Suicide is a tragic and costly yet preventable issue in public health that affects people of all races, ethnicities, ages, genders, and sexual orientation in the United States (U.S.) and worldwide. Over the years, suicide has remained the third leading cause of death for youths between 15-24 years of age in the U.S [1]. Suicide and self- inflicting injurious behaviors in LGBTQ adolescents are associated with mental health challenges that include lack of acceptance from peers, discrimination, family rejection, and school failure. The purpose of this article is to report current suicide statistics by demographics, discuss suicide risk and protective factors, and review prevention strategies and intervention efforts.

• Suicide

• Risk factors

• LGBTQ

• Youth

Aranmolate R, Bogan DR, Hoard T, Mawson AR (2017) Suicide Risk Factors among LGBTQ Youth: Review. JSM Schizophr 2(2): 1011.

US: United States; AFSP: American Foundation Suicide Prevention; LGBTQ: Lesbian Gay Bisexual Transgender Queer; AAS: American Association of Suicidology; HHS: United States Department of Health and Human Services; YRBSS: Youth Risk and Behavior Surveillance System; CDC: Center for Disease Control and Prevention; APA: American Psychology Association; NHOPI: Native Hawaiian and Other Pacific Islander

In 2012, the U.S. Surgeon General issued the National Strategy for Suicide Prevention, a document describing suicide as a major public health problem [2], but one that can be reduced and prevented by a joint effort of all sectors of society. Suicide is the second leading cause of death among the nation’s teenagers [3]. It is the third leading cause of death for persons between 15-24 years old, and LGBT youth are more likely to have suicidal ideation and attempt suicide than their heterosexual counterparts. Approximately 1 out of every 15 high school students report attempting suicide each year [1]. Suicide and selfinflicting injurious behavior in LGBTQ adolescents are associated with mental health challenges that include lack of acceptance from peers, discrimination, family rejection, and school failure. According to the Youth Risk and Behavior Surveillance System (YRBSS) 2015, among high school students who identified as LGB, 60.4% felt sad and hopeless, 42.8% seriously considered suicide, and 38.2% planned how they would attempt suicide; 29.4% attempted suicide one or more times, and 9.4% made a suicide attempt that resulted in an injury, including poisoning or overdose that had to be treated by a medical professional [4]. The purpose of this article is to review current suicide statistics by demographics, discuss suicide risk and protective factors, and review prevention strategies and intervention efforts.

 

In 2015, suicide was the 10th leading cause of death in the U.S. [1]. About 800,000 people die worldwide due to suicide every year [5] and more than 40,000 in the U.S., at a rate of 13.26 per 100,000 individuals, which is equal to 121 suicides per day. This accounted for $44 billion in combined direct and indirect costs. Suicide rates were higher among middle age adults between ages 45-64 (19.6%) and 19.4% occurred in the elderly (85 years and older) [1]. Nevertheless, males were 3.5 times more likely to commit suicide than females in all age groups, but more females attempted suicide by nonviolent measures, such as overdosing on medication or drugs compared to males, who typically used firearms and died in consequence. In regards to racial and ethnic groups, Caucasians (15.1%) and American Indians and Alaskan Natives (12.6%) were 2.5 times more likely to commit suicide than Hispanics (5.8%), Asians and Pacific Islanders (6.4%), and African Americans (5.6%) [1].

The contemporary key terms lesbian, gay, bisexual, transgender, and queer are used as distinct constructs to refer to an individual’s sexuality and gender. Sexual orientation and sexuality towards an individual are rapidly evolving over time with much debate and research. The associations among gender non-conformity (how an individual’s gender expression differs from societal norms), gender identity (self-identifying as male or female), sexual orientation (the sexual and emotional attraction to someone else) can be categorized by the attraction to same sex (gay men or lesbians), attraction to the opposite sex (heterosexuals), and attraction to the same and opposite sex (bisexuals), and show cultural conceptions of an individual’s sexuality and gender. The term transgender refers to how an individual’s gender identity is different from their assigned gender at birth. The term queer is used as a negative connotation when the gender identity does not conform to society norms [6].

LGBTQ youth often lack the life skills and experience to cope with feelings of fear and anxiety related to their acceptance in the society. LGBTQ youth encounter several problems with social interaction, which include discrimination and isolation. These factors may cause loss of self-esteem and depression. Many become suicidal and helpless. Suicidal thoughts and behaviors can lead to suicidal ideation, suicide attempts, and death by suicide. The risk factors for suicide among LGBTQ youth include: bullying, feelings of hopelessness, cultural and religious beliefs, and unwillingness to seek help because of the stigma [7]. The YRBSS 2015 revealed a total of 1,229 participants self-identifying as LGBTQ, with females (66.5%) reporting a higher rate of feeling sad or hopeless compared to males (43.9%). In regards to race, Whites (67.4%) were more likely to feel sad or hopeless compared to other races. The frequency of feeling sad was higher in the 10th grade (60.9%) compared to other grade levels (Table 1) [4]

Table 1: Sad or Hopelessness among Lesbian, Gay, or Bisexual students in the last 12 Months.
Feel Sad or Hopeless
Sex	Male N (%)	Female N (%)		Total (N)
	321 (43.9)	896 (66.5)		1217
Race	American Indian/Alaskan Native N (%)	Asian N (%)	Black N (%)	Hispanic N (%)	White N (%)	NHOPI N (%)	Multiple Race N (%)	Total (N)
	13 (N/A)	36(55.9)	160(44.8)	382(58.2)	514(67.4)	7(N/A)	85(54.1)	1229
Grade	9th N (%)	10th N (%)		11th N (%)		12th N (%)		Total
	330 (63.1)	321 (62.9)		308 (60.9)		256 (52.1)		1229
Abbreviations: NHOPI: National Hawaiian and Other Pacific Islanders  Source: Youth Risk Behavioral Surveillance System (YRBSS), 2015

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The YRBSS (2015) showed that Hispanics (37.9%) had a higher suicide plan compared to other races. Also, individuals in the 9th grade had a higher tendency to plan suicide (63.1%) than 10thgraders (62.9%), while 11th and 12th graders recorded 60.9% and 52.1%, respectively (Table 2) [4]

Table 2: Suicide Plan among Lesbian, Gay, or Bisexual Students in the last 12 Months.
Suicide Plan
Sex	Male N (%)	Female N (%)		Total (N)
	313 (27.0)	881 (42.0)		1205
Race	American Indian/Alaskan Native N (%)	Asian N (%)	Black N (%)	Hispanic N (%)	White N (%)	NHOPI N (%)	Multiple Race N (%)	Total (N)
	14 (N/A)	29(N/A)	155(32.9)	372(37.9)	515(30.1)	7(N/A)	82(30.9)	1205
Grade	9th N (%)	10th N (%)		11th N (%)		12th N (%)		Total
	320 (43.8)	322 (38.6)		301 (36.7)		249 (31.4)		1205
Abbreviations: NHOPI: National Hawaiian and Other Pacific Islanders Source: Youth Risk Behavioral Surveillance System (YRBSS), 2015

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other risk factors include making a prior suicide attempt (most significant risk factor), a history of mental disorder, history of alcohol and substance abuse, impulsive and aggressive tendencies; having a family history of suicide or violence, recent loss, and access to lethal methods. In regards to suicide contemplation, Whites had a higher rate (48.9%) compared to Asians (43.8%) and Hispanics (40.8%). According to grade level, individuals in the 11th grade are more likely to consider suicide (47.8%), while those enrolled in the 12th grade had the lowest tendency (34.8%) (Table 3) [4]

Table 3: Suicide Consideration among Lesbian, Gay, or Bisexual Students in the last 12 Months.
Suicide Consideration
Sex	Male N (%)	Female N (%)		Total (N)
	321 (43.9)	889 (66.5)		1221
Race	American   Indian/Alaskan   Native   N (%)	Asian   N (%)	Black   N (%)	Hispanic   N (%)	White   N (%)	NHOPI   N (%)	Multiple   Race   N (%)	Total   (N)
	14(N/A)	34(43.8)	161(34.4)	379(40.7)	510(48.9)	7(N/A)	85(30.9)	1221
Grade	9th N (%)	10th N (%)		11th N (%)		12th N (%)		Total
	326 (43.5)	324 (43.9)		305 (47.8)		253 (34.8)		1221
Abbreviations: NHOPI: National Hawaiian and Other Pacific Islanders Source: Youth Risk Behavioral Surveillance System (YRBSS), 2015

LGBTQ youth are four to six times more likely to attempt suicide, which results in injury, poisoning, or overdose that requires treatment from a doctor or nurse than heterosexual youth [3]. The data from YRBSS, 2015 revealed that females have a higher tendency to attempt suicide than males. Hispanics had a higher attempted suicide rate (31.4%) followed by Asians (30.6%). Furthermore, individuals in the 9th and 10th grade had the highest suicide attempts (34.5% and 30.6%, respectively) (Table 4) [4]

Table 4: Attempted Suicide among Lesbian, Gay, or Bisexual students in the last 12 Months.
Attempted Suicide
Sex	Male (N/%)	Female (N/%)		Total (N)
	252 (19.4)	746 (32.8)		1010
Race	American Indian/Alaskan Native N (%)	Asian N (%)	Black N (%)	Hispanic N (%)	White N (%)	NHOPI N (%)	Multiple Race N (%)	Total (N)
	12(N/A)	32(30.6)	123(29.2)	334(31.4)	403(28.6)	6(N/A)	76(29.5)	1010
Grade	9th N (%)	10th N (%)		11th N (%)		12th N (%)		Total
	283(34.5)	263 (30.6)		253 (25.7)		202 (25.0)		1010
Abbreviations: NHOPI: National Hawaiian and Other Pacific Islanders Source: Youth Risk Behavioral Surveillance System (YRBSS), 2015

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Injuries resulting from suicide attempts were more common among females than males. In terms of ethnicity, Hispanics recorded the highest injurious attempt (13.3%), and individuals in the 9th grade recorded a higher rate of injurious suicide attempt (11.6%) (Table 5) [4]

Table 5: Injurious Suicide Attempt among Lesbian, Gay, or Bisexual students in the last months.
Injurious Suicide Attempt
Sex	Male N (%)	Female N (%)		Total (N)
	249 (7.0)	741 (10.3)		1001
Race	American Indian/Alaskan Native N (%)	Asian N (%)	Black N (%)	Hispanic N (%)	White N (%)	NHOPI N (%)	Multiple Race N (%)	Total (N)
	11(N/A)	32(2.5)	122(5.9)	328(13.3)	403(9.3)	6(N/A)	76(8.8)	1001
Grade	9th N (%)	10th N (%)		11th N (%)		12th N (%)		Total
	281 (11.6)	263 (9.3)		248 (9.6)		199 (5.9)		1229
Abbreviations: NHOPI: National Hawaiian and Other Pacific Islanders Source: Youth Risk Surveillance System (YRBSS), 2015

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Negative attitudes toward LGBTQ lifestyles and gender bias may lead to isolation, family rejection, and lack of access to support groups. Consequently, this may increase stress levels, depression, and substance abuse, which may contribute to suicide risk in LGBTQ youth [8]. Besides the discrimination and bullying received at school, LGBTQ youth often deal with homophobic attitudes at home due to their parent’s perception of their sexual orientation. Subsequently, LGBTQ adolescents must cope with developing a sexual identity, while encountering negative remarks and threat of violence. Parents may not realize the bias of their comments, but the child may interpret their remarks as indicating that their family would not accept them if they revealed their sexual orientation. With regards to the prevalence of homophobia in American families, Morrow states: “internalization of homophobic and heterosexist messages begins very early—often before LGBT youth fully realize their sexual orientation and gender identity” and “that positive role models for LGBT youth are hard to find” [8]. A negative family reaction to an adolescent’s sexual orientation is associated with negative health outcomes in LGBT young adults. LGBTQ youth whose family highly rejected their sexual orientation are 8.4 times more likely to have attempted suicide compared to their LGBTQ peers that experience no or low levels of family rejection [9].

Research suggests that preventing depression by fostering a sense of belonging may reduce or deter suicidal tendencies among LGBTQ adolescents. Protective factors against suicide among LGBTQ youth include; effective clinical care, family/ community support, cultural/religious beliefs that discourage suicide, and support of tendencies for self-preservation [7]. These findings suggest that LGBTQ youth require support programs, policies, and resources to decrease the risk for suicidal ideation and suicide attempts. The “Out of Equity” program was started in Minnesota’s public school to reduce high risk behavior among LGBTQ youth, reduction of violence, harassment and creating safe environments that encourage diversity. School staffs are trained to recognize LGBTQ issues, stop actions that enhance violence, and respect confidentiality of the LGBTQ youth [10]. In addition, The GLBT Health Access Project in Massachusetts develops standard practices that allow LGBT youth to access quality health care services. This program also focuses on the delivery of services by the administrative personnel, which includes: the rights of the clients, confidentiality issues, outreach in the community, and health promotion [11].

Morrow et al. [12], developed guidelines for social work practice with LGBT youth, which include the following:

• Assess the positive and negative facets of self-identity as LGBT youth.

• Evaluate the level of disclosure of sexual orientation to others and help young people to explore the consequences of disclosure.

• Assess safety from threats and violence.

• Provide accurate educational information on sexual orientation and gender identity.

• Advocate for enhanced social services, a more supportive school environment, and civil Rights/social change.

According to Morrow, “Family connectedness, support from other adults, and school safety are all characteristics that are amenable to change and would be appropriate targets for interventions to protect young people from self-harm. Educating the parents and other influential adults to connect with and support adolescents grappling with issues of sexual identity may be a critical component of mental health promotion and protection for these young people” [8].

1. American Foundation Suicide Prevention Suicide: 2016 Facts & figures. 2016.

2. American Association of Suicidology. Suicidal behavior among lesbian, gay, and bisexual 2016 youth. 2016.

3. U.S. Department of Health and Human Services. Public Health Service, Office of the Surgeon General. A report of the U.S. surgeon general and of the national action alliance for suicide prevention. 2012.

4. Center for Disease Control and Prevention. Youth risk behavior risk surveillance system: Mississippi youth 2015. 2016.

5. World Health Organization. Suicide fact sheet. 2015.

6. American Psychological Association. Key terms and concepts in understanding gender diversity and sexual orientation among students. 2015.

7. Center for Disease Control and Prevention. Suicide: risk and protective factors. 2016.

8. Morrow DF. Social work practice with gay, lesbian, bisexual, and transgender adolescents. Families in Society. 2004; 8: 91-99.

9. Ryan C, Huebner D, Diaz RM, Sanchez J. Family rejection as a predictor of negative health outcomes in white and Latino lesbian, gay, and bisexual young adults. Pediatrics. 2009; 346-352.

10.Morrow DF, Messinger L. Sexual orientation and gender expression in social work practice: working with gay, lesbian, bisexual, and transgender people. New York: Columbia University Press. 2006; 177- 195.

11. Horowitz A, oehning G. (Editors). Safe Schools Manual: Saint Paul Public Schools Out for Equity. 2005.

12.Gay, Lesbian, Bisexual, and Transgender Health Access Project. Community standards of practice for the provision of quality health care services to lesbian, gay, bisexual, and transgender clients. Boston, MA: Justice Resource Institute Inc. 2006.