Homicide Homicide

Homicide Homicide Homicide

andSuicide andSuicide
andSuicide andSuicide andSuicide
AmongNativeAmericans
19791992
ViolenceSurveillanceSummarySeries,No.2
L.J L.J L.J L.J L.J. .. ..DavidW DavidW DavidW DavidW DavidWallace,MSEH allace,MSEH allace,MSEH allace,MSEH allace,MSEH
AliceD AliceD AliceD AliceD AliceD.Calhoun,MD .Calhoun,MD .Calhoun,MD .Calhoun,MD .Calhoun,MD,MPH ,MPH ,MPH ,MPH ,MPH
K KK KKennethE.P ennethE.P ennethE.P ennethE.P ennethE.Powell,MD owell,MD owell,MD owell,MD owell,MD,MPH ,MPH ,MPH ,MPH ,MPH
JoannO JoannO JoannO JoannO JoannONeil,BS Neil,BS Neil,BS Neil,BS Neil,BS
StephenP StephenP StephenP StephenP StephenP.James,BS .James,BS .James,BS .James,BS .James,BS
NationalCenterforInjuryPreventionandControl NationalCenterforInjuryPreventionandControl NationalCenterforInjuryPreventionandControl NationalCenterforInjuryPreventionandControl NationalCenterforInjuryPreventionandControl
Atlanta,Georgia Atlanta,Georgia Atlanta,Georgia Atlanta,Georgia Atlanta,Georgia
1996 1996 1996 1996 1996
TheViolenceSurveillanceSummarySeriesisapublicationoftheNationalCenterfor
InjuryPreventionandControloftheCentersforDiseaseControlandPrevention:
CentersforDiseaseControlandPrevention
DavidSatcher,MD,PhD,Director
NationalCenterforInjuryPreventionandControl
MarkL.Rosenberg,MD,MPP,Director
DivisionofViolencePrevention
JamesA.Mercy,PhD,ActingDirector
ProductionserviceswereprovidedbystaffoftheOfficeofHealthCommunications,
NationalCenterforInjuryPreventionandControl:
EditingandTextDesign
GwendolynA.Ingraham
GraphicDesign
MarilynL.Kirk
MaryAnnBraun
LauraS.Dansbury
CoverDesign
MaryAnnBraun
Layout
SandraS.Emrich
SuggestedCitation:WallaceLJD,CalhounAD,PowellKE,ONeilJ,JamesSP.
HomicideandsuicideamongNativeAmericans,19791992.Atlanta,GA:Centers
forDiseaseControlandPrevention,NationalCenterforInjuryPreventionand
Control,1996.ViolenceSurveillanceSummarySeries,No.2.
ExecutiveSummary ExecutiveSummary ExecutiveSummary ExecutiveSummary ExecutiveSummary
From19791992,4,718AmericanIndiansandAlaskanNatives
(NativeAmericans)whoresidedonornearreservationsdied
fromviolence2,324fromhomicidesand2,394fromsuicide.
Duringthis14-yearperiod,overallhomicideratesforNative
Americanswereabout2.0timeshigher,andsuiciderates
wereabout1.5timeshigher,thanU.S.nationalrates.Native
AmericansresidinginthesouthwesternUnitedStates,northern
RockyMountainandPlainsstates,andAlaskahadthehighest
ratesofhomicideandsuicide.
Bothhomicidesandsuicidesoccurreddisproportionatelyamong
youngNativeAmericans,particularlymales.From19901992,
homicideandsuicidealternatedbetweensecondandthird
rankingsasleadingcausesofdeathforNativeAmericanmales
1034yearsofage.ForNativeAmericanfemalesaged1534
years,homicidewasthethirdleadingcauseofdeath.Almost
two-thirds(63%)ofmalevictimsandthree-quarters(75%)of
femalevictimswerekilledbyfamilymembersoracquaintances.
Firearmswerethepredominantmethodusedinbothhomicides
andsuicides.From19791992,justoverone-thirdofNative
Americanhomicidevictimswerekilledwithafirearm,withthe
firearm-relatedhomiciderateamongNativeAmericansincreas-
ing36%from19851992.Firearmswereusedinnearly60%of
NativeAmericansuicides.
SeveraldistinctivecharacteristicsofviolentdeathamongNative
Americansemergedfromthisstudy:
TheagedistributionofsuicideratesforNativeAmericansis
quiteunlikethatforthegeneralpopulation,becauseofhigh
ratesamongyoungadultsandlowerratesamongtheelderly.
iii
Althoughfirearmsarethepredominatemethodforboth
homicidesandsuicides,NativeAmericanshavealower
proportionoffirearm-relatedhomicidesandsuicidesthan
isfoundintheU.S.population.
Theproportionofhomicidesinwhichthevictimand
perpetratorwerefamilymembersoracquaintancesis
somewhatgreaterforNativeAmericansthanforthe
U.S.populationatlarge.
PatternsandratesofhomicideandsuicideamongNative
Americansdiffergreatlyfromregiontoregion.
Therearemanypromisinginterventionstopreventviolence,but
becauseeachNativeAmericancommunityisunique,prevention
strategiesshouldbeplannedwithcarefulattentiontolocalinjury
patternsandlocalpracticesandcultures.Givencommunity
differencesandthemultipleandcomplexcausesofhomicideand
suicide,asimpleanduniformapproachisinappropriate.Success
willcomeonlythroughavarietyofinterventions,tailoredtothe
specificlocalsettingsandproblems.Alsoessentialiscontinued
surveillanceandevaluationoftheeffectivenessoftheprevention
programsthatareputintoplace.
Theinformationinthisreportshouldbeusefultopublichealth
practitioners,researchers,andpolicymakersinaddressingthe
problemofhomicideandsuicideamongNativeAmericans.
iv
Contents Contents Contents Contents Contents
ExecutiveSummary iii
Introduction 1
DataSources 3
Results: Homicide 7
Results: Suicide 17
Discussion 23
StudyLimitations 23
CharacteristicsofViolenceamongNativeAmericans 24
Prevention 26
References 29
Tables 33
ForMoreInformation... 51
F FF FFigures igures igures igures igures
F FF FFigure1. igure1. igure1. igure1. igure1. IndianHealthServiceAreas 2
F FF FFigure2. igure2. igure2. igure2. LeadingCausesofYearsofPotentialLifeLostbefore 8 igure2.
Age65(YPLL-65)NativeAmericans,19901992
F FF FFigure3. igure3. igure3. igure3. igure3. HomicideRates,byRaceandSexNativeAmericans, 9
Blacks,Whites,19791992
F FF FFigure4. igure4. igure4. igure4. igure4. HomicideRates,byAgeGroupandSex 9
NativeAmericans,19791992
F FF FFigure5. igure5. igure5. igure5. igure5. HomicideRates,byFirearmUseNativeAmerican 10
MalesAged1524Years,19791992
F FF FFigure6. igure6. igure6. igure6. igure6. PercentageofHomicides,byWeaponUsedand 11
SexofVictimNativeAmericans,19881991
F FF FFigure7. igure7. igure7. igure7. igure7. PercentageofHomicides,byRelationshipbetweenVictim 12
andAssailant,andbySexNativeAmericans,19881991
F FF FFigure8. igure8. igure8. igure8. igure8. PercentageofHomicides,bySexofVictimandOffender 13
NativeAmericans,19881991
F FF FFigure9. igure9. igure9. igure9. igure9. PercentageofHomicides,byRaceofOffender 13
NativeAmericans,19881991
F FF FFigure10. igure10. igure10. igure10. igure10. VariationsinAge-AdjustedHomicideRates,byIHSServiceArea 15
UnitedStates,19911992
F FF FFigure11. igure11. igure11. igure11. igure11. SuicideRates,byRaceandSexNativeAmericans, 18
Blacks,Whites,19791992
igure12. SuicideRates,byAgeGroupandSex 19
NativeAmericans,19791992
F FF FFigure12. igure12. igure12. igure12.
igure13. SuicideRatesforPersonsAged65YearsandOlder 20
NativeAmericansandAllU.S.Races,19791992
F FF FFigure13. igure13. igure13. igure13.
F FF FFigure14. igure14. igure14. igure14. igure14. SuicideRates,byFirearmUseNativeAmerican 20
MalesAged1524Years,19791992
igure15. PercentageofSuicides,byMethodandSexof 21
VictimNativeAmericans,19791992
F FF FFigure15. igure15. igure15. igure15.
F FF FFigure16. igure16. igure16. igure16. igure16. VariationsinAge-AdjustedSuicideRates,byIHSServiceArea 22
UnitedStates,19911992
Introduction Introduction Introduction Introduction Introduction
Violenceisaleadingcauseofdeathanddisabilityforall
Americans,butitisaparticularthreattoAmericanIndiansand
AlaskanNatives(NativeAmericans).*Previousreportshave
shownthatfrom19791987,theage-adjustedhomicideand
suicideratesforNativeAmericanslivingonornearreservations
wereatorabovethe90thpercentileratesforallAmericans.
1
From19901992,homicideandsuicidecombinedrankedasthe
fourthleadingcauseofdeathforNativeAmericans,exceeded
onlybyheartdisease,cancer,andunintentionalinjuries.For
morethanhalfofthe14-yearstudyperiod(19791992),the
annualnumberofsuicidesamongNativeAmericansexceeded
homicides,withmostoftheexcessoccurringsince1984.
TheNativeAmericanpopulationfor1995isprojectedat
approximately2.27million.
2
Nearlyhalf(1.37million
3
)liveinthe
geographicareasinwhichtheIndianHealthService(IHS)has
responsibilities(i.e.,onornear federallyrecognizedreserva-
tions)andarethuseligibleforIHSservices.Foradministrative
purposes,IHShasgroupedtheseareas,whichcomprise571
countiesin34states,into12regions,orareaoffices:
4
Aberdeen
Area,AlaskaArea,AlbuquerqueArea,BemidjiArea,Billings
Area,CaliforniaArea,NashvilleArea,NavajoArea,Oklahoma
Area,PhoenixArea,PortlandArea,andTucsonArea(Figure1).
Eachoftheseareasrepresentsauniquecombinationoftraditions
andculture.Therearealsovastdifferencesingovernment
structure,economiclevel,populationsize,rurality,andthe
degreeofacculturation.
Vi ol ence i s a
l eadi ng cause of
deat h for al l
Ameri cans, but
i t i s a part i cul ar
t hreat t o Nat i ve
Ameri cans.
*Throughoutthisreport,theterm NativeAmericans isusedtoindicateAmerican
IndiansandAlaskanNativestogether.AmericanIndians isusedtoreferonlyto
residentsofthecontiguousUnitedStates,andAlaskanNatives, toreferonlyto
thoseresidinginAlaska.
2 Introduction
Thissurveillancesummarylooksattheproblemofhomicide
andsuicideamongNativeAmericansintheIHSregionsfrom
19791992.ItisthefirstCDCsurveillancereporttofocuson
NativeAmericans.Itspurposeistoprovidebackgroundinfor-
mationforpublichealthpractitionersandpolicymakerstoaid
theminaddressingviolenceinthisvulnerablepopulation.
*
*
*
*
*
AK
CA
MT
WA
OR
ID
WY
ND
SD
NE
MN
IA
MI
WI
IN
KS
OK
TX
TN
NC
MS
AL SC
LA
FL
PA
NY
ME
MA
CT
RI
NV
UT
CO
AZ
NM
*
*
*
*
*
*
*
DataSources DataSources DataSources DataSources DataSources
Thedataonhomicideandsuicideweredrawnfromthreesources:
detailedmortalitytapespreparedbyCDCsNationalCenter
forHealthStatistics(NCHS)andbasedondatafromstate
deathcertificates
thesesameNCHSmortalitydata,whichIHShascategorized
byareaoffices
data(homicideonly)compiledfromtheFederalBureauof
InvestigationsSupplementaryHomicideReport(FBI-SHR)
Thedataderivedfromthesesourcesareasfollows:
P PP PPopulationand opulationand opulationand opulationand opulationand
Source Source Source Source Source T TT TTypeofData ypeofData ypeofData ypeofData ypeofData Y YY YYearEncompassed earEncompassed earEncompassed earEncompassed earEncompassed
IHS Mortalityratesall IHSserviceareas
NativeAmericans 19791992
NCHS Mortalitydataall EntireUnitedStates
otherraces 19791992
NCHS YPLL-65*;10leading AllNativeAmericans
causesofdeath 19901992
FBI-SHR Homicidetypeof AllNativeAmericans
firearm,relationship 19881991
ofvictimandperpetrator
Dat a for t hi s
st udy are from
t he Cent ers for
Di sease Cont rol
and Prevent i on,
t he I ndi an Heal t h
Ser vi ce, and t he
Federal Bureau
of I nvest i gat i on.
*Yearsofpotentiallifelostbeforeage65(seepage7fordescription).
4 DataSources
NCHSMortalityData NCHSMortalityData NCHSMortalityData NCHSMortalityData NCHSMortalityData
InformationonNCHSmortalitytapesisprovidedbythe50
statesandtheDistrictofColumbiaandincludesallpersons
reportedasNativeAmericans.Thedataincludeage,race,sex,
geographicinformation,andcauseofdeath,codedaccordingto
theInternationalClassificationofDiseases,NinthRevision,Clinical
Modification.
5
Homicideswereidentifiedusingcause-of-death
codesE960E978,*andsuicides,usingcodesE950E959.
IHSMortalityData IHSMortalityData IHSMortalityData IHSMortalityData IHSMortalityData
Eachyear,NCHSprovidesIHSwithamultiple-cause-of-death
mortalitytapeofallU.S.decedents.IHScategorizesthesedata
byIHSareaofficestocreateitsownmortalitydataset.TheIHS
mortalitydataincludethoseNativeAmericanswhoresided
withinanIHSareaatthetimeofdeathandwhowereeligiblefor
IHSservices.
4
IHSmortalitydatarepresentthelargelyrural,reservation-based
NativeAmericanpopulationmorecloselythandoNCHSdata,
whichincludeallNativeAmericansresidingintheUnitedStates.
TheIHSmortalitydatafor19791992contained74%ofthe
homicidesand80%ofthesuicidesreflectedintheNCHSdata
forNativeAmericans.Inthisreport,allhomicideandsuicide
ratesforNativeAmericansarefromIHSmortalitydata.
FBI- FBI- FBI- FBI- FBI-SHRHomicideData SHRHomicideData SHRHomicideData SHRHomicideData SHRHomicideData
TheFBI-SHRcompileshomicidedatathathavebeensubmitted
voluntarilybycounty,city,andstateagencies;theBureauof
IndianAffairs;andNativeAmericantriballawenforcement
agenciesthroughouttheUnitedStates.In1988,approximately
98%oftheU.S.populationwascoveredbythisreporting
system.
6
Inthisdataset,homicideisdefinedasmurderand
nonnegligentmanslaughter(thewillfulkillingofonehuman
beingbyanother),includingjustifiablehomicidesbyprivate
citizens(killingofsomeonewhoisintheactofcommittinga
felony)andkillingofasuspectedfelonbyalawenforcement
officerinthelineofduty.
6
*Specificcodesare homicideandinjurypurposelyinflictedbyotherpersons
(E960E969)and legalinterventions (E970E978),whichincludelegal
executionsanddeathfrominjuryinflictedbylawenforcementagentsinthe
courseofduty.Deathresultingfromlegalinterventionsaccountedfor2.1%of
homicidesinvolvingNativeAmericans.
5 DataSources
TheFBI-SHRdataareimportantbecausetheyincludedemo-
graphicinformationonthevictimandassailant,therelationship
betweenvictimandassailant,anddetailedinformationonthe
typeofweaponused.Thedataarebasedsolelyonthereportsof
theinvestigatinglawenforcementofficials.
7
WeusedFBI-SHRdataforNativeAmericanhomicidevictims
whodiedduring19881991.NCHSsU.S.VitalStatisticsdata
routinelyreportabout10%morehomicidesnationallyperyear
thandoFBI-SHRdata.
7
For19881991,however,NCHSreported
about44%morehomicidesamongNativeAmericansthandid
theFBI-SHR.Thisdifferenceisthoughttobelargelyduetothe
voluntarynatureoftheFBI-SHRreportingsystemandto
misclassificationofrace.Also,fourstatesdidnotreporttothe
FBI-SHR:Florida,for19881991;Maine,for1991;Iowa,for1991;
andKentucky,for1988.Nonetheless,thedatashouldberepre-
sentativeofhomicidesofNativeAmericansonreservations
becausetheFBIisroutinelyinvolvedinthoseinvestigations
(personalcommunication:BennieJeannotte,AssistantChief,
LawEnforcementDivision,BureauofIndianAffairs).
Despitetheapparentunderreporting,weusedFBI-SHRdata
becauseinformationaboutrelationshipsbetweenvictimsand
offendersisavailableonlyfromtheFBI-SHRandbecausethe
typeoffirearmusedisreportedmorecompletelyinFBI-SHR
datathaninNCHSdata.FBI-SHRdataareusedforallinforma-
tionaboutoffendersandtypeoffirearmused.
P PP PPopulationData opulationData opulationData opulationData opulationData
WecalculatedratesusingestimatesoftheIHSservicepopulation
for19791992,basedonthe1980andrevised1990census,as
denominators.AllratesspecifictoIHSareas,race,andsexwere
age-adjustedbythedirectmethodusingthe1940U.S.popula-
tionasthestandard.
The1990censusindicatesthattheNativeAmericanpopulation
residinginIHSserviceareasisyoungerthantheU.S.population
asawhole.Thirty-fourpercentofNativeAmericansareunder
15yearsofage,andthemedianageis24.2years.Only22%of
thetotalU.S.populationisunder15,andthemedianageis
32.9years.
4
Results:Homicide Results:Homicide Results:Homicide Results:Homicide Results:Homicide
OverallHomicideRatesandPrematureMortality OverallHomicideRatesandPrematureMortality OverallHomicideRatesandPrematureMortality OverallHomicideRatesandPrematureMortality OverallHomicideRatesandPrematureMortality
From19791992,2,324NativeAmericansresidinginthe12IHS
areasdiedfromhomicide.Duringthisperiod,thetotalnumber
ofNativeAmericanhomicideswasessentiallyunchanged,with
164in1979and168in1992.TherateofhomicideforNative
Americans,however,hadageneraldownwardtrend,froma
highof23.7per100,000in1979toalowof13.2per100,000in
1990(Table1).*Duringthefirsthalfoftheperiod,homicide
ratesfortheUnitedStatesasawholealsodeclined.However,
duringthelasthalfoftheperiod,whentheratesforNative
Americanswererelativelystable,overallU.S.ratesincreased.
During19901992,homicidewastheninthleadingcauseof
deathforallNativeAmericans(Table2).Despitethesetrends,
theratesforNativeAmericanswereapproximatelytwicethe
U.S.ratesthroughoutthefirsthalfoftheperiodandcontinued
toexceedtheU.S.ratesduringthelateryears.
Yearsofpotentiallifelostbeforetheageof65(YPLL-65),which
measuresprematuremortality,isanotherwayofdefiningthe
scopeofapublichealthproblem.
8
Bycalculatingtheyears
betweentheageatdeathandage65,thistechniqueweighsmore
heavilythoseconditionsthatkillchildren,teenagers,andyoung
adults.For19901992,homicidewasthethirdleadingcauseof
yearsoflifelostbeforeage65(Figure2,Table5).Itaccountedfor
7%ofYPLL-65amongNativeAmericansandwasexceededonly
byunintentionalinjuryandheartdisease.YPLL-65attributable
tohomicideincreasedby13%forNativeAmericansfrom
19791981to19901992.
Al t hough homi ci de
rat es for Nat i ve
Ameri cans decl i ned
from 19791990,
t hey remai ned
hi gher t han U.S.
rat es.
*Tablesareinaseparatesectionatthebackofthebook.
8 Results:Homicide
Race Race Race Race Race-andSex -andSex -andSex -andSex -andSex- -- --SpecificHomicideRates SpecificHomicideRates SpecificHomicideRates SpecificHomicideRates SpecificHomicideRates
Duringthestudyperiod,1,759NativeAmericanmalesand
565femaleswerevictimsofhomicide(Table1).Throughoutthis
period,homicideratesintheUnitedStateswerehighestfor
blackmales,followedbyNativeAmericanmalesandthenblack
females(Figure3).HomicideratesforwhitemalesandNative
Americanfemaleswerecomparableandwerehigherthanrates
forwhitefemales.HomicideratesforNativeAmericansdeclined
forbothmalesandfemalesduringtheearlieryearsofthestudy
period,thenremainedstableformalesandrelativelystablefor
females.HomicideratesforNativeAmericansfrom19791992
werethreetimestheratesforwhites,butonlyhalftheratesfor
blacks.Duringthelasthalfoftheperiod,whentheratesfor
NativeAmericanshadstabilized,thoseforblacksincreased.
Age Age Age Age Age-andSex -andSex -andSex -andSex -andSex- -- --SpecificHomicideRates SpecificHomicideRates SpecificHomicideRates SpecificHomicideRates SpecificHomicideRates
ForNativeAmericans,homicideismostcommonamongyoung
adults(Figure4).During19791992,themedianageofNative
Americanhomicidevictimswas28years.Malesaged1544
accountedfor60%ofallhomicidesofNativeAmericans.The
Homi ci de i s t he
t hi rd l eadi ng
cause of years
of pot ent i al l i fe
l ost before age 65
for Nat i ve
Ameri cans.
Nat i ve Ameri can
mal es had t he
second hi ghest
homi ci de rat es
duri ng t he st udy
peri od.
9 Results:Homicide
Young adul t s
had t he hi ghest
homi ci de rat es
among Nat i ve
Ameri cans.
10 Results:Homicide
groupathighestriskwasmalesaged2534years(47.0per
100,000).From19901992,homiciderankedsixthinoverall
leadingcausesofdeathamongNativeAmericanmalesinthe
UnitedStates,butsecondamongmalesaged2534andthird
amongmales14and1024years(Table3).
ThepatternforNativeAmericanmalesaged1524years,for
bothfirearm-relatedhomicidesandhomicidesnotinvolvinga
firearm,reflectstheoveralldeclineinhomicideinthisgroup
from19791992(Figure5).Incontrast,amongblackmalesaged
1524years,thetotalhomicideratemirrorsariseinratesof
firearm-relatedhomicide.
7
ForNativeAmericanfemales,the25-to34-yearagegroupwas
alsoathighestrisk(13.8per100,000)(Figure4).Although
homicidewasnotoneofthe10leadingcausesofdeathoverall
forNativeAmericanfemalesduring19901992,itwasthesecond
leadingcauseforgirlsaged14yearsandthethirdforfemales
aged1534(Table4).
Despi t e hi gh rat es,
homi ci des among
young Nat i ve
Ameri can mal es
decl i ned over t he
st udy peri od,
refl ect i ng a decrease
i n t he use of bot h
fi rearms and ot her
means.
Results:Homicide 11
MethodsofHomicide MethodsofHomicide MethodsofHomicide MethodsofHomicide MethodsofHomicide
AccordingtotheFBI-SHRfor19881991,44%ofhomicidesof
NativeAmericansinvolvedfirearms,with64%oftheseinvolving
ahandgun(Table6).Malevictimsweremostlikelytobekilledby
afirearm(48%),andfemalevictims,byothermethods(36%),
suchasbluntobjects,bodilyforce,orstrangulation(Figure6).
Cuttingandstabbingaccountedforasubstantialnumberof
deathsamongbothmales(29%)andfemales(23%).
Mal e vi ct i ms were
most l i kel y t o be
ki l l ed by a fi re-
arm, and femal e
vi ct i ms, by ot her
met hods, such as
bl unt obj ect s,
bodi l y force, or
st rangul at i on.
AlthoughfirearmsarethepredominantweaponusedinNative
Americanhomicides,theyarelesslikelytobeusedinthis
group(38%)thanintheU.S.populationasawhole(63%).From
19791992,firearmswereusedinabout63%ofhomicidesinthe
UnitedStates,butin38%ofhomicidesofNativeAmericans
residinginIHSareas.
TheprevalenceoffirearmusevariedacrossIHSareas,from28%
ofhomicidesintheAberdeenAreato53%intheCaliforniaArea
(Table7).FirearmusewasalsohighintheAlaskaArea(47%),the
NashvilleArea(48%),andtheOklahomaArea(50%).Despitethe
predominanceoffirearmuse,cuttingandstabbingwasthelead-
ingmethodofhomicideinthreeareas:Aberdeen,Albuquerque,
andNavajo.
12 Results:Homicide
RelationshipofV RelationshipofV RelationshipofV RelationshipofV RelationshipofVictimstoAssailants ictimstoAssailants ictimstoAssailants ictimstoAssailants ictimstoAssailants
From19881991,two-thirds(66%)ofNativeAmericanhomicide
victimswerekilledbypersonstheyknew:19%byfamily
membersand47%byacquaintances.Thisproportionislarger
thantheproportionfortheUnitedStatesasawhole.
Femaleswereparticularlyatriskofbeingkilledbysomeonethey
knew(75%),withalmostone-thirdoffemalevictimsbeingkilled
byfamilymembers(Figure7).Nationwide,about65%offemale
victimswerekilledbysomeonetheyknew.
7
Duringthestudy
period,63%ofNativeAmericanmalevictimswerekilledby
familymembersoracquaintances,incontrastwith50%
nationwide.Two-thirdsofallNativeAmericanhomicidevictims
weremaleswhowerekilledbymales(Figure8).
MostNativeAmericanswerekilledbyotherNativeAmericans
(51%)orbywhites(39%)(Figure9).Femalesweremostlikely
(59%)tobekilledbyotherNativeAmericans.
Two-t hi rds of
Nat i ve Ameri can
homi ci de vi ct i ms
were ki l l ed by
someone t hey
knew.
Results:Homicide 13
The maj ori t y of
t hese homi ci des
i nvol ved mal es
ki l l i ng mal es.
Most Nat i ve
Ameri can
homi ci de vi ct i ms
were ki l l ed by
ot her Nat i ve
Ameri cans.
14 Results:Homicide
GeographicP GeographicP GeographicP GeographicP GeographicPatternsofHomicide atternsofHomicide atternsofHomicide atternsofHomicide atternsofHomicide
During19791992,homicideratesvariedwidelyacrossthe
12IHSareas,fromalowof10.6per100,000intheOklahoma
Areato27.8per100,000intheAberdeenArea(Table8).The
homiciderateintheAberdeenAreawasapproximatelysix
timesgreaterthantherateforallSouthDakotaresidents.
RatesforallIHSareaswerehigherthantheaverageU.S.rate
(9.5per100,000)duringthestudyperiod.TheIHSareaswith
thehighestoverallhomicideratesandthehighestratesformales
wereinthenorthernmidwest(AberdeenArea),thenorthern
RockyMountainstates(BillingsArea),andthedesertsouthwest
(TucsonAreaandPhoenixArea).ForNativeAmericanfemales,
homiciderateswerehighestinthenorthern-midwest(Aberdeen
Area)andthedesertsouthwest(TucsonAreaandPhoenixArea)
(Table8).
AlthoughtheAberdeenAreahadconsistentlyhighrates,itdid
nothavethehighestrateafter1982.Instead,thehighestrate
usuallyoccurredintheTucson,Phoenix,orBillingsareas.
During19911992,Tucson(24.9)hadthehighestrate,followed
byBillings(23.9)andPhoenix(23.0)(Figure10,Table7).
Nat i ve Ameri can
homi ci de rat es
were hi ghest i n
t he nort hern
mi dwest , t he
nort hern Rocky
Mount ai n st at es,
and t he desert
sout hwest .
Results:Homicide 15
*
*
*
*
*
AK
CA
MT
WA
OR
ID
WY
ND
SD
NE
MN
IA
MI
WI
IN
KS
OK
TX
TN
NC
MS
AL SC
LA
FL
PA
NY
ME
MA
CT
RI
NV
UT
CO
AZ
NM
*
*
*
*
*
*
*
Results:Suicide Results:Suicide Results:Suicide Results:Suicide Results:Suicide
OverallSuicideRatesandPrematureMortality OverallSuicideRatesandPrematureMortality OverallSuicideRatesandPrematureMortality OverallSuicideRatesandPrematureMortality OverallSuicideRatesandPrematureMortality
From19791992,2,394NativeAmericansresidinginIHSservice
areasdiedfromsuicide.Duringthisperiod,thenumberof
suicidesincreasedby19%,from162in1979to193in1992
(Table9).Thesuicideratedeclined26%duringthefirstsixyears
ofthestudyperiod,fromahighof21.1per100,000in1979toa
lowof15.6per100,000in1984.From19841985,therewasan
11%increaseinsuicideratesforNativeAmericans,afterwhich
theratestendedtostabilize.From19901992,suicidewasthe
eighthleadingcauseofdeathoverallforNativeAmericans
(Table2)andthefourthleadingcauseofYPLL-65(Figure2
[page8],Table5).YPLL-65attributabletosuicideamongNative
Americansincreasedby18%from19791981to19901992.
In1992,thesuiciderateforNativeAmericans(16.2per100,000)
was1.5timesgreaterthantherateforallAmericans(11.1per
100,000).Itwas1.4timeshigherthantherateforwhitesand2.4
timeshigherthantherateforblacks.
Race Race Race Race Race-andSex -andSex -andSex -andSex -andSex- -- --SpecificSuicideRates SpecificSuicideRates SpecificSuicideRates SpecificSuicideRates SpecificSuicideRates
NativeAmericanmaleshadthehighestsuicideratesinthe
countryduringthestudyperiod,followedbywhitemalesand
thenblackmales(Figure11).Blackfemaleshadthelowest
suiciderates,andNativeAmericanfemales,thenextlowestrates.
Theratesforwhitefemaleswereonlyslightlyhigherthanthose
forNativeAmericanfemales.
Sui ci de rat es for
Nat i ve Ameri cans
decl i ned overal l
duri ng t he st udy
peri od, but t hey
remai ned hi gher
t han U.S. rat es.
18 Results:Suicide
From19791984,thesuiciderateforNativeAmericanmales
declined27%,butfrom1984to1990therateincreased10%.The
ratethendeclinedin1991andremainedvirtuallyunchangedin
1992(Table9).TherateforNativeAmericanfemalesfluctuated
throughout19791992,withnooveralldecrease(Figure11).
Nat i ve Ameri can
mal es had t he
hi ghest sui ci de
rat es i n t he
count r y.
Age Age Age Age Age-andSex -andSex -andSex -andSex -andSex- -- --SpecificSuicideRates SpecificSuicideRates SpecificSuicideRates SpecificSuicideRates SpecificSuicideRates
SuicideamongNativeAmericans,likehomicide,ismostcom-
monamongyoungadults,particularlyyoungmales(Figure12).
During19791992,themedianageofaNativeAmericansuicide
victimwas26years.Malesaged1534yearsaccountedfor64%
ofallsuicidesbyNativeAmericans.Malesandfemalesaged
1524yearswereathighestrisk,withsuicideratesof62.0per
100,000and10.0per100,000,respectively.
Mal es 1534 years
ol d account ed for
64% of Nat i ve
Ameri can sui ci des.
Results:Suicide 19
Inkepingwithpasttrends,suiciderateswerelowestforNative
Americansover65yearsofage.Thispatternischanging,how-
ever:ratesforolderNativeAmericansincreasedalmost200%
from19791981to19911992(Figure13).Incontrast,although
suicideratesintheUnitedStatesoverallarehighestforpersons
over65,theratesforthisgroupincreasedonly15%duringthe
sameperiod.AlargemajorityofolderNativeAmericanswho
committedsuicideweremale(83%),andfirearmswerebyfarthe
leadingmethod(74%).
From19901992,suicidewasthefifthleadingcauseofdeath
amongNativeAmericanmalesintheUnitedStatesandthe
secondamongmalesaged1024years(Table3).Suicideis
notamongthe10leadingcausesofdeathoverallforNative
Americanfemales(Table4).Itis,however,thesecondleading
causeforthoseaged1524andthefifthforthoseaged2534.
Thedeclinefrom19791984insuicideratesforNativeAmerican
malesaged1524yearsmirrorsthedeclineinfirearm-related
suicidesduringthattime(Figure14).Since1983,however,other
means,suchashangingandpoisoning,combinedhavebeen
usedalmostasoftenasfirearmsinsuicidesbyyoungNative
Americanmales.
Of al l Nat i ve
Ameri cans,
young peopl e
were at hi ghest
ri sk for sui ci de.
20 Results:Suicide
Al t hough sui ci de
rat es for ol der
Nat i ve Ameri cans
are l ow, t hey are
on t he ri se.
Si nce 1983, ot her
means, such as
hangi ng and
poi soni ng, have
been used i n
sui ci des al most as
oft en as fi rearms.
Results:Suicide 21
MethodsofSuicide MethodsofSuicide MethodsofSuicide MethodsofSuicide MethodsofSuicide
Firearmswereusedinthemajority(57%)ofsuicidesbyNative
Americans.Thenextmostcommonmethodswerestrangulation
byhanging(29%)andpoisoning(9%)(Table10).Maleswere
mostlikelytochoosefirearms(59%)andhanging(31%)
(Figure15).Femalesweremostlikelytousefirearms(41%)and
poisoning(35%).NativeAmericansweretwiceaslikelyasall
U.S.residentstochoosehangingasamethodofsuicide,but
onlyhalfaslikelytousepoisoning.
9
MethodsofsuicidevariedacrossIHSareas.Firearmuseranged
from45%(AberdeenArea)to76%(NashvilleArea).Hanging
wastheleadingmethodofsuicideintheAberdeenAreafrom
19851992.Poisoningwasthesecondleadingmethodinthe
BemidjiArea.
Fi rearms were
t he predomi nant
met hod of sui ci de
for bot h mal es
and femal es.
GeographicP GeographicP GeographicP GeographicP GeographicPatternsofSuicide atternsofSuicide atternsofSuicide atternsofSuicide atternsofSuicide
Aswithhomiciderates,suicideratesamongNativeAmericans
during19791992variedgeographically,fromalowof7.5per
100,000intheOklahomaAreatoahighof29.6per100,000inthe
BillingsArea(Table11).However,forthesecondhalfofthestudy
period(19851992),suicideratesandfirearmsuiciderateswere
highestinAlaska(Table12).TheAlaskaAreaalsohadthegreatest
22 Results:Suicide
numberoffirearmsuicidesduringthestudyperiod.During
19911992,thehighestsuiciderateswereintheAlaskaArea
(30.7),theAlbuquerqueArea(25.8),andtheAberdeenArea
(24.9)(Figure16).
Threeareashadmale-to-femalesuicideratiosthatwereconsider-
ablyhigherthanthenationalratioof4.0.Thesuicideratefor
malesintheAlbuquerqueArea(54.0per100,000)was17times
greaterthanthatforfemales(3.2per100,000)(Table11).The
male-to-femalesuicideratiowas9.8intheNavajoAreaand8.5
intheBillingsArea.
*
*
*
*
*
AK
CA
MT
WA
OR
ID
WY
ND
SD
NE
MN
IA
MI
WI
IN
KS
OK
TX
TN
NC
MS
AL SC
LA
FL
PA
NY
ME
MA
CT
RI
NV
UT
CO
AZ
NM
*
*
*
*
*
*
*
Sui ci de rat es
were hi ghest i n
Al aska, t he
Rocky Mount ai n
st at es, and part s
of t he mi dwest .
Discussion Discussion Discussion Discussion Discussion
StudyLimitations StudyLimitations StudyLimitations StudyLimitations StudyLimitations
UnderreportingofNativeAmericanraceonstatedeathcertifi-
catesisthoughttobecommoninmanyregionsoftheUnited
States.
4
Undoubtedly,underreportinginfluencesthenumbers
andratesofeventsinthisreport.IHShaslongrecognizedthis
problemintheCalifornia,Oklahoma,andPortlandareas.
4,10
Consequently,ratespresentedforthesethreeareasandforall
areascombinedshouldbeconsideredconservativeestimates.
ForNativeAmericanslivingoutsideofIHSserviceareas,mis-
classificationofraceondeathcertificatesislikelytobean
evengreaterproblem,especiallyamongthosewithAnglo-or
Hispanic-soundingnames.IHSestimatesthatmisclassification
ofraceleadstounderestimatesofdeathratesforAmerican
Indiansinsomeregionsofasmuchas25%35%(writtencom-
munication:AaronHandler,Chief,DemographicStatistics
Branch,IHS).Despitetheprobabilitythattheratesinthisstudy
areunderestimated,theresultssupportpreviousworkshowing
thathomicideandsuicidearemorecommonamongNative
AmericansthanintheoverallU.S.population.
1,11
Asecondlimitationconcernsthenumberofsuicidesandhomi-
cidesamongAlaskanNatives.Duringthestudyperiod,data
fromtheAlaskaBureauofVitalStatisticsconsistentlyshow
about70%moresuicidesand40%morehomicidesthanare
includedintheNCHSandIHSdatatapes(writtencommuni-
cation:StephanieWalden,AlaskaDepartmentofHealthand
SocialServices,BureauofVitalStatistics).Thisdiscrepancy
occurs,inpart,becausedataaredueeachyearatNCHSbefore
theinvestigationsofmanysuicidesandhomicideshavebeen
completed.Wheninvestigationsarefinalized,thedeathsare
recordedatthestatelevel,butnotatthefederallevel.
The dat a i n t hi s
report support
previ ous work
showi ng t hat
homi ci de and
sui ci de are more
common among
Nat i ve Ameri cans
t han i n t he
Uni t ed St at es
overal l .
24 Discussion
ThissituationappliestoalldeathsinAlaska,notjustthosefor
AlaskanNatives.NCHSandtheAlaskaBureauofVitalStatistics
areawareoftheproblem,
12
anditisnowthoughttobecorrected
(personalcommunication:HarryRosenberg,Chief,Mortality
StatisticsBranch,NCHS;AlZangri,Chief,BureauofVital
Statistics,AlaskaDepartmentofHealthandSocialServices).
CharacteristicsofV CharacteristicsofV CharacteristicsofV CharacteristicsofV CharacteristicsofViolenceamongNativeAmericans iolenceamongNativeAmericans iolenceamongNativeAmericans iolenceamongNativeAmericans iolenceamongNativeAmericans
Inadditiontooverallhighrates,severaldistinctivecharacteristics
ofviolentdeathsamongNativeAmericansemergedfromthe
study:
anagedistributionofsuicideratesquiteunlikethat
forthegeneralpopulation
alowerproportionoffirearm-relatedhomicides
andsuicidesthaninthegeneralU.S.population
asomewhatgreaterproportionofhomicidesin
whichthevictimandperpetratorwereknownto
befamilymembersoracquaintances
markedvariationinpatternsandratesamongthe
IHSareas
Theseobservations,whicharediscussedbelow,haveimplica-
tionsforthedesignandfocusofpreventiveactivities.
Age di st ri but i on of Nat i ve Ameri can sui ci de rat es.FortheUnited
Statesasawhole,suicideratesincreaseduringtheteenageyears,
arerelativelysimilarforallagegroupsfromtheearlytwenties
throughthelatesixties,andthenincreasewithage.Incontrast,
suicideratesamongNativeAmericansaged1534yearswere
aboutfivetimesgreaterduringthestudyperiodthantherates
forthose65yearsandolderandwereovertwotimesgreater
thannationalU.S.ratesforthesameagegroup.Therefore,
whilesuicideamongadolescentsandyoungadultsisanational
concernaffectingallAmericans,youngNativeAmericans,
especiallymales,areatunusuallyhighrisk.Itisnoteworthythat
therateswerehighestforyoungadultsbeyondschoolage,an
agegroupthattendstobeneglectedinmanysuicideprevention
programs.
13
Fi rearm-rel at ed homi ci des and sui ci des.Firearmswerethepre-
dominantweaponusedbyNativeAmericansinbothsuicides
andhomicides.Theyarelesslikelytobeusedbythisgroup,
however,thanbytheoverallU.S.population.From19791992,
Young Nat i ve
Ameri can mal es
are at unusual l y
hi gh ri sk for
sui ci de.
57%ofsuicidesbyNativeAmericansinvolvedafirearm,com-
paredwithabout59%fortheUnitedStatesasawhole.Despite
thislowerpercentageoverall,threeIHSareaswerewellabove
thenationalpercentage:NashvilleArea(76%),AlaskaArea
(72%),andCaliforniaArea(69%).
Increasesinhomicidesinvolvingafirearmaccountforalarge
proportion(68%)oftheincreaseinthetotalU.S.homiciderate
since1985.Nationally,firearmuseinhomicidesincreased49%
from19851992,withthegreatestincreaseoccurringamong
blacks(63%).
14
HomicidesamongNativeAmericanshave
generallyinvolvedothermeans,suchasknivesandblunt
trauma,butthismaybechanging.From19851992,thefirearm-
relatedhomiciderateamongNativeAmericansincreased36%.
Itisimportanttocontinuetomonitorfirearmuseinthisgroup,
becauseifitcontinuestoincrease,homicideratescanbe
expectedtoincreaseaswell.
Homi ci des i nvol vi ng fami l y members or acquai nt ances.Thelarge
proportionofhomicidesnotinvolvingfirearmsandthehigh
incidenceofperpetrationbyfamilyandacquaintancesmay
indicatehighratesofalcohol-relatedviolenceamongNative
Americans.Studieshaveshownthat,formanyNativeAmerican
communities,alcoholplaysasubstantialroleinpremature
mortality,includingdeathsduetoviolence.
1517
Researchershave
estimatedthatinNewMexicoandotherreservationstates,75%
ofAmericanIndiansuicidesand80%ofhomicidesarealcohol-
related.
15,17,18
Theseproportionsaremuchhigherthanthosefor
allNewMexicoresidents:42%ofsuicidesand54%ofhomi-
cides.
15
Objectivesurveillanceofalcohol-relatedinjury,alcohol
screeningofinjurypatients,andreferraltoappropriatesources
ofhelpforpersonswithsubstanceabuseproblemsarenecessary
componentsinreducingthisrisk.Althoughalcoholappearsto
beanimportantriskfactorforviolentdeathamongNative
Americans,asubstantialproportionofthepopulation,especially
olderadults,donotdrink.
17
Itshouldalsobenotedthatjustas
tribalculturesdiffer,sodoexperienceswithalcoholandalcohol
policies.Consequently,sometribeshaveserioussubstanceabuse
problems,whileothersdonot.
19
Vari at i ons i n pat t erns and rat es of homi ci de and sui ci de.
Ingeneral,IHSareaswithhighhomicideratesalsohadhigh
suiciderates.HomicideandsuicideratesintheAberdeen,
Alaska,Billings,Phoenix,andTucsonareasweremorethan
twicetheU.S.nationalrate.Thesesameareasalsohadthe
highestfirearm-relateddeathrates,withAlaskarankingfirst.
1
Discussion 25
Al t hough fi re-
arms are t he
predomi nant
weapon i n
Nat i ve Ameri can
homi ci des and
sui ci des, t hey
are used l ess
oft en t han i n t he
U.S. popul at i on
overal l .
The hi gh
i nci dence of
homi ci de
perpet rat ed by
fami l y and
acquai nt ances
may i ndi cat e
hi gh rat es of
al cohol -rel at ed
vi ol ence, at
l east i n some
I HS areas.
26 Discussion
Therateofgunownershipintheseareas,especiallyinAlaska,
couldplayaroleinthesehighrates.Informationonfirearm
ownership,storagemethods,andattitudesaboutfirearmswould
bevaluableforplanninginterventions.
Prevention Prevention Prevention Prevention Prevention
Giventhemultipleandcomplexcausesofhomicideandsuicide
andthevariationsintribalculture,simpleanduniformpreven-
tionrecommendationsareinappropriate.Interventionstailored
tospecificlocalsettingsandproblemswillbenecessary.Never-
theless,somecommonapproachestopreventingsuicideand
homicidecanbesuggested.
First,educationalprogramscanencouragechangesinbehavior
thatmayhelpreducehomicide.Examplesarementoringpro-
grams,traininginparentingskillsforyoungparents,andcam-
paignstoraiseawarenessabouttheadverseeffectsofalcohol
misuse,therisksandbenefitsoffirearmpossession,andthesafe
useandstorageoffirearms.Tobesuccessful,however,these
programsmustbedesignedwiththecultureofeachtribein
mind.Second,legislativemeasures,suchasregulatingtheuseof,
andaccessto,alcoholinacommunityandenforcinglawsthat
restrictaccesstofirearmsbygroupsthatshouldnothavethem,
likefelonsandchildren,areofvalue.Third,providingorim-
provingservicessuchasspecialrecreationalprogramsforyouth,
homevisitationprogramsforhigh-riskyoungmothers,and
sheltersforbatteredwomenandtheirchildrencouldhelp
reduceviolence.
20,21
Suicidepreventionactivitiesshouldbelinkedwithprofessional
mentalhealthresourcesinthecommunity.Programscould
includeseveralofthefollowingpromisingstrategies:
13
trainingschoolgatekeepers,suchasteachers,counselors,
andcoaches
trainingcommunitygatekeepers,suchasclergy,elders,
police,medicalstaff,merchants,andrecreationstaff
educatingthecommunity
screeningforsuicideinschoolsandclinics
developingpeersupportprojects
establishingcrisiscentersandhotlines
restrictingaccesstolethalmeans
providingspecialservicestofriendsandfamilies
ofsuicidevictims
I n general , I HS areas
wi t h hi gh homi ci de
rat es al so had hi gh
sui ci de rat es. These
same areas had t he
hi ghest fi rear m-
rel at ed deat h rat es.
Educat i onal
programs may
hel p reduce
homi ci de, but
t hey must be
t ai l ored t o l ocal
set t i ngs and
probl ems.
Restrictingaccesstolethalmeansforthoseconsideredatrisk
maybethemosteffective,yetunderused,strategyforprevent-
ingsuicide.Friendsandrelativesofpersonsatriskforsuicide,
andthepublicatlarge,shouldbemadeawareoffindings
indicatingthathavingafirearminthehomeisassociatedwith
approximatelyafive-foldincreaseintheriskofsuicideamong
householdresidents.
22
Restrictingaccesstolethalmeans,
promotinglockedstorageoffirearmsandammunition,and
raisingpublicawarenessoftheriskof havingafirearminthe
homecouldbeespeciallyimportanttoNativeAmericansin
theAlaska,Albuquerque,Billings,andPhoenixareas,since
easyaccesstofirearmsmaycontributetotheirhighratesof
firearmsuicide.
Since1986,ateaminIHSsMentalHealthProgramsBranchhas
beenrespondingtothewidespreadconcernofbothNative
AmericancommunitiesandtheIHSregardingviolence.This
group,theFamilyViolencePreventionTeam,*offerscrisis
consultation,communityassessment,programplanning,and
programdevelopmenttohelppreventviolenceamongNative
Americans.
23
Theteamisavailabletoconsultwithcommunities,
tribalorganizations,andIHSstaffoncrisisinterventionand
preventionstrategies.Theyhaveworkedwithseveral
community-basedviolencepreventionprograms,including
thoseinNewMexico,Arizona,Wyoming,andMinnesota.
Manypromisinginterventionstopreventviolencehavebeen
developed.BecauseeachNativeAmericancommunityisunique,
however,carefulassessmentsoflocalpatternsofviolenceand
considerationsoflocalpracticesandculturesneedtobe
addressedforinterventionstobesuccessful.Continued
surveillanceofviolenceinNativeAmericancommunitiesand
evaluationoftheeffectivenessofpreventionprogramsare
greatlyneeded.Inaddressingtheproblemofviolenceintheir
communities,localpublichealthpractitionersshouldexamine
thecausesofviolenceandworktodevelop,implement,and
evaluatemultifacetedinterventionprogramstoreducethe
burdenofinjuryanddeathcausedbyviolence.
Discussion 27
Rest ri ct i ng
access t o l et hal
means for t hose
consi dered at
ri sk may be t he
most effect i ve,
yet under used,
st rat egy for
prevent i ng
sui ci de.
The need t o
consi der t he
uni queness of
each Nat i ve
Ameri can
communi t y
when pl anni ng
i nt ervent i ons
cannot be
overemphasi zed.
*FormoreinformationabouttheFamilyViolencePreventionTeamorto
requestassistance,contacttheFamilyViolencePreventionTeam,IHSMental
Health/SocialServicesProgramsBranch,5300HomesteadRoad,NE,
Albuquerque,NM87110.
References References References References References
1. NationalCenterforInjuryPreventionandControl.Injury
mortalityatlasofIndianHealthServiceareas,19791987.
Atlanta,GA:CentersforDiseaseControlandPrevention,1993.
2. IndianHealthService.ProjectedAmericanIndianandAlaska
NativepopulationfortheUnitedStates,19902005.Rockville,
MD:IndianHealthService,1994.
3. IndianHealthService.ProjectedAmericanIndianandAlaska
NativeIHSservicepopulationbyarea,19902005.Rockville,
MD:IndianHealthService,1994.
4. IndianHealthService.TrendsinIndianhealth,1994.
Rockville,MD:U.S.PublicHealthService,1994.
5. PublicHealthService.Internationalclassificationofdiseases:
9threvision,clinicalmodification.Washington,DC:U.S.
DepartmentofHealthandHumanServices,1989.ReportNo.
DHHS-PHS-891260.
6. FederalBureauofInvestigation.CrimeintheUnitedStates:
uniformcrimereports,1988.Washington,DC:U.S.
DepartmentofJustice,1988.
7. NationalCenterforInjuryPreventionandControl.Homicide
surveillance,19791988.Atlanta,GA:CentersforDisease
Control,1992.
8. GardnerJW,SanbornJS.Yearsofpotentiallifelost(YPLL):
whatdoesitmeasure?Epidemiology1990;1(4):3229.
30 References
9. KachurSP,PotterLB,James,SP,PowellKE.SuicideintheUnited
States,19801992.Atlanta,GA:CentersforDiseaseControland
Prevention,NationalCenterforInjuryPreventionandControl,
1995.ViolenceSurveillanceSummarySeries,No.1.
10. SugarmanJR,SoderbergR,GordonJE,RivaraFP.Racial
misclassificationofAmericanIndians:itseffectoninjury
ratesinOregon,19891990.AmJPublicHealth1993;83:6814.
11. BakerSP,ONeillB,GinsburgMJ,LiG.Theinjuryfactbook.
2nded.NewYork:OxfordUniversityPress,1992.
12. NationalCenterforHealthStatistics.Technicalappendix.
In:VitalstatisticsoftheUnitedStates,1990.VolumeII.
Hyattsville,MD:CentersforDiseaseControlandPrevention,
1994:19.
13. NationalCenterforInjuryPreventionandControl.Youth
suicidepreventionprograms:aresourceguide.Atlanta,GA:
CentersforDiseaseControlandPrevention,1992.
14. NationalCenterforInjuryPreventionandControl.Injury
mortality:nationalsummaryofinjurymortalitydata,
19851992.Atlanta,GA:CentersforDiseaseControland
Prevention,1995.
15. BeckerTM,SametJM,WigginsCL,KeyCR.Violentdeathinthe
West:suicideandhomicideinNewMexico,19581987.
SuicideLifeThreatBehav1990;20(4):32434.
16. GallaherMM,FlemingDW,BergerLR,SewellCM.Pedestrian
andhypothermiadeathsamongNativeAmericansinNew
Mexico:betweenbarandhome.JAMA1992;267:13458.
17. MayPA.AlcoholabuseandalcoholismamongAmerican
Indians:anoverview.In:WattsTD,WrightR,editors.
Alcoholisminminoritypopulations.Springfield,IL:
CharlesC.Thomas,1989.
18. MayPA.TheepidemiologyofalcoholabuseamongAmerican
Indians:themythicalandrealproperties.AmIndianCulture
ResJ1994;18(2):12143.
19. LujanCC.Alcohol-relateddeathsofAmericanIndians:
stereotypesandstrategies.JAMA1992;267:1384.
References 31
20. NationalCenterforInjuryPreventionandControl.The
preventionofyouthviolence:aframeworkforcommunity
action.Atlanta,GA:CentersforDiseaseControland
Prevention,1993.
21. NationalCenterforInjuryPreventionandControl.Deaths
resultingfromfirearmandmotor-vehicle-relatedinjuries
UnitedStates,19681991.MMWR1994;43:3742.
22. KellermanAL,RivaraFP,SomesG,etal.Suicideinthehomein
relationtogunownership.NEnglJMed1992;327:46772.
23. DeBruynL,WilkinsB.Familyviolencepreventionteamofthe
IHSMentalHealth/SocialServicesProgramsBranch.IHSPrim
CareProvider1994;19:83.
T TT TTables ables ables ables ables
T TT TTable1. able1. able1. able1. able1. NumbersandRatesofHomicide,bySexofVictim 35
andYearofDeathNativeAmericans,19791992
T TT TTable2. able2. able2. able2. able2. TenLeadingCausesofDeath,byAgeGroup 36
NativeAmericans,19901992
T TT TTable3. able3. able3. able3. able3. TenLeadingCausesofDeath,byAgeGroup 37
NativeAmericanMales,19901992
T TT TTable4. able4. able4. able4. able4. TenLeadingCausesofDeath,byAgeGroup 38
NativeAmericanFemales,19901992
able5. T TT TTable able able able TenLeadingCausesofYearsofPotentialLifeLostbefore 39
Age65(YPLL-65)NativeAmericans,19901992
T TT TTable6. able6. able6. able6. able6. PercentagesofHomicide,bySexandMethod 40
NativeAmericans,19891991
T TT TTable7. able7. able7. able7. able7. NumbersandRatesofHomicide,byIHSAreaand 41
LeadingMethods;andPercentagesofFirearmUse
NativeAmericans,19791992
T TT TTable8. able8. able8. able8. able8. NumbersandRatesofHomicide,bySexofVictimand 44
IHSArea;andNativeAmerican-to-U.S.RateRatios,19791992
T TT TTable9. able9. able9. able9. able9. NumbersandRatesofSuicide,bySexandYearofDeath 45
NativeAmericans,19791992
T TT TTable10. able10. able10. able10. able10. NumbersandPercentagesofSuicide,bySexandMethod 45
NativeAmericans,19891991
T TT TTable11. able11. able11. able11. NumbersandRatesofSuicide,bySexandIHSArea; 46 able11.
andNativeAmerican-to-U.S.RateRatios,19791992
T TT TTable12. able12. able12. able12. NumbersandRatesofSuicide,byIHSAreaand 47 able12.
LeadingMethods;andPercentagesofFirearmUse
NativeAmericans,19791992