The relation between sexual orientation and suicide attempts in Austria

Ambient Discrimination, Victimization, and Suicidality in a Non-Probability U.S. Sample of LGBTQ Adults

Individuals who identify as lesbian, gay, bisexual, transgender, or queer (LGBTQ) are at a higher risk for suicidality compared to the general population. A growing body of research has investigated this risk, particularly with attention to systemic factors such as discrimination and harassment. Unfortunately, research has only examined the impact of direct discrimination on suicidality and has neglected to examine how ambient discrimination (i.e., witnessing or being made aware of discriminatory behaviors directed at someone other than yourself in your group) relates to suicidality. Additionally, although some links exist between discrimination and suicidality, the mechanisms by which these are related are understudied. This study aimed to address these gaps by exploring the effect of ambient discrimination on suicidal ideation and examining psychological pain as a mediator in this relationship. Data were collected from a sample of 200 LGBTQ-identified individuals (M age = 35 years; 53.5% female; 86% White). Results of independent t tests and a one-way multivariate ANOVA revealed greater vulnerability for ambient/direct discrimination and psychache among individuals identifying as transgender, queer, and other. Regression and mediation analyses revealed that while both ambient and direct discrimination predicted suicidal ideation, only direct discrimination accounted for unique variance in the outcome; however, both ambient and direct discrimination contributed unique variance to psychological pain, which fully mediated their relationships to suicidal ideation. Results of this study may begin to provide insight into the pathways of risk and points of intervention for suicidality in the LGBTQ community.

Effects of Multiple Forms of Information Bias on Estimated Prevalence of Suicide Attempts According to Sexual Orientation: An Application of a Bayesian Misclassification Correction Method to Data From a Systematic Review

Multiple epidemiologic studies demonstrate a disparity in suicide risk between sexual minority (lesbian, gay, bisexual) and heterosexual populations; however, both "exposure" (sexual minority status) and outcome (suicide attempts) may be affected by information bias related to errors in self-reporting. We therefore applied a Bayesian misclassification correction method to account for possible information biases. A systematic literature search identified studies of lifetime suicide attempts in sexual minority and heterosexual adults, and frequentist meta-analysis was used to generate unadjusted estimates of relative risk. A Bayesian model accounting for prior information about sensitivity and specificity of exposure and outcome measures was used to adjust for misclassification biases. In unadjusted frequentist analysis, the relative risk of lifetime suicide attempt comparing sexual minority with heterosexual groups was 3.38 (95% confidence interval: 2.65, 4.32). In Bayesian reanalysis, the estimated prevalence was slightly reduced in heterosexual adults and increased in sexual minority adults, yielding a relative risk of 4.67 (95% credible interval: 3.94, 5.73). The disparity in lifetime suicide attempts between sexual minority and heterosexual adults is greater than previously estimated, when accounting for multiple forms of information bias. Additional research on the impact of information bias in studies of sexual minority health should be pursued.

A Systematic Review and Meta-Analysis of Disparities in the Prevalence of Suicide Ideation and Attempt Among Bisexual Populations

Sexual minorities are at increased risk of suicide; however, it is unclear whether there are within-sexual minority differences in risk across specific sexual identities-notably between bisexual and lesbian/gay subgroups. We therefore conducted a systematic review and meta-analysis to quantify associations between bisexual identity and self-reported suicide ideation and attempt and the moderation of these associations by gender/sex, age, sampling strategy, and measurement of sexuality. Abstracts and full texts were independently screened by two reviewers, resulting in a total of 46 studies that met inclusion criteria and reported 12-month or lifetime prevalence estimates for suicide ideation or attempt. A consistent gradient was observed across all four outcomes, whereby bisexual respondents reported the highest proportion of suicide ideation or attempt, lesbian/gay respondents the next highest proportion, and heterosexual respondents the lowest proportion. Random-effects meta-analysis comparing bisexual individuals with lesbian/gay individuals yielded odds ratios (ORs) ranging between 1.22-1.52 across the four outcomes examined. Between-study variability in ORs was large. Thirty-one percent of heterogeneity was explained by sample type (e.g., probability vs. non-probability) and 17% by gender/sex. ORs were consistently larger for women (range: 1.48-1.95, all statistically significant at p < .05) than for men (range: 1.00-1.48, all p > .05), suggesting that gender/sex moderates the association between bisexual identity and suicide risk. Within-sexual minority differences in suicide risk may be attributed to structural and interpersonal experiences of monosexism, bisexual erasure and invisibility, or lack of bisexual-affirming social support, each of which may be experienced differently across gender/sex identities.

Sexual orientation measurement, bisexuality, and mental health in a sample of men who have sex with men in Vancouver, Canada

This cross-sectional study used a validated index (i.e., Hospital Anxiety and Depression Scale) to measure anxiety and depression (caseness score: ≥8) among men who have sex with men recruited via respondent-driven sampling in Vancouver, Canada (n=774), and investigated whether differences in mental health outcomes varied by sexual orientation measure (i.e., identity, attraction, behavior). Of the sample, 15.5% identified as bisexual, 33.4% reported any bisexual attraction, and 22.7% reported any bisexual sexual activity. More bisexual than gay men met the case definition for anxiety and depression, across all sexual orientation measures. In adjusted multivariable models, bisexual men had higher odds of anxiety by attraction and identity and higher odds of depression by identity. Findings highlight the value of measuring multiple sexual orientation dimensions in surveys and routine surveillance, and the need to ensure sexual minority groups and sexual orientation dimensions are not considered commensurate for mental health prevention and treatment.

Depression and Suicidality in Gay Men: Implications for Health Care Providers

Gay men are a subgroup vulnerable to depression and suicidality. The prevalence of depression among gay men is three times higher than the general adult population. Because depression is a known risk factor for suicide, gay men are also at high risk for suicidality. Despite the high prevalence of depression and suicidality, health researchers and health care providers have tended to focus on sexual health issues, most often human immunodeficiency virus in gay men. Related to this, gay men's health has often been defined by sexual practices, and poorly understood are the intersections of gay men's physical and mental health with social determinants of health including ethnicity, locale, education level, and socioeconomic status. In the current article summated is literature addressing risk factors for depression and suicidality among gay men including family acceptance of their sexual identities, social cohesion and belonging, internalized stigma, and victimization. Barriers to gay men's help seeking are also discussed in detailing how health care providers might advance the well-being of this underserved subgroup by effectively addressing depression and suicidality.

Suicidality and Associated Factors Among Men Who Have Sex With Men in Estonia

Many studies over the last decade provide strong evidence of elevated rates of suicidality among lesbian, gay, bisexual, and transgender populations compared to heterosexual populations. The aim of the current study was to investigate suicidal ideation and attempts and related factors among men who have sex with men (MSM) in Estonia. We conducted a nationwide Internet-based study among MSM with 265 eligible participants. Our results reveal high rates of self-reported suicidal ideation (lifetime prevalence 45%) and attempts (lifetime prevalence 11%) as well as a high rate of problem drinking (33%) and depressive symptoms (32%) among MSM. Recent suicidal ideation (14% had thought about suicide in the last 12 months) was related to depressive symptoms and lower socioeconomic situation. There is a need to develop specific interventions to address these issues among MSM and to provide gay-friendly mental health services.

Mental health of sexual minorities. A systematic review

Many studies, reviews, and meta-analyses have reported elevated mental health problems for sexual minority (SM) individuals. This systematic review provides an update by including numerous recent studies, and explores whether SM individuals are at increased risk across selected mental health problems as per dimensions of sexual orientation (SO), genders, life-stages, geographic regions, and in higher quality studies. A systematic search in PubMed produced 199 studies appropriate for review. A clear majority of studies reported elevated risks for depression, anxiety, suicide attempts or suicides, and substance-related problems for SM men and women, as adolescents or adults from many geographic regions, and with varied SO dimensions (behaviour, attraction, identity), especially in more recent and higher quality studies. One notable exception is alcohol-related problems, where many studies reported zero or reversed effects, especially for SM men. All SM subgroups were at increased risk, but bisexual individuals were at highest risk in the majority of studies. Other subgroup and gender differences are more complex and are discussed. The review supports the long-standing mental health risk proposition for SM individuals, overall and as subgroups.

Lifetime Prevalence of Suicide Attempts Among Sexual Minority Adults by Study Sampling Strategies: A Systematic Review and Meta-Analysis

BACKGROUND

Previous reviews have demonstrated a higher risk of suicide attempts for lesbian, gay, and bisexual (LGB) persons (sexual minorities), compared with heterosexual groups, but these were restricted to general population studies, thereby excluding individuals sampled through LGB community venues. Each sampling strategy, however, has particular methodological strengths and limitations. For instance, general population probability studies have defined sampling frames but are prone to information bias associated with underreporting of LGB identities. By contrast, LGB community surveys may support disclosure of sexuality but overrepresent individuals with strong LGB community attachment.

OBJECTIVES

To reassess the burden of suicide-related behavior among LGB adults, directly comparing estimates derived from population- versus LGB community-based samples.

SEARCH METHODS

In 2014, we searched MEDLINE, EMBASE, PsycInfo, CINAHL, and Scopus databases for articles addressing suicide-related behavior (ideation, attempts) among sexual minorities.

SELECTION CRITERIA

We selected quantitative studies of sexual minority adults conducted in nonclinical settings in the United States, Canada, Europe, Australia, and New Zealand.

DATA COLLECTION AND ANALYSIS

Random effects meta-analysis and meta-regression assessed for a difference in prevalence of suicide-related behavior by sample type, adjusted for study or sample-level variables, including context (year, country), methods (medium, response rate), and subgroup characteristics (age, gender, sexual minority construct). We examined residual heterogeneity by using τ(2).

MAIN RESULTS

We pooled 30 cross-sectional studies, including 21,201 sexual minority adults, generating the following lifetime prevalence estimates of suicide attempts: 4% (95% confidence interval [CI] = 3%, 5%) for heterosexual respondents to population surveys, 11% (95% CI = 8%, 15%) for LGB respondents to population surveys, and 20% (95% CI = 18%, 22%) for LGB respondents to community surveys (Figure 1). The difference in LGB estimates by sample type persisted after we accounted for covariates with meta-regression. Sample type explained 33% of the between-study variability.

AUTHOR'S CONCLUSIONS

Regardless of sample type examined, sexual minorities had a higher lifetime prevalence of suicide attempts than heterosexual persons; however, the magnitude of this disparity was contingent upon sample type. Community-based surveys of LGB people suggest that 20% of sexual minority adults have attempted suicide.

PUBLIC HEALTH IMPLICATIONS

Accurate estimates of sexual minority health disparities are necessary for public health monitoring and research. Most data describing these disparities are derived from 2 sample types, which yield different estimates of the lifetime prevalence of suicide attempts. Additional studies should explore the differential effects of selection and information biases on the 2 predominant sampling approaches used to understand sexual minority health.

Non-suicidal self-injury and suicidal thoughts and behaviors in heterosexual and sexual minority young adults

OBJECTIVE

Despite consistently greater rates of non-suicidal self-injury (NSSI) and suicidal thoughts and behaviors (STBs; i.e., suicidal ideation, method/plan, and attempts) in lesbian, gay, and bisexual (LGB) individuals, prevalence, characteristics, and relations between these dangerous thoughts and behaviors are equivocal. The present study sought to examine and compare the rates of NSSI and STBs in a large sample of sexual minority and majority young adults.

METHODS

Participants were 12,422 college students (ages 18-29; 57.3% female) who self-reported demographic characteristics, NSSI frequency, the number of NSSI forms used, the number of NSSI functions, as well as STB history (i.e., ideation, method/plan, and attempts). Each participant's degree of SA was assessed via a 7-point scale (i.e., K0-K6) from Alfred Kinsey's research of sexual attraction and sexual experiences. This scale was collapsed to create five categories of SA: exclusively other SA (K0), mostly other SA (K1/2), equally other and same SA (K3), mostly same SA (K4/5), and exclusively same SA (K6).

RESULTS

Consistent with previous research, we found that being a sexual minority young adult was associated with significantly higher odds of STBs compared to being a heterosexual young adult. In addition, compared to the exclusively other SA group (K0), being in the mostly other SA group (K1/2), equally other and same SA group (K3), or mostly same SA group (K4/5) was associated with significantly higher odds of NSSI engagement. Among those with NSSI, we found that the number of NSSI forms was significantly associated with suicide attempts, but was not associated with either suicidal ideation or suicide method/plan in the mostly other SA group (K1/2) or in the equally other and same SA group (K3). We also found a significant curvilinear relation between NSSI frequency and STBs in the mostly other SA group (K1/2) and between NSSI frequency and suicide method/plan and attempt in the exclusively other SA group (K0). In addition, we revealed specificity with regard to the relation between the number of lifetime NSSI episodes and risk for STBs among the equally other and same SA (K3), mostly same SA (K4/5), and exclusively same SA (K6) groups.

CONCLUSION

Our findings suggest that among sexual minority young adults, equally other and same SA individuals may be at higher risk of NSSI and STBs than their sexual minority counterparts. In addition, these findings extend previous research by suggesting that the relations between NSSI frequency, number of forms, and number of functions and STBs might vary according to SA. A multi-theory based explanation is provided to explain the key findings and the study implications are discussed.

Suicidality and sexual orientation: Characteristics of symptom severity, disclosure, and timing across the life course

This investigation explored suicide-related characteristics and help-seeking behavior by sexual orientation. Population-based data are from the California Quality of Life Surveys, which included 1,478 sexual minority (lesbian, gay, bisexual, and homosexually experienced individuals) and 3,465 heterosexual individuals. Bisexual women had a nearly six-fold increased risk of lifetime suicide attempts than heterosexual women (RR = 5.88, 95%CI: 3.89-8.90), and homosexually experienced men had almost 7 times higher risk of lifetime suicide attempts than heterosexual men (RR = 6.93, 95%CI: 3.65-13.15). Sexual minority men and women were more likely than heterosexual men and women to have disclosed suicide attempts to a medical professional (RR = 1.48 and RR = 1.44, respectively). Among persons who ever attempted suicide, sexual minority women had a younger age of index attempt than heterosexual women (15.9 vs. 19.6 years of age, respectively). Healthcare professionals should be aware of suicidal risk heterogeneity among sexual minority individuals, including vulnerable points of risk and evidenced-based treatments.

Suicidal risk and sexual orientation in adolescence: a population-based study in Iceland

AIM

Suicidality is an important public health problem, particularly among lesbian, gay, and bisexual (LGB) adolescents and young adults. The purpose of the present study is to compare the rate of suicide ideations and attempts among LGB adolescent to that of non-LGB adolescents in a population-based sample, and to identify important protective factors as well as risk factors Method: We used the Icelandic data set from the 2009/2010 Health Behaviour in School-aged Children (HBSC) study. The sample consisted of 3813 grade 10 Icelandic adolescents; 1876 girls and 1937 boys. The participants were asked about attraction and/or activity, as well as about suicidal ideation and/or attempts. The questionnaire also included various other items regarding health and lifestyle.

RESULTS

LGB adolescents were five to six times more likely to have had frequent suicidal ideations. Factors that were associated with less suicide ideations and fewer attempts were easy communication and liking school. The LGB girls were six times more likely to have had frequent suicide attempts, whilst the LGB boys were 17 times more likely to have attempted suicide that often. No specific protective or risk factors were identified for suicidality in LGB adolescents other than bullying.

CONCLUSIONS

Adolescents that had engaged in heterosexual activity and those that had LGB attraction had similarly heightened risk for suicidality, but sexually active LGB adolescents were far more likely to have suicidal ideations or to have attempted suicide.

Sexual orientation and non-suicidal self-injury: a meta-analytic review

The aim of this study was to conduct the first meta-analysis comparing risk for NSSI between sexual minority and heterosexual persons. Eleven published and 4 unpublished studies were reviewed, describing associations between sexual orientation and NSSI in 7,147 sexual minority and 61,701 heterosexual participants. The overall weighted effect size for the relationship between sexual orientation and NSSI using a random-effects model was OR = 3.00 (95% CI = 2.46-3.66), indicating a medium-to-large effect. Sexual minority adolescents and bisexuals were found to be at particularly high-risk. These findings highlight the need to examine mechanisms linking sexual orientation and NSSI in future research. Building on these findings can add to understanding the associations between sexual orientation, NSSI, and suicidality, as well as prevention/intervention.

An open debate about the object and purpose of global health knowledge in the context of an interdisciplinary research partnership on HIV/STI prevention priorities in Peru

Background

With the failure of the latest vaccine trial, HVTN-505, HIV prevention efforts remain critical. Social and structural factors contributing to HIV and STI transmission include stigma regarding sexual violence, HIV infection and sexual orientation. For instance, HIV prevention and overall sexual health programs in Peru have been implemented yet key populations of youth (sex workers, male and transgender youth) continue to be overrepresented in new cases of HIV and STI. This suggests that interventions must take new directions and highlights the need for additional research.

Discussion

While interdisciplinary, international research collaborations often are indicated as best practice in developing new knowledge in global health and an important component of the leadership in health systems, this does not mean they are free of challenges. In this debate we document our reflections on some of the challenges in developing an interdisciplinary and international research team to understand HIV and STI prevention priorities among youth in two culturally diverse cities in Peru: Lima, the capital city, and Ayacucho, in the Andean region.

Summary

Rather than offering solutions we aim to contribute to the debate about the object and purpose of global health research in the context of developing international research partnerships that genuinely promote a reciprocal and bidirectional flow of knowledge between the Global South and the Global North, and researchers at intersections of these locations.

Religion and suicide risk in lesbian, gay and bisexual Austrians

Religion is known to be a protective factor against suicide. However, religiously affiliated sexual minority individuals often report a conflict between religion and sexual identity. Therefore, the protective role of religion against suicide in sexual minority people is unclear. We investigated the effect of religion on suicide risk in a sample of 358 lesbian, gay and bisexual Austrians. Religion was associated with higher scores of internalized homophobia, but with fewer suicide attempts. Our data indicate that religion might be both a risk and a protective factor against suicidality in religiously affiliated sexual minority individuals.

Measures of sexual minority status and suicide risk among young adults in the United States

Multiple measures of sexual minority status are necessary to accurately describe the diversity of attractions, identities, and behaviors in sexual minority populations. We investigated whether four measures of sexual minority status (sexual minority attraction, sexual minority identity, sexual minority lifetime behavior, and sexual minority recent 12-month behavior) were associated with suicidal thoughts and suicide attempts among young adults ages 24 to 34 in the United States. We analyzed data from Wave IV (2007-2008) of the National Longitudinal Study of Adolescent Health. We employed logistic regression models in the analysis. Multiple sexual minority status measures had significant associations with increased suicidal thoughts among women and men. Multiple sexual minority status measures had significant associations with increased suicide attempts among women, but not among men. Diverse sexual minority populations are at increased risk for suicidal thoughts and suicide attempts. Multiple measures of sexual minority status should be utilized in future studies of sexual minority status and suicide risk. Suicide prevention programs should ensure intervention is available across diverse sexual minority populations.

Sexuality and suicidality: matched-pairs analyses reveal unique characteristics in non-heterosexual suicidal behaviors

The present findings offer new perspectives on differences between suicide-risk heterosexuals and non-heterosexuals (lesbian, gay, bisexual, and questioning: LGBQ). Results from an anonymous online survey, employing standardized scales, showed that LGBQ participants reported significantly greater suicide-risk than heterosexuals. Seventy-nine matched pairs of suicide-risk LGBQ and heterosexuals were examined by individual suicide risk factors. Results showed no significant differences on separate measures of suicidal ideation; however, LGBQ participants were more likely to report suicide attempts, disclosure of suicidal intentions, and prediction of future suicide attempts. The LGBQ group also indicated greater likelihood of going online to develop new personal relationships. Multiple regression modeling was conducted to guide outreach and support efforts, revealing unique factors predicting help-seeking denial of suicide-risk LGBQ. Implications include the importance of online support and considering sexual minorities not just as a potential high-risk group, but also as a population with unique suicide risks and behaviors.

Suicide risk and sexual orientation: a critical review

Many studies have reported higher rates of suicide attempts among sexual minority individuals compared with their heterosexual counterparts. For suicides, however, it has been argued that there is no sexual orientation risk difference, based on the results of psychological autopsy studies. The purpose of this article was to clarify the reasons for the seemingly discrepant findings for suicide attempts and suicides. First, we reviewed studies that investigated if the increased suicide attempt risk of sexual minorities resulted from biased self-reports or less rigorous assessments of suicide attempts. Second, we reanalyzed the only two available case-control autopsy studies and challenge their original "no difference" conclusion by pointing out problems with the interpretation of significance tests and by applying Bayesian statistics and meta-analytical procedures. Third, we reviewed register based and clinical studies on the association of suicides and sexual orientation. We conclude that studies of both suicide attempts and suicides do, in fact, point to an increased suicide risk among sexual minorities, thus solving the discrepancy. We also discuss methodological challenges inherent in research on sexual minorities and potential ethical issues. The arguments in this article are necessary to judge the weight of the evidence and how the evidence might be translated into practice.

Marriage, cohabitation and mortality in Denmark: national cohort study of 6.5 million persons followed for up to three decades (1982-2011)

BACKGROUND

Living arrangements have changed markedly in recent decades, so we wanted to provide an up-to-date assessment of mortality as a function of marital status and cohabitation status in a complete population.

METHODS

We studied mortality in a national cohort of 6.5 million Danes followed for 122.5 million person-years during 1982-2011, using continuously updated individual-level information on living arrangements, socio-demographic covariates and causes of deaths. Hazard ratios (HRs) estimated relative mortality in categories of marital status, cohabitation status and combinations thereof.

RESULTS

HRs for overall mortality changed markedly over time, most notably for persons in same-sex marriage. In 2000-2011, opposite-sex married persons (reference, HR = 1) had consistently lower mortality than persons in other marital status categories in women (HRs 1.37-1.89) and men (HRs 1.37-1.66). Mortality was particularly high for same-sex married women (HR = 1.89), notably from suicide (HR = 6.40) and cancer (HR = 1.62), whereas rates for same-sex married men (HR = 1.38) were equal to or lower than those for unmarried, divorced and widowed men. Prior marriages (whether opposite-sex or same-sex) were associated with increased mortality in both women and men (HR = 1.16-1.45 per additional prior marriage).

CONCLUSION

Our study provides a detailed account of living arrangements and their associations with mortality over three decades, thus yielding accurate and statistically powerful analyses of public health relevance to countries with marriage and cohabitation patterns comparable to Denmark's. Of note, mortality among same-sex married men has declined markedly since the mid-1990s and is now at or below that of unmarried, divorced and widowed men, whereas same-sex married women emerge as the group of women with highest and, in recent years, even further increasing mortality.

The case for the World Health Organization's Commission on the Social Determinants of Health to address sexual orientation

The World Health Organization's (WHO's) social determinants of health discussion underscores the need for health equity and social justice. Yet sexual orientation was not addressed within the WHO Commission on the Social Determinants of Health final report Closing the Gap in a Generation. This omission of sexual orientation as a social determinant of health stands in stark contrast with a body of evidence that demonstrates that sexual minorities are disproportionately affected by health problems associated with stigma and discrimination, such as mental health disorders. I propose strategies to integrate sexual orientation into the WHO's social determinants of health dialogue. Recognizing sexual orientation as a social determinant of health is an important first step toward health equity for sexual minorities.