PTSD: National Center for PTSD
PTSD Among Ethnic Minority Veterans
PTSD Among Ethnic Minority Veterans
Studies of ethnic minority Veterans have helped us understand how race and ethnicity relate to PTSD. In particular, ethnic minority Vietnam Veterans, through their participation in surveys, research studies, and clinical case studies, have made a major contribution toward our understanding of PTSD in these special populations.
Are there differences in rates of PTSD among ethnic minorities and whites?
Researchers have conducted various studies of PTSD in ethnic minority Vietnam Veteran populations. The results of the studies are not entirely consistent, but the overall finding seems to be that most ethnic minority Veteran groups have a higher rate of PTSD than White Veterans. Some of this may be due to psychological conflicts related to identification with the Vietnamese. Another factor may be higher exposure to war zone stressors.
The different findings across various studies may be because of differences in the samples, use of different measures, or differences in whether the interviewer and participant were racially paired. Ethnic minority Veterans may be more likely to disclose problems or engage in treatment when paired with a clinician of the same race (1). Despite study differences, the trend suggests that being an ethnic minority may cause one to be more "at risk" for PTSD.
The National Vietnam Veterans Readjustment Study found differences among Hispanic, African American, and White Vietnam theater Veterans in terms of readjustment after military service (2). Both Hispanic and African American male Vietnam theater Veterans had higher rates of PTSD than Whites. Rates of current PTSD in the 1990 study were 28% among Hispanics, 21% among African Americans, and 14% among Whites (2).
African Americans had greater exposure to war stresses and had more predisposing factors than Whites, which appeared to account for their higher rate of PTSD. After controlling for these factors, the differences in PTSD rates between Whites and African Americans largely disappeared. On the other hand, the difference in rates of PTSD between Hispanics and Whites remained even after controlling for the fact that Hispanics had greater exposure to war stresses (2).
Rates of PTSD among American Indian Vietnam Veterans ranged from 22% to 25% (depending on the tribe) (3). American Indians were exposed to greater war zone stresses (e.g., atrocities, violence, and combat) than Whites, including psychological conflict resulting from identification with the enemy. Differences in PTSD rates between American Indians and Whites disappeared after controlling for the greater war zone stresses experienced by American Indians. Clinical case studies of African American and American Indian Veterans described psychological tension and ambivalence because the African American and American Indian participants associated the condition of the Vietnamese with that of their own people (4-5).
The rates of current PTSD were lower among Native Hawaiian Vietnam Veterans (12%) and Japanese Americans (2%) than the 14% current prevalence seen for Whites (6). However, lifetime prevalence rates for PTSD were higher among all ethnic minority Veteran samples, except for Japanese Americans, than among Whites. Between 45% and 57% of the American Indian Vietnam Veterans had PTSD for lifetime events, 43% of the African Americans suffered from PTSD associated with lifetime events, 39% of the Hispanic Vietnam Veterans suffered from lifetime PTSD, and 38% of Native Hawaiian Vietnam Veterans suffered from lifetime PTSD, compared to 24% of the Whites and 9% of the Japanese Americans(2-3,6).
The experience of the Japanese Americans does not appear to be the experience of other Asian American Pacific Islander Vietnam Veterans. Clinical case studies of Vietnam Veterans of Asian American Pacific Islander ancestry describe ethnic-related stresses associated with racially looking like the enemy. These Veterans also experienced psychological conflicts that arose because they personally identified with the Vietnamese as persons of the same race (7-8). In a survey of Asian American Pacific Islander Vietnam Veterans, a majority felt they were similar or very similar to the Vietnamese in terms of physical characteristics, felt they were mistaken for Vietnamese, felt their ethnicity affected how others perceived them as soldiers, and felt their ethnicity affected how the Vietnamese people treated them (9). Native Hawaiians had a higher PTSD prevalence rate than Chinese Americans, who had a higher rate than Japanese Americans.
A study of Chinese, Filipino, Korean, Japanese, Hawaiian, Chamorro, and Asian-mixed race Vietnam Veterans found that 37% suffered from PTSD, using the Mississippi Scale as the measure of PTSD (10). This percentage was within the range of what had been found for African Americans, Hispanics, Native Americans, and Native Hawaiians in other studies using this same measure.
Can negative race-related events cause PTSD in Veterans who look like the enemy?
A study of Asian American Pacific Islander Vietnam Veterans found that race-related stressors were an important predictor of PTSD symptoms. This effect was found over what was accounted for by combat exposure and military rank. Thus, even after controlling for combat exposure, the effect of exposure to race-related stressors on PTSD symptomatology was strong and statistically significant (10). Race-related events included being shot at by fellow Americans when mistaken for the enemy; being harassed and physically injured because one was perceived as resembling or symbolizing the enemy; or being reminded of family members, relatives, or friends when seeing a Vietnamese who was alive, wounded, or killed (11).
Race-related stressors and personal experiences of racial prejudice or stigmatization are potent risk factors for PTSD, as is bicultural identification and conflict when one ethnically identifies with civilians who suffered from the impact or abuses of war (10). Asian American Pacific Islanders fighting a war in Asia may be at greater risk for developing PTSD symptoms or other psychiatric distress due to exposure to negative race-related events. Ethnic minority Veterans of the same race as the enemy can be exposed to life- threatening events that are related to being stigmatized or targeted as the enemy.
How does this relate to mental health service professionals' responsibility to ethnic minorities?
Several writers have pointed out that clinicians who work with minority Veterans need to understand the additional complications these Veterans may have experienced (5,8,12,13). Being an ethnic minority in the military may increase stresses and stress reactions. It is therefore important for VA clinicians to assess what the experience of being an ethnic minority was like for that particular Veteran. By only assessing for combat exposure, a VA clinician may miss some important aspects of the Veteran's problem. In fact, research has revealed that failure to assess race-related stressor experiences of Asian American Pacific Islander Veterans could result in missing as much as 20% of the Veteran's PTSD symptoms (10). As VA clinicians, it is our professional responsibility to make sure that we are assessing and treating the full range of problems faced by ethnic minority Veterans.
Professional responsibility in providing appropriate services to ethnic minority Veterans also applies to Compensation and Pensions examinations. If clinicians do not evaluate for negative race-related events that may have led to psychiatric problems, the ethnic minority Veteran may not be receiving the appropriate disability rating or compensation. Thus, it behooves VA clinicians to be particularly attentive to examining possible race, ethnic, or cultural issues among ethnic minority Veterans.
Making use of validated measures of race-related stressors (10) and having a conceptual framework by which to understand and interview ethnic minority Veterans (14) are steps toward assuring that we are assessing for stressors related to ethnicity, culture, or race. Some clinicians have stressed the importance of developing guidelines for assessing and treating ethnic issues associated with PTSD and military service. Using ethnically relevant measures to screen for PTSD is important because it advances the cultural-based competence level of practitioners who work with ethnic minorities.
Because racial pairing of clinician and Veteran has been shown to enhance length of treatment (1), efforts toward recruiting clinicians of ethnic minority backgrounds become important. This will afford the ethnic minority Veteran the choice of a same-race clinician, should the Veteran prefer this option. Furthermore, since some have suggested that ethnic minorities may not use VA facilities or mental health services commensurate with their need, outreach to minority Veterans and specialized treatment that addresses the special needs of American minority Veterans are important (13). Higher treatment drop-out rates among ethnic minority Veterans suggest that we may not be fulfilling our mission to serve minority Veterans in the fullest way possible. We need to be particularly alert to avoiding such problems in service delivery.
For more information, see additional fact sheets in our section on effects of War.
- Rosenheck, R. A., Fontana, A, & Cottol, C. (1995). Effect of clinician-Veteran racial pairing in the treatment of posttraumatic stress disorder. American Journal of Psychiatry, 152 (4), 555-563.
- Kulka, R.A., Schlenger, W.A., Fairbanks, J.A., Hough, R.L., Jordan, B.K., Marmar, C.R.,... Cranston, A.S. (1990). Trauma and the Vietnam War generation: Report of findings from the National Vietnam Veterans Readjustment Study. New York: Brunner/Mazel. 503-520.
- Beals, J., Manson, S.M., Shore, J.H., Friedman, M., Ashcraft, M., Fairbank, J.A., et al. (2002). The prevalence of posttraumatic stress disorder among American Indian Vietnam veterans: Disparities and context. Journal of Traumatic Stress, 15, 89-97.
- Holm, T. (1992). Statistics and data: The National Survey of Indian Vietnam Veterans. In Report of the Working Group on American Indian Vietnam Era Veterans (pp. 25-34). Washington, DC: Readjustment Counseling Service, Department of Veterans Affairs.
- Parson, E.R. (1984). The gook-identification and post-traumatic stress disorder. Black Psychiatrist of American Quarterly, 25, 65- 85.
- National Center for American Indian and Alaska Native Mental Health Research and National Center for Post-Traumatic Stress Disorder. (1997). Matsunaga Vietnam Veterans Project: Final report. White River Junction, VT: National Center for PTSD.
- Kiang, P. (1991). About face: Recognizing Asian and Pacific American Vietnam veterans in Asian American Studies. Amerasia Journal, 17 , 22-40.
- Loo, C.M. (1994). Race-related trauma and PTSD: The Asian American Vietnam veteran. Journal of Traumatic Stress, 7, 1-20.
- Matsuoka, J., Hamada, R., Kilauano, W. & Coalson, R. (1992). Asian-Pacific American Vietnam veterans: An exploratory study of wartime experiences and post-war adjustment. Journal of Multicultural Social Work. 2, 103-111.
- Loo, C. M., Fairbank, J.A., Scurfield, R.M., Ruch, L.O., King, D.W., Adams, L., et al. (2001). Measuring exposure to racism: Development and validation of a race-related stressor scale (RRSS) for Asian American Vietnam veterans. Psychological Assessment, 13, 503-520.
- Loo, C.M. & Kiang, P. N. (2003). Race-related stressors and psychological trauma: Contributions of Asian American Vietnam veterans. In L. Zhan (Ed.), Asian Americans: Vulnerable populations, model interventions, and clarifying agendas (pp. 19-42). Sudbury, MA: Jones and Bartlett Publishers, Inc.
- Hamada, R., Chemtob, C. M., Sautner, R., & Sato, R. (1988). Ethnic identity and Vietnam: A Japanese-American Vietnam veteran with PTSD. Hawaii Medical Journal, 47, 100-109.
- Penk, W. E. & Allen, I. M. (1991). Clinical assessment of post-traumatic stress disorder (PTSD) among American minorities who served in Vietnam. Journal of Traumatic Stress, 4, 41-66.
- Loo, C. M., Singh, K., Scurfield, R., & Kilauano, B. (1998). Race-related stress among Asian American veterans: A model to enhance diagnosis and treatment. Cultural Diversity and Mental Health, 4, 75-90.