Therapy
Recent developments in understanding ethnocultural and race differences in trauma exposure and PTSD Anu Asnaani1 and Brittany Hall-Clark2
Our understanding of demographic specifications that put
certain individuals at greater risk for trauma exposure and
subsequent development of post-traumatic stress disorder
(PTSD) has grown significantly over the past few decades. This
brief review specifically examines the studies exploring the
potential influence of ethnocultural and racial group status on
trauma exposure and PTSD, with a focus on findings published
recently in the past five years. We first provide a brief review of
current epidemiological data examining associations among
ethnicity/culture/race and trauma exposure/PTSD. We then
explore a few related constructs (namely, stigma,
acculturation/ethnic identity, and discrimination) in relation to
trauma exposure and PTSD, with a focus on what is currently
known about how these variables are empirically related to one
another.
Addresses 1Department of Psychiatry, Center for the Treatment and Study of
Anxiety, University of Pennsylvania, 3535 Market St., Suite 600N,
Philadelphia, PA 19104, United States 2University of Texas Health Science Center at San Antonio,
United States
Corresponding author: Asnaani, Anu (aasnaani@mail.med.upenn.edu)
Current Opinion in Psychology 2017, 14:96–101
This review comes from a themed issue on Traumatic stress
Edited by Anka A. Vujanovic and Paula P. Schnurr
For a complete overview see the Issue and the Editorial
Available online 3rd January 2017
http://dx.doi.org/10.1016/j.copsyc.2016.12.005
2352-250X/ã 2016 Elsevier Ltd. All rights reserved.
Significant efforts have been spent on increasing our
understanding about which treatments work for whom
in the realm of post-traumatic stress disorder (PTSD), and
part of this discourse lies in examining how various
demographic factors, including racial/ethnic/cultural
diversity, influence the effective detection and treatment
of PTSD. This review will focus on the current state of
the literature in this domain, synthesizing recent data to
provide current prevalence estimates of PTSD across
racially diverse groups, and [67_TD$DIFF]will examine the recent
empirical work conducted on several key factors hypoth-
esized to underlie cultural differences in PTSD (i.e., stigma, acculturation, ethnic identity, discrimination).
Table 1 defines terms used throughout this brief review
such as ‘race’, ‘ethnicity’ and ‘culture’.
Racial/ethnic differences in PTSD prevalence There is mixed evidence for the existence of racial/ethnic
differences in PTSD prevalence. This section focuses on
aggregate data, when possible, to aid generalizability.
There have been several rigorous review articles and
national studies. While Hinton and Lewis-Fernandez
[1] concluded that community and Veterans Affairs
(VA) research has yielded few racial/ethnic differences
in PTSD prevalence, there is ample evidence to the
contrary. Among studies that have found racial/ethnic
differences, the literature has generally concluded that
African Americans and Latinos have the highest rates of
PTSD, while Asians have the lowest [2�� [65_TD$DIFF],3]. Elevated rates of PTSD have also been observed among Native
Americans and American Indians relative to Whites and
other minority racial/ethnic groups [4], although data is
limited. However, it is unclear whether Latinos or Blacks
present with the highest rates of PTSD when compared
to each other, with some earlier studies finding slightly
higher rates of probable lifetime PTSD in African Amer-
icans, even after accounting for trauma exposure [3,5��] and sociodemographic, clinical, and social support factors
[6].
Racial/ethnic variations in PTSD prevalence among
veterans have also received some attention in the last
5 years, reflecting the impact of long-standing
Afghanistan and Iraq conflicts. However, the literature
could be more informative if larger studies of veterans
would report on presence or absence racial/ethnic differ-
ences and provide details on such differences. Echoing
the findings in national and civilian samples, one smaller
study (N = 236) found that fewer Asian American veterans
met screening criteria for PTSD compared to Native
Hawaiian/Pacific Islander, European American, African
American, and Latino American veterans [7]. However, in
contrast to previous findings, no other minority veteran
groups differed significantly from their European Ameri-
can counterparts on prevalence of PTSD. In a treatment-
seeking active duty sample of 303 service members, Hall-
Clark et al. [8] found that Hispanic/Latino and African
American service members reported more re-experienc-
ing symptoms, more fear, and more guilt/numbing than
White participants. Some larger studies reference racial/
ethnic differences, but do not explain symptom-level
patterns observed within the data, limiting interpretation.
In a larger study (N = 765), Fortney et al. [9] found that
Available online at www.sciencedirect.com
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Current Opinion in Psychology 2017, 14:96–101 www.sciencedirect.com
students were more likely to screen positively for PTSD
relative to non-veterans, but not significantly so when
adjusting for age, gender, and race/ethnicity. However,
the authors did not provide details of racial/ethnic preva-
lence rates. Similarly, a recent national study indicated
that female veterans relying on VA for their treatment are
more likely to screen positive for PTSD than males or
non-VA-using female veterans and are more likely to be
racial/ethnic minorities [10].
Methodological variations in assessment of traumatic
events likely contribute to such mixed findings in the
literature. Researchers classify traumatic events differ-
ently, with some using broader categories (e.g., [5��] used six categories) and others using more specific categories
(e.g., [6] used 11 different categories: combat, political
violence, victimization, among others). Some researchers
report ethnicity, others race, and still others report both,
or combine terms. Given the role of trauma exposure in
racial/ethnic differences, it is important to consider how
geographical, political, and regional influences result in
different types of trauma. Some general patterns have
been observed in this respect. Specifically, Roberts et al.
[5��] noted that while Whites endorsed higher exposure
to trauma overall relative to ethnoracial minorities, PTSD
tended to develop more often in racial/ethnic minorities,
which may reflect differences in the types of trauma
racial/ethnic minorities experienced. For example, Afri-
can Americans have been found to report more interper-
sonal trauma, violence (i.e., homicide, physical assault,
rape), and combat exposure compared to non-Hispanic
Whites, which is possibly related to lower socioeconomic
status [5��,6]. Asians tend to endorse more exposure to
political violence, higher rates of war-related events, and
are more likely to have been a refugee or civilian in a war
zone [5��,6], which could reflect patterns of immigration
to the U.S. to escape from volatile environments in their
countries of origin. Whites may be more likely to learn
about trauma of loved ones or unexpected death, experi-
ence unwanted sex, neglect, emotional/verbal abuse,
accidents, and injuries relative to Asians, African
Americans, and Latinos [5��]. Additionally, Whites are
more likely to experience loss than Latinos and Asians,
but experience similar levels of loss compared to African
Americans [6].
Scholars have also noted the role of cultural factors, such
as norms related to symptom disclosure, reporting style,
cultural interpretations of symptoms and distress, and
coping styles [1,7,11,12�], all of which can influence
findings of racial/ethnic differences in PTSD. In addi-
tion, Hinton and Lewis-Fernandez [1] noted that the
salience of avoidance and numbing symptoms tends to
vary culturally, and these symptoms in particular may be
more affected by behavior and attitudes, as opposed
to the biological manifestations of re-experiencing
and hyperarousal. Overall, the field would benefit from
consensus in the categorization of traumatic events
and racial/ethnic reporting conventions consonant
with how participants identify racially and ethnically.
In addition, attending to cultural differences within
racial/ethnic groups may also disentangle these inconsis-
tent findings.
Relevant cultural factors Stigma
The role of stigma as a major barrier to endorsement of
PTSD symptoms and treatment-seeking behaviors in
minority populations has been the subject of considerable
discussion in minority mental health, well-documented
elsewhere [13,14]. Relevant to the current review, previ-
ous studies have found that type of trauma may affect
willingness to disclose trauma exposure in prevalence
studies; for instance, Latinos may be more willing to
report exposure to large-scale traumas versus events that
are more individual or personal [15]. Others have
explored culturally-specific social constructs that may
create stigma in ethnic minority groups by impeding
willingness to disclose or discuss reactions to trauma such
as caballerismo and machismo (Latino cultural beliefs
regarding roles of males in society to protect others and
to have pride or honor in roles; [16]), or the concept of
Ethnicity, culture & race in PTSD Asnaani and Hall-Clark 97
Table 1
Definitions of frequently-used terminology in the discussion of race and ethnic differences in PTSD
Term Definition
Race Phenotypical characteristics, such as skin color or hair [46]
Ethnicity A group that shares cultural traditions, language, customs, values, beliefs, attitudes, and practices [46]
Culture Social groups that share specific or homogenous attributes and values/practices [47]
Latinx An alternative term that is sensitive to Latinos/as who identify as gay/lesbian or gender fluid [30]
Acculturation Efforts made by immigrants in order to integrate and adjust to life in their new countries of residence [48]
Ethnic identity An individual’s self-concept in reference tomembership in an ethnic group, one that is itself defined by a shared set of cultural
and historical norms, behaviors, and value systems [49]
Stigma In the context of mental health, the belief that mental health symptoms are indications of weakness, shameful, abnormal, or
even morally deficient in some way [14]
Discrimination Differential treatment of members of a particular demographic group caused by negative attitudes or feelings about that
minority group [50]
www.sciencedirect.com Current Opinion in Psychology 2017, 14:96–101
‘John Henryism’ in African Americans which stresses
determination and hard work in order to resolve life
stressors [17]. Similarly, Asian American cultural groups
have been shown to place greater stock in one’s ability to
exercise self-control or use intellectualization in order to
deal with negative internal mental states rather than
expressing how one feels (for an example: [18]).
Each of these constructs and culturally-informed coping
styles has a number of positive elements, but in PTSD
they can be problematic in terms of impeding disclosure
and expression of PTSD symptoms in these ethnic
minority groups. There is increasing focus on addressing
stigma as a potential barrier within the context of
PTSD and other trauma-related mental health sequelae
for the growing number of refugees in first-world
countries, who have high rates of trauma exposure but
appear hesitant to disclose such symptoms in their new
host countries in some studies (e.g., [19,20]). On the
other hand, others have found no such occurrence of
stigma in a range of refugee groups arriving in the U.S.
(i.e., [21]).
The majority of other stigma-related work has con-
cerned the impact of stigma on treatment-seeking for
PTSD within military (e.g., [22]), HIV-positive (e.g., [23]) and sexual minority (e.g., [24]) populations, all of which are comprised of a significant number of ethnic/
racial minorities. The current literature suggests that
use of better, more integrated detection measures for
PTSD [19] and stigma (e.g., [25]), consideration of online
interventions for PTSD [26], and other efforts to
improve access to care for a greater diversity of patients
stigmatized by PTSD [27–29], are needed to more
systematically study stigma (and subsequent interven-
tions to decrease it).
Acculturation and ethnic identity
Given that cultural values such as familism and spiritual-
ity may influence the expression of PTSD and coping in
response to traumatic events, several researchers have
investigated the relationship of ethnocultural identity or
acculturation with PTSD symptoms. In the past five
years, the acculturation literature has focused on Latino
populations, women, and youth and adolescents with
PTSD [3,12�,30–34]. There has been mixed evidence
regarding the role of acculturation in racial/ethnic differ-
ences in PTSD [2��,3]. For example, a review by Alcán-
tara et al. [3] examining conditional risk of PTSD among
Latinos found one study suggesting that U.S.-born Lati-
nos were more at-risk, another study suggesting that
Spanish-speakers were more at-risk, and a third failed
to find any significant correlation between acculturation
status and PTSD. Another recent study [35] also did not
find an association between acculturation and PTSD
symptoms. It is important to note that acculturation
was operationalized as language preference or nativity.
Studies that use bi-dimensional acculturation identity
measures may yield more conclusive results.
Age appears to be an important variable to consider within
the context of acculturation in trauma survivors. Specifi-
cally, one study found that acculturation significantly
moderated the relationship between timing of the worst
traumatic event and PTSD symptoms. Specifically, those
with the lowest levels of acculturation who reported that
their worst traumatic event occurred during childhood
endorsed the highest number of PTSD symptoms [31]. In
addition, others found that acculturation was a significant
moderator for African American adolescents exposed to a
wildfire, but not for Whites [36]. Several authors have
noted that acculturation, through increased exposure to
American culture, may facilitate trauma disclosure, access
to care [31], effective social support networks, and cul-
tural competence [33]. Researchers have also considered
mechanisms by which trauma may be transmitted
through generations such as parental coping to traumatic
stressors (or lack thereof). and prenatal exposure to lower
cortisol levels in pregnant women with PTSD which
could result in lower cortisol (and consequently higher
vulnerability to anxiety and stress caused by a compro-
mised stress response) in newborn infants [34]. It is
unclear whether acculturation may be a more significant
factor for adolescents as compared to adults, or whether
researchers are more prone to examine acculturation
during adolescence, which is a formative stage of identity.
In adults, a recent study found that, in sexual minority
female immigrants, acculturation was not significantly
associated with PTSD after controlling for age, education,
& income [30]. Future research could directly compare
the role of acculturation in PTSD among adolescent
versus adult populations.
Discrimination
Discrimination is intrinsically more frequently reported
by minority or marginalized groups in any society, and
within the context of PTSD specifically, blatant acts of
discrimination (e.g., actually being assaulted due to one’s
race) have been highlighted as potential sources of imme-
diate or eventual post-traumatic stress in minority groups
[37]. Further, large epidemiological studies (e.g., [15,38]) suggest that not only do racial minority groups (particu-
larly African Americans) experience more discrimination,
but also that higher levels of perceived discrimination are
associated with more likely PTSD diagnosis or greater
severity of PTSD. Other previous empirical studies also
found evidence for higher rates of hypervigilance and
PTSD-associated emotions such as guilt, shame, and low
self-worth in ethnic/racial minorities experiencing direct
discrimination based on race [39].
In the past several years, there have been continued
efforts to study discrimination and its role in the devel-
opment and perpetuation of PTSD and other
98 Traumatic stress
Current Opinion in Psychology 2017, 14:96–101 www.sciencedirect.com
psychopathology following a traumatic event. For
instance, one study found that in women reporting greater
experiences of discrimination, PTSD predicted greater
alcohol abuse [40�], echoing another study finding the
same pattern in Latino students [41]. Another study
found that perceived discrimination (in combination with
other adverse childhood experiences) contributed signifi-
cantly to PTSD symptoms in a large sample of Native
Americans living on reservations [42]. Others have con-
sistently found similar patterns for deleterious effects of
discrimination on mental health outcomes in both trau-
matized ethnoracial [30,43��] and sexual minorities
[44,45]. Taken together, the current literature suggests
that the role of perceived discrimination based on one’s
minority status in perpetuating and maintaining PTSD
and other mental health sequelae of trauma is not trivial
for multiple ethnic or racial minority groups. The con-
struct of discrimination therefore deserves more attention
in interventions for trauma-exposed minorities.
Conclusion This brief review highlights what is currently known
about PTSD prevalence rates across racial/ethnic minor-
ity groups, and how associated cultural factors may impact
the endorsement and development of PTSD symptoms.
Indeed, recent empirical data in the past 5 years suggests
that in the U.S., African Americans, Latino Americans and
Native Americans tend to present with the highest rates
of PTSD, while Asian Americans tend to present with the
lowest. Consideration of phenomena such as stigma,
acculturation, and discrimination is important when pre-
dicting and interpreting the typical expression of specific
PTSD symptoms in various ethnic minority groups. Fur-
thermore, these factors each have implications for the
subsequent treatment of PTSD in minorities, such as the
format of therapy (e.g., online interventions to overcome
stigma) or the content explored within the context of
therapy (e.g., discussing discrimination explicitly).
Conflict of interest statement Nothing declared.
Acknowledgement The authors express their sincerest appreciation to Hallie Tannahill, who assisted with the formatting of this manuscript in preparation for its submission.
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