Two areas of eastern Siberia, the republic of Buryatia and the Chita region, had a suicide rate of approximately 60/100,000 in 2001, and Krasnoyarsk territory had a suicide rate of some 52/100,000 (Andreeva 2005). Lester (2006) reports that some indigenous groups, such as the Gilyak in south-east Siberia and the Chukchee, Koryak and Kamchadal in north-east Siberia, have relatively high suicide rates. The Chukchee and Gilyak have high suicide rates even in comparison with other indigenous groups around the world (Lester 2006).

In Taiwan, there are nine indigenous tribes, with a combined population of approximately 330,000, accounting for 1.5 per cent of the total Taiwanese population (Wen et al. 2004). Very little is known about the indigenous peoples and suicide in this region. One study has found that suicide mortality among the indigenous population is two to three times greater than the general population in Taiwan. The disparity is even greater among females, whose suicide mortality is three to eight times higher than that of the general population. The study also shows that of the 212 female Aboriginals investigated, 20.3 per cent had suicidal ideation (Yang and Yang 2000).

Indigenous groups throughout the world appear to have higher suicide and attempted-suicide rates than the general population in their respective societies. Hunter and Harvey (2002) discuss colonization as a factor contributing to the elevated suicide rates. The process of colonization throughout the world pushed indigenous people out of their territories into remote areas where they now have less access to health care, social welfare and education.

Bjerregaard and Curtis (2002) discuss the role of rapid societal development caused by colonization and globalization; how people cope with loss or change of cultural identity; and how indigenous groups can become integrated in modern society.

Studies have also revealed universal risk factors that can be detected in many indigenous groups. Examples are high poverty rates, low education, unemployment and substance abuse (Advisory Group on Suicide Prevention 2002).

Risk factors for suicide and attempted suicide among indigenous people, as in the general population, include substance abuse by individuals or their parents, depression, somatic diseases, physical or sexual abuse, family and relationship problems, emotional problems, gang involvement, gun availability and prior suicide attempts. These factors have been identified among American Indian and Alaska Native (Inupiat) groups (Borowsky et al. 1999; Wexler and Goodwin 2006).

Aboriginal people in Australia and Maori in New Zealand, too, show similar characteristics which boost the risk for suicide and attempted suicide: lack of a sense of purpose in life, a lack of recognized role models, disintegration of the family, lack of support networks, sexual assault, psychological distress, prior suicide attempts, socially and/or educationally disadvantaged backgrounds, substance abuse and alienation (Coupe 2001; Elliot-Farrelly 2004).

Protective factors have also been studied, and have proved valuable as a basis for interventions and reducing risks for suicidal behaviour.

One study conducted on the First Nations in Canada (Advisory Group on Suicide Prevention 2002) identified the following protective factors: self-government and access to land, education, health care and cultural facilities.

Other studies have also identified certain protective factors that reduce risk for suicide and attempted suicide (Kirmayer et al. 1996; Pharris et al. 1997; Coupe 2001). These include a history of receiving treatment for psychiatric problems, frequent church attendance, a high level of academic achievement, family attention and supportive networks, the degree of caring displayed by the family, good models in adults and tribal leaders, enjoyment of school, involvement in traditional activities, coping skills, high self-esteem, a sense of belonging through family and/or school connections, and cultural identity.

In the US, Canada, Greenland, Australia and New Zealand, there are national and regional guidelines, goals and objectives to produce effective suicide-preventive programmes for the indigenous populations of these countries. Many are currently being implemented and have yet to be evaluated. Although there are many obstacles to implementing such interventions—language barriers, cultural differences and even mistrust on the part of the indigenous groups—some studies have implemented minor preventive programmes, with a degree of success (Capp et al. 2001; Echohawk 2006).

Coupe (2000), who drew attention to the fact that suicide is a major issue among the Maori, suggested that application of the present national suicide prevention strategy in New Zealand is somewhat restrictive to the Maori community. However, a culturally specific strategy reflecting suicide trends amongst the Maori now exists in New Zealand (Associate Minister of Health 2006).

Capp et al. (2001) stated that concern about the high suicide rate of Aboriginal people on the south coast of New South Wales had led to the development of a project aimed at preventing youth suicide in the Aboriginal communities of the Shoalhaven region. The main focus was a series of community gatekeeper training workshops, intended to increase the capacity of members of the Aboriginal community to identify and support people at risk of suicide and to facilitate their access to health and social care services (Cantor and Baume 1999). The present suicide-preventive strategy in Australia is adapted to indigenous people's needs.

Overall, suicide interventions should take into consideration the difficulties in intervening in societies with heterogeneous ethnic and cultural backgrounds, languages and values. It is important to involve the tribal leaders in the communities, clergy and schools, and to sustain the indigenous heritage of the region. Involving local tribal leaders and councils, and fostering distinctive protective factors in these communities, as well as reducing risk factors, may enhance the prospects of a suicide intervention proving successful and bringing about a truly significant change.