Core Concepts for Grief-Sensitive Care
Disparities in Grief
While grief is a universal human experience, some populations are more likely to be exposed to multiple ongoing losses, which can increase the likelihood of repeated or layered grief experiences.
Loss Is Not Equally Distributed
Some examples of disparities in grief include:
- American Indian and Alaska Native adults have among the highest age-adjusted death rates in the U.S., exceeding 870 deaths per 100,000 people.
- American Indian and Alaska Native populations experience life expectancy that is approximately 6 to 8 years shorter than the U.S. average.
- Black adults in the U.S. experience all-cause mortality rates approximately 24% higher than White adults.
- Black and Indigenous women are approximately 3 to 4 times more likely to die from pregnancy-related causes compared to White women
- Non-Hispanic Black adults in the U.S. experience age-adjusted cardiovascular mortality rates that are approximately 25–30% higher than those of non-Hispanic White adults.
- Black and Native American infants are more than twice as likely to die than White infants in the U.S.
- Transgender adults enrolled in private insurance were nearly twice as likely to die during the study period compared to non-trans adults
- Among adults with intellectual and developmental disabilities, non-Hispanic White individuals live an average of 9 to 12 years longer than peers from other racial and ethnic groups.
- 65% of children orphaned by COVID-19 in the U.S. were from racial or ethnic minorities.
- Black individuals had a 1.68 times higher mortality rate from COVID-19 compared to White individuals
- All-cause mortality among American Indian and Alaska Native populations increased by approximately 45% during the COVID-19 pandemic, the largest rise of any racial or ethnic group.
Socioeconomic status, shaped in part by structural inequities related to race, ethnicity, and disability status, is associated with differences in health and longevity.
Adults with lower income are estimated to have a 70 to 80 percent higher risk of all-cause mortality compared with higher-income peers.
These disproportionate patterns reflect deep rooted inequities that can shape who is more likely to experience repeated, early, or cumulative losses. Repeated exposure to loss, instability, discrimination, or community trauma can also create chronic stress burdens that affect physical and emotional health over time.
Earlier and More Frequent Exposure to Loss
Children from marginalized backgrounds are more likely to experience loss earlier in life and more frequently over time.
- Black and Brown children are approximately 2× more likely to lose a father and 3× more likely to lose a mother before young adulthood compared to White peers
- Indigenous children (American Indian / Alaska Native) experience caregiver death at nearly 4× the rate of White children, particularly during the COVID‑19 era
- Black and Hispanic youth face roughly twice the lifetime risk of parental death by age 18 compared to their White counterparts (14.0% vs. 6.0%)
Ongoing exposure to threats such as violence, discrimination, or structural injustice can also mean that conversations about death and personal safety arise earlier than they often do for peers from more privileged groups.
The first death that White parents are likely to talk to their children about is a family pet’s or an elderly grandparent’s. The first death Black parents talk to their children about is their children’s own.
Grief that begins early and recurs often can shape a child’s development, identity, and worldview. Premature and repeated family member bereavement has been associated with increased long term risks for mental and physical health conditions and earlier mortality, making cumulative loss an important context for grief sensitive care.
Grief, Learning, and Long-Term Outcomes
Because children often express grief differently than adults, their responses may be misunderstood, overlooked, or interpreted as behavioral concerns. In some cases, normal grief responses may be labeled as “problem behavior,” which can contribute to negative expectations and increased risk of misidentification or misdiagnosis. These patterns may shape how children are perceived and supported over time.
"Bereavement is the strongest predictor of poor school outcomes above and beyond any other form of trauma, including childhood physical or sexual abuse and/or witnessing domestic violence"
Bereaved youth are also disproportionately represented in the juvenile justice system. Research indicates that most detained youth report the death of a close loved one, with more than 70 percent having experienced two or more significant losses.
The Myth of Apathy
When a person has experienced cumulative grief, emotional capacity can become strained or overwhelmed. Guardedness or reduced expression may reflect adaptation to chronic stress, repeated grief exposure, or environments where emotional expression has not felt safe or supported. Interpreting this presentation as apathy or desensitization can be inaccurate and harmful.
In this clip, courtesy of WPSU, Dr. Tashel Bordere explains how what may look like emotional distance is often a strategy for survival rather than an absence of care or feeling.
These stereotypes can obscure real grief, limit access to support, and shape how young people are treated across systems.
Dr. Tashel Bordere coined the term Suffocated Grief to describe when grieving individuals, especially from marginalized communities, are punished or silenced for expressing grief. Often misinterpreted as defiance or dysfunction, this grief is pathologized instead of supported.
Examples:
- A teen whose anger or withdrawal after a loss is labeled as behavioral rather than recognized as grief
- A patient whose expressions of distress after loss are interpreted as noncompliance or hostility.
Grief-Related Bias Is Not Age-Specific
Noncompliant
Uncooperative
Hostile
Resistant to care
Defensive
Children and teens are not the only age group whose grief can be misinterpreted. In clinical settings, survival responses may be labeled as nonadherent, uncooperative, agitated, hostile, or resistant to care. These interpretations can shape how individuals are perceived and treated and may increase the risk of misunderstanding, missed needs, or inadequate support.
Bias, Grief, and Equity in Healthcare
When grief responses are misinterpreted, they have the potential to exacerbate existing biases, further influencing how patients are perceived, treated, and supported. Examples of existing bias include:
Race and Ethnicity
Research consistently shows that patients from marginalized racial and ethnic groups are more likely to experience lower-quality care and face greater barriers to accessing services. Studies demonstrate implicit preference for White patients over Black, Indigenous, and other people of color, with documented effects on empathy, pain management, communication, and referral patterns.
Gender
Women are more likely than men to report being ignored or dismissed, with 20 percent feeling dismissed and 17 percent reporting differential treatment based on gender. Among nurses, studies have found strong implicit preference for cisgender patients over transgender or nonbinary individuals, despite stated commitments to affirming care.
Age
About one in five adults over age 50 report experiencing ageism in healthcare settings, including having symptoms dismissed or attributed to aging rather than assessed clinically.
Disability
Adults with disabilities report unfair treatment at nearly twice the rate of nondisabled peers, with roughly 40 percent describing negative healthcare experiences.
People with disabilities are often not recognized as a health disparity population, yet they may face structural barriers related to access, income, education, transportation, and inclusive care. These barriers can contribute to higher rates of chronic conditions, preventable complications, and earlier mortality. Recognizing disability as a dimension of health equity can support more accessible, inclusive, and equitable healthcare.
These patterns can contribute to misdiagnosis, delayed treatment, inadequate pain management, and reduced trust in healthcare systems. When grief is present, these risks may be amplified, potentially compromising patient outcomes.
Implications for Grief-Sensitive Care
Patients who have experienced cumulative loss may carry layered grief histories that influence emotional regulation and responses to illness or injury. Experiences of discrimination, inequity, or dismissal within healthcare systems can also contribute to mistrust and influence how individuals engage with care.
For healthcare professionals, this means recognizing that current symptoms or behaviors may be connected not only to present circumstances, but also to earlier losses that may have gone un- or under-supported.
Screening for loss, including multiple or early losses, can be a helpful practice for patients of any age, as it may provide important context for emotional responses as well as for mental and physical health concerns.
Grief-Sensitive Language for Exploring Loss History
Below are examples of grief-sensitive language that may be helpful in different contexts.
During Intake
- “Many people I work with have experienced more than one loss over time. If you’re comfortable sharing, has loss been part of your story?”
- “Sometimes earlier losses can shape how people are feeling now. Would it be okay if I asked a little about that?”
- “You can share as much or as little as you’d like. I ask because experiences of loss can sometimes affect health in ways that aren’t always obvious.”
When Learning of a Recent Death
- “For some people, a new loss also brings up earlier losses. Has this death connected to other losses you’ve experienced?”
- “Sometimes experiences like this can connect to other losses or difficult experiences. Would it be okay if we talked about that?”
Exploring Cumulative Loss Gently
- “It sounds like you’ve been carrying a lot over the years. What kinds of losses or changes have you had to navigate?”
- “Has your child experienced other losses or big changes that might be important for us to know about?”
Centering Choice and Control
- “You don’t have to share anything you’re not ready to. If you’d like to talk about what you’ve been carrying, I’m here to listen.”
- “If it feels helpful, we can come back to this another time.”
- “Some people find it helpful to have space outside of medical visits to process cumulative loss. I can share options if you’d like.”
Normalizing Follow-Up
- “Many people don’t realize how much earlier losses can still affect them. If that’s true for you, we can keep that in mind as part of your care.”
- “You don’t have to go into details. Even knowing that there have been multiple losses can help us support you better.”
- “Experiencing multiple losses can add up over time. Many people notice it affects stress, sleep, or how safe they feel.”
Awareness of early and cumulative loss can help healthcare professionals better recognize patients and supporters who may be at higher risk for grief-related health concerns.
Links Between Bereavement Due to Sudden Death and Academic Functioning: Results From a Nationally Representative Sample of Adolescents
In addition to screening for loss, healthcare professionals can take practical steps to support more equitable and grief-sensitive care.
- Engage in continued learning - Strengthen understanding of grief literacy, structural inequities, and trauma-informed, culturally responsive practice through ongoing education and reflection.
- Practice mentalization - Mentalization is a skill set rather than a single framework. Practicing curiosity about one’s own assumptions and others’ internal experiences over time can strengthen this skill and support more thoughtful, less biased responses to grief.
- Collaborate - Building partnerships with community organizations that serve marginalized populations can help expand access to culturally informed and comprehensive care.
Connect - Support patients by connecting them with inclusive resources, such as support groups or mental health services that affirm diverse identities and lived experiences.
The Importance of Grief-Sensitive Care Where Disparities Exist
Grief can be hidden beneath layers of self protection and survival, especially for those who have experienced early or cumulative loss. Using a grief sensitive lens can help prevent mislabeling and ensure that those carrying multiple layers of grief are not overlooked or misjudged, supporting more compassionate and effective care.