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Dradt of a Review Paper to be published in Crisis: The Journal of Crisis Intervention and Suicide Prevention
 
Social Construction of Male Homosexuality and Related Suicide Problems...*Crisis: - The Journal of Crisis Intervention and Suicide Prevention Published under the Auspices of the International Association for Suicide Prevention (IASP). PubMed Abstract.  Bagley C, Tremblay P (2000). Elevated rates of suicidal behavior in gay, lesbian and bisexual youth. Crisis, 21(3): 111-17.
 
Social Construction of Male Homosexuality and Related Suicide Problems...11.07.2000

Elevated Rates of Suicidal Behaviour in Gay, Lesbian and Bisexual Youth: A Review and Account of Possible Causes

Christopher Bagley, Professor, Pierre Tremblay, Research Associate
Dept of Social Work Studies, University of Southampton, Southampton, SO17 1BJ.

Abstract: Both clinical and epidemiological literature point to elevated rates of suicidal behaviours in Gay, Lesbian and Bisexual Youth (GLBY). Recent North American and New Zealand studies of large populations (especially the US Youth Risk Behavior Surveys from several States) indicate that gay, lesbian and bisexual adolescents (and males in particular) can have rates of serious suicide attempts which are least four times those in apparently heterosexual youth. There are various reasons why this figure is likely to be an underestimate. Reasons for these elevated rates of suicidal behaviour include a climate of homophobic persecution in schools, and sometimes in family and community - values and actions which stigmatise homosexuality and which the youth who has not yet ‘come out’ has to endure in silence.

Introduction

The  debate in Britain surrounding  a law which forbade the use of public funds for counselling and support of homosexual youth in schools and in some health and social service settings (Bagley & D’Augelli, 2000), has prompted us to examine the research evidence focussing on the impact of the development of homosexual identity in adolescence, and the mental health costs of growing up in a climate of homophobic intolerance.

In fact, there is virtually no relevant British research on this topic, and it is to America, Canada and New Zealand that we must turn for relevant studies (Tremblay, 2000a).  These studies are worth reviewing since they indicate that Gay, Lesbian and Bisexual Youth (GLBY) do experience significant stresses during adolescence, sometimes reflected in elevated rates of suicidal behaviour, which might be addressed through counselling, social work support and psychiatric consultation, which accepts that being Gay or Lesbian is a legitimate and worthy status (Bagley & Tremblay, 1997).

There is evidence from biographical accounts that for many youth who become homosexual adolescents, sexual orientation emerged strongly in early adolescence, regardless of whether this orientation was known to family and school friends (Herdt & Boxer, 1993; Remafedi, 1994; Mays et al., 1998). A well-designed twin study could not however establish a genetic component in homosexuality, but did conclude that: “ … lifetime measures of suicidality are strongly associated with a same-gender sexual orientation. These effects cannot be explained by abuse of alcohol or drugs, nonsuicidal depressive symptoms, or the numerous genetic and nongenetic familial factors accounted for in the co-twin control design.” (Herrell et al., 1999, p. 873). A random survey of 750 young adult men in Canada suggests that some 14% had some kind of homosexual relationship in adolescence, with about 5% emerging with a permanent homosexual orientation (Bagley & Tremblay, 1998). Because of the methodology of this study we proffer it as a benchmark figure for the estimate of rates of prevalence of homosexuality in male populations. Estimates below these figures are, because of methodological reasons, likely to be underestimates.

The youth with an emerging homosexual identity in a generally homophobic climate faces a particular  dilemma.  He or she is well aware of secondary school cultures which use the words “fag”, “poofter” and “dyke” as terms of denigration, and that anyone with an overt homosexual identity is open to social exclusion, and physical persecution, facts well-established in various studies (Remafedi, 1994; Martin & Hetrick, 1988; Savin-Williams, 1994; Jordan, 1997; Oregon, 1997). The family too (especially that with a religious orientation) will often express negative feelings about homosexuals (Hecht, 1998; Proctor & Groze, 1994; D’Augelli, Hershberger, 1993). Research has shown that coming out to one's family is associated with higher incidences of suicide attempts and suicide ideation, with 41% of those who have come out to family making a suicide bid, compared with 12% of those who remain ‘in the closet’, the elevated rates apparently linked to verbal and physical abuse by family members (D’Augelli, et al, 1998).

The youth who feels that he or she is Gay or Lesbian must either pretend to go along with current views; or they must face the risk of ‘coming out’ to family and peers.  Either course is perilous, and one sequel may be suicidal behaviour (Savin-Williams, 1994; Hershberger, et al., 1997).

Evidence on the prevalence of suicidal behaviours in GLBY

Until recently no reliable epidemiological evidence was available on prevalence. Now several studies establishing either period or point prevalence are available (Tremblay, 2000a; Remafedi, 1999).  Most important are the studies of large numbers of high school students undertaken by several US states, as part of initiatives on violence, drug and HIV prevention education (Remafedi et al., 1998; Saewyc et al., 1998; Faulkner & Cranston, 1998; Massachusetts, 1995; Seattle, 1995).   These have used pencil-and-paper methods for questionnaire completion, accessing available students.  Questions about sexual orientation have been relatively brief. These methods involve biases which will likely lead to conservative estimates of the numbers of GLBY and their suicidal problems, and these potential biases must be outlined before interpreting the data in Table 1, below.

Competing an interactive computer programme in a private setting is significantly more likely to elicit sensitive information about sexual histories (Bagley & Genuis, 1991), the most efficient method being the use of headphones in which aural questions are responded to on a keyboard (Turner et al., 1998).  This latter American study is extremely important: 1,672 males aged 15 to 19 were assigned to random halves and asked either to read and tick boxes in a conventional pencil-and-paper questionnaire; or to press a computer key as questions simultaneously appeared on screen and aurally through headphones. Differences in response to sensitive questions about sexuality were remarkable: using pencil and paper, 1.5% reported sexual contact with someone of the same gender, compared with 5.5% agreeing positively under the audio response condition - a statistically significant 3.7 times difference.  A further US study supports these results (Supple et al., 1999).

Generalising these findings to the YRBS, these surveys will have underestimated the number of male Gay and Bisexual youth by a factor of up to four, so that the 'heterosexual' contrast group is likely to contain at least as many GLBY as those actually designated GLBY, an artefact working against significance.   In addition,  excluding students who are 'unsure' about sexual identity (e.g. Faulkner & Cranston,  1998) may exclude a group undergoing acute identity crises which might be associated with suicidality.

Although valuable for population estimates of rates of suicidality in GLBY, high schools may be significantly under-represented by crucial ‘at risk’ groups. It is known that some young teenaged male prostitutes are permanent dropouts from school (Kruks, 1991; Savin-Williams, 1994; Rotheram-Borus et al., 1994).

'Effeminate' male youth may also escape the oppression of high school culture, seeking sanctuary within gay communities which exist in all large cities (Remafedi et al., 1991; O’Brien et al., 1993).  This means that 'ordinary' high school populations may be under-represented by GLBY youth who are experiencing persecution or identity problems: this is another artefact working against significance, leading to the undercounting of the link between GLBY and suicidal behaviours. A link has been reported between early-age gender nonconformity and suicide ideation in both male and female adolescents (Reinherz et al., 1995), and elevated risk for suicide attempts has been reported for the most ‘feminine’ gay and bisexual youth, compared to their less feminine gay and bisexual counterparts (Remafedi et al., 1991).

The Vermont YRBS (Du Rant et al., 1998) obtained data on a random sample of 3,996 "sexually active" adolescents, and found that frequently not attending school because of fear was a significant correlate of having been the subject of physical attacks based on same-gender sexual orientation (the leading correlate with this variable was the number of suicide attempts - unfortunately data in the report of the Vermont study were not presented in a form which made it possible to include its results in Table 1).

The American Youth Risk Behavior Surveys (YRBS) summarised in Table 1 are simultaneously heartening and discouraging: at long last the possible links between being Gay, Lesbian or Bisexual and suicidal behaviour are being explored in large-scale studies of youth, based on random sampling of available high school populations using standardized instruments of known reliability (Du Rant et al., 1998), although the validity of many responses is hard to determine.  One problem is the definition of who is 'gay' or 'bisexual' - some studies accept the statement of sexual orientation by the respondent whilst others such as the Vermont study (Du Rant et al., 1998) use an extreme definition including only males who have had 'intercourse' with other males. Another frustrating aspect of reporting results from the YRBS is that the sexes are frequently combined when it would have been easy to report rates separately by gender.

Whenever this is done (Remafedi et al., 1998; Saewyc et al., 1998; Du Rant et al., 1998; Garofalo et al., 1999) Gay and Bisexual adolescent males have very much higher rates than their apparently heterosexual counterparts. Attempts requiring medical care have a much higher incidence in GLBY.  Despite some problems in reporting results from the various YRBS, there are grounds for supposing that these differential rates significantly underestimate the amount of suicidal behaviour in GLBY, for the reasons outlined above.

A New Zealand study (Fergusson et al., 1999) is based on a longitudinal, general population cohort followed up to age 21. Sexual orientation was elicited in a personal interview, and the advantage of such a technique as compared to any other method is unknown, although the method will almost certainly underestimate the true amount of homosexual status (Turner et al., 1998; Supple et al., 1999).  The amount of this underestimation, given the results obtained by Bagley & Tremblay (1998), could be up to a factor of four.

In the New Zealand study, only 2.8% of the 1,007 subjects declared a Gay, Lesbian or Bisexual orientation. The GLB group was not analysed separately by gender: the ‘attempted suicide’ rate of this GLB group was 6.2 times that in the remaining subjects, a highly significant difference.  This figure represents an estimate of period prevalence, rather than point prevalence as in the YRBS.

Possible Reasons for Higher Rates of Suicidal Behaviours in GLBY in the Youth Risk Behavior Surveys (YRBS)

A number of supplementary questions in the American Youth Risk Behavior Surveys (YRBS) give important clues to reasons for the elevated and more serious suicide attempt rates in GLBY, reasons which confirm the clinical research outlined above. In the Seattle Teen Health Risk Study (Seattle, 1995) 7,437 students aged 15 to 18 were asked about sexual orientation: 5% said they were gay or bisexual while another 4% were "unsure".  The researchers used the most conservative definition of gay orientation, those who were "unsure" about sexual orientation being excluded in reported results from this YRBS. The conservatively defined group of GLBY were three times more likely than others to have been beaten in a fight to the extent they required medical attention; they were also 1.8 times more likely to have been threatened with a weapon in the past 12 months. Twice as many "felt unsafe at school most or all of the time", and twice as many had skipped school for at least a day in the past month because of these fears (meaning that GLBY will be underestimated in surveys such as this because of this absenteeism factor).

The Seattle study (1995) reported that 20% of students in grades 9 to 12 were absent on the day of testing: “If ? Gay, Lesbian or Bisexual students were more likely to have dropped out than other students (a distinct finding supported by the HRS findings and other research) they would be undercounted in this survey.”  (p. 9). Of the GLBY in the Seattle survey, 35.8% reported heavy or high-risk drug use, compared with 22.5% of other youth – such high levels of drug use are also likely to be associated with higher levels of absenteeism.

Although causal analyses are not usually available for these data, there is a clear inference when read in conjunction with previous clinical studies that the frequent harassment and persecution of GLBY who have come out  (and the fear of such persecution in GLBY who have not) is likely to be implicated in suicidal behaviour in this high school population, as well as associated substance abuse for which GLBY are at high risk (Garofalo et al., 1998).

The Massachusetts YRBS described both sexual orientation and suicidality profiles in a random sample of 3,054 Massachusetts high school students (Faulkner & Cranston, 1998) aged 15 to 18: 1.7 % reported sexual activity with both genders, while 2.0 % were sexually active only with the same gender giving a total of 3.7 % who said they were actively bisexual, homosexual or lesbian. Attempted suicide rates were eight times higher in the actively gay and bisexual group of adolescents, compared with their heterosexual counterparts.  Another analysis of these data extended the definition of being gay or bisexual to those with this orientation, not merely including those who were sexually active, giving a figure of 4.4% (almost certainly an underestimate). These GLBY were significantly more likely to have been threatened or beaten, to carry a weapon for protection, to be heavy alcohol or drug users: 36.5 % had “attempted suicide” in the past year, compared with 8.9% of those who claimed themselves to be heterosexual.

Two of the YRBS have used logistic regression in order to provide models of why GLBY have elevated rates of attempted suicide .The net result seems to be a model in which being a GLBY at risk of suicidal behaviour involves four factors - increased drug and alcoholism risk; increased sexual activity risk; increased risk of being the victim of violence; and increased risk of becoming defensively violent as a result of persecution about being visibly gay. These interactive factors combine to place visibly GLBY at greatly elevated risk for self-harm.  The model seems to be much more applicable to males. How families and non-school communities react to the revelation of being a GLBY was not explored in these studies, but may be additional, linked or interactive stressors for such youth.

Some YRBS have reported on harassment in schools (including  the journey to and from school) based on perceived homosexual orientation, and have reported significantly elevated rates of suicidality for these adolescents. The Oregon (1997) YRBS reported that 21% of the students harassed in the previous month had made a suicide attempt in the past year, compared with 5% of the non-harassed, a 4.2 times difference. The Seattle (1995) YRBS gives data making secondary analyses possible, indicating that harassed versus non-harassed students (in the past 12 month) were 3.3 times more likely to report a suicide attempt in the same period (20.4% versus 6.1%) (Tremblay, 2000b). This harassed 7.5% of students who were perceived as Gay or Lesbian accounted for 21.3% of suicide attempters, and 27.8% of adolescents reporting that their suicide attempt was of the more serious nature, requiring medical attention. Using logistic regression analysis, Garofalo et al. (1999) found that experiencing violence and victimisation was a significant predictor of suicide attempts by GLBY. Harassment based on one's perceived homosexual orientation is often the consequence of individuals manifesting a detectable degree of gender nonconformity., supporting the Oregon (1997) findings.

Further evidence of the hazards experienced by GLBY in schools comes from the most recent research of D’Augelli et al (2000) which showed in a cross-national sample of 350 youth that ‘gender atypical’ males were most likely to experience abuse. Abuse was in turn linked to a range of negative mental health profiles, including suicidality. Remafedi et al. (1991) have also reported on the basis of logistic regression analysis, that the more ‘feminine’ GB male youth were three times more likely to be suicide attempters than other GB male youth.

Discussion

Despite methodological shortcomings (brief questions not covering the full range of homosexual identities and behaviours; use of pencil-and-paper tests, or interview methods which are likely to underestimate revelations of sensitive behaviour; and potential for undercounting groups most at risk) all of the YRBS plus the NZ cohort show that youth (and particularly male youth) who have a self-declared or perceived homosexual orientation or activity have a rate of suicidal behaviour that is between two and eight times greater than in others.  Moreover, differences are greatest for suicidal behaviours requiring medical attention i.e. the most serious end of the suicidal behaviour spectrum.

The point prevalence estimates are lower than the period prevalence rate estimated from a Canadian study of unselected males (Bagley & Tremblay, 1997) which indicated that Gay and Bisexual men up to age 27 had a suicide attempt rate 13.9 times that in men who had not declared a Gay or Bisexual identity, using a computerised response format. Further analyses of the national US survey data reported in Cochran & Mays (2000) for the age group 17 to 29 provides corroborative evidence supporting these Canadian findings (Tremblay, 2000a).

No study available has shown that GLBY have elevated rates of completed suicide.  Showing this has to overcome the problem that some youth may have killed themselves when in a state of confusion or depression over an emerging Gay identity in a climate of homophobia, but failed to communicate this to any person consulted by a Coroner or Medical Examiner. Or parents, teachers or others may have suppressed this information for various reasons.  We note however that our Canadian study (Bagley, 1992) of several hundred cases of youth suicide in Medical Examiners’ files did identity a type of suicide in males in which no clear reason other than recent depression, could be adduced for the act of self-killing. It is possible that this group includes an uncounted number of Gay youth.

Consider the following English case known to us: two girls aged 18 and 16 told their parents they were in love and wanted to live together. Parents forbade this, reacting with confusion at this 'lesbian phase'.  Forced to part, the pair climbed on to a bridge parapet but were prevented by police from jumping. They laid themselves across a rail line, but again were apprehended and endured brief psychiatric hospitalisation. The following day they jumped from a multi-storey car park, killing themselves. Cross-checking this case with a regional suicide register (Wessex, 1999) indicated that the Coroner had not recorded facts of persecution or doubt over lesbian orientation as  relevant factors in his verdict, and any research trying to link GLB status with completed suicide would miss cases such as these.

American research identifies several types of stress associated with an emerging Gay and Lesbian identity: personal feelings of self-doubt in those who have no help or support network; loss of peers, emotional denigration and physical harassment in those whose sexual orientation is known in school; and family rejection of youth who have identified themselves as Gay or Lesbian. Substance use is very much higher in youth denigrated in school settings, and they are likely to skip school frequently or drop out altogether, and may be pulled into subcultures of drug use, promiscuity and prostitution, where suicidal intent may also be acted out by contracting HIV (Seal et al., 2000; Tompkins-Rosenblatt, 1997). Many of these factors are known to be associated with higher rates of suicidal behaviour (Remafedi, 1999).

Evidence continues to emerge from US studies of the risks for suicidality associated with being publicly gay in a climate of homophobia (D'Augelli et al, 1998; Friedman, 1999; Safren & Heimberg, 1999; Cochran & Mays, 2000), although the exact role of substance abuse in suicidal behaviour of GLBY remains unclear (Bailey, 1999; Lock & Steiner, 1999).  What is possible however is that GLBY who use alcohol or drugs as means of escape from persecution and doubt over an emerging Gay or Lesbian identity have elevated profiles for suicidal risk compared with other GLBY (Remafedi, 1991; D'Augelli and Hershberger, 1993). These possibilities require further clinical and epidemiological investigations, given that elevated rates of drug and/or alcohol use have been reported for GLB adolescents, compared with their heterosexual counterparts (Garofalo et al., 1998; Smith et al., 1999).

The establishment of a high school culture, and counselling and health systems which accept the emerging and evolving identities of Gay, Lesbian and Bisexual Youth is an important antecedent of programmes which might prevent serious suicidal behaviours in a vulnerable and highly stressed group of young people (Uribe & Harbeck, 1992; Grossman & Kerner, 1998; Hammelman, 1993; Hershberger et al., 1997; Lock & Steiner, 1999). Unfortunately, youth suicidality risk programs which take into account youth homosexuality (e.g. Stoelb & Chiriboga, 1998) are rare. As Remafedi (1994) observed, the issues of homophobia and youth suicidality continue to be ignored.

Table 1 The American 'Youth Risk Behavior Surveys’ of Students Aged 14-18
 
 
State and Year 'Suicide Attempt' in Gay, Bisexual & Lesbian Youth 'Suicide attempt' in apparently heterosexual youth Ratio of 'heterosexual' rate to GLBY rate
Minnesota (1997) -
Males, any attempt:

Females, any attempt:

28.1% of 178 
 

20.5% of 166

4.2% of 168 age, SES & race matched controls 

14.5% of 145    matched controls


1:6.7*** 
 

 1:1.41 
 

Massachusetts (1993) - m & f 'sexually active'

Any Attempt  Attempt 4+ times
Attempt needed
Medical care 


 
 

27.5% of 105 
16.1% of 105 

20.0% of 105


 
 

13.4% of 1563 
 2.0% of 1563 

 4.7% of 1563


 
 

1:2.0*** 
1:8.0*** 

1:4.2***

Massachusetts
(1995) 
m & f 'Suicide
Attempt in past year'
Attempt needed
Medical care
Any Attempt,
Males only

 

38.3% of 128 

19.0% of 128 

42.0%  of 88


 

11.3% of 3237 

 3.0% of 3237 

15.5% of 1543


 

1:3.4*** 

 1:6.3*** 

 1:6.5***

Seattle (1995)
M & f (20)
Any Attempt

Attempt needed medical care
 


20.6% of 331 
 

9.4% of 331


6.7% of 7145 
 

 2.2% of 7145 
 


1:3.1*** 
 

 1:4.3*** 
 

Note: *** indicates difference between GLBY and apparently heterosexual group significant at the 1% level or beyond.
For all comparisons, GLBY and heterosexual contrast group did not differ significantly on demographic profiles.

References

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Bagley, C. & D’Augelli, A. (2000).  Gay, lesbian and bisexual youth have elevated rates of suicidal behaviour: an international problem, associated with homophobia and homophobic legislation. British Medical Journal, 320 (June 16), 1617-1618..

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Bagley, C. & Tremblay, P. (1998). On the prevalence of homosexuality and bisexuality in a random community sample of 750 men aged 18 to 27. Journal of Homosexuality, 36, 1-18.

Bailey, J. (1999).  Homosexuality and mental illness. Archives of General Psychiatry,  56, 883-886.

Cochran, S. & Mays, V. (2000). Lifetime prevalence of suicide symptoms and affective disorders among men reporting same-sex sexual partners: Results from the NHANES III. American Journal of Public Health, 90, 573-578.

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D’Augelli, A., Pilkington, N. & Hershberger, S. (2000). The mental health impact of sexual orientation victimization of lesbian, gay and bisexual youth in high school. Unpublished paper.

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