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Suicide and Life-Threatening Behavior © 2017 The American Association of Suicidology DOI: 10.1111/sltb.12332

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The Association Between Gender, Ethnicity, and Suicidality Among Vocational Students in Israel JOY BENATOV, PHD, ORA NAKASH, PHD, SHAI CHEN-GAL, PHD, KLOMEK, PHD

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ANAT BRUNSTEIN

Gender and ethnicity are significant factors when evaluating suicidal risk, especially among ethnically diverse populations. In the current study we explored the association between gender, ethnicity, and suicide ideation and attempts among Arab and Jewish vocational education and training high school students in Israel. Students (N = 3,554) completed a self-report survey evaluating suicide ideation and attempts, depression, anxiety, somatization, and sense of belonging. Hierarchical generalized linear modeling indicated that female Arab adolescents had elevated levels of suicide ideation, higher rates of suicide attempts, and greater psychological distress than Arab males and Jewish students. Furthermore, female Arab adolescents were found to be more susceptible to suicide ideation when depression levels were high. These results are discussed in the context of the double-jeopardy Arab young women face, as members of a minority ethnic group in Israel and their status as women within the patriarchal Arab culture.

Suicide is a leading cause of death among adolescents (World Health Organization, 2014) and its prevention is a top priority. However, suicide is a highly complex phenomenon that is influenced by many factors. Research has identified suicide ideation, suicide attempts, depression, anxiety, and somatization as significant risk factors for suicide (Berk & Asarnow, 2014; Fergusson, Woodward, & Horwood, 2000). Gender plays an important role in the prediction of suicidality as well, in that males show higher suicide rates than females, although the reverse trend has been documented for suicide ideation and attempts (Canetto &

Sakinofsky, 1998). One interpretation that has been attributed to these gender differences is that suicidal behavior among females may more often serve as means to communicate distress rather than an actual intent to die (Nock & Kessler, 2006). Culture has also been identified as an important component in understanding suicidality and its trajectories (Chu, Goldblum, Floyd, & Bongar, 2010; Goldston et al., 2008; Nakash, Barchana, Liphshitz, Keinan-Boker, & Levav, 2013; Nakash, Liphshitz, Keinan-Boker, & Levav, 2013). Cultural values and attitudes toward distress and suicide play a key role in the

JOY BENATOV, Psychology, College of Management Academic Studies, Rishon LeZion, Israel; ORA NAKASH, School of Psychology, Interdisciplinary Center (IDC) Herzliya, Herzliya, Israel; SHAI CHEN-GAL, Psychology, Tel Aviv University, Tel Aviv, Israel; ANAT BRUNSTEIN

KLOMEK, School of Psychology, Interdisciplinary Center (IDC) Herzliya, Herzliya, Israel. Address correspondence to Joy Benatov, Psychology, College of Management Academic Studies, Rishon LeZion, eli visel 2, Rishon LeZion 75190, Israel; E-mail: [email protected]

2 pathways leading to suicide (Chu et al., 2010). Cultural norms concerning gender issues also influence experienced stress, thus making the intersectionality between gender and culture a locus of valuable insights into suicidal risk among ethnically diverse populations (van Bergen, Eikelenboom, Smit, van de Looij-Jansen, & Saharso, 2010; Langhinrichsen-Rohling, Friend, & Powell, 2009). For example, van Bergen et al. (2010) examined suicidal behavior among minority young women in the Netherlands. Surprisingly, Moroccan females had lower suicide attempt rates than Dutch female adolescents, whereas female adolescents from other minority groups (Turkish and South Asian Surinamese) had higher rates than Dutch females. Therefore, although female adolescents belonging to ethnic minority groups tend to have higher rates of suicide attempts which are ascribed to lower socioeconomic status and culturally unfavorable family factors, Moroccan females were the exception. The authors suggested that processes of social change leading to women’s increased emancipation and autonomy in Moroccan communities could account for the findings (van Bergen et al., 2010). The importance of considering both gender and ethnicity is also eminent when examining suicidality in the United States, a highly multicultural society. For instance, African American females have the lowest suicide rate in the United States, whereas the rates for African American males are similar to those of males from other minority groups (Goldston et al., 2008; Langhinrichsen-Rohling et al., 2009). It has been suggested that African American females in particular have greater access to familial and community protective factors (Nisbet, 1996). Hence, cultural variables may have a differential effect on gender, which highlights the importance of evaluating mental distress and suicidality for both genders within each ethnic group. I the current study we focused on suicide risk factors in two distinct ethnic groups in Israel: Arabs

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and Jews, while accounting for gender differences as well.

SUICIDE AND ETHNICITY IN ISRAEL

The Israeli population is comprised of two major culturally and religiously distinct groups: a Jewish majority (75%) and an Arab minority (21%) (Israel Central Bureau of Statistics [CBS], 2014). The Arab minority group is in itself heterogeneous and is comprised of mostly Arab Muslims (72%), including Bedouins that were originally nomadic tribes of Muslims (20%), Christians, and Druze (each about 8%–9%). These groups differ in many respects, including religious beliefs and practices as well as attitudes toward women and suicide (Brunstein Klomek et al., 2016, CBS, 2014; Gal et al., 2012). Among members of the Arab minorities in Israel, unemployment rates are higher and formal education levels are lower compared to their Jewish majority counterparts (CBS, 2015). Although the percentage of minority youth attending institutions of higher education has been rising in recent years, Arab students are still underrepresented in colleges and universities in Israel (CBS, 2015). Furthermore, although differences in status between men and women exist in all societies, the gap is greater in the Arab than the Jewish sectors in Israel (Ibrahim, 1998). For example, Arabs tend to endorse more traditional gender-role attitudes (Cinamon, 2009; Feldman, Masalha, & Nadam, 2001), patriarchal patterns of authority, and conservative sexual standards (Abudabbeh, 1996). Several studies have evaluated the prevalence of suicide (Gal et al., 2012; Levav & Aisenberg, 1989), suicide attempts (Gal et al., 2012; Harel-Fisch, Abdeen, Walsh, Radwan, & Fogel-Grinvald, 2012; Kohn, Levav, Chang, Halperin, & Zadka, 1997), and suicide ideation (Harel-Fisch et al., 2012) among Arabs and Jews in Israel. Overall suicide rates in the Arab population were lower than for the Jewish population

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(Kohn et al., 1997; Lubin, Glasser, Boyko, & Barell, 2001; Morad, Merrick, Schwarz, & Merrick, 2005), whereas suicide ideation was higher (Barzilay et al., 2015; Gal et al., 2012; Goldberger, Aburbeh, & Haklai, 2014; Harel-Fisch et al., 2012). This disparity is suggestive of the complexity of suicidality among Arabs in Israel. The lower prevalence of completed suicides among Arabs has been attributed to the stronger social ties and collectivist values characterizing Arab society (Hamdan et al., 2012; Morad et al., 2005), in addition to leading a more religious way of life, as compared to the Jewish population (Hamdan et al., 2012). Moreover, suicide may be more underreported in Arab society due to its heavy associated stigma (Bursztein & Apter, 2009; Gal et al., 2012). Nevertheless, despite the fact that religiosity and social ties may serve as protective factors, depression, suicide ideation, and other variables indicative of psychological distress are higher among Arabs in Israel (Abu-Kaf & Braun-Lewensohn, 2015; Kaplan et al., 2010). Importantly, gender serves as a moderating factor in suicidality among members of the Arab minority in Israel, thus suggesting that the study of the intersectionality between gender and ethnicity with regard to suicide is imperative. A recent study examining suicide rates in the Arab Israeli population found young male Druze to have the highest suicide rate (8.7 per 100,000) compared to both other Arab groups and the total Israeli population (Brunstein Klomek et al., 2016). Among women, no significant differences were observed. The authors attributed this finding to elevated stress and accessibility to firearms during military service, which is mandatory for Druze men (and not for women) while voluntary for other Arab groups. An elevation of suicide rates in the age group of youth serving in the military has been noted in the Jewish population as well (Kohn et al., 1997). Among Arab young women (15-24 years of age), suicide attempts have been rising notably in recent years and now exceed those of

3 Jewish women (Goldberger et al., 2014; Harel-Fisch et al., 2012). Overall, suicide rates in the Arab Israeli population have risen moderately in recent years, thus reinforcing the need to study suicidality in this population (Morad et al., 2005). In the current study, we explored gender differences among Jewish and Arab adolescents in Israel while focusing on a unique population of vocational education and training students. Vocational High Schools in Israel The Ministry of Economy and Industry operates 62 vocational education and training (VET) high schools throughout Israel. These high schools are unique in the educational setting in Israel since they provide both practical training in workplaces (e.g., nursing, electronic engineering, car mechanics, electricity, cooking) and theoretical knowledge. According to the Ministry of Economy and Industry, over 50% of the graduates are integrated in the labor market in their vocational field (Ministry of Economy and Industry, 2013). Therefore, students who wish to pursue vocational training during their high school years and students struggling with school who are at risk of dropping out from the general education system are referred to VET schooling. Approximately, 4% of all high school students attend these schools. In 2014, roughly 13,000 students attended VET high schools, of whom 45% were Arabs and 55% were Jews. Very few studies have examined the mental health of VET students. To the best of our knowledge, there have been only four studies examining suicide ideation and attempts among VET students (Dalen, 2012; Silviken & Kvernmo, 2007; Tandon, Marshall, Templeman, & Sonenstein, 2008; Tsai, Chen, Chen, Hsiao, & Chien, 2011). The findings are inconsistent with regard to whether VET students present higher rates of suicide ideation and attempts than students in the general education system. This is not unexpected since VET education

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systems and the population attending them differ considerably across countries. A study conducted in a secondary school in a Norwegian county found VET students to have an elevated suicide risk (Dalen, 2012); by contrast, a study conducted in the United States (Baltimore) found VET students to have a lower suicide risk compared to nonVET students (Tandon et al., 2008). Studies that have addressed gender differences report results that are aligned with trends in the general population; namely, that females report higher rates of suicide ideation and attempts than males (Tandon et al., 2008; Tsai et al., 2011). A study of Norwegian adolescents found vocational studies to be a risk factor for suicide attempts among majority Norwegian adolescents, but not among indigenous Sami adolescents (Silviken & Kvernmo, 2007). However, no study has examined both ethnicity and gender among VET students with regard to suicidality. The current study is thus the first to examine the association among gender, ethnicity, and suicide ideation and attempts among students attending the VET system in Israel. In addition, several risk factors (depression, anxiety, and somatization) and a single protective (sense of belonging) factor were explored. We hypothesized that belonging to two disadvantaged groups would significantly increase suicide risk. Specifically, we expected minority females to report the highest rates of suicide ideation and attempts. In addition, we hypothesized that female Arab minority adolescents would report higher levels of somatization, depression, and anxiety and a diminished sense of belonging than either Arab males or Jewish students of both genders.

METHOD

Participants The sample was composed of all 10th grade classes and two 11th grade classes (randomly sampled) from each of the 62

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VET schools run by the Ministry of Economy and Industry (total sample size = 3,954). The sample included 30% of the total population of VET students, which was 13,000 in 2014. Participants completed questionnaires in Hebrew or Arabic according to the student’s native language. Due to missing data, the final number of students included in the data analysis was 3,554 accounting for a response rate of 90%. The remaining 10% were administered the survey but did not answer substantial parts of it and were therefore not included. The participants’ socio demographic information is described in Table 1. A majority of students were boys (n = 2,832, 79.7%), and 52% (n = 1,853) were Arabs. The students’ ages ranged from 13 to 20 (M = 15.42, SD = .97). The majority of the students reported that their parents were living together (81.6%) with an average or above socioeconomic status (94.2%). The study was approved by the educational committee of the Ministry of Economy and Industry. Parental consent and students’ TABLE 1

Socio demographic Information of the Sample of Vocational Education High School Students in Israel (N = 3,554)

Gender Males Females Grade Tenth Eleventh Ethnic–religious Jews Arabs Economic status Below average Average Above average Well above average Family status Parents living together Parents living apart Age (M, SD)

n

%

2,832 722

79.7 20.3

2,395 1,159

67.4 32.6

1,701 1,853

48 52

213 746 1,358 1,237

6 21.3 38.2 34.5

2,900 654 15.42

81.6 18.4 .97

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agreement were obtained prior to administering the survey. Measures Socio demographic information as reported by the students included gender, age, family status (parents living together or apart), family’s socioeconomic status (below average, average, above average, high beyond average), and ethnicity (Jewish, Arab). Suicide ideation and suicide attempts were based on the “The Saving and Empowering Young Lives in Europe” (SEYLE) study. The questions were based on the Paykel Suicide Scale (PSS; Paykel, Myers, Lindenthal, & Tanner, 1974). We used two questions. The suicide ideation item was as follows: “During the past 2 weeks, did you seriously consider attempting suicide? (no/ yes).” The item regarding suicide attempts was as follows: “During the past 3 months, did you attempt suicide? (no/yes).” Psychological distress was measured using the short version of the Brief Symptoms Inventory (BSI-18; Derogatis, 2000). This version includes a total of 18 items divided into three subscales: depression (e.g., “feeling no interest in things”), anxiety (e.g., “feeling tense or keyed up”), and somatization (e.g., “nausea or upset stomach”). Each item was rated on a five-point scale ranging from not at all (1) to very much (5). The final score on each scale was calculated as the mean of the items comprising the subscale. One item from the depression scale addressing “thoughts about ending your life” was omitted since it was redundant with our dependent variable of suicide ideation. Internal consistency was good for all three subscales (Cronbach’s a for depression = .73, anxiety = .73, somatization = .78). Sense of belonging to the class was measured using the belonging subscale from the Optimal Educational Climate questionnaire (Erhard, 2000), developed by the Israeli Ministry of Education. It is made up of eight items (e.g., “I can count on my classmates to help me in times of need”) each rated on five-point Likert scale,

5 ranging from 1 (not at all true) to 5 (very true). The total score was computed by averaging the item scores. This measure showed high internal consistency in the current sample (Cronbach’s a = .83). Statistical Analysis Differences between the two ethnoreligious groups were examined using v2 test for categorical variables (suicide ideation and attempts) and t test for continuous variables. Gender differences within each ethnic group were evaluated in a similar manner. These analyses were performed using SPSS version 20.0 for Windows. In order to examine the unique effect of each of the independent variables and the possible interactions between ethnicity and risk and protective factors on suicide ideation and attempts, we employed a multilevel modeling analysis (MLM; Raudenbush & Bryk, 2002). Since the data were hierarchically nested, we used MLM, which controls for between-school variance while assessing the associations between the variables. Specifically, we employed hierarchical generalized linear modeling (HGLM), which is appropriate for binary outcomes using a Bernoulli estimation. In the first step, the socio demographic variables (i.e., gender, age, family status, family economic status, religion–ethnicity) were entered; in the second step, the risk and protective factors (i.e., depression, anxiety, somatization, belonging) were entered; in the third step of the regression, the two-way interactions between religious ethnicity and the risk and protective factors were examined; and in the fourth and final step, the three-way interactions were entered. The MLM equations were computed using hierarchical linear model (HLM) software version 7.

RESULTS

Overall, substantial suicide ideation and attempts rates were observed among VET students. In particular, 8.6% of the

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Arab and 3.6% of the Jewish students reported seriously considering suicide in the last 2 weeks. Seven and a half percent and 2.2% of the Arab and Jewish students, respectively, reported attempting suicide in the last 3 months. Comparison between the two ethnic groups revealed Arab students had higher rates of suicide ideation and attempts, and had higher levels of depression, anxiety, and somatization than the Jewish students. Interestingly, the Arab students reported higher levels of belonging than their Jewish counterparts (Table 2). Comparison between girls and boys within each ethnic group revealed that Arab girls reported more than twice the rates of suicide ideation and attempts than Arab boys. Their levels of depression, somatization, and anxiety were higher as well, compared to their male counterparts. Jewish girls, however, did not differ in suicide ideation and attempts rates from Jewish boys (Table 2), but did report higher depression, anxiety, and somatization levels than Jewish boys. In addition, girls reported higher levels of belonging compared to boys in both ethnic groups (Table 2).

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prediction of suicide ideation. Depression doubled the odds of experiencing suicide ideation, while somatization and anxiety increased these odds by over 50%. In contrast, sense of belonging decreased the odds of experiencing suicide ideation by 30%. Furthermore, the suicide ideation predictive model revealed a significant two-way interaction effect for gender 9 depression. However, the interaction between gender and depression without taking ethnicity into account may be misleading since major gender variations were found between the two ethnic groups and therefore the interaction was not further explored. Instead, a more precise reflection of the data was embedded in the threeway interaction found for gender, ethnicity, and depression. Namely, at low levels of depression, females from both ethnic groups had slightly higher suicide ideation rates compared to boys in their respective groups. However, at high levels of depression, Arab girls reported drastically higher rates of suicide ideation compared to Arab boys, whereas Jewish girls’ suicide ideation rates remained relatively low and did not differ from Jewish boys rates (Figure 1).

Suicide Ideation Suicide Attempts The hierarchical regression model revealed several factors to have a significant contribution to the prediction of suicide ideation. The presents coefficients of the final regression model, including all study variables, are presented in Table 3. Previous steps of the model did not distinctively differ and therefore were not presented separately. As can be seen in Table 3, among the background variables, being female, Arab, and having a lower economic status predicted higher rates of suicide ideation. Specifically, being female or Arab nearly doubled the odds of experiencing suicide ideation. By contrast, coming from a higher economic status decreased the odds of experiencing suicide ideation by 40%. As for the psychological distress factors, each factor was found to have a unique significant contribution to the

Several factors were found to have a significant contribution to the prediction of suicide attempts. The coefficients of the final regression model are presented in Table 4. As can be seen in the table, being female, Arab, and having a lower economic status predicted higher rates of suicide attempts. Specifically, being Arab triples the odds of attempting suicide and being female doubled these odds. By contrast, coming from a higher economic status decreased the odds of attempting suicide by half. As for the psychological distress factors, each factor was found to have a unique significant contribution to the prediction of suicide attempts. Anxiety had the strongest predictive contribution, as it increased odds for attempting suicide over two and a half times. Depression increased odds for

Boys (n = 1,378)

*p < .05, **p < .01, ***p < .001.

Suicide ideation No 1,639 (96.4%) 1,331 (96.6%) Yes 62 (3.6%) 47 (3.4%) Suicide attempts No 1,663 (97.8%) 1,347 (97.8%) Yes 38 (2.2%) 31 (2.2%) Depression 1.58 (.68) 1.53 (.64) Anxiety 1.59 (.52) 1.54 (.48) Somatization 1.47 (.61) 1.43 (.57) Belonging 3.32 (.89) 3.30 (.88)

Total (n = 1,701)

Statistic Gender Comparison

316 7 1.77 1.81 1.65 3.41

(97.8%) (2.2%) (.81) (.61) (.72) (.90) t t t t

= = = =

Boys (n = 1,455)

(92.5%) 1,373 (94.4) (7.5%) 82 (5.6%) (.78) 1.66 (.72) (.61) 1.61 (.51) (.67) 1.47 (.61) (.96) 3.40 (.98)

Statistic Gender Comparison

Statistic Ethnic Comparison

341 57 2.08 2.12 1.79 3.58

(85.7%) (14.3%) (.89) (.73) (.81) (.88)

t t t t

= = = =

8.73*** 13.04*** 7.64*** 3.66***

t t t t

= = = =

6.94*** 6.91*** 3.1** 3.67***

X2 = 33.98*** X2 = 52***

336 (84.4%) X2 = 30.97*** X2 = 37.7*** 62 (15.6%)

Girls (n = 398)

Arab Students in VET

1,693 (91.4%) 1,357 (93.3%) 160 (8.6%) 98 (6.7%)

Total (n = 1,853)

1,714 139 5.01*** 1.75 7.41*** 1.72 5.17*** 1.54 2.04* 3.44

X2 = .01

308 (95.4%) X2 = 1.13 15 (4.6%)

Girls (n = 323)

Jewish Students in VET

Prevalence of Suicide Ideation, Suicide Attempts, and Levels of Risk and Protective Factors by Ethnic Group and Gender (N = 3,554)

TABLE 2

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TABLE 3

Multilevel Hierarchical Logistic Regression Models Predicting Suicide Ideation Suicide Ideation

Gender Age Economic status Family status Minority Somatization Depression Anxiety Belonging Depression 9 Minority Depression 9 Gender Minority 9 Gender Depression 9 Minority 9 Gender

B

SE

OR

95% CI

.67*** .17 .48*** .14 .71*** .45*** .71*** .54*** .38** .29 .49* .58+ (p = .09) 1.29**

.15 .08 .09 .19 .20 .08 .13 .17 .10 .22 .19 .42

1.95 .84 .62 1.15 2.04 1.56 2.02 1.67 .68 1.43 .61 1.79

1.45–2.65 .71–1.01 .51–.74 .79–1.67 1.38–3.02 1.32–1.85 1.58–2.59 1.24–2.39 .54–.87 .87–2.09 .42–.89 .91–3.52

.47

3.63

1.45–9.01

+ p < .10, *p < .05, **p < .01, ***p < .001; Gender: 0 = male, 1 = female; Minority: 0 = majority, 1 = minority.

30.00%

26.60%

SI prevelance

25.00% 20.00% 14.40%

15.00%

Minority–Arab

10.00% 5.00%

2.40% 1.50%

Majority–Jews

7%

6.10%

4.90%

4.40%

0.00% Boys

Girls

Low Depression

Boys

Girls

High Depression

Figure 1. Suicide ideation (SI) prevalence for low and high levels of depression by gender and ethnicity.

attempting suicide by 48% and somatization increased these odds by 37%. Sense of belonging decreased the odds of attempting suicide by 34%.

Furthermore, the suicide attempt predictive model revealed a significant two-way interaction effect for gender 9 minority and gender 9 depression.

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TABLE 4

Multilevel Hierarchical Logistic Regression Models Predicting Suicide Attempts Suicide Attempts

Gender Age Economic status Family status Minority Somatization Depression Anxiety Belonging Depression 9 Minority Depression 9 Gender Minority 9 Gender Depression 9 Minority 9 Gender

B

SE

OR

95% CI

.71*** .07 .48*** .16 1.11*** .32* .39** 1.01*** .42** .34 .48* .94* .82+ (p = .09)

.18 .08 .10 .25 .23 .10 .14 .17 .13 .23 .21 .47 .46

2.02 1.07 .61 1.18 3.05 1.37 1.48 2.75 .66 1.41 .62 2.55 2.27

1.43–2.86 .91–1.26 .50–.75 .72–1.94 1.93–4.81 1.14–1.66 1.17–1.96 1.97–3.86 .51–.85 .90–2.21 .41–.94 1.01–6.49 .88–5.89

+ p < .10, *p < .05, **p < .01, ***p < .001; Gender: 0 = male, 1 = female; Minority: 0 = majority, 1 = minority.

The gender 9 minority interaction effect goes to show that gender was differentially associated with suicide attempts among the two ethnic groups. Specifically, as can be seen in Table 1, Arab girls’ suicide attempt rates were distinctly higher (14.3%) compared to Arab boys’ (5.6%) rates, while no gender differences were evident among Jewish students (2.2% boys; 2.2% girls). The two-way interaction effect for gender 9 depression was not further interpreted for reasons mentioned earlier, as not taking ethnicity into account yields a partial representation of the data. The three-way interaction for gender, ethnicity, and depression was close to significance (p = .09) for suicide attempts and its pattern was similar to that found for suicide ideation.

DISCUSSION

This is the first study to examine the associations among gender, ethnicity, and suicide ideation and attempts among VET students in Israel. Results confirmed that both ethnicity and gender were significantly associated with suicide ideation and

attempts. However, the associations between gender and suicide ideation and attempts differed between the ethnic groups. Interestingly, Arab girls exhibited higher levels of suicide ideation and attempts than Arab boys, but no such differences were found among Jewish students. Furthermore, Arab girls were found to be susceptible to depression, such that in the case of high levels of depression, their suicide ideation and attempts rates significantly increased compared to their male counterparts. In line with previous studies (Harel-Fisch et al., 2012), the results indicated that young Arab women experience significantly more psychological distress (depression, anxiety, and somatization) than Arab boys or Jewish students. Young Arab women are a particularly vulnerable population who are exposed to the double jeopardy associated with their status as an ethnic minority group in Israel and being female. Therefore, they may be exposed to stressors associated with their disadvantaged social status, such as experiences of discrimination (Semyonov & Yuchtman-Yaar, 1988), as well as culturespecific stressors due to women’s status in

10 society in general and in Arab society in particular. Although Arab society is undergoing some changes, it is still highly patriarchal (Abudabbeh, 1996) and women are expected to comply with male authority (Buchbinder & Karayanni, 2015). Furthermore, Arab social norms are more dismissive of psychological difficulties (Al-Krenawi, 1999; Hamdi, Amin, & Abou-Saleh, 1997), with studies documenting the underutilization of mental health services among Arabs and especially Arab women compared to the Jewish population (Al-Krenawi, 2002). Altogether, young Arab women may be exposed to more stressors but have limited means for expressing their distress and receiving appropriate mental health services. As a result, they may be more vulnerable to suicide ideation and behavior which may serve as a channel for expressing distress. Interestingly, contrary to our prediction, Arab girls had a higher sense of belonging, which may indicate that the source of their distress is not within the VET schools. Our findings highlight that belonging to multiple disadvantaged groups may substantially increase suicidal risk. A similar effect was observed in a study examining the intersectionality of sexual orientation and race with regard to suicide ideation and attempts among college students in the United States (Shadick, Dagirmanjian, & Barbot, 2015). Shadick et al. (2015) found that students belonging to two minority groups by being both homosexual and nonWhite had a considerably higher suicide risk compared to each of the other groups. In contrast to the robust empirical finding that women report higher levels of suicide ideation and attempts than men (e.g., Langhinrichsen-Rohling et al., 2009), no differences in suicide ideation and attempt rates were observed between girls and boys among Jewish students. One explanation for this might have to do with the specific status of Jewish girls in the Israeli VET high schools. Jewish girls are extremely underrepresented in the VET educational system, and comprise only 10% of the VET student population. Since this

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subpopulation is rare within the VET schools, they may enjoy special organizational support and attention. Moreover, the overall rate of suicide ideation and attempts among VET students was lower compared to students in the general education system for both Jewish and Arab students. Harel-Fisch et al. (2012) examined suicidality among Israeli Jewish and Arab 10th grade high school students in the regular education system and reported suicide attempt rates to be 7.8% and 17.7% among Jews and Arabs, respectively, and suicide ideation rates to be 7.4% and 20.5%, respectively. Harel’s figures are higher than the results reported here. Hence, VET students may be at lower suicidal risk than their counterparts in the regular education system. This finding is consistent with Tandon et al.’s (2008) study that found a lower prevalence of suicide ideation and attempts among VET students in Baltimore who had dropped out of traditional high schools compared to their in-school counterparts. However, the study also revealed that VET students exhibited higher levels of violence, tobacco, and marijuana usage. Therefore, in order to better understand the emergence of mental distress among this unique youth population, it would be beneficial in future studies to evaluate a broader spectrum of risk behaviors such as alcohol and drug consumption, smoking, truancy, and bullying.

LIMITATIONS

This study was cross sectional and therefore causality cannot be inferred. In addition, all measures were based on selfreport. Furthermore, Arab society is comprised of diverse subgroups (Muslims, Druze, Christians), which although sharing much in common, each still maintains different norms and attitudes toward women and mental health. In the current study, all subgroups were collapsed due to the limited sample size of some of the groups (Levav et al., 2007). Furthermore, it should be noted that perceived minority status as

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experienced by each individual is potentially an important factor and was not measured in the current study. Future studies should examine perceived minority status as well as culture-specific factors such as social support, attitudes toward women, and perception of discrimination.

CONCLUSIONS

Young Arab women present higher levels of psychological distress (i.e., depression, anxiety, somatization) and are at

11 elevated risk of experiencing suicide ideation and attempting suicide, especially when their depression levels are high. The VET education system should pay special attention to minority female students and find constructive ways to relieve their distress and empower them. Researchers and practitioners are advised to take ethnicity, culture, and gender into account when examining suicidal tendencies, as they are important for an integrative and a more profound understanding of psychological distress and its transition to suicidality.

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