Suicidal problems of youth with homosexual or bisexual orientations: research, problems, and proposals.
By Pierre Tremblay and Richard Ramsay
The paper below was translated into French and published in the Spetember issues of «Vis-à-Vie», "le journal de l'Association Québécoise de Suicidologie" as part of a special issue on «Sexual Orientation and Suicide» : «Orientation Sexuelle et Suicide». The reference is:
Tremblay, Pierre et Ramsay, Richard (2000). "Orientations homosexuelles ou bisexuelles chez les jeunes présentant des problèmes suicidaires: recherche, problématique et propositions. Vis-à-Vie, 10(2), 5-8.
Pierre Tremblay and Richard Ramsay
Gay, lesbian, and bisexual (GLB) youth are at greater risk for suicide problems than their heterosexual counterparts (1). The relative risk is highest for GB males. The most recent support for this higher risk is found in two studies and related articles (2-6). Odds Ratios of 6 for lifetime suicide attempts of homosexual identified individuals compared to their heterosexual counterparts were reported in an American study of a middle-aged male twin cohort (5) and in a New Zealand male and female birth cohort studied at the age of 21 years (6). This Odds Ratio support comes with a caveat and is considered a minimum difference given the methodology deficits that still exist when taboo subject data is gathered.
The greater risk for GB males was initially recognized from a variety of voluntary sample studies of gay youth that reported self-defined lifetime suicide attempts between 20 and 42 percent (1). The average across these studies was 30 percent (7). In 1997, a Calgary study based on a stratified random sample of 750 young adult males and the use of an improved data gathering methodology (7) produced results consonant with a 1978 Kinsey Institute study. This study used a large voluntary sample of homosexual males and a randomly selected control sample of heterosexual males in the same city (8). Both studies found GB males to be 14 times more likely to report a suicide attempt during their youth, and they accounted for 62.5% of suicide attempters in the Calgary study.
The higher risk status of GLB adolescents compared to their heterosexual counterparts, especially GB males, is found in recent American public school Youth Risk Behavior Surveys (YRBS). Two surveys (9, 10) reporting on "lifetime" and "previous 12 month" suicide attempts show GB males to be 6 times (28.1:4.2%; mean age = 15 years) and 7 times higher (33:5.1%; mean age = 16 years) more at risk. In the latter study, 4.7% of "GBN" (N = "Not Sure of their sexual orientation") students accounted for almost 25 percent of self-reported male suicide attempters (Note 1). The higher risk factor for LB females was 1.5 and 2 times higher.
Most of the YRBS data containing homosexuality information has not been published in peer reviewed journals, but some of the undifferentiated gender data has been analyzed and reported at scholarly meetings (11). The results for five YRBS data sets indicate that GLB adolescents (defined on the basis of self-identification and/or self-reported same-gender sexual activity) are at greater risk for the most serious suicide behaviors. The averages from these studies show an increasing risk for GLB youth that report suicidal problems in a previous 12-month period (11). The differences ranged from almost 2 times higher for those who had considered (47:26%) or planned (39:21%) suicide to 3.3 times for those who attempted suicide (32:10%), and almost 5 times for those whose attempts required medical attention (19:4%).
Peer reviewed publications using the rich source of data from these YRB Surveys are awaited along with a need for gender differentiated analyses to be reported. The gender undifferentiated factor of 3.3 for attempted suicide is likely to be closer to a multiplier of 6 to 7 for males (10), and 9 to 10 times higher for whose attempts require medical attention. The latter figures are similar to the multiplier of 14 for serious suicide attempts that was reported in the Calgary study. The higher figure in Calgary is likely related to the use of a recent error reducing computer-assisted methodology to solicit taboo sexual information (7, 13). This method minimizes the possibility of GB males remaining unidentified and therefore inadvertently having their suicide problems attributed to heterosexual males.
The potential to minimize sexuality differentiation errors was reported in a 1998 random sampling study of 15- to 19-year-old males which compared the conventional methodology of pencil-and-paper questionnaires (used in YRBS) to computer-assisted questionnaires when soliciting taboo information. The former method produced underestimates averaging 400 percent for solicited homosexuality information when compared to the results obtained from the computer-assisted method (12). This difference is similar to the "200% to 800% underestimate" predicted from the Calgary study when demographic studies identify various homosexual attributes using conventional methods of data collection in lieu of computer-assisted methods (13). This magnitude of error factor should be unacceptable in social science research, however; deficient data gathering methods continue to be used in studies dealing with taboo sexual realities and other taboo behaviors. These include "illicit drug use" which is also greatly underestimated when conventional methods are used (12), and GLB adolescents are more at risk for illicit drug use (14, 15).
A number of variables that are significantly associated with GB male suicide problems from the non-random community samples are an early age of self-identification, being feminine, family problems, substance abuse, friends attempting suicide, dropping out of school, homelessness, lack of social support, violence, prostitution, and psychiatric symptoms (1, 11). When attempts to understand the significance of these variables are made, another higher risk caveat must be noted. The community samples of GB male youth generally form a subset of the 3 to 5 percent of adolescent GB males identified in school-based youth risk behavior surveys. These subsets, in turn, form an adolescent subset of the 9 to 12 percent of young GB adult males identified in the random sampled Calgary study.
This higher risk caveat is important when one understands that the community based samples produced an average "lifetime" suicide attempt incidence of 30 percent compared to a slightly higher incidence (mean = 32%) in a much shorter "12-month period" in the five YRBS studies (11). Adding this to the fact that the majority of serious suicide attempters in the Calgary study were GB males, it becomes apparent that suicide problems for all GB male youth may be more serious than previously believed (7). The magnitude of increasing risk within shorter time periods and for more serious attempts is likely to have major life-threatening implications if the homosexuality factor in the suicidal problems of male youth continues to be ignored by researchers, educators and training specialists. Additional research is needed to better understand the tendency of health professionals to ignore or dismiss the cumulative evidence of GB male contributions to youth suicidal problems. The research questions also need to explore the documented anti-homosexuality history and ongoing bias-related responses of health professionals toward homosexual oriented people (16, 17).
Other unpublished information from existing data sets that requires deeper analysis is the effect of homophobia related abuses directed at adolescents known or suspected to be homosexual. These harassment behaviors are usually initiated on the basis of perceived gender nonconformity, which has recently been documented (18). The 1995 Seattle YRBS reports a 12-month "suicide attempt" incidence of 5.7 percent for heterosexual adolescents who were not targeted for homophobia-related harassment, compared to a 20 percent incidence for heterosexual adolescents who were (19). GLB adolescents who were targeted or not targeted for homophobia related abuses had the same higher incidence. These higher risk adolescents (10.4% of study sample) account for almost 30 percent of suicide attempters and almost 40 percent of the ones reporting suicide attempts requiring medical treatment (11). A recent YRBS in Oregon produced similar results (20).
Homophobia has been prevalent in North American societies, including research communities in the social sciences, medicine, and suicidology. Therefore, it may be more than mere coincidence that homosexual related data and associated suicidal problems from the YRB surveys are not prepared for peer-reviewed publications, even though some published results confirm the higher risk of GB male youth (1,4). An evaluation of many risk factors associated with suicide problems also indicates that GB males may account for up to 50 percent of the North American youth suicide problem. This information contrasts with the peer-reviewed publications of significantly flawed postmortem studies that indicate otherwise (1, 11).
There is a need for the full story to be published from the existing YRBS data sets. In addition, there needs to be well designed population based surveys to explore the suicide problems of identified GLB youth, as well as the underestimated number that have not been identified in previous studies relying on conventional methods of data gathering. Longitudinal studies are also required to better understand the evolving often interrelated risks attributes for GLB youth and, hopefully, how and when their socially and professionally inflicted homophobia-related problems are resolved for some youth, but not for others.
Note 1: GBN male are 6.5 times
more likely than heterosexual males to report attempting suicide in the
past 12 months, but the related incidences were not supplied (10). Given
the suicide attempt incidence of 6.4% for all males, and using the male
population estimate of 4.7% for GBN males (3.8% GB males + 0.9% "not sure"),
the relative incidence would be 33% versus 5.1% for GBN males compared
to heterosexual males. GBN males therefore account for 24.3 percent of
male suicide attempters, a minimum given the related caveats.
1. Remafedi G (1999). Sexual Orientation and Youth Suicide (Review). JAMA, 282, 1291-1292. Internet Availability: - http://www.ama-assn.org/sci-pubs/msjama/articles/vol_282/no_13/jms90031.htm .
2. *Bailey M (1999). Homosexuality and mental illness. Archives of General Psychiatry, 56(10), 883-4.
3. *Friedman R (1999). Homosexuality, psychopathology, and suicidality. Archives of General Psychiatry, 56(10), 887-8.
4. *Remafedi G (1999). Suicide and sexual orientation: nearing the end of controversy? Archives of General Psychiatry, 56(10), 885-6.
5. *Herrell R, et al. (1999). Sexual orientation and suicidality: a co-twin control study in adult men. Archives of General Psychiatry, 56(10), 867-874.
6. *Fergusson D, et al. (1999). Is sexual orientation related to mental health problems and suicidality in young people? Archives of General Psychiatry, 56(10), 876-880.
7. **Bagley C, Tremblay P (1997). Suicidal behaviors in homosexual and bisexual males. Crisis, 18(1), 24-34.
8. Bell A, Weinberg M (1978). Homosexualities: A Study of Diversity Among Men and Women. New York: Simon & Shuster.
9. Remafedi G, et al. (1998). The relationship between suicide risk and sexual orientation: results of a population-based study. American Journal of Public Health, 88(1), 57-60.
10. Garofalo R, et al. (1999). Sexual orientation and risk of suicide attempts among a representative sample of youth. Archives of Pediatric and Adolescent Medicine, 153(5), 487-93.
11. **Tremblay P, with Ramsay R (2000). The social construction of male homosexuality and related suicide problems: research proposals for the twenty first century. Paper presented at the Sociological Symposium on Suicide, San Diego State University, March, 2000. The results of 5 Youth Risk Behavior Surveys are given at - http://www.youth-suicide.com/gay-bisexual/b-gay-male-youth-suicide.htm#table-2 .
12. Turner C, et al. (1998). Adolescent sexual behavior, drug use, and violence: Increased reporting with computer survey technology. Science Magazine, 280(5365-8), 867-73.
13. **Bagley C, Tremblay P (1998). On the prevalence of homosexuality and bisexuality in a random community survey of 750 men aged 18 to 27. The Journal of Homosexuality, 36(2), 1-18.
14. Remafedi G et al. (1991). Risk factors for attempted suicide in gay and bisexual youth. Pediatrics, 87(6), 869-75.
15. Garofalo, R et al. (1998). The association between health risk behaviors and sexual orientation among a school-based sample of adolescents. Pediatrics, 101(5), 895-902.
16. Bayer, Ronald (1981). Homosexuality and American Psychiatry: The politics of diagnosis. New York: Basic Books.
17. Scarce Michael (1999). Smearing the Queer: Medical Bias in the Health Care of Gay Men. New York: Harrington Park Press.
18. Plummer D (1999). One of the Boys: Masculinity and homophobia and modern manhood. New York: Harrington Park Press.
19. Reis B (1996). The Seattle Public Schools' Teen Health Risk Survey. Available at: - http://www.safeschools-wa.org/ssp_part2.html . If unavailable, see Table 4: - http://www.safeschools-wa.org/quant_mh.html - and Table 6: http://www.safeschools-wa.org/quant_so.html . **Additional Statistics. The CDC's YRBS questionnaire (not containing questions related to homosexuality) is available at: - http://www.cdc.gov/nccdphp/dash/yrbs/survey99.htm .
20. Bloodworth, Ron (2000). Coordinator, Oregon Health Department Youth Suicide Prevention Program. Personal communication related to the Oregon Youth Risk Behavior Survey (1999).
*The full text for the referenced papers in Archives of General Psychiatry are available via the Contents web page at: - http://archpsyc.ama-assn.org/issues/v56n10/toc.html .
**Links to full text for the cited papers and additional statistics are available at: - http://www.youth-suicide.com/gay-bisexual/quebec-suicide-gai.htm . The same resources will soon be available at : http://www.sws.soton.ac.uk/gay-youth-suicide/05-quebec-suicide-gai.htm .