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By Christopher Bagley, Professor, Pierre Tremblay, Research Associate
Dept of Social Work Studies, University of Southampton, Southampton, SO17 1BJ.
Posted by permission of Pierre Tremblay and Chris Bagley. Originally appeared at https://www.fsw.ucalgary.ca/ramsay/homosexuality-suicide/05-crisis-suicide-paper.htm. Copyrights by Bagley and Tremblay.
Abstract: Both clinical andepidemiological literature point to elevated rates of suicidal behavioursin Gay, Lesbian and Bisexual Youth (GLBY). Recent North American and NewZealand studies of large populations (especially the US Youth Risk BehaviorSurveys from several States) indicate that gay, lesbian and bisexual adolescents(and males in particular) can have rates of serious suicide attempts whichare least four times those in apparently heterosexual youth. There arevarious reasons why this figure is likely to be an underestimate. Reasonsfor these elevated rates of suicidal behaviour include a climate of homophobicpersecution in schools, and sometimes in family and community – valuesand actions which stigmatise homosexuality and which the youth who hasnot yet ‘come out’ has to endure in silence.
The debate in Britain surrounding a law which forbade the use of public funds for counselling and supportof homosexual youth in schools and in some health and social service settings(Bagley & D’Augelli, 2000), has prompted us to examine the researchevidence focussing on the impact of the development of homosexual identityin adolescence, and the mental health costs of growing up in a climateof homophobic intolerance.
In fact, there is virtually no relevantBritish research on this topic, and it is to America, Canada and New Zealandthat we must turn for relevant studies (Tremblay, 2000a). These studiesare worth reviewing since they indicate that Gay, Lesbian and BisexualYouth (GLBY) do experience significant stresses during adolescence, sometimesreflected in elevated rates of suicidal behaviour, which might be addressedthrough 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 biographicalaccounts that for many youth who become homosexual adolescents, sexualorientation emerged strongly in early adolescence, regardless of whetherthis orientation was known to family and school friends (Herdt & Boxer,1993; Remafedi, 1994; Mays et al., 1998). A well-designed twin study couldnot however establish a genetic component in homosexuality, but did concludethat: ” … lifetime measures of suicidality are strongly associated witha same-gender sexual orientation. These effects cannot be explained byabuse of alcohol or drugs, nonsuicidal depressive symptoms, or the numerousgenetic and nongenetic familial factors accounted for in the co-twin controldesign.” (Herrell et al., 1999, p. 873). A random survey of 750 young adultmen in Canada suggests that some 14% had some kind of homosexual relationshipin adolescence, with about 5% emerging with a permanent homosexual orientation(Bagley & Tremblay, 1998). Because of the methodology of this studywe proffer it as a benchmark figure for the estimate of rates of prevalenceof homosexuality in male populations. Estimates below these figures are,because of methodological reasons, likely to be underestimates.
The youth with an emerging homosexualidentity 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 withan overt homosexual identity is open to social exclusion, and physicalpersecution, 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) willoften express negative feelings about homosexuals (Hecht, 1998; Proctor& Groze, 1994; D’Augelli, Hershberger, 1993). Research has shown thatcoming out to one’s family is associated with higher incidences of suicideattempts and suicide ideation, with 41% of those who have come out to familymaking a suicide bid, compared with 12% of those who remain ‘in the closet’,the elevated rates apparently linked to verbal and physical abuse by familymembers (D’Augelli, et al, 1998).
The youth who feels that he or sheis Gay or Lesbian must either pretend to go along with current views; orthey must face the risk of ‘coming out’ to family and peers. Eithercourse is perilous, and one sequel may be suicidal behaviour (Savin-Williams,1994; Hershberger, et al., 1997).
Until recently no reliable epidemiologicalevidence was available on prevalence. Now several studies establishingeither period or point prevalence are available (Tremblay, 2000a; Remafedi,1999). Most important are the studies of large numbers of high schoolstudents 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 orientationhave been relatively brief. These methods involve biases which will likelylead to conservative estimates of the numbers of GLBY and their suicidalproblems, and these potential biases must be outlined before interpretingthe data in Table 1, below.
Competing an interactive computerprogramme in a private setting is significantly more likely to elicit sensitiveinformation about sexual histories (Bagley & Genuis, 1991), the mostefficient method being the use of headphones in which aural questions areresponded to on a keyboard (Turner et al., 1998). This latter Americanstudy is extremely important: 1,672 males aged 15 to 19 were assigned torandom halves and asked either to read and tick boxes in a conventionalpencil-and-paper questionnaire; or to press a computer key as questionssimultaneously appeared on screen and aurally through headphones. Differencesin response to sensitive questions about sexuality were remarkable: usingpencil and paper, 1.5% reported sexual contact with someone of the samegender, compared with 5.5% agreeing positively under the audio responsecondition – a statistically significant 3.7 times difference. A furtherUS study supports these results (Supple et al., 1999).
Generalising these findings to theYRBS, these surveys will have underestimated the number of male Gay andBisexual youth by a factor of up to four, so that the ‘heterosexual’ contrastgroup is likely to contain at least as many GLBY as those actually designatedGLBY, 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 identitycrises which might be associated with suicidality.
Although valuable for populationestimates of rates of suicidality in GLBY, high schools may be significantlyunder-represented by crucial ‘at risk’ groups. It is known that some youngteenaged male prostitutes are permanent dropouts from school (Kruks, 1991;Savin-Williams, 1994; Rotheram-Borus et al., 1994).
‘Effeminate’ male youth may alsoescape the oppression of high school culture, seeking sanctuary withingay communities which exist in all large cities (Remafedi et al., 1991;O’Brien et al., 1993). This means that ‘ordinary’ high school populationsmay be under-represented by GLBY youth who are experiencing persecutionor 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 suicideideation in both male and female adolescents (Reinherz et al., 1995), andelevated risk for suicide attempts has been reported for the most ‘feminine’gay and bisexual youth, compared to their less feminine gay and bisexualcounterparts (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 significantcorrelate of having been the subject of physical attacks based on same-gendersexual orientation (the leading correlate with this variable was the numberof suicide attempts – unfortunately data in the report of the Vermont studywere not presented in a form which made it possible to include its resultsin Table 1).
The American Youth Risk BehaviorSurveys (YRBS) summarised in Table 1 are simultaneously heartening anddiscouraging: at long last the possible links between being Gay, Lesbianor Bisexual and suicidal behaviour are being explored in large-scale studiesof youth, based on random sampling of available high school populationsusing standardized instruments of known reliability (Du Rant et al., 1998),although the validity of many responses is hard to determine. Oneproblem is the definition of who is ‘gay’ or ‘bisexual’ – some studiesaccept the statement of sexual orientation by the respondent whilst otherssuch as the Vermont study (Du Rant et al., 1998) use an extreme definitionincluding only males who have had ‘intercourse’ with other males. Anotherfrustrating aspect of reporting results from the YRBS is that the sexesare frequently combined when it would have been easy to report rates separatelyby gender.
Whenever this is done (Remafedi etal., 1998; Saewyc et al., 1998; Du Rant et al., 1998; Garofalo et al.,1999) Gay and Bisexual adolescent males have very much higher rates thantheir apparently heterosexual counterparts. Attempts requiring medicalcare have a much higher incidence in GLBY. Despite some problemsin reporting results from the various YRBS, there are grounds for supposingthat these differential rates significantly underestimate the amount ofsuicidal behaviour in GLBY, for the reasons outlined above.
A New Zealand study (Fergusson etal., 1999) is based on a longitudinal, general population cohort followedup to age 21. Sexual orientation was elicited in a personal interview,and the advantage of such a technique as compared to any other method isunknown, although the method will almost certainly underestimate the trueamount 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, ahighly significant difference. This figure represents an estimateof period prevalence, rather than point prevalence as in the YRBS.
A number of supplementary questionsin the American Youth Risk Behavior Surveys (YRBS) give important cluesto reasons for the elevated and more serious suicide attempt rates in GLBY,reasons which confirm the clinical research outlined above. In the SeattleTeen Health Risk Study (Seattle, 1995) 7,437 students aged 15 to 18 wereasked about sexual orientation: 5% said they were gay or bisexual whileanother 4% were “unsure”. The researchers used the most conservativedefinition of gay orientation, those who were “unsure” about sexual orientationbeing excluded in reported results from this YRBS. The conservatively definedgroup of GLBY were three times more likely than others to have been beatenin a fight to the extent they required medical attention; they were also1.8 times more likely to have been threatened with a weapon in the past12 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 monthbecause of these fears (meaning that GLBY will be underestimated in surveyssuch as this because of this absenteeism factor).
The Seattle study (1995) reportedthat 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 droppedout than other students (a distinct finding supported by the HRS findingsand other research) they would be undercounted in this survey.” (p.9). Of the GLBY in the Seattle survey, 35.8% reported heavy or high-riskdrug use, compared with 22.5% of other youth – such high levels of druguse are also likely to be associated with higher levels of absenteeism.
Although causal analyses are notusually available for these data, there is a clear inference when readin conjunction with previous clinical studies that the frequent harassmentand persecution of GLBY who have come out (and the fear of such persecutionin GLBY who have not) is likely to be implicated in suicidal behaviourin this high school population, as well as associated substance abuse forwhich GLBY are at high risk (Garofalo et al., 1998).
The Massachusetts YRBS describedboth sexual orientation and suicidality profiles in a random sample of3,054 Massachusetts high school students (Faulkner & Cranston, 1998)aged 15 to 18: 1.7 % reported sexual activity with both genders, while2.0 % were sexually active only with the same gender giving a total of3.7 % who said they were actively bisexual, homosexual or lesbian. Attemptedsuicide rates were eight times higher in the actively gay and bisexualgroup of adolescents, compared with their heterosexual counterparts. Another analysis of these data extended the definition of being gay orbisexual to those with this orientation, not merely including those whowere 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 thosewho claimed themselves to be heterosexual.
Two of the YRBS have used logisticregression in order to provide models of why GLBY have elevated rates ofattempted suicide .The net result seems to be a model in which being aGLBY at risk of suicidal behaviour involves four factors – increased drugand alcoholism risk; increased sexual activity risk; increased risk ofbeing the victim of violence; and increased risk of becoming defensivelyviolent as a result of persecution about being visibly gay. These interactivefactors 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-schoolcommunities react to the revelation of being a GLBY was not explored inthese studies, but may be additional, linked or interactive stressors forsuch youth.
Some YRBS have reported on harassmentin schools (including the journey to and from school) based on perceivedhomosexual orientation, and have reported significantly elevated ratesof suicidality for these adolescents. The Oregon (1997) YRBS reported that21% of the students harassed in the previous month had made a suicide attemptin 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 whowere perceived as Gay or Lesbian accounted for 21.3% of suicide attempters,and 27.8% of adolescents reporting that their suicide attempt was of themore serious nature, requiring medical attention. Using logistic regressionanalysis, Garofalo et al. (1999) found that experiencing violence and victimisationwas a significant predictor of suicide attempts by GLBY. Harassment basedon one’s perceived homosexual orientation is often the consequence of individualsmanifesting a detectable degree of gender nonconformity., supporting theOregon (1997) findings.
Further evidence of the hazards experiencedby GLBY in schools comes from the most recent research of D’Augelli etal (2000) which showed in a cross-national sample of 350 youth that ‘genderatypical’ males were most likely to experience abuse. Abuse was in turnlinked to a range of negative mental health profiles, including suicidality.Remafedi et al. (1991) have also reported on the basis of logistic regressionanalysis, that the more ‘feminine’ GB male youth were three times morelikely to be suicide attempters than other GB male youth.
Despite methodological shortcomings(brief questions not covering the full range of homosexual identities andbehaviours; use of pencil-and-paper tests, or interview methods which arelikely to underestimate revelations of sensitive behaviour; and potentialfor undercounting groups most at risk) all of the YRBS plus the NZ cohortshow that youth (and particularly male youth) who have a self-declaredor perceived homosexual orientation or activity have a rate of suicidalbehaviour that is between two and eight times greater than in others. Moreover, differences are greatest for suicidal behaviours requiring medicalattention i.e. the most serious end of the suicidal behaviour spectrum.
The point prevalence estimates arelower than the period prevalence rate estimated from a Canadian study ofunselected males (Bagley & Tremblay, 1997) which indicated that Gayand Bisexual men up to age 27 had a suicide attempt rate 13.9 times thatin men who had not declared a Gay or Bisexual identity, using a computerisedresponse format. Further analyses of the national US survey data reportedin Cochran & Mays (2000) for the age group 17 to 29 provides corroborativeevidence supporting these Canadian findings (Tremblay, 2000a).
No study available has shown thatGLBY have elevated rates of completed suicide. Showing this has toovercome the problem that some youth may have killed themselves when ina state of confusion or depression over an emerging Gay identity in a climateof homophobia, but failed to communicate this to any person consulted bya Coroner or Medical Examiner. Or parents, teachers or others may havesuppressed this information for various reasons. We note howeverthat our Canadian study (Bagley, 1992) of several hundred cases of youthsuicide in Medical Examiners’ files did identity a type of suicide in malesin which no clear reason other than recent depression, could be adducedfor the act of self-killing. It is possible that this group includes anuncounted number of Gay youth.
Consider the following English caseknown to us: two girls aged 18 and 16 told their parents they were in loveand wanted to live together. Parents forbade this, reacting with confusionat this ‘lesbian phase’. Forced to part, the pair climbed on to abridge parapet but were prevented by police from jumping. They laid themselvesacross a rail line, but again were apprehended and endured brief psychiatrichospitalisation. The following day they jumped from a multi-storey carpark, killing themselves. Cross-checking this case with a regional suicideregister (Wessex, 1999) indicated that the Coroner had not recorded factsof persecution or doubt over lesbian orientation as relevant factorsin his verdict, and any research trying to link GLB status with completedsuicide would miss cases such as these.
American research identifies severaltypes of stress associated with an emerging Gay and Lesbian identity: personalfeelings of self-doubt in those who have no help or support network; lossof peers, emotional denigration and physical harassment in those whosesexual orientation is known in school; and family rejection of youth whohave identified themselves as Gay or Lesbian. Substance use is very muchhigher in youth denigrated in school settings, and they are likely to skipschool frequently or drop out altogether, and may be pulled into subculturesof drug use, promiscuity and prostitution, where suicidal intent may alsobe acted out by contracting HIV (Seal et al., 2000; Tompkins-Rosenblatt,1997). Many of these factors are known to be associated with higher ratesof suicidal behaviour (Remafedi, 1999).
Evidence continues to emerge fromUS studies of the risks for suicidality associated with being publiclygay in a climate of homophobia (D’Augelli et al, 1998; Friedman, 1999;Safren & Heimberg, 1999; Cochran & Mays, 2000), although the exactrole of substance abuse in suicidal behaviour of GLBY remains unclear (Bailey,1999; Lock & Steiner, 1999). What is possible however is thatGLBY who use alcohol or drugs as means of escape from persecution and doubtover an emerging Gay or Lesbian identity have elevated profiles for suicidalrisk compared with other GLBY (Remafedi, 1991; D’Augelli and Hershberger,1993). These possibilities require further clinical and epidemiologicalinvestigations, given that elevated rates of drug and/or alcohol use havebeen reported for GLB adolescents, compared with their heterosexual counterparts(Garofalo et al., 1998; Smith et al., 1999).
The establishment of a high schoolculture, and counselling and health systems which accept the emerging andevolving identities of Gay, Lesbian and Bisexual Youth is an importantantecedent of programmes which might prevent serious suicidal behavioursin a vulnerable and highly stressed group of young people (Uribe &Harbeck, 1992; Grossman & Kerner, 1998; Hammelman, 1993; Hershbergeret al., 1997; Lock & Steiner, 1999). Unfortunately, youth suicidalityrisk programs which take into account youth homosexuality (e.g. Stoelb& Chiriboga, 1998) are rare. As Remafedi (1994) observed, the issuesof homophobia and youth suicidality continue to be ignored.
Table 1 The American ‘Youth Risk BehaviorSurveys’ of Students Aged 14-18
|
State and Year |
‘Suicide Attempt’ in Gay, Bisexual& Lesbian Youth |
‘Suicide attempt’ in apparentlyheterosexual youth |
Ratio of ‘heterosexual’ rateto GLBY rate |
|
Minnesota (1997) – Females, any attempt: |
28.1% of 178 20.5% of 166 |
4.2% of 168 age, SES & racematched controls 14.5% of 145 matchedcontrols |
1:6.7*** 1:1.41 |
|
Massachusetts (1993) – m &f ‘sexually active’ Any Attempt |
27.5% of 105 20.0% of 105 |
13.4% of 1563 4.7% of 1563 |
1:2.0*** 1:4.2*** |
|
Massachusetts |
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) 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 betweenGLBY and apparently heterosexual group significant at the 1% level or beyond.
For all comparisons, GLBY and heterosexualcontrast group did not differ significantly on demographic profiles.
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