Intimate Partner Sexual Coercion Mediates the Childhood Sexual Abuse–Suicidal Ideation Link Among African American Women

Abstract

Suicide is a leading cause of morbidity and mortality among women. Childhood sexual abuse (CSA) and intimate partner violence are significant risk factors for suicidal ideation among women. The purpose of this study was to examine the interrelationships among these three constructs and test if intimate partner sexual coercion may explain the CSA–suicidal ideation link. African American women (N = 141) completed an assessment of childhood trauma, intimate partner sexual coercion, and suicide ideation. A significant positive correlation was found between CSA and sexual coercion, between CSA and suicidal ideation, and between sexual coercion and suicidal ideation. Also, intimate partner sexual coercion was found to mediate the relationship between CSA and suicidal ideation when controlling for covariates such as spiritual well-being, self-esteem, and barriers to services. The association between CSA and suicidal ideation may be explained by sexual revictimization in the context of an intimate relationship among African American women. Clinically, practitioners should engage in regular screening for suicide ideation among African American women who have experienced CSA and intimate partner sexual coercion.

Keywords

sexual coercion childhood sexual abuse suicidal ideation African Americans

Suicide is a top 10 cause of death among women in the United States. This also is true for African American adult females, ages 18 to 34 years (Centers for Disease Prevention and Control [CDC], 2015). In addition to loss of lives, suicide adversely affects friends and family members of the deceased (CDC, 2014; Cerel, Jordan, & Duberstein, 2008). Most women who attempt suicide have persistent suicidal ideation (Wilsnack, Wilsnack, Kristjanson, Vogeltanz-Holm, & Windle, 2004), a result also documented among African Americans (Joe, Baser, Breeden, Neighbors, & Jackson, 2006). Suicide attempts are a risk factor for death by suicide (CDC, 2013). Thus, research examining correlates of any suicidal behaviors may inform suicide prevention efforts. Such a focus in traditional underresearched populations, such as African American women, also is a worthy endeavor.

Adverse childhood experiences (e.g., emotional, physical, and sexual abuse) markedly increase the risk of suicide attempts (Dube et al., 2001). Among African American women, the more the types of childhood abuse experienced, the greater this risk becomes (Anderson, Tiro, Price, Bender, & Caslow, 2002). The interaction between exposure to adverse events in childhood and adulthood predicts future suicide attempts in African American women (Thompson, Kaslow, & Kingree, 2002).

Childhood sexual abuse (CSA) is the form of childhood abuse that places individuals at the greatest risk for suicidal behaviors, which has been attributed to the associated shame and internal attributions of blame (Brodsky & Stanley, 2008). Given that national estimates indicate that nearly one third of females have experienced sexual abuse or assault by age 17 years (Finkelhor, Shattuck, Turner, & Hamby, 2014), CSA has garnered attention as a risk factor for suicidal behavior (Devries et al., 2014; Maniglio, 2011). This may be particularly true among African Americans, who endorse higher rates of CSA than their White counterparts, particularly if they are from lower socioeconomic backgrounds (Amodeo, Griffin, Fassler, Clay, & Ellis, 2006). CSA results in problems secondary to traumatic sexualization, betrayal, stigmatization, and powerlessness, and these psychological problems may increase risk for suicidal behaviors.

Most studies investigating the CSA-suicidality link have suggested a positive association between these variables among women (Molnar, Berkman, & Buka, 2001; Vaszari, Bradford, O’Leary, Ben Abdallah, & Cottler, 2011). For example, female cocaine users who experienced CSA had 2.51 greater odds of reporting suicidal ideation compared with their counterparts who had not experienced CSA after controlling for covariates (Vaszari et al., 2011). In a national study, women who reported childhood molestation or rape had 1.6 and 2.5 greater odds, respectively, of having made a suicide attempt while controlling for other childhood adversities and covariates (Molnar et al., 2001). However, a recent meta-analysis revealed that although there is a link between CSA and suicide attempts even when various confounders are controlled, the association is heterogeneous (Devries et al., 2014). Of note, we were unable to locate any studies that specifically examined the CSA-suicidality association in African American women.

The strong connection between exposure to CSA and revictimization in adulthood has also emerged in African American women (Banyard, Williams, Siegel, & West, 2002). Of relevance, many CSA survivors also experience sexual assault in adulthood (Classen, 2005; Ports, Ford, & Merrick, 2015), including intimate partner sexual coercion (Daigneault, Hebert, & McDuff, 2009; Messing, La Flair, Cavanaugh, Kanga, & Campbell, 2012). This link also has been found in African American samples (Campbell, Greeson, Bybee, & Raja, 2008). Women who report CSA have a four-to fivefold increase in odds of endorsing sexual intimate partner violence (IPV), after controlling for covariates (Daigneault et al., 2009). Furthermore, sexual IPV in isolation (Weaver et al., 2007) or combined with physical IPV has been associated with suicidal behavior (Ellsberg, Jansen, Heise, Watts, & Garcia-Moreno, 2008; McLaughlin, O’Carroll, & O’Connor, 2012). In an international study, pooled analyses revealed that women who had experienced physical or sexual IPV had 2.9 and 3.8 greater odds, respectively, of lifetime suicidal thoughts or attempts than women with no such histories (Ellsberg et al., 2008). Although data support an overall link between IPV and suicidal behavior among African American women, little research has focused specifically on the sexual IPV–suicidal behavior association.

The interpersonal psychological theory of suicide (IPTS; Joiner, 2005) provides a conceptual framework for the dynamics that increase suicidal ideation for women who are survivors of CSA and sexual IPV. According to the IPTS, one of the three interpersonal-psychological precursors to suicidal behavior in addition to perceived burdensomeness and thwarted belongingness is acquired capability. This construct refers to habituation to pain and fear, which enables one to more readily engage in self-harm. This model posits that challenging life experiences, such as CSA, may elicit pain and fear, and habituation to these distressing experiences may increase one’s threshold (i.e., acquired capability) to engage in suicidal behavior (Joiner et al., 2007; Van Orden et al., 2010). The IPTS typically has focused on suicide attempts or deaths by suicide when considering acquired capability. However, some research has supported its relevance to the contemplation of suicide, namely suicidal ideation, which is a part of the suicidal behavior continuum (Anestis, Bagge, Tull, & Joiner, 2011). Moreover, inspired by Joiner’s work, Klonsky and May (2015) have recently proposed an “ideation to action” framework suggesting that the first step toward suicidal ideation begins with pain. This theory further views the progression from ideation to attempts as facilitated by dispositional, acquired, and practical contributors to the capacity to attempt suicide, which includes sources of pain and fear such as CSA and sexual IPV (May & Klonsky, 2013).

Although CSA and sexual IPV both have been associated with suicidal behavior among women, many studies examining sexual IPV and suicidal behavior have not controlled for childhood trauma (Devries et al., 2013) or other forms of IPV (e.g., Spokas, Wenzel, Stirman, Brown, & Beck, 2009). The lack of well-controlled research challenges the understanding of the role both CSA and sexual IPV have on women’s suicidal behavior. Recent victimization may have a greater influence on current functioning, including suicidal behavior, than more distant victimization like CSA. Indeed, some studies have found that sexual IPV, but not CSA, was associated with suicidal ideation (Bryan, McNaugton-Cassill, Osman, & Hernandez, 2013).

There is a need for such research among African American women. Although they have the lowest rates of suicide among females in the United States (CDC, 2014), suicide is a leading cause of death for 18- to 34-year-olds in this demographic group (CDC, 2015). Additionally, African American women have the highest rates of sexual revictimization (Urquiza & Goodwin-Jones, 1994) and when this occurs, are at elevated risk for suicide attempts (Baca-Garcia et al., 2010). However, few, if any studies examine sexual IPV as a mediator of the CSA-suicidal ideation link.

Thus, consistent with theory and with a sample of low-income African American women, this study was designed to extend the literature in two ways: (1) examine the associations among two potential causes of acquired capability, CSA and sexual IPV in the form sexual coercion, as potential predictors of suicidal ideation and (2) determine if sexual coercion in adulthood mediates the CSA–suicidal ideation association. We hypothesized the following associations in low-income African American women: (1) CSA and intimate partner sexual coercion would both be positively associated with suicidal ideation, (2) CSA would be positively associated with intimate partner sexual coercion, and (3) intimate partner sexual coercion would mediate the association between CSA and suicidal ideation. We tested the aforementioned relations controlling for covariates shown in prior research to be associated with suicidal ideation: age, relationship status, childhood physical abuse and emotional abuse/neglect (Miller, Esposito-Smythers, Weismoore, & Renshaw, 2013), barriers to accessing services, spiritual well-being (Mihaljevic et al., 2011), and self-esteem (Chioqueta & Stiles, 2007).

Method

Participants

The sample consisted of 141 African American women of low socioeconomic status, aged 18 to 56 years (M = 32.71 years, SD = 10.39), who presented to a large public sector hospital for medical or psychiatric reasons. Most were unemployed (88.5%), nearly half (47.5%) reported monthly household income less than $500, and 56.7% classified themselves as homeless. Within the prior year, all participants had attempted suicide and been in a relationship with an abusive intimate partner. Women with significant intellectual or cognitive impairment, as assessed on the Mini-Mental State Examination (MMSE; Folstein, Folstein, McHugh, & Fanjiang, 2001), were excluded. Moreover, they were excluded if they were determined to be functionally illiterate on the Rapid Estimate of Adult Literacy in Medicine (REALM; Williams et al., 1995) or if psychotic symptoms prevented them from completing the assessment battery.

Procedure

The protocol was approved by the institutional review boards of both the university and public hospital where patients participated in the clinical research study. African American women aged 18 to 64 years who presented to the hospital’s medical or psychiatric emergency rooms or outpatient clinics with a history of IPV exposure and a serious suicide attempt (e.g., required medical attention, reported significant suicidal intent) in the prior year were recruited by research assistants to determine their willingness to participate once medically stable. If they did not meet study criteria or were not interested, they received information about community resources and support groups.

Eligible women were assessed within a week of initial screening. Following a written informed consent process, 29 measures were administered verbally by a trained member of the research team. The comprehensive assessment took approximately 2 to 3 hours to complete, and on completion, participants received $20 and a roundtrip fare for the city transit system. Participants excluded during the screening phase were not paid; however, those who met inclusion criteria during the screening phase, but then voluntarily discontinued during the administration of the comprehensive assessment were paid. If at any time during the interview a woman was identified as imminently suicidal or homicidal or severely depressed, manic, or psychotic, she was referred for appropriate evaluation and intervention in addition to remaining in the study. Moreover, a senior research team member was available 24/7 via pager to assist participants in crisis. Additional resources (e.g., GED testing materials) were provided to all participants throughout the study and they were appropriately referred to individual and/or group therapy as well as ongoing medication management with a psychiatrist at the conclusion of the study.

Primary Study Variables

The 28-item Childhood Trauma Questionnaire–Short Form (CTQ-SF; Bernstein et al., 1994) retrospectively assesses 5 types of child maltreatment: physical abuse, emotional abuse, sexual abuse, emotional neglect, and physical neglect. Each subscale contains five questions and three questions assess minimization and denial. Although only the continuous measure of CSA was examined as an independent variable, the other subscales (emotional abuse, physical abuse, emotional neglect, physical neglect) were included as covariates in the analyses. Each item begins with the anchor, “When I was growing up” and respondents indicate on a 5-point Likert-type scale the frequency of a particular incident (1 = never true; 5 = very often true). A sample item on the sexual abuse subscale includes, “Someone tried to touch me in a sexual way or tried to make me touch them.” Convergent validity with interviews on child abuse histories (Bernstein et al., 1994) and solid internal consistency reliability (Bernstein & Fink, 1998) have been found. Moreover, the CTQ-SF has been previously used in samples of African Americans (Lamis, Wilson, Shahane, & Kaslow, 2014; Roy, Roy, & Goldman, 2011). In the current study, coefficient alphas for the sexual abuse, emotional abuse, physical abuse, emotional neglect, and physical neglect subscales were .94, .86, .89, .84, and .76, respectively.

The Conflict Tactics Scales–2 (CTS-2; Straus, Hamby, Boney-McCoy, & Sugarman, 1996) consists of 78 self-report items arranged in 39 item pairs, assessing positive and negative relationship behaviors that may occur in the context of IPV. It includes five subscales to tap abusive behaviors: psychological aggression, physical assault, sexual coercion, positive conflict resolution strategies (negotiation), and outcomes associated with physical forms of abuse (injury). The paired items ask participants to report acts that they have committed toward a partner (perpetration) and acts committed by a partner toward them (victimization). In the present study, we examined the sexual coercion scale inquiring about behaviors committed by a partner toward the women. The sexual coercion victimization subscale consists of seven items that assess an intimate partner having used force, threats, or insisting on sex when the respondent did not want to (e.g., “my partner used threats to make me have sex”). Each response was rated on a scale of 0 to 6 (happened 1 time, 2 times, 3-5 times, 6-10 times, 11-20 times, more than 20 times) and raw responses were summed to reflect the frequency of sexual coercion during the past year. The CTS-2 has been successfully used in various samples of African American women (Fischer et al., 2015; Kocot & Goodman, 2003). There were high correlations between intimate partner sexual coercion and physical assault (r = .82) and psychological aggression (r = .66) in our study. The internal consistency reliability estimate for the sexual coercion scale on the CTS-2 was .89, which is very high.

The Beck Scale for Suicide Ideation (BSS; Beck & Steer, 1991) is a 21-item, self-report questionnaire measuring suicide ideation in the past week. Items provide participants three response options (e.g., “I have no wish to die,” “I have a weak wish to die,” or “I have a moderate to strong wish to die”) and are rated on a scale from 0 to 2, based on intensity. Scores are summed to provide a total score indicative of suicide risk (Brown, 2000). It has good internal consistency reliability across multiple samples (Beck & Steer, 1991; Pinninti, Steer, Rissmiller, Nelson, & Beck, 2002), including African Americans (Leiner, Compton, Houry, & Kaslow, 2008) and strong convergent validity (high correlations with self-reported and clinician rated measures of suicidal ideation and associated symptoms) (Healy, Barry, Blow, Welsh, & Milner, 2006; Lamis & Kaslow, 2014). In this study, the internal consistency reliability estimate was .84.

Covariates

Demographic Data Form

Designed for this project, this tool includes questions about demographics (e.g., age, relationship status, employment status, monthly income) and living situation (homeless vs. not homeless).

The Barriers to Accessing Services Scale (BASS), an 18-item instrument developed for this study, was adapted from a scale assessing barriers to care in HIV/AIDS populations (Heckman et al., 1998) and modified based on findings from studies assessing barriers to care (Fox, Blank, Rovnyak, & Barnett, 2001; Yeh, McCabe, Hough, Dupuis, & Hazen, 2003), including for abused women (Baker, Cook, & Norris, 2003). Participants were asked to what extent specific circumstances make it difficult for them to receive the healthcare services or opportunities they wish to obtain, with response options in a Likert format (1 = no problem, 4 = major problem). Higher scores indicated more barriers to receiving services in the community. In the current study, the reliability coefficient was .88.

The Spiritual Well-Being Scale (SWBS; Paloutzian & Ellison, 1991) determined spirituality level: affirmation of life in relationship with a God (religious well-being) and perception that life has meaning (existential well-being). This 20-item Likert scale includes six response options (strongly disagree to strongly agree), with higher scores indicating higher well-being. Previous studies have found good validity and internal consistency reliability of the total score (Gow, Watson, Whiteman, & Deary, 2011). It has been used with African American women (Lamis, Wilson, Tarantino, Lansford, & Kaslow, 2014). In the current study, its internal consistency reliability was .91.

The Beck Self-Esteem Scale (BSE; Beck, Brown, Steer, Kuyken, & Grisham, 2001) consists of two scales that assess beliefs about oneself (Self) and beliefs about how one is perceived by others (Other). Each scale consists of 18 pairs of semantic-differential adjectives (e.g., smart-dumb, lovable-unlovable) and respondents indicate their evaluation of themselves (Self) and how others would rate them (Other). In the current study, only the BSE Self Scale was used, which consists of a 10-point rating scale (1 = very much, 10 = not very much). To convert self-ratings into values reflecting positive self-esteem, each recorded rating value is subtracted from 11. A total scale is calculated by summing the 18 subtracted ratings; total scores range from 18 to 180. Adequate concurrent validity and internal consistency and test-retest reliability have been demonstrated with the BSE Self scale (Beck et al., 2001). In the current study, the coefficient alpha for the BSE Self scale was .92.

Analysis Strategy

Correlations were analyzed to determine relations among the primary variables. In addition, associations among potential confounding constructs and suicidal ideation were examined. Childhood emotional abuse (r = .27), childhood physical abuse (r = .19), childhood emotional neglect (r = .20), barriers to accessing services (r = .26), spiritual well-being (r = −.49), and self-esteem (r = −.26) correlated with suicidal ideation (p < .05); however, childhood physical neglect (r = .13) was not. Only the covariates found to be significantly related to suicidal ideation were included in the mediation model.

The key hypotheses were evaluated in a single, saturated (i.e., just-identified) path analytic model. The above significant covariates, along with age and relationship status, were modeled as exogenous variables predicting all study variables. Model fit indices are not presented due to the just-identified nature of the model. Mediated paths and total effects were tested as the product of coefficients in a single saturated path model estimated in Mplus v.7.0 (Muthén & Muthén, 1998-2012), using the software’s facility for maximum likelihood estimation in the context of missing data. The null hypothesis is that the sum of the two indirect paths—from the predictor (CSA) to the mediator (sexual coercion) and from the mediator to the outcome (suicidal ideation)—is equal to zero, indicating no indirect effect.

As described in any standard treatment of indirect effects (MacKinnon, 2008; MacKinnon & Tofighi, 2013), the model was a conventional three-variable mediation system, with the addition of the suite of covariates. We tested for the significance of indirect (mediated) effects using the percentile bootstrap with 3,000 draws to generate empirical confidence intervals for the products of the coefficients composing the mediated paths, one of the methods recommended for specific indirect effects. Bootstrapping, a nonparametric resampling technique, has been demonstrated to be robust against normality violations and strongly recommended over casual step approaches to mediation (MacKinnon, 2008; MacKinnon, Cheong, & Pirlott, 2012). Furthermore, bootstrapping procedures yield higher estimates of statistical power, greater control over Type I error rates, and are less sensitive to specification errors (Schumacker & Lomax, 2010). Overall, when compared with more traditional approaches of assessing mediation, the bootstrapping procedure has been shown to be a more powerful and statistically appropriate method.

Results

Descriptive statistics and correlations among the primary study variables—CSA, intimate partner sexual coercion, and suicidal ideation, are presented in Table 1. All bivariate and partial correlations were significant at p < .05 in the expected direction. Although these results support Hypothesis 1 and 2, we further tested the predictive relations among study constructs in the context of the mediational model adjusting for relevant covariates, which were modeled as exogenous predictors of the study variables. The model is diagrammed in Figure 1, with standardized coefficients shown. In the mediational model and consistent with our hypotheses, the path coefficient between CSA and suicidal ideation was significant (b = 1.36, 95% confidence interval [CI] = 0.08-2.49); the path coefficient between CSA and sexual coercion also was significant (b = 1.01, 95% CI = 0.12-1.97); and the path coefficient between sexual coercion and suicidal ideation was significant (b = 0.31, 95% CI = 0.05-0.55).

Table 1.

Correlation Matrix, Means, Standard Deviation, and Ranges of Study Measures.

Variable	1	2	3	4	5	6	7	8	9
1. Childhood Emotional Abuse	—
2. Childhood Physical Abuse	.67**	—
3. Childhood Emotional Neglect	.72**	.66**	—
4. Barriers to Accessing Resources	.34**	.24**	.21*	—
5. Spiritual Well-Being	−.28**	−.17*	−.34**	−.25**	—
6. Self-Esteem	−.24*	−.10	−.34**	−.27**	.42**	—
7. Childhood Sexual Abuse	.45**	.44**	.44**	.14	−.12	−.06	—
8. Intimate Partner Sexual Coercion	.21*	.13	.11	.21*	−.08	−.21*	.24**	—
9. Suicidal Ideation	.28**	.19*	.20*	−.26**	−.49**	−.26**	.27**	.29**	—
M	3.34	2.72	2.94	2.34	81.67	120.53	3.31	5.58	15.06
SD	1.27	1.35	1.15	0.64	19.14	36.97	1.48	7.07	11.82
Range	1-5	1-5	1-5	0.44-4.0	28-125	33-180	1-5	0-25	0-41

Note: N = 141. Tabled values are zero-order correlations.

p < .05; **p < .01.

Figure 1.

Model with standardized regression coefficients depicting sexual coercion as a mediator in the relation between childhood sexual abuse and suicidal ideation.

The primary hypothesis (Hypothesis 3) focused on the mediation of the link from CSA to suicidal ideation through sexual coercion. In the model, the total effect of CSA on suicidal ideation was positive and significant, with a point estimate of 1.67, 95% CI: 0.45-2.81, standardized estimate of 0.21. Consistent with Hypothesis 3, this effect was significantly mediated by sexual coercion, ab = 0.31, 95% CI = 0.001-0.804, which revealed a large effect size for the indirect effect (Fritz, Taylor, & MacKinnon, 2012; Preacher & Hayes, 2011). The confidence interval excluded zero, indicating a significant indirect effect of CSA on suicidal ideation via sexual coercion, supporting the mediation hypothesis. Moreover, the standardized effect size for the indirect effect was 0.04, indicating that suicidal ideation increases by 0.04 SD for every 1-SD increase in CSA indirectly via sexual coercion, after accounting for several important covariates. In other words, African American women sexually abused in childhood were at heightened risk of experiencing sexual coercion in an intimate partner relationship, which in turn, increased their risk for suicidal thoughts.

Discussion

This study advances our knowledge in critically important ways. First, no prior studies have examined the CSA-suicidality link in African American women. The findings confirm the association found in other racial and ethnic groups (Devries et al., 2014) and highlight the significance of CSA as a risk factor for suicidality in African Americans. Second, this investigation extends our understanding of the link between acquired capability and painful experiences, reflected in CSA and sexual coercion during adulthood, and suicidal behavior (Devries et al., 2011; Devries et al., 2014; Eshelman, & Levendosky, 2012; Mclaughlin et al., 2012) through examining a frequently overlooked population, low-income African American women and controlling for covariates including other types of childhood abuse and neglect. Finally, our results confirm the powerful role that trauma experienced in adulthood, such as in the form of sexual coercion, plays in explaining the association between CSA and suicidal ideation.

As hypothesized and consistent with most prior studies with adults (Bedi et al., 2011; Calder, McVean, & Yang, 2010; Chan, Straus, Brownridge, Tiwari, & Leung, 2008; Maniglio, 2011), albeit not all (Nilsen & Conner, 2002), both CSA and intimate partner sexual coercion were associated with suicidal ideation. Moreover, as found in other studies (Classen, 2005; Devries et al., 2014; Kuijpers, van der Knapp, & Lodewijks, 2011; Ports et al., 2015), CSA was positively associated with intimate partner sexual coercion. However, this finding contrasts with data from another investigation that did not find this association to be true after controlling for childhood physical abuse (Desai, Arias, Thompson, & Basile, 2002). This was unexpected as we also controlled for other forms of childhood maltreatment, such as physical abuse, emotional abuse, and emotional neglect.

We found that intimate partner sexual coercion mediated the association between CSA and suicidal ideation, supporting our main hypothesis. Results suggest that African American women who have experienced CSA may be more likely to be involved in a sexually coercive relationship with an intimate partner, which, in turn, may be associated with increased likelihood of suicidal behavior. Thus, studies that report an association between CSA and suicidal ideation without taking into account adult victimization, such as intimate partner sexual coercion, may overestimate the association between CSA and suicidal ideation. The finding builds on an emerging literature that considers mediators of the CSA–suicidal ideation link and has found that psychological symptoms/diagnoses, such as hopelessness, depression, posttraumatic stress disorder, and substance use also may be key mediators (Brabant, Hebert, & Chagnon, 2014; Spokas et al., 2009; McLaughlin et al., 2012). Future investigations that consider a multitude of variables that potentially underlie CSA and the emergence of suicidal ideation are warranted.

There are some noteworthy study limitations. First, this small study used nonrandom sampling strategies to recruit African American woman who had experienced IPV and suicidal ideation within the past year. Therefore, results may not generalize to other populations of women. Second, the cross-sectional design precludes causal statements about the pathways tested. Third, the study was retrospective and relied on self-report of past experiences, so the validity of the data could have been affected by poor or inaccurate recall. Fourth, there are likely additional mediators to explain the CSA–suicidal ideation link (e.g., mental health problems or other types of IPV). It is critical for future research to identify the range of mediators, as these can serve as key intervention targets. Fifth, women who experience intimate partner sexual coercion often endorse other types of IPV and thus, it remains unclear as to which types of IPV mediate the association between CSA and suicidal ideation. Sixth, the measures did not assess the type and duration of CSA and therefore it is not possible to examine the subgroup that may be at highest risk for suicidal ideation. Finally, it is important to note that although guided by the IPTS (Joiner, 2005) and “ideation-to-action” framework (Klonsky & May, 2015), this study is not a test of either model, as many variables integral to these theories were not examined. However, our findings should be viewed as an important preliminary step that points to the relevance of these models for understanding suicide among African American women. Accordingly, future research is needed to fully examine these models to potentially reduce the incidence of suicidal ideation, attempts, and deaths among this high risk population.

Despite the aforementioned limitations, results provide insight into possible clinical strategies when working with African American women. Specifically, low-income African American women who report intimate partner sexual coercion should be screened for both a history of CSA and for past and current suicidal ideation, and those who report suicidal ideation should be screened for both a history of CSA and past or current intimate partner sexual coercion. Those women with a history of CSA, intimate partner sexual coercion, and suicidal ideation can benefit from interventions that build upon the IPTS (Joiner et al., 2009) and “ideation-to-action” framework (Klonsky & May, 2015) and are designed for suicidal African American women, such as the Grady Nia Project (Davis et al., 2009; Kaslow et al., 2010). These interventions would focus on interpersonal violence in both childhood and adulthood as potential vulnerability factors for suicidal ideation and behavior. For example, this might include dialectical behavior therapy techniques that discourage involvement in painful and provocative experiences, such as interactions with abusive individuals, and encourage engagement in effective and planful problem solving (Linehan, 2015). Pertinent Grady Nia Project interventions would be those devoted toward increasing the women’s understanding of the link between violence and suicidal behavior, reducing their social and situational risk factors (e.g., long-term impact of CSA, involvement in sexually coercive intimate relationships) and enhancing their social and situational protective factors (e.g., family and social support).

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by grants from the Centers for Disease Control and Prevention National Center for Injury Prevention and Control (R49 CCR421767-01, Group interventions with suicidal African American women) and the National Institute of Mental Health (1R01MH078002-01A2, Group interviews for abused, suicidal Black women) awarded to the last author (Kaslow).

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