There are different interpretations of the causes of LGBT youth suicide, especially given high-profile incidents in 2010. As part of a recent summit of LGBT journalists, editors and bloggers in San Francisco, experts addressed the topic and presented information from recent studies of the problem. The Evelyn and Walter Haas Jr. Fund sponsored the March 12 event, and the program was held at their San Francisco headquarters.
More than two dozen LGBT editors, journalists and bloggers heard about and discussed the issues with experts from the around the country, including Ann Haas, director of prevention projects for the American Foundation for Suicide Prevention (AFSP).
Since the 1970s, there have been many reports of elevated suicide risk in LGBT populations, Haas said. But major suicide research documents have not dealt with this topic. The 2001 U.S. National Strategy for Suicide Prevention did not touch on LGBT suicide. A 2002 Institute of Medicine report, Suicide: A National Imperative, identified gay and bisexual youth as at risk for suicide, but only dealt briefly with the issue.
In 2007, Ann Haas said AFSP partnered with the Gay and Lesbian Medical Association (GLMA) and Suicide Prevention Resource Center (SPRC) to investigate "what we know and what we don't know" about LGBT youth and suicide. The goal was to:
Identify what is known about completed suicide, suicide attempts and suicide risk in LGBT populations.
Identify knowledge gaps and make recommendations for addressing them.
Make recommendations for applying what is already known to reduce LGBT suicidal behavior and suicide risk.
The Journal of Homosexuality reported these findings in January 2011.
The report said they found very limited data on completed suicide in LGBTs. For example, information about sexual orientation and gender identity is not collected on death records, and often "psychological autopsies" are not ideal for determining a suicide decedents' sexuality or gender identity. Haas said they also found that reliable alternative methods of identifying LGBTs among suicide decedents had not yet been developed.
However, Haas said other studies may help as a starting point when discussing suicide in both adult and youth LGBTs. A 2009 Denmark study (Mathy et al.) found that adult men in same-sex domestic partnerships were eight times more like to die by suicide than heterosexual married men, and they were twice as likely as never-married men. It also found that suicide rates of same-sex-partnered and heterosexually married women were not significantly different. But a U.S. study (Cochran & Mays, 2011), following men for 18 years, did not find elevated suicide rates in gay men with partners.
Haas noted that a 2008 analysis of 25 international adolescent/adult studies (King et al.) showed:
Lifetime rate of reported suicide attempts in gay/bi males is four times higher than comparable heterosexual males.
Lifetime rate of reported suicide attempts on lesbian/bi females is twice that of heterosexual females.
LGB adolescents and adults were more than twice as likely as comparable heterosexual persons to report a past-year suicide attempt.
In the U.S. population-based surveys, Haas said the summary data showed:
LGB adolescents and adults have two-to-six times higher rates of reported suicide attempts.
Suicide attempts are higher in gay/bi men than lesbian/bi women (opposite the gender difference in the general population).
Suicide attempts reported by a minority of LGB people (12-19 percent of gay/bi men, smaller percent of lesbian/bi women).
Non-probability surveys of transgender people consistently report markedly elevated rates of suicide attempts (30+ percent). (Non-probability sampling is a process that is not random; it does not give all individuals in the population an equal chance of being picked.)
Haas warned that studies show that making a suicide attempt is a risk for completed suicide, but it is actually not a strong predictor of a completed suicide. She said less than 10 percent of those admitted to an emergency room following a suicide attempt die by suicide over the next 20+ years, and suicidal ideation (a term used for thoughts about suicide) is a far less potent predictor than a suicide attempt.
Based on these limited LGBT studies, Haas said males are more likely to attempt suicide. Also, she cautioned that while being young is also a risk factor, youth have been more studied in this area than adults, and surveys of adults have not always identified their age at the time of reported suicide attempts. There is also not much data on suicidal behavior among LGBT older adults.
Haas said that in the general population, the highest suicide rates occur in middle-aged and elderly people, not in youth. So, as with gender, age patterns for LGBT suicidality may differ from the general population, "but the logic is not entirely compelling," she said, "since older sexual minority individuals share many factors that have been found to contribute to high rates of elderly suicide overall, such as depression, chronic illness and social isolation."
Mental health plays an important role in assessing for suicide risk factors, Haas said. The 2008 King study found that depression, anxiety disorders and substance use disorders were 1.5 times higher in LGB people than comparable heterosexuals. Gay/bi men also show higher rates of depressions and panic disorder, and lesbian/bi women show higher rates of substance use disorders (these two are opposite of the gender pattern in the general population). The prevalence of mental disorders is less in lesbian women than gay man, and both bisexual men and women have elevated rates of mood and anxiety disorders, according to Haas.
Another study Haas mentioned used data from a 2004-2005 National Epidemiologic Survey of Alcohol and Related Conditions (NESARC), which defined LGBT status by sexual identity, behavior and attraction (Bostwick, et al., 2010). Bostwick found that:
Persons who identified as lesbian, gay or bisexual had higher prevalence of mental disorders compared to comparable heterosexuals.
Men with same-sex behavior and attraction also showed higher prevalence of disorders than other men.
Women with only-female sexual behavior and attraction had fewer mental disorders than women in all other behavior or attraction categories.
Haas said the definition of sexual orientation varies across studies, sometimes leading to inconsistent findings. Lumping LGB or LG together may also obscure the real differences that exist among those groups.
After adjusting for mental disorders, the NESARC data showed rates of reported suicide attempts among self-identified LGB people were two-to-three times higher than among comparable heterosexuals (Belik & Sarin, 2010). Thus, mental disorders appear to "explain" suicide attempts less well in LGBs than heterosexuals.
As for LGBT youth, Haas said several studies point to a link between suicidal ideation and behavior, and individual experiences of stigma, discrimination and victimization based on known or perceived sexual orientation or gender identity. She said gender non-conformity appears to be more important as a risk factor than sexual orientation or gender identity per se.
Also important is a 2009 study by Ryan et al. showing that parental rejection is an especially powerful risk factor for suicidal ideation and behavior in LGBT youth. Peer victimization has also been reported by a significantly higher percentage of LGBT vs. heterosexual youth.
Haas said that both international and U.S. studies show an increased prevalence of depression, suicidal ideation and suicidal behavior in youth who report being bullied and youth who bully others. But, she said, the large majority of youth who are bullied don't engage in self-harm behavior.
An AFSP-funded five-year longitudinal study found suicidal behavior following involvement in bullying "only in youth who reported symptoms of depression during the period that the bullying occurred," Haas said.
Therefore, there is a complex relationship between bullying and suicide, Haas said, noting:
Persistent bullying can precipitate depression, anxiety and isolation, which in turn increase suicide risk.
Bullying can be a catalyst for suicidal behavior in youth who are already struggling with depression, anxiety and isolation.
Depression and other mental disorders increase the likelihood of being bullied, which exacerbates the disorder and increases suicide risk.
A fascinating part of Haas' presentation looked at how institutional discrimination can affect suicide rates.
Haas said two recent studies (Hatzenbuehler et. al., 2009; 2010) have shown elevated rates of mental disorders among LGB adults who live in states that have anti-gay laws and policies. In the latter study, these researchers found that state-specific campaigns for constitutional amendments restricting marriage to heterosexual couples were also associated with increased prevalence of mental disorders among LGBTs living in neighboring states. "Such increases," Haas said, "were not found in heterosexuals, whether in the states in which such amendments were enacted or in other states."
Although the effects of discriminatory laws and policies on suicidal behavior have not yet been studied, Haas noted that "strong evidence exists for a link between mental disorders and suicide risk." Another factor contributing to suicide risk in LGBT people, she said, is lack of access to mental health services. Cited in this regard was a recent study in California that linked federal prohibition of same-sex marriage to disparities in health insurance coverage, and thus lowered access to treatment, for same-sex couples (Ponce et al., 2010).
The impact of living in an anti-gay region of the country was further reported in Mark Hatzenbuehler's analysis published April 18, 2011 in the journal Pediatrics, and reportedly widely in the gay and non-gay media. The report showed that gay teens living in politically conservative areas, and with no gay-supportive programs in their schools, are more likely to attempt suicide.
Hatzenbuehler, from the Mailman School of Public Health, Columbia University, New York, New York, writes about his conclusions in "The Social Environment and Suicide Attempts in Lesbian, Gay, and Bisexual Youth." His objective was to "determine whether the social environment surrounding lesbian, gay, and bisexual youth may contribute to their higher rates of suicide attempts, controlling for individual-level risk factors."
According to his report in Pediatrics: "A total of 31,852 11th grade students (1,413 [4.4 percent] lesbian, gay, and bisexual individuals) in Oregon completed the Oregon Healthy Teens survey in 2006—2008. We created a composite index of the social environment in 34 counties, including (1) the proportion of same-sex couples, (2) the proportion of registered Democrats, (3) the presence of gay-straight alliances in schools, and (4) school policies (nondiscrimination and anti-bullying) that specifically protected lesbian, gay, and bisexual students.
"Lesbian, gay, and bisexual youth were significantly more likely to attempt suicide in the previous 12 months, compared with heterosexuals (21.5 percent vs. 4.2 percent). Among lesbian, gay and bisexual youth, the risk of attempting suicide was 20 percent greater in unsupportive environments compared to supportive environments. A more supportive social environment was significantly associated with fewer suicide attempts, controlling for sociodemographic variables and multiple risk factors for suicide attempts, including depressive symptoms, binge drinking, peer victimization, and physical abuse by an adult (odds ratio: 0.97 [95 percent confidence interval: 0.96—0.99])."
Hatzenbuehler thus concluded that there is "an association between an objective measure of the social environment and suicide attempts among lesbian, gay, and bisexual youth. The social environment appears to confer risk for suicide attempts over and above individual-level risk factors. These results have important implications for the development of policies and interventions to reduce sexual orientation—related disparities in suicide attempts."
Returning to Ann Haas' presentation at the LGBT media summit, she said there are some documented factors that can protect against suicide attempts. LGBT youth, she said, benefit from having family acceptance, caring relationships with older adults and school safety. Protective factors among LGBT adults include connection to the LGBT community, positive sexual identity and stability in their intimate relationships. She also said lesbian adults are at less risk overall.
Although relatively few suicide prevention programs exist specifically for LGBT people, Haas pointed to suicide prevention strategies that have found to be generally effective in the overall population, including:
Clinical care/mental health treatment.
Awareness campaigns/educational programs (general public, primary care physicians, parents/caregivers, community gatekeepers, etc.).
Screening programs, crisis lines, and other activities to identify and refer at-risk individuals to treatment/support.
Restriction of lethal means used for suicide (such as gun access and control).
Media/communications education to reduce contagion and misinformation, and increase dissemination of accurate information about suicide and suicide risk.
On this last point, Haas said there is a concern that the intense media coverage of LGBT youth suicides has at times oversimplified the role of bullying as a causative factor, without sufficient attention to other factors known to play a key role in suicidal behavior, especially unrecognized or untreated depression. In this regard, she cautioned against using the term, "bullycide," which she said may imply that all LGBT youth who experience bullying are at high risk for suicide, or that LGBT suicide following bullying is far more common than it actually is. Such implications, she said, may lead vulnerable LGBT youth to perceive suicide as a solution to problems they may be experiencing.
Other prevention strategies include increasing awareness and education about mental-health issues as risk factors for LGBT suicidal behavior; increasing identification and referral of high-risk LGBT persons, including victims of bullying and harassment; expanding availability and access to culturally appropriate, high-quality mental health treatments; and increasing social support and decreasing social isolation among LGBT people.
Haas said additional strategies include working with families to increase parental/caregiver acceptance and support of LGBT youth; increasing safety and respect of LGBT people in schools, workplaces and communities; and changing laws and policies that discriminate against LGBT people or fail to provide adequate protections against discrimination.
Making it count
Haas notes that more federal and private research funding is "essential to better inform the knowledge base" about LGBT suicide. Especially important, she said, is determining the prevalence of suicide deaths among LGBT people, as "official mortality statistics are the ultimate barometer of health disparities." A critical action step is to ensure the inclusion of sexual orientation and gender identity among the characteristics of the deceased that are routinely noted in official death records. Haas also called for more consistent and widespread inclusion of sexual orientation measures in national benchmark health and mental health surveys, and development and inclusion of consistent measures of gender identity in such surveys.
Some positive moves have been made by the White House and the Department of Health and Human Services, led by HHS Secretary Kathleen Sebelius. HHS has made some significant reporting changes as well as policy changes effecting millions of LGBTs. In addition, Sebelius commented on the March, 2011 Institute of Medicine Report (IOM) on Lesbian, Gay, Bisexual and Transgender Health: "I want to thank the [IOM] for conducting this important study, at the request of the National Institutes of Health (NIH), on the state of the science regarding the health of lesbian, gay, bisexual and transgender (LGBT) people.
"The report provides the scientific community with the first comprehensive overview of health-related research in this important area. It concludes by recommending that NIH develop and implement a comprehensive research agenda to advance our knowledge and understanding of LGBT health, including demographic studies and inequities in health care, and the social contexts in which LGBT people live. The report also calls for federally funded surveys and electronic health records to collect data on sexual orientation and gender identity while protecting patient confidentiality. In addition, the report recommends enhanced training to strengthen LGBT health research at NIH, and asks NIH to encourage grant applicants to address explicitly the inclusion or exclusion of sexual and gender minorities in their clinical studies.
"This report is an important step in identifying research gaps and opportunities, as part of an overall effort to understand and address the health needs of lesbian, gay, bisexual and transgender people. We look forward to continuing our work to address these needs and reduce LGBT health disparities."
Haas said it is also important that more states measure sexual orientation and gender identity in school-based surveys. She noted the recent increase in the number of states and metropolitan areas opting to measure these characteristics in the Youth Risk Behavior Survey administered by the U.S. Centers for Disease Control and Prevention (CDC), which she attributed largely to advocacy by LGBT groups. But, the majority of states still do not ask such questions and none are mandated by the CDC. Haas added that activists "may be more successful moving forward on this as a health issue rather than [as a] political issue, to get LGBTs counted in studies."
Ultimately, even when LGBT questions are on surveys, it comes down to how comfortable people are "coming out" in such documents. "If LGBTs don't report themselves on surveys, we won't be counted. That has political, funding, health and other ramifications," Haas said. "We need to get the federal government to change the forms and the process."
For more information:
American Foundation for Suicide Prevention (AFSP): www.afsp.org/
Ann Haas report on "Suicide and Suicide Risk in Lesbian, Gay, Bisexual, and Transgender Populations: Review and Recommendations": www.informaworld.com/smpp/section?content=a931819675&fulltext=713240928
Pediatrics magazine study: pediatrics.aappublications.org/