Protecting our Most Vulnerable: The Suicidality Crisis in Black Children

A Call to Action

In April 2019 the Congressional Black Caucus (CBC) gathered to confront the pressing concern over Black children who were dying by suicide at an unprecedented rate in America.[1] After its meeting, the caucus determined that it was their responsibility to identify this crisis as a Black health emergency, and subsequently built a coalition that has since spent the past four years working towards solutions. 

The suicidality issue amongst young Black Americans initially came as a surprise to the CBC and other researchers within the mental health sector. Historically, the suicide rate within the overall Black community has been lower than that of the national average, particularly in comparison to White Americans.[2] Even between 2021 and 2022 the Center for Disease Control (CDC) recorded 48,183 suicides within the United States, with only 7% of the group identifying as Black American.[3] However, a closer look at suicide trends began to indicate a growing rate in Black children. Price & Khubchandani (2020) analyzed data between 2001 and 2017, discovering that the rate of suicides in young Black men and women increased by 60% and 182%, respectively.[4] They also found that suicide was the second highest cause of death for Black adolescents.[5]

Research conducted by the CDC in 2021 also drew similar conclusions: Black male children aged five to 11 are at risk to the point where they are twice as likely to die by suicide over their White counterparts.[6] Similarly, the Journal of the American Academy of Child & Adolescent Psychiatry analyzed data between 2003 to 2017 and found Black girls between the ages of 15 to 17 had the largest percentage in suicides of all race and gender-based demographics.[7]

Understanding the “Why” behind Black Youth Suicidality

With Black children dying by suicide at such an unprecedented rate, the CBC began to focus on the causes, supposing that each cause would later have an accompanying solution it could implement in order to address this crisis. While all children are vulnerable to bullying, issues with self-identity, and hormonal changes that can cause depression and suicidal ideations, the CBC found that the compounding impacts of trauma, cultural stigmas, and socioeconomic barriers are uniquely faced by Black children. Mathew et al. (2020) found that of children who attempt suicide, having a hostile family environment and perceiving a lack of care from family members within a household have been discovered as contributing factors to suicidal behavior among adolescents and young adults.[8] Black children have the highest likelihood of witnessing home violence, experiencing communal stigmas in response to mental crisis, and enduring distressing racism and discrimination, all of which have the potential to exacerbate their likelihood of not wanting to live.[9,10] In the face of these compounding factors, young Black men often feel a sense of hopeless that is further aggravated by the racism and discrimination they face within society.[11] Black girls also combat the complex intersectionality of race and gender-based discrimination, encountering racism while also having a higher likelihood than their male counterparts of being sexually assaulted. With race and gender-based pressures mounting, young Black women have a singular struggle in overcoming sexual harassment, misogyny, and racism - all of which make them more vulnerable to depression and suicidal ideations.[12]

The Necessity of Support

For all children, familial and community support play pivotal roles in mental health outcomes. A strong support system can serve as a protective factor against suicide, especially for Black children where familial support and communalism are heavily integrated in Black culture.[13] In the absence of a strong support system, children often feel isolated and have a higher likelihood of experiencing depression and/or suicidal ideation.[14] In a 2020 report conducted by the U.S. Department of Health and Human Services, researchers concluded that Black children had a high likelihood of experiencing crisis in the two weeks prior to their death by suicide.[15] Further, nearly 40% of Black youth had a crisis or dispute with a family member, romantic partner, or friend before their death by suicide; 30% of this group had an argument within 24 hours of their death.[16] Within the Black community, providing accessible resources to navigate relationship issues and familial trauma can provide useful support to save a child’s life.

The Trouble in Exhibiting Mental Health Issues

For all children suffering from depression and mental health struggles, early detection and timely treatment are essential to mitigating their symptoms. However, Black children are the most likely to be suspended, expelled, or labeled with “behavioral issues” when they are actually displaying mental health issues. A 2015 study conducted by Okonofua & Eberhart concluded that educators often perceive black students’ behaviors as more problematic and more punishable than those of their White counterparts.[17] This study not only exhibits racial disparities in disciplinary action, but it also points to the isolation Black children face in the midst of a crisis. 

The Lack of Mental Health Intervention

While intervention is key to preventing a child from getting to the point where they attempt suicide, mental health issues remain underdiagnosed and stigmatized within the Black community. In its 2020 report to Congress, the U.S. Department of Health and Human Services identified this contradiction: despite dying by suicide at a faster rate than any other racial/ethnic group, Black youth had lower reported rates of known mental health problems and documented histories of suicidal thoughts or plans. However, the lack of reported rates of mental health issues is not equivalent to these problems being nonexistent for Black children. On the contrary, the low rates of recorded mental health disorders that stand in contrast to the high rates of past suicide attempts suggest that Black youth are still experiencing depression, but they have limited access to mental healthcare and proper treatments. Not only do Black children face barriers to attaining effective mental health resources because of the high cost of therapy, but the American Psychological Association (APA) note the United States has a shortage of culturally-competent therapists across the country.[18] With over 88% of mental health providers identifying as white, young Black children continue to have more difficulty finding therapists that look like them and with whom they can identify.[19]

Mental Health Stigma Within the Black Community

Within the Black community, mental health conditions are not only misunderstood, but many Black adults view mental health conditions as a weakness.[20] As a result, people within this community may face embarrassment about their mental health condition and worry that they may be ostracized if they share how they are struggling with friends or family.[21] This perspective is not only damaging to Black adults, who will often mask their mental health disorders, but also to Black children who are the most vulnerable and often also the most susceptible to being silenced in a time of distress.[22] 

Further, another obstacle for this cohort is that many Black Americans turn to spirituality and a faith-based community rather than seeking a medical diagnosis.[23] While spirituality is a proven source of resiliency for many ethnic minorities and can provide healthy outlets and reduce isolation, it is not always effective or effective enough in crisis.[24] In contrast, children should be encouraged to seek out multiple treatment avenues to ensure the highest chance of recovery from mental illness.

Solutions to the Suicide Crisis 

The CBC concluded that addressing the issue of youth suicide within the Black community demanded a comprehensive approach that continues to consider the complex intersection of mental health, cultural, and socioeconomic factors. They note the following factors are essential to halting the trend of Black children ending their lives:

1. Schools stand at the forefront of community-based care and they can close the gap in mental-health access by offering all students access to affirming environments and well-trained professionals. Unlike mental health care provided by hospitals, mental health professionals in schools have the ability to provide resources and assistance to students without the barriers of insurance and financial security. Schools within a child’s community also have the potential to help a child overcome their mental health challenges with culturally-relevant care.

2. Expanding access to underprivileged communities has the potential to give Black children access to treatment that would otherwise be unavailable. As the American Psychological Association (APA) asserts, telehealth with expanded coverage via the assistance of insurance companies is an equity-based solution that may allow Black children to get the treatment they are seeking.[25]

3. Black researchers must also be given adequate funding and support in order to narrow the knowledge gap that leaves Black-specific illnesses underreported. Research topics proposed by Black scientists are less likely to be funded, leaving profound gaps in the level of understanding that is required to protect Black youths from the unique challenges they face.

In 2019, Congresswomen Coleman and Napolitano led the CBC in proposing the “Pursuing Equity in Mental Health Act.” The act has successfully passed the House of Representatives, and once it is officially enacted it will provide $750 million annually between fiscal years 2024 to 2029 for the National Institute on Minority Health and Health Disparities.[26] The future act will also authorize $150 million dollars to the National Institutes of Health (NIH) to build mental health facilities within Black communities, support clinical research, and work to end racial/ethnic disparities in healthcare.[27]

Ensuring Children Have Hope in their Future

Ultimately, Black children face the unique challenge of navigating their lives at the intersection of race, gender, and sexual orientation all while carrying the basic challenge of simply “being kids”. With societal pressures and feelings of isolation becoming prevalent within the current generation, it is essential for the adults within their lives to make sure that they are protected and supported. Children are a vulnerable population who are not fully capable of self-advocacy, and for this reason the rising suicide rates among Black children necessitates collective action. By addressing the mental health stigma within the Black community, systemic inequalities and cultural factors, American society will build a mental healthcare system where, regardless of their background, all children feel supported and capable of overcoming trauma.

If you or someone you know is struggling with depression, hopelessness and/or suicidal thoughts, please call 911, 988, or go to the closest emergency room. Individuals seeking non-crisis support can also reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and additional resources. 

Contributed by: Kate Campbell

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 Coleman, B.W. (2023). Emergency Task Force on Black Youth Suicide and Mental Health.https://watsoncoleman.house.gov/suicidetaskforce/

2 Kung, K. C., Liu, X., & Juon, H. S. (1998). Risk factors for suicide in Caucasians and in African-Americans: a matched case-control study. Social psychiatry and psychiatric epidemiology, 33(4), 155–161. https://doi.org/10.1007/s001270050038

3 Langston, L. & Truman, J.L. (2014). Socio-Emotional Impact of Violence. Bureau of Justice Statistics. https://bjs.ojp.gov/library/publications/socio-emotional-impact-violent-crime

4 Price, J. H., & Khubchandani, J. (2019). The Changing Characteristics of African-American Adolescent Suicides, 2001-2017. Journal of community health, 44(4), 756–763. https://doi.org/10.1007/s10900-019-00678-x

5 Ibid

6 Meza, J.L., Patel, K., Bath, E. (2022). Black Youth Suicide Crisis: Prevalence Rates, Review of Risk and Protective Factors, and Current Evidence-Based Practices. Focus: The Journal of Lifelong Learning in Psychiatry, 20(2), 197-203. https://doi.org/10.1176/appi.focus.20210034

7 Sheftall, A. H., Vakil, F., Ruch, D. A., Boyd, R. C., Lindsey, M. A., & Bridge, J. A. (2022). Black Youth Suicide: Investigation of Current Trends and Precipitating Circumstances. Journal of the American Academy of Child and Adolescent Psychiatry, 61(5), 662–675. https://doi.org/10.1016/j.jaac.2021.08.021

8 Mathew, A., Saradamma, R., Krishnapillai, V., & Muthubeevi, S. B. (2021). Exploring the Family factors associated with Suicide Attempts among Adolescents and Young Adults: A Qualitative Study. Indian journal of psychological medicine, 43(2), 113–118. https://doi.org/10.1177/0253717620957113

9 Chopra, S. (2022, September 9). Black girls are experiencing record rates of self-injury and death by suicide. https://youthtoday.org/2022/09/black-girls-are-experiencing-record-rates-of-self-injury-and-death-by-suicide/

10 Langston, L. & Truman J.L. (2014)

11 Meza, J.L., Patel, K., Bath, E. (2022)

12 American Academy on Child and Adolescent Psychiatry. (2022) AACAP Policy Statement on Increased Suicide Among Black Youth in the US. https://www.aacap.org/aacap/Policy_Statements/2022/AACAP_Policy_Statement_Increased_Suicide_Among_Black_Youth_US.aspx

13 Langston, L. & Truman, J.L. (2014)

14 Bethune, S. (2022). Increased need for mental health care strains capacity. American Psychological Association (APA). https://www.apa.org/news/press/releases/2022/11/mental-health-care-strains

15 Okonofua, J. A., & Eberhardt, J. L. (2015). Two Strikes: Race and the Disciplining of Young Students. Psychological Science, 26(5), 617–624. https://doi.org/10.1177/0956797615570365

16 Okoya, Wenimo. (2022, March 30). The fight for Black Lives needs to happen in schools. The Hechinger Report. https://hechingerreport.org/opinion-the-fight-for-black-lives-needs-to-happen-in-schools/

17 Okonofua, J.A., & Eberhardt, J.L. (2015)

18 Ward, E. C., Wiltshire, J. C., Detry, M. A., & Brown, R. L. (2013). African American men and women's attitude toward mental illness, perceptions of stigma, and preferred coping behaviors. Nursing research, 62(3), 185–194. https://doi.org/10.1097/NNR.0b013e31827bf533

19 Meza, J.L., Patel, K., Bath, E. (2022)

20 Ibid.

21 Okonofua, J. A., & Eberhardt, J. L. (2015) Nguyen A. W. (2020). 

22 Bethune (2022)

23 Religion and Mental Health in Racial and Ethnic Minority Populations: A Review of the Literature. Innovation in aging, 4(5), https://doi.org/10.1093/geroni/igaa035

24 Ibid.

25 The Mental Health Liaison Group.(2023).  MHLG Letter of Support - Pursuing Equity in Mental Health Act 118th Congress. https://adaa.org/MHLG098402

26 Ibid.

27 Ibid.

Exploring The Psychological Impacts of Pornography

Porn: The Widespread Taboo

Pornography is the most available it has ever been due to online accessibility. Consequently, the more views that pornography accumulates, the increasing amount of societal and psychological consequences people face. This includes, but is not limited to: stereotyping of gender and racial fetishes, sexual violence and misconduct, sex misinformation, content addiction, and sex worker stigmas. Solano et al. (2020) found that among a sample of 1,392 adults in the U.S. (ages 18 to 73), 91.5% of men and 60.2% of women reported that they had engaged in some type of pornography within the past month.[1] Exposure to sexual content seems to be a frequent and inevitable component of being connected to the internet. However, a wave of sexual health research indicates its usage is not inherently negative. Discussions surrounding the psychological impacts of pornography provide insights into how porn can be distributed in healthy ways while also reducing negative consequences. Understanding this research is pivotal in approaching mental health and its relationship with pornography in an exponentially growing online world.

Understanding Pornography

Pornography exists in a variety of forms ranging from written, still imagery, video and auditory content. The Merriam-Webster Dictionary defines pornography as the depiction of erotica for sexual enhancement or excitement.[2] Free online platforms invite higher usage of video content than other forms of porn.[3] Additionally, Solano et al. (2020) found that women are more likely to consume written porn than men.[4] Reasons for pornography usage were researched by Burtăverde et al. (2021), who found that many people seek content for short-term sexual enjoyment and masturbation.[5] Likely due to its increased availability, pornography viewership is also beginning at younger ages; among responses from university students, Biota et al. (2022) found that porn usage began at an average age of 10.4 years, with those partaking primarily out of curiosity.[6] Further, as many students from this study reported feeling that their sex education has been inadequate, this perceived lack of education has likely led to their increased search for sexual information online, through porn.[7] 

Opinions about users of porn, as well as actors, vary by culture and social norms. Societal attitudes about the motivations behind pornographers were studied by Evans-DeCicco & Cowan (2001) in which male performers were perceived as having more positive motivations for partaking in porn production (such as enjoying their work and being at the top of their profession) as opposed to female performers.[8] Female performers were more often than men perceived/stereotyped to come from dysfunctional families, have a lack of employment opportunities and be coerced into the work.[9] Additionally, Perry & Whitehead (2022) point out that in the U.S., the desire for anti-pornography legislation is predicted by Christain nationalism and strict values of sexual order.[10] 

The Neuroscience of Pornography & Addiction

Pornography addiction is not considered a DSM-5 categorized disorder, however, concern exists about the adverse effects of over-watching porn. For instance, Egan & Parmar (2013) note that online porn usage can be reflective of compulsive tendencies in men.[11] Market et al. (2021) also found that for men with higher sexual motivation, attention to pornographic pictures was enhanced but that there were also no connections made with symptoms of cybersex addiction.[12] A study done by Wang et al. (2022) likewise found that people with problematic internet pornography use display higher attention and brain responses to new sexual stimuli, maintaining a cycle of problematic porn consumption when they are presented with more porn.[13] Further, Biota et al. (2022) found that the self-perceived negative effects of pornography use were mainly decreased sexual satisfaction and the need for more stimuli and longer stimulation, suggesting possible reasons for cyclical tendencies.[14]

Behavioral addictions in the brain impair reward systems through the frontal lobes via hyprofrontal syndromes (i.e., cerebral dysfunctions of addiction) leading to compulsivity and flawed judgment;[15] substance abuse, internet gaming disorder, compulsive eating and trauma may change the brain in the same way.[16] More research is warranted for problematic hypersexual tendencies and pornography use, as its general consumption may be completely healthy, while its over-usage may be indicative of compulsive tendencies.

Psychological Effects of Pornography

The sheer variety of porn produced has resulted in a range of negative and positive psychological effects on viewers, reflected in several conflicting pieces of evidence in the research. Since 2016, 17 states have introduced nonbinding resolutions declaring pornography a public health crisis, with concerns ranging from infidelity, addiction and sex trafficking.[17] Conversely, Nelson & Rothman (2020) report that porn, itself, does not meet the criteria for a public health crisis and that it has also been found to increase feelings of acceptance and health-promoting behaviors such as increased intimacy, communication and safer sexual practice.[18]

However, other researchers have found negative psychological and behavioral associations with pornography. In examining the link between porn and body image, Gewirtz-Meydan & Spivak-Lavi (2023) found that increased porn usage related to more body comparisons being made as well as an increase in eating disorder symptoms in men.[19] Additionally, Rostad et al. found that porn exposure is associated with teen dating violence and aggression (with a higher effect in boys than girls),[20] and Kohut, & Štulhofer (2018) note that porn use is associated with low adult quality of life.[21] 

These associations, however, do not imply a causal relationship with porn. Such consideration may be informative of the demographics of porn users, as porn may be used to improve or satisfy already-impaired psychological states.[22] Kohut, & Štulhofer add that controlling for external factors in an individual’s life (such as family environment and impulsiveness) may help us understand what porn actually does to our mental health.[23] While Mollaioli et al. (2021) found that more sexual activity is generally related to better mental health with lower participant depression and anxiety scores,[24] one must be aware that viewing certain portrayals in porn (e.g., flawless body image, condomless sex and violent fetishization), as well as a user’s dispositions may actually result in adverse effects. 

Relationship Function & Dysfunction

Kohut et al., (2021) investigated the notion that pornography use leads to poor relationship quality and satisfaction and found that differences in partner sex drive is what actually accounts for discrepancies in relationship quality.[25] Differences in sex drive can lead to differences in porn usage among partners, which leads to varied perceptions of the relationship and each person’s sexual satisfaction.[26] Further, when respondents were generally less accepting of porn, more porn usage led to lower perceived relationship satisfaction - but when men were more accepting of porn, they indicated higher relationship satisfaction.[27] These findings provide insight into the effects of the meaning that one places on using pornography, and how the stigmatization of its usage infiltrates itself into relationships.

Addressing The Issues

While the topic of sex and pornography is incredibly taboo in most cultures, increased dialogue surrounding the effects of pornography is important to promote mental health and safe porn use. Porn that portrays harmful aspects of society like nonconsent (i.e., assault) is damaging, such as instances where porn is leaked or promoted without the consent of the people involved.[28] Gius (2022) notes these leaks are societally perceived as extremely negative due to sexism and gender inequality, leading to social pressure on the assaulted/exposed individuals and even suicide.[29] 

Hilton & Watts (2011) add that some people argue for all porn usage to be viewed from a public health lens due to factors ranging from stigmatization of sex to addiction research.[30] Others believe that explicit sexual content is inevitable and that while compulsive use can be targeted with treatment, outlawing porn will not alter its use. Reducing life-impairing over-usage of pornography may be achieved through psychotherapeutic methods and Camilleri et al. (2021) found that morals, faith, and individual motivation were the most effective factors in reducing porn use.[31] Historically, since anti-sex views have not taken away sex from people, approaching porn in an open and informed way may help younger generations form healthy practices. 

For adolescents, sex education regarding healthy, consensual sex may help to reduce the harmful effects of mainstream porn content. Consuming online porn is among the many factors for intimate partner violence among young people.[32] Pathmedra et al. (2023) note that adolescent exposure to sexual content has a large role in establishing healthy sexual and romantic relationships - but acknowledge that it also has a role in establishing unhealthy relationships.[33] A conscientious approach to the way that porn is produced would be beneficial regarding the stereotypes and values it projects to its audiences.[34]

Overall, pornography usage is self-perceived as positive among both adolescents[35] and adults.[36] Additionally, an increased amount of people are participating in generating pornography through online platforms (such as OnlyFans), where they can personally capitalize off of content creation more lucratively than many professional productions and mainstream career paths. Further, Toder & Barak-Brandes (2022) examined homosexual WhatsApp exchanges for profit and discussed how it grants users sexual freedom, escaping from paths of porn careers that promote unethical sex.[37] 

Sexual openness and literacy may help to reduce the negative effects of pornography. Biota et al. (2022) stress that since people tend to consume porn at early ages, sex education needs to be tailored so that people can have a normalized understanding of porn and what is healthy.[38] Further, this education may aid in helping people identify what is unethical and ethical in portrayals of sex so that rape culture and violence are not perpetuated by porn. Regarding problematic or compulsive porn usage, Testa et al. (2023) note that promoting media literacy is an effective strategy to use in order to develop greater critical thinking skills, reduce the shame associated with porn, recognize unrealistic productions of sex and interpret the meaning behind what is being viewed, thereby creating healthier choices. In addition, cognitive behavioral therapy (CBT) and mindfulness-based therapies are evidence-based modalities that can help with compulsive porn usage.[39] Many different factors combine to create the negative mental health and societal effects of porn, and these may be generally addressed through open and updated sex perspectives, in addition to conscientiousness surrounding porn production and distribution. 

If one is experiencing problematic pornography consumption that impairs well-being, relationships and/or daily life, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support.

Contributed by: Phoebe Elliott

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 Solano, I., Eaton, N. R., & O'Leary, K. D. (2020). Pornography Consumption, Modality and Function in a Large Internet Sample. Journal of sex research, 57(1), 92–103. https://doi.org/10.1080/00224499.2018.1532488 

2 Merriam-Webster. (n.d.). Pornography. In Merriam-Webster.com dictionary. Retrieved July 3, 2023, from https://www.merriam-webster.com/dictionary/pornography 

3 Ibid.

4 Ibid.

5 Burtăverde, V., Jonason, P. K., Giosan, C., & Ene, C. (2021). Why Do People Watch Porn? An Evolutionary Perspective on the Reasons for Pornography Consumption. Evolutionary Psychology, 19(2). https://doi.org/10.1177/14747049211028798

6 Biota, I., Dosil-Santamaria, M., Mondragon, N.I., Ozamiz-Etxebarria, N. (2022). Analyzing University Students' Perceptions Regarding Mainstream Pornography and Its Link to SDG5. Int J Environ Res Public Health. Jun 30;19(13):8055. doi: 10.3390/ijerph19138055. PMID: 35805712; PMCID: PMC9265877.

7 Ibid. 

8 Evans-DeCicco, Jennee & Cowan, Gloria. (2001). Attitudes Toward Pornography and the Characteristics Attributed to Pornography Actors. Sex Roles. 44. 351-361. 10.1023/A:1010985817751.  

9 Ibid.

10 Perry, S. L., & Whitehead, A. L. (2022). Porn as a threat to the mythic social order: Christian nationalism, anti-pornography legislation, and fear of pornography as a public menace. Sociological Quarterly, 63(2), 316-336. doi:10.1080/00380253.2020.1822220 

11 Egan, V., & Parmar, R. (2013). Dirty habits? Online pornography use, personality, obsessionality, and compulsivity. Journal of sex & marital therapy, 39(5), 394–409. https://doi.org/10.1080/0092623X.2012.710182

12 Markert, C., Baranowski, A. M., Koch, S., Stark, R., & Strahler, J. (2021). The impact of negative mood on event-related potentials when viewing pornographic pictures. Frontiers in Psychology, 12 doi:10.3389/fpsyg.2021.673023

13 Wang, J., Chen, Y., & Zhang, H. (2022). Electrophysiological evidence of enhanced processing of novel pornographic images in individuals with tendencies toward problematic internet pornography use. Frontiers in Human Neuroscience, 16 doi:10.3389/fnhum.2022.897536 

14 Biota et al. (2022)

15 Hilton DL, Watts C. Pornography addiction: A neuroscience perspective. Surg Neurol Int. 2011 Feb 21;2:19. doi: 10.4103/2152-7806.76977. PMID: 21427788; PMCID: PMC3050060.

16 Ibid.

17 Nelson, K. M., & Rothman, E. F. (2020). Should Public Health Professionals Consider Pornography a Public Health Crisis?. American journal of public health, 110(2), 151–153. https://doi.org/10.2105/AJPH.2019.305498

18 Ibid.

19 Gewirtz-Meydan, A., & Spivak-Lavi, Z. (2023). The association between problematic pornography use and eating disorder symptoms among heterosexual and sexual minority men. Body Image, 45, 284-295. doi:10.1016/j.bodyim.2023.03.008

20 Rostad et al. (2019)

21 Kohut, T., & Štulhofer, A. (2018). Is pornography use a risk for adolescent well-being? An examination of temporal relationships in two independent panel samples. PloS one, 13(8), e0202048. https://doi.org/10.1371/journal.pone.0202048 

22 Ibid.

23 Ibid.

24 Mollaioli, D., Sansone, A., Ciocca, G., Limoncin, E., Colonnello, E., Di Lorenzo, G., & Jannini, E. A. (2021). Benefits of Sexual Activity on Psychological, Relational, and Sexual Health During the COVID-19 Breakout. The journal of sexual medicine, 18(1), 35–49. https://doi.org/10.1016/j.jsxm.2020.10.008

25 Kohut, T., Dobson, K. A., Balzarini, R. N., Rogge, R. D., Shaw, A. M., McNulty, J. K., Russell, V. M., Fisher, W. A., & Campbell, L. (2021). But What's Your Partner Up to? Associations Between Relationship Quality and Pornography Use Depend on Contextual Patterns of Use Within the Couple. Frontiers in psychology, 12, 661347. https://doi.org/10.3389/fpsyg.2021.661347 

26 Ibid.

27 Maas, M. K., Vasilenko, S. A., & Willoughby, B. J. (2018). A Dyadic Approach to Pornography Use and Relationship Satisfaction Among Heterosexual Couples: The Role of Pornography Acceptance and Anxious Attachment. Journal of sex research, 55(6), 772–782. https://doi.org/10.1080/00224499.2018.1440281

28 Gius, C. (2022). Addressing the blurred question of ‘responsibility’: Insights from online news comments on a case of nonconsensual pornography. Journal of Gender Studies, 31(2), 193-203. doi:10.1080/09589236.2021.1892610 

29 Ibid.

30 Hilton & Watts (2011)

31 Camilleri, C., Perry, J. T., & Sammut, S. (2021). Compulsive Internet Pornography Use and Mental Health: A Cross-Sectional Study in a Sample of University Students in the United States. Frontiers in Psychology, 11, Article 613244. https://doi.org/10.3389/fpsyg.2020.613244

32 Barter, C., Lanau, A., Stanley, N., Aghtaie, N., & Överlien, C. (2022). Factors associated with the perpetration of interpersonal violence and abuse in young people’s intimate relationships. Journal of Youth Studies, 25(5), 547-563. doi:10.1080/13676261.2021.1910223

33 Pathmendra, P., Raggatt, M., Lim, M. S. C., Marino, J. L., & Skinner, S. R. (2023). Exposure to pornography and adolescent sexual behavior: Systematic review. Journal of Medical Internet Research, 25 doi:10.2196/43116

34 Ibid. 

35 Dwulit, A. D., & Rzymski, P. (2019). Prevalence, Patterns and Self-Perceived Effects of Pornography Consumption in Polish University Students: A Cross-Sectional Study. International journal of environmental research and public health, 16(10), 1861. https://doi.org/10.3390/ijerph16101861

36 Hald, G.M., Malamuth, N.M. Self-Perceived Effects of Pornography Consumption. Arch Sex Behav 37, 614–625 (2008). https://doi.org/10.1007/s10508-007-9212-1

37 Toder, N., & Barak-Brandes, S. (2022). A booty of booties: Men accumulating capital by homosocial porn exchange on WhatsApp. Porn Studies, 9(2), 145-158. doi:10.1080/23268743.2021.1947880  

38 Biota et al. (2022)

39 Testa, G., Mestre-Bach, G., Chiclana Actis, C., & Potenza, M. N. (2023). Problematic pornography use in adolescents: From prevention to intervention. Current Addiction Reports, 10(2), 210-218. doi:10.1007/s40429-023-00469-4  

Autism Diagnosis & Treatment: Understanding Racial Disparities

Diagnostic Symptoms & Patterns 

Autism Spectrum Disorder (ASD) is a neurological developmental disability that causes individuals to have lifelong difficulties in communication, interpretation and behavior. ASD is most commonly referred to as a developmental disorder because symptoms first appear within the first two years of a person’s life.[1] Commonly observed ASD symptoms within a child’s first 24 months include:[2]

- Limited social interaction (avoiding eye contact, disinterest in interactive games)

- Repetitive behaviors (playing with the same toy, having obsessive interests) 

-Delayed language and/mobility 

-Mood or emotional reactions that deviate from the norm

-High comorbidity with anxiety, depression, and attention-deficit hyperactivity disorder (ADHD)

As a spectrum disorder, it is common to see different combinations and severities of ASD symptoms in each diagnosed person. Regardless of which symptoms manifest in a person, treatment typically still has the potential to effectively mitigate some of ASD’s long-term challenges. With proper intervention and therapy, adults with ASD are often capable of achieving significant autonomy and social integration.[3] But, early detection is crucial. The American Academy of Pediatrics recommends that all children receive “well-child visits” (including screening for autism) at 18 and 24 month appointments; the sooner a child with symptoms receives an accurate screening, the sooner they are able to begin effective intervention and treatment.[4] Through assessment methods such as observation, blood tests and interactive tests, the accuracy of ASD assessments continues to improve - thus improving the odds of developmental and social progress in children with ASD.[5] 

In 2023, there was a groundbreaking shift in autism diagnosis statistics: for the first year in U.S. history, Black and Hispanic youth were diagnosed at a higher rate than their White counterparts.[6] This comes after decades of underrepresentation of autism in minority populations. However, understanding racial differences in access, culture and environment among marginalized communities provides insight into the progress required to see continual improvements in ASD disparities.

Early Assumptions 

When Leo Kanner first published his observations in 1943, he referred to this condition as “early infantile autism” and asserted that it occurred most often in children belonging to White middle and upper-class families.[7] Unfortunately, Kanner overlooked the reality that the parents who could typically seek help regarding their child’s developmental problems were likely those with resources, privilege and access to appropriate healthcare. In the 1940s those parents were almost exclusively White, and decades later White children continue to have disproportionate access to autism treatment and resources.[8,9] Research from the Center for Disease Control (CDC) has since established that ASD has no disposition toward a particular ethnic group, so factors other than biological differences contribute to White American children receiving the quickest and most frequent ASD diagnosis of all socioeconomic groups.[10] 

ASD in Black Children

According to a 2017 study conducted by the American Journal of Public Health, Black children are 19 percent less likely than their White counterparts to receive an autism diagnosis.[11] Similarly to other health disparities in America, high poverty rates and limited access to treatment facilities contribute to autism’s underdiagnosis in Black Americans. Research continues to identify racism as one of the greatest determinants in a person’s long-term health.[12] It is estimated that Black Americans live four years less than their White counterparts from compounding issues that contribute to a poorer quality of life (e.g., Black Americans are under-represented in higher income jobs and have a disproportionately high rate of chronic diseases in comparison to their White counterparts).[13] 

Addressing this socioeconomic gap is crucial to improving Black Americans’ ASD diagnosis. Research conducted between 2002 and 2010 on the prevalence of autism in White, Black and Hispanic children found autism diagnosis was higher in high socioeconomic Black Americans than their counterparts. Therefore, diminishing socioeconomic differences is key to improving ASD diagnosis for all Black Americans, who remain the demographic with the lowest average annual income in America.[14,15] 

Diagnosis issues also tend to arise when Black families seek autism treatment facilities with concerns. The majority of school documentation of ASD children identifies the child’s history as “bad behavior” instead of a developmental disorder.[16] A 2007 study conducted at the University of Pennsylvania found that Black children with ASD are 5.1 times more likely to be misdiagnosed with behavior disorders before they are correctly diagnosed with autism.[17] Another 2007 study found that African-American children were 5.1 times more likely than White children to receive a diagnosis of adjustment disorder, and 2.4 times more likely to receive a diagnosis of conduct disorder.[18] 

Racist stigmas labeling Black children as rude, unruly, and aggressive also extends to teachers. A 2020 American Psychological Association study on 178 prospective teachers across universities in southeastern states revealed that the majority of teachers within the study inaccurately observed anger in both genders of Black children at higher rates than of White children. The implications of this study extend to autism: teachers and other school administrators (e.g., school psychologists) play an instrumental role in referring children for further behavioral assessments.[19]

ASD in Hispanic Children

In past decades, Hispanic children were diagnosed at an average 65% lower rate than their White counterparts.[20] Recent strides in autism awareness within the Hispanic community have contributed to their improvements in ASD diagnosis, but there are still improvements to make in resources, treatment accessibility and awareness. Similarly to Black children, Latino children often have delayed diagnoses caused by low socioeconomic standings and limited accessibility to treatment and resources.

Spanish is also the second highest primary language spoken in the U.S, and is a factor that has been identified as both a barrier to identifying ASD and a communication challenge between parents and healthcare providers. In a 2004 study by Shapiro et al. 16 young, low-income Hispanic mothers described feelings of “alienation” in their interactions with healthcare providers.[21] The mothers described how information was not always explained enough and if a translator is not present, they felt as though they missed a lot of information.[22] Another study conducted in 2016 by Steinberg et al. found that Spanish-speaking parents are often asked less about their developmental concerns even if their child is known to be at risk, and have reported trouble connecting with providers because they are treated as though they lack knowledge.[23] These experiences not only dissuade parents from asking questions, but also intensify a caregiver’s skepticism, as families with limited English proficiency report less trust in providers compared to English proficient families.[24]

Emerging solutions to disparities in ASD diagnosis/treatment

There are growing resources available to help families from underrepresented communities better understand and identify ASD in their children, aiding in diagnosis and treatment and help close these racial disparities. 

• The Autism Society of Los Angeles (ASLA) runs a hotline at (424) 299-1531 to help parents navigate the diagnosis and healthcare landscape. This organization also offers services in English and Spanish, providing families the resources they need without a financial burden.[25]

• The Children's Hospital, Los Angeles employs liaisons to connect families to further assessment, locate other treatment facilities and gain general support. This hospital is physically located in Los Angeles, and it also provides a virtual autism assessment that can be accessed at: https://chla.purview.net/patient/start.

• “Autism in Black” is a non-profit that aims to provide support to black parents who have a child on the spectrum, through educational and advocacy services like podcasts, free consultations and  hosting outreach events to better educate local communities. Managed by licensed mental health providers, “Autism in Black” is grounded in a mission to improve awareness of and reduce the stigma associated with ASD in the Black community.[26]

• The Center for Disease Control (CDC) has a “Learn the Signs. Act Early.” program that provides free resources in English and Spanish to monitor children’s development starting at 2 months of age. Additionally, by downloading the CDC’s free Milestone Tracker mobile app, caregivers can log and monitor their child’s behavior to later share with healthcare providers.[27]

Community-based Intervention for ASD

JAMA Pediatrics (2022) conducted analysis of decades of autism studies and found that compounding factors increase the likelihood of early morbidity for individuals with autism in comparison to the general population as well as for minorities in comparison to their White counterparts.[28] Under this consideration, marginalized individuals with ASD are uniquely vulnerable to compounding issues related to how they must navigate the world due to their racial identity and neurodivergence (e.g., non-verbal communication, self-harming, and dependence on a caretaker).[29]

 People of color have a higher likelihood of limited availability of treatment centers, fewer services provided by Medicare providers, and of belonging to a lower socioeconomic group.[30] Equal access to healthcare is the foundation for children with mental disabilities to find the resources and treatment plans that will enable them to not only survive but also reach their full. With Hispanic people comprising both the largest minority population in the United States and the majority of the 25 million people in the United States with limited English proficiency, healthcare must continue to make adjustments in order to ensure that ASD is not only diagnosed accurately for this population, but healthcare providers also need to ensure that this demographic continues to feel supported as they navigate this complex condition.[31] Similarly, Black Americans continue to face the greatest discrimination of any group in America, and improving access to timely quality ASD treatment is crucial.[32]

As a growing pediatric concern, ASD was found to occur in 1-in-125 children in 2018 only to triple to 1-in-36 in 2023.[33] As the ASD population increases and the conversation shifts towards finding the resources to assist individuals on the spectrum better integrate into their communities, understanding the health disparities that affect progress is paramount. By diminishing the barriers to affordable and accessible care for marginalized communities, autism advocates will continue to become better equipped to serve the diverse population of individuals with ASD.

Help and support are available: If you or someone you know is struggling to obtain an ASD diagnosis and/or treatment, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support.

Contributed by: Kate Campbell

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 National Institutes of Health. Autism Spectrum Disorder. National Institute of Health Website. Updated 2023. Accessed June 12, 2023.  https://www.nimh.nih.gov/health/topics/autism-spectrum-disorders-asd

2 Centers for Disease Control and Prevention. Signs and Symptoms of Autism of Spectrum Disorder. Centers for Disease Control and Prevention Website. Updated March 28, 2022. Accessed June 12, 2023. https://www.cdc.gov/ncbddd/autism/signs.html

3 Whiteley, P., Carr, K., & Shattock, P. (2019). Is Autism Inborn And Lifelong For Everyone?. Neuropsychiatric disease and treatment, 15, 2885–2891. https://doi.org/10.2147/NDT.S221901

4 Durkin, M. S., Maenner, M. J., Baio, J., Christensen, D., Daniels, J., Fitzgerald, R., Imm, P., Lee, L. C., Schieve, L. A., Van Naarden Braun, K., Wingate, M. S., & Yeargin-Allsopp, M. (2017). Autism Spectrum Disorder Among US Children (2002-2010): Socioeconomic, Racial, and Ethnic Disparities. American journal of public health, 107(11), 1818–1826. https://doi.org/10.2105/AJPH.2017.304032

5 Ibid.

6 Centers for Disease Control and Prevention. Autism Prevalence Higher, According to Data from 11 ADDM Communities. Centers for Disease Control and Prevention Website Updated March 23, 2023. Accessed June 10, 2023. 

7 Rosen, N. E., Lord, C., & Volkmar, F. R. (2021). The Diagnosis of Autism: From Kanner to DSM-III to DSM-5 and Beyond. Journal of autism and developmental disorders, 51(12), 4253–4270. https://doi.org/10.1007/s10803-021-04904-1

8 American Psychiatric Association. (2023). New Research Points to Disparities in Autism Prevalence and Access to Care. Last updated April 23, 2023. Accessed June 20, 2023. https://www.psychiatry.org/news-room/apa-blogs/disparities-in-autism-prevalence-and-access

9 Mandell, D.S., Listerud, J., Levy, S.E., Pinto-Martin, J.A. (2002). Race Differences in the Age at Diagnosis Among Medicaid-Eligible Children with Autism. Journal of Child & Adolescent Psychiatry, 41(12), 1447-1453. https://doi.org/10.1097/00004583-200212000-00016.

10 Centers for Disease Control and Prevention. Spotlight on Closing the Racial and Ethnic Gaps in the Identification of Autism Spectrum Disorder among 8-year-old-Children. Centers for Disease Control and Prevention Website. Last updated March 23, 2023. Accessed June 23, 2023. https://www.cdc.gov/ncbddd/autism/addm-community-report/spotlight-on-closing-racial-gaps.html

11 Ibid.

12 Paradies, Y., Ben, J., Denson, N., Elias, A., Priest, N., Pieterse, A., Gupta, A., Kelaher, M., & Gee, G. (2015). Racism as a Determinant of Health: A Systematic Review and Meta-Analysis. PloS one, 10(9), e0138511. https://doi.org/10.1371/journal.pone.0138511

13 Price, J. H., Khubchandani, J., McKinney, M., & Braun, R. (2013). Racial/ethnic disparities in chronic diseases of youths and access to healthcare in the United States. BioMed research international, 2013, 787616. https://doi.org/10.1155/2013/787616

14 Mehta, N. K., Lee, H., & Ylitalo, K. R. (2013). Child health in the United States: recent trends in racial/ethnic disparities. Social science & medicine (1982), 95, 6–15. https://doi.org/10.1016/j.socscimed.2012.09.011

15 The Urban Institute.(2009). Racial and Ethnic Disparities among Low-Income Families [Fact sheet]. https://www.urban.org/sites/default/files/publication/32976/411936-racial-and-ethnic-disparities-among-low-income-families.pdf

16 Mandell, D. S., Ittenbach, R. F., Levy, S. E., & Pinto-Martin, J. A. (2007). Disparities in diagnoses received prior to a diagnosis of autism spectrum disorder. Journal of autism and developmental disorders, 37(9), 1795–1802. https://doi.org/10.1007/s10803-006-0314-8

17 Halberstadt, A. G., Cooke, A. N., Garner, P. W., Hughes, S. A., Oertwig, D., & Neupert, S. D. (2022). Racialized emotion recognition accuracy and anger bias of children’s faces. Emotion, 22(3), 403–417. https://doi.org/10.1037/emo0000756

18 Ibid.

19 Centers for Disease Control and Prevention. Spotlight on Closing the Racial and Ethnic Gaps in the Identification of Autism Spectrum Disorder among 8-year-old-Children. Centers for Disease Control and Prevention Website. Last updated March 23, 2023. Accessed June 23, 2023. https://www.cdc.gov/ncbddd/autism/addm-community-report/spotlight-on-closing-racial-gaps.html

20 Shapiro, J., Monzó, L. D., Rueda, R., Gomez, J. A., & Blacher, J. (2004). Alienated advocacy: perspectives of Latina mothers of young adults with developmental disabilities on service systems. Mental retardation, 42(1), 37–54. https://doi.org/10.1352/0047-6765(2004)42<37:AAPOLM>2.0.CO;2

21 Ibid.

22 Steinberg, E. M., Valenzuela-Araujo, D., Zickafoose, J. S., Kieffer, E., & DeCamp, L. R. (2016). The "Battle" of Managing Language Barriers in Health Care. Clinical pediatrics, 55(14), 1318–1327. https://doi.org/10.1177/0009922816629760

23 Ibid.

24 Warm Line. (2021). Autism Society of Los Angeles. https://www.autismla.org/1/program/speaker-series/

25 Advocacy, Education, and Support. (2023). Autism in Black. https://www.autisminblack.org/

26 About CDC’s Learn the Signs. Act Early. Program. (2023). Centers for Disease Control and Prevention. https://www.cdc.gov/ncbddd/wicguide/about-cdcs-learn-the-signs-act-early-program.html

27 Ferrán, C. L., Hutton, B., Page, M.L., Driver, J.A., Ridao, M., Arroyo, A.A., Valencia, A., Saint-Gerons, D.M.,Tabarés-Seisdedos, R. (2022). Mortality in Persons With Autism Spectrum Disorder or Attention-Deficit/Hyperactivity Disorder. JAMA Pediatr, 176(4), e216401. https://doi.org/10.1001/jamapediatrics.2021.6401

28 Ibid.

29 Ibid.

30 Steinberg, E. M., Valenzuela-Araujo, D., Zickafoose, J. S., Kieffer, E., & DeCamp, L. R. (2016). The "Battle" of Managing Language Barriers in Health Care. Clinical pediatrics, 55(14), 1318–1327. https://doi.org/10.1177/0009922816629760

31 Dietrich, S., Hernandez, E. (2022). What Languages Do We Speak in the United States? United States Census Bureau Website. Last updated December 06, 2022. Accessed June 27, 2023.

32 The Texas Politics Project. Most Discriminated Group (April 2022). The Texas Politics Project at the University of Texas at Austin Website. https://texaspolitics.utexas.edu/set/most-discriminated-group-april-2022

33 Centers for Disease Control and Prevention. Data and Statistics on Autism Spectrum Disorder, Centers for Disease Control and Prevention Website. Last updated April 4, 2023. Accessed June 25, 2023.

Mental Health Representation in Television & Film

Mental Health & Our Relationship With Film

As the television and film industry has expanded over the past century, filmmakers have increasingly turned to crafting the most sensational stories to bring in money at the box office.[1] Because television portrayals of atypical or dangerous characters have proven especially lucrative, American films often portray mental illness in ways that emphasize or exaggerate the otherness of characters.[2] Thus, severe mental illness has become overrepresented in film: filmmakers prefer the utility of mental illnesses such as antisocial personality disorder, dissociative identity disorder (DID), and schizophrenia in developing mass appeal narratives with "sensational" stories, effectively erasing more invisible mental illnesses such as social phobias and anxiety.[3,4] In fact, in a study of 60 top-grossing films, schizophrenia and DID were found to be distortedly overrepresented in comparison to their relative rarity in the real world.[5] In exaggerating the prevalence of severe mental illness, films can influence viewers to begin seeing such sensational stories as the reality of mental illness around them.

Our experience with film is not confined to the theater. Whether a passenger on the metro brings to mind a character from Netflix, or an office we visit is reminiscent of a movie scene, the media we consume is incorporated into our daily realities. "Film dominates the environment of the viewer, who interacts with the film psychophysically," writes film researcher O'Hara (2019).[6] Our immediate experience with a film is physical and visceral, experiencing emotions as sensations.[7] Subsequently, this hyperrealism within film can blur the lines between fiction and reality, a "mystification" causing us to incorporate flawed and even harmful representations into our understanding of certain groups and conditions.[8] 

Riles et al. (2021) find that routine exposure to popular messages, themes, and associations in film can influence viewers' judgment to make less systematic processing of content.[9] Riles (2020) explains this phenomenon: according to media priming theory, when a disparaging message is presented frequently, that message becomes more accessible in the mind of the viewer when encountering an individual meeting the criteria of that message via the availability heuristic.[10] Quintero Johnson & Riles (2018) add that mass media depictions can shape viewers' mental schema and enhance the accessibility of those schema, influencing their subsequent evaluations and behaviors.[11] With American films grossing more than 10 billion dollars USD at the box office annually, and with streaming services bringing film into our homes, media consumption has become one of the main pathways to expose Americans to these potentially harmful mass messages.[12] 

As many Americans use media as their primary source of information about mental illness, the exaggerated exposure perpetuates stigma towards disorders that are already misunderstood: recall of disparaging messages about mental illness when encountering individuals with mental illness is strongest when this message is "vividly" and "exaggeratedly" portrayed.[13] According to exemplification theory, representations of mental illness that are most extreme are also the most cognitively accessible.[14] In fact, vivid exposure to negative portrayals of mental illness is associated with stereotypical and stigmatizing perceptions of mental illness, less positive attitudes, and heightened social distance preferences towards people with mental illness.[15-17] These effects are widespread; a study by Quintero Johnson & Riles (2018) found that weekly television use predicted disproportionately higher estimates of the prevalence of both general and severe mental illness.[18] While the National Institute for Mental Health (NIMH) reports an 18.6% incidence of mental illness at any given time, participants estimated an incidence of 31%—close to twice as high.[19] Even worse were participants' estimates for severe mental illness. While the NIMH reports 4.1% of the population having serious mental illness, participants estimated that 14.7% of the population has severe illness—well over three times as high—and that 46% of those with mental illness are dangerous.[20] With television broadcasting highly dramatized caricatures of people with mental illness, viewers are incorporating those stereotypes into their conceptions of the population around them and perpetuating stigma towards mental illness. 

Prevalence of Othering Stereotypes

In addition to exaggeration, media representations can serve to alienate people with mental illness by using negatively charged, imprecise language and representations, such as using the word "crazy" to conflate different mental illnesses with one another.[21] In fact, in Quintero Johnson & Riles' (2018) study, a significant number of participants wrote "he acted like a crazy person" when asked to describe the characteristics and conditions of mentally ill media characters, noting abnormal speech patterns and unkempt or dirty appearances.[22] Such stigmatizing conceptions are othering towards people with mental illness and perpetuate their marginalization within society. As discussed by O'Hara (2019), films such as The Fisher King (1991) banish the mentally ill to the basement and other fringes of society, a depiction of behavioral and psychological disturbance as "craziness" and "monstrosity" that ostracizes this group.[23] Notions of mental illness as "craziness" can even cast doubt on the efficacy of therapy: Byrne (1997) discusses how stereotypes of psychiatrists, themselves, as "crazy" and ineffectual can parallel references to patients as "simple idiots" and "loonies."[24] In fact, Quintero Johnson & Riles (2018) found a negative association between television viewing and perceived benefits of talking to a mental health therapist.[25] 

Stereotypes of mental illness as incurable and all-consuming can also serve to alienate therapists and patients. Byrne (1997) discusses a second film stereotype of psychiatrists as "pitiable good fellows" trying to "cure the incurable," paralleling patient stereotypes as "poor wretches who cannot cope with life's adversities."[26] By casting a lens of pity and futility onto the realm of mental illness, films distance viewers from patients. Representations of mental illness disproportionately depict patients excessively struggling and participating in risky behaviors to cope, with muted success with dealing with their pressures in life.[27] In a study by Riles et al. (2021), 48% of mentally ill characters were depicted crying, 10% had their struggles diminished by others, and 5% attempted suicide, while 33% drank alcohol and 24% smoked cigarettes.[28] Such depictions perpetuate stereotypes of those with mental illness as weak and lacking willpower, or even as a lost cause. This can alienate viewers with mental illness and lead them to see these unhealthy coping representations as the only possible solutions or end results.[29] 

Overrepresentation of Violence and Danger

Another side to the misrepresentation of people with mental illness as less able to engage in healthy living and adversity management is the overrepresentation of characters as erratic, violent, and dangerous.[30] Doing so similarly discredits people with mental illness from social acceptance: in a survey of families of people with mental illness and their perceptions of what causes stigma, 86.6% blamed "popular movies about mentally ill killers."[31] This blame is not unfounded: a study by Quintero Johnson & Riles (2018) found that 72% of mentally ill television characters hurt or killed other characters and were ten times more likely to commit violent crime than other characters, despite the relatively low actual risk of violence among this population.[32-34] Riles et al. (2021) similarly found that 70% of characters with mental illness were associated with physical aggression, 55% with verbal aggression, and 12% with sexual aggression.[35] 

According to stigma theory, the "association of a particular social identity with physical or social threats and abnormalities is a potent means through which that identity can be disqualified from social acceptance."[36] With the media showcasing mental illness as synonymous with increased violence and danger, viewers begin to associate mental illness with fear and criminality. Especially with news reports tending to focus on the most sensational stories, reporting individuals with schizophrenia involved with major violent crimes, public attitudes towards people with mental illness are shifted towards greater preference for social distance.[37] Quintero Johnson & Riles (2018) corroborate this finding, discussing how when behaviors of a target character are labeled as mental illness, college students' perceptions about the dangerousness of and their desire for social distance from that person increase.[38] The lack of differentiation between psychotic (losing touch with reality) and psychopathic (exhibiting abnormal or violent social behavior) mental illness in popular media contributes to this desire for social distance, as people with mental illness are grouped into a single stereotype of violence.[39,40] 

Horror films are particularly notorious for crude and sensationalized depictions of mental illness as monstrous. Films as early as The Maniac Cook in 1909 and The Cabinet of Dr. Caligari in 1920 have held inaccurate and stigmatizing representations of psychosis, depicting mental health environments as cruel, prison-like Victorian institutions and their inhabitants as grotesque creatures and villains.[41] A study of 55 horror feature films made between 2000 and 2012 by Goodwin (2013) finds that similar stereotypes persist in films featuring psychosis today.[42] A troubling 78.78% of the films studied included the stereotype of a "homicidal maniac," while 72.73% featured "pathetic and sad characters" and 12.12% treated patients as "zoo specimens."[43] An additional 66.67% of films studied commonly used glass imagery to showcase fragility or a split personality, an othering depiction of a "whole self" that the patients have "lost."[44] Other stereotypes can be dismissive of the gravity of mental illness. These include horror films where harmless eccentricity is labeled as mental illness and inappropriately treated, in addition to 18.18% of films studied where supposedly delusional people were in fact telling the truth.[45] Such characterizations of mental illness can be misleading, dismissing the legitimacy of psychosis and its capacity to make its patients lose touch with reality. 

In addition to othering patients with mental illness, horror films can be highly stigmatizing towards mental health care professionals and institutions, further dissuading people from seeking treatment. In Goodwin's (2013) study, 51.11% of films featured dangerous hospital staff tackling clients with batons and tasers, along with 64.44% using some kind of restraint such as a straitjacket or chaining clients to a wall.[46] 37.77% of films included a stereotype of an evil doctor or nurse, and 35.55% involved boundary violations by the therapist in treating their patient. Within the mental health setting itself, 57.77% of films also included dirty and unhygienic environments, while 53.33% included haunted or supernatural hospitals patients needed to escape from. Harmful stereotypes also abound toward neurosurgery and biological psychiatric treatments in horror films, casting them as primitive tools that block creativity and intelligence; 28.89% of films studied included negative depictions of electroconvulsive therapy and lobotomies.[47] Such representations can be extremely harmful given the success rate of these psychiatric treatments for treatment-resistant mental health conditions. By contributing to misinformation about these treatments' stereotyped "barbarism," horror films stigmatize seeking life-saving help.

Romanticization of Mental Health Conditions

Another form of misrepresentation and sensationalization of mental health in film includes romanticization. In the effort to craft a compelling tale, film makers will often embellish, simplify, or decontextualize complex mental health conditions, resorting to unrealistic tropes where "willpower" or "love" can "conquer" mental illness.[48,49] O'Hara (2019) examines this sensationalization in studying A Beautiful Mind, a 2001 film telling the story of John Nash, a successful mathematician who won the Nobel Prize with paranoid schizophrenia.[50] From his study, O'Hara argues that the movie exhibits "schizophilia," a modernist tradition of "overvaluing madness" through prioritizing and sensationalizing Nash's psychiatric disorder over other aspects of his life. For example, the film places a large focus on vivid visual hallucinations, when in actuality Nash had auditory hallucinations as is most common in patients with schizophrenia. Through emphasizing twists, suspicions, and intrigues, the film becomes "a blindly dumb attempt to turn schizophrenia into an adventure for the audience … schizophrenia becomes an occasion for a cinematic magic trick that leaves the viewer with no concept of the difficulty in getting well."[51]

Perhaps the most harmful example of this romanticization comes with the film's choice of ending: in it, Nash stops taking his medication and decides to reject his hallucinations by simply refusing to interact with them. By doing so, his life becomes seemingly normal and controllable, and he wins the Nobel Prize.[52] This ending is highly misleading and serves more the purposes of a dramatic narrative than realistically portraying schizophrenia; by promoting the idea that schizophrenia can be cured with self-discipline, the film heavily simplifies mental illness and implies that patients with schizophrenia may just lack willpower. Like in the horror movies discussed earlier, this film similarly stigmatizes medication by making halting medication by personal choice appear to be the "brave" action, when in reality stopping medication usage can cause rapid relapse or withdrawal effects and should not be done without consulting a medical professional. 

Although not a mental illness, autism spectrum disorder (ASD) is a neurodevelopmental disorder with mental effects that are often depicted and misrepresented on screen. Because many people do not have substantial or direct contact with those on the spectrum, they often look to other sources, like film, to draw understanding.[53] This can have benefits and drawbacks: while some film representations of ASD are highly matched to diagnostic characteristics, fictional autistic characters showcase an overrepresentation of savant-like skills. In a study of 26 films and TV series featuring ASD across four continents, savant-like skills were reported in 46% of characters, when in fact savantism is estimated to exist in 10-30% of populations with ASD.[54] Although the inclusion of these skills can develop a character's value and capability within a dramatic narrative, the exaggerated representation can serve to romanticize the condition and propagate the message that these skills constitute a person with ASD's worth, when in fact only a minority of the population exhibit them. Another misrepresentation was noted in the 1999 film Molly, which depicts experimental brain surgery "curing" autism.[55] Though such a depiction again facilitates the resolution of a dramatic narrative, it contributes to attitudes towards autism as a disease and can be very stigmatizing towards people who identify as neurodivergent. 

Additional concerns can actually arise when ASD is represented correctly on screen. The majority of characters with ASD on screen typically show the maximum possible score on the DSM-5 symptom scale for ASD, acting as "archetypes" for the diagnostic criteria.[56] Although this shows diagnostic accuracy, it actually increases the likelihood of stereotyping by lacking nuance and does not fully represent the broad spectrum of experiences with ASD. Nordahl-Hansen et al. (2018) argue that films should not only show diagnostic accuracy, but also accurately portray the real-life obstacles faced by people on the spectrum in addition to what they can accomplish in a supportive environment, a fully fleshed out representation of their autonomy and personhood.[57] 

Other Inaccuracies in Representation

Films on mental health exhibit additional overarching misrepresentations. One of the largest concerns is that mental illness is predominantly portrayed in privileged majority populations: a study by Riles et al. (2021) found that 97% of characters with mental illness were white, 79% were male, 88% were adult-aged, 94% were heterosexual, and 72% were non-religious.[58] When the media fails to portray marginalized populations experiencing mental illness, it casts mental health as a "Caucasian phenomenon" and reinforces ideas in many minority populations that mental healthcare and therapy are also only for the majority populations.[59] Doing so also ignores the compounded effects of mental illness and marginalized identity, particularly with the higher likelihood for certain ethnic groups and LGBTQ+ youth to experience mental health conditions.[60] Increasing portrayal of minority groups with mental illness would also help to address an overall lack of representation: although 25% of adults experience mental illness, only 5% of film characters have a mental illness.[61] Increasing representation of mental health in film, in a thoughtful and accurate way, is crucial to help mediate this inaccuracy.

Moving Forward in Film

Moving forward, Goodwin (2013) recommends that the mental health sector work more closely with the film and television industry to reduce stigmatizing content and voice their opinions in advocacy groups.[62] Byrne (1997) concurs, suggesting setting up a mental health information service where complaints from interest groups and inquiries from the media could both be addressed.[63] During production, O'Hara (2019) suggests film makers consider a series of ethical questions: What effect will this portrayal have on the audience? Is this portrayal exploiting the lived experiences of persons with psychological disabilities? How does this portrayal engage with the agency, voice, and access of people with mental illness? If symptoms manifest differently in different patients, how can we depict the condition without reinforcing stereotypes and stigmatizing attitudes?[64] By making these considerations, films can reduce harm and exploitation of people with mental illness.

Another important way to combat misrepresentation begins with public education, especially in K-12 schools when children are forming their first conceptions of mental illness.[65] Byrne (1997) suggests disseminating mental health information through audiovisual packages for schools that have been regulated for accuracy.[66] O'Hara (2019) leans more towards developing critical thinking skills in children so that whether or not they end up consuming misrepresentative media, they can be more wary of its stereotypes and flaws.[67] O'Hara suggests incorporating discussions around deconstructing stereotypes and critical questioning skills in classrooms, and reminds us that "students viewing movies create meaning through their past experiences in relation to images on the screen."[68] In this way, mental health film can be used to instruct about equity if done well, including perhaps increased exposure to nonfiction films and documentaries on mental illness.[69] By starting education about mental illness and critical thinking early, teachers can help to dismantle stereotypes and lessen the stigmatizing effects of the media around us. 

Contributed by: Anna Kiesewetter

Editors: Jennifer (Ghahari) Smith, Ph.D. & Brittany Canfield, Psy.D.

References

1 O'Hara, M. (2019), Cinema of the Monstrous: Disability and “Eye-Feel”. Journal of Curriculum Theorizing, 34 (5): 44-57. https://journal.jctonline.org/index.php/jct/article/view/869. 

2 Ibid.

3 Riles, J.M., Miller, B., Funk, M., Morrow, E. (2021), The Modern Character of Mental Health Stigma: A 30-Year Examination of Popular Film. Communication Studies, 72 (4): 668-683. https://doi.org/10.1016/j.psychres.2017.08.050. 

4 Riles, J.M. (2020), The social effect of exposure to mental illness media portrayals: Influencing interpersonal interaction intentions. Psychology of Popular Media Culture, 9 (2): 145-154. https://psycnet.apa.org/buy/2018-58786-001. 

5 Riles et al. (2021)

6 O'Hara (2019)

7 Ibid.

8 Nordahl-Hansen, A., Tondevold, M., Fletcher-Watson, S. (2018), Mental health on screen: A DSM-5 dissection of portrayals of autism spectrum disorders in film and on TV. Psychiatry Research, 262: 351-353. https://doi.org/10.1016/j.psychres.2017.08.050. 

9 Riles et al. (2021)

10 Riles (2020)

11 Quintero Johnson, J.M., Riles, J.M. (2018), "He acted like a crazy person”: Exploring the influence of college students’ recall of stereotypic media representations of mental illness. Psychology of Popular Media Culture, 7 (2): 146-163. https://psycnet.apa.org/buy/2016-19244-001. 

12 Riles et al. (2021)

13 Riles (2020)

14 Quintero Johnson & Riles (2018)

15 Ibid.

16 Riles (2020)

17 Riles et al. (2021)

18 Quintero Johnson & Riles (2018)

19 Ibid.

20 Ibid. 

21 Riles (2020)

22 Quintero Johnson & Riles (2018)

23 O'Hara (2019)

24 Byrne, P. (1997), Psychiatric stigma: past, passing and to come. Journal of the Royal Society of Medicine, 90: 618-621. https://journals.sagepub.com/doi/pdf/10.1177/014107689709001107. 

25 Quintero Johnson & Riles (2018)

26 Byrne (1997)

27 Riles et al. (2021)

28 Ibid. 

29 Ibid. 

30 Ibid. 

31 Byrne (1997)

32 Quintero Johnson & Riles (2018)

33 Riles et al. (2021)

34 Riles (2020)

35 Riles et al. (2021)

36 Ibid. 

37 Riles (2020)

38 Quintero Johnson & Riles (2018)

39 Byrne (1997)

40 Goodwin, J. (2014), The Horror of Stigma: Psychosis and Mental Health Care Environments in Twenty-First-Century Horror Film (Part II). Perspect Psychiatr Care, 50: 224-234. https://doi.org/10.1111/ppc.12044 

41 Ibid.

42 Ibid. 

43 Ibid.

44 Ibid.

45 Ibid.

46 Ibid. 

47 Ibid. 

48 Ibid.

49 O'Hara (2019)

50 Ibid. 

51 Rockwell, C. (2002). A Beautiful Mind [Review of the motion picture]. Cineaste, 27(3). 36-37.

52 O'Hara (2019)

53 Nordahl-Hansen et al. (2018)

54 Ibid. 

55 Ibid.

56 Ibid. 

57 Ibid. 

58 Riles et al. (2021)

59 Ibid.

60 Mental Health America. (2022) https://www.mhanational.org/issues/lgbtq-communities-and-mental-health. 

61 Riles et al. (2021)

62 Goodwin (2013)

63 Byrne (1997)

64 O'Hara (2019)

65 Ibid. 

66 Byrne (1997)

67 O'Hara (2019)

68 Ibid.

69 Ibid.