Re-Thinking Ethics and Politics in Suicide Prevention: Bringing Narrative Ideas into Dialogue with Critical Suicide Studies

Risk and protective factors for suicidality among lesbian, gay, bisexual, transgender, and queer (LGBTQ+) young people, from countries with a high global acceptance index (GAI), within the context of the socio-ecological model: A scoping review

INTRODUCTION

Lesbian, gay, bisexual, transgender, and queer (LGBTQ+) young people experience higher prevalence rates of suicidality than their heterosexual and/or cisgender peers. However, there is limited research that can inform suicide prevention efforts. Our aim was to synthesize quantitative, qualitative, and mixed methods research on risk and protective factors among LGBTQ+ young people, from countries with a high Global Acceptance Index.

METHODS

A scoping review guided by Arksey and O'Malley's five-stage framework, using the Preferred Reporting Items for Systematic Reviews and Meta-analysis Extension for Scoping Reviews protocol. Five databases and grey literature were searched for relevant studies. Identified factors were clustered by thematic type, according to the socio-ecological model to identify empirical trends and knowledge gaps. The mixed methods appraisal tool was used for quality assessment of studies.

RESULTS

Sixty-six studies met our inclusion criteria. Overall, 59 unique risk factors and 37 unique protective factors were identified. Key risk factors include past suicidality, adverse childhood experiences, internalized queerphobia, minority stress, interpersonal violence, bullying, familial conflict, and anti-LGBTQ+ policies/legislation. Key protective factors include self-affirming strategies, adult/peer support, at-school safety, access to inclusive healthcare, family connectedness, positive coming out experiences, gender-affirming services and LGBTQ+ inclusive policies and legislation.

CONCLUSIONS

Overall, our findings affirm that multiple risk and protective factors, at all levels of the socio-ecological model, interact in complex, unique and diverse ways upon suicidality among LGBTQ+ young people. Implications for suicide prevention are discussed. Further empirical studies are required, particularly at the communities, policies, and societal levels of the socio-ecological model, and these studies should include a focus on protective factors and significant within-group differences.

Teen Perspectives on Suicides and Deaths in an Affluent Community: Perfectionism, Protection, and Exclusion

Clusters of youth suicide and death are tragic for communities and present long-term consequences for the surviving youths. Despite an awareness of community-based patterns in youth suicide, our understanding of the social and community factors behind these events remains poor. While links between poverty and suicide have been well documented, wealthy communities are rarely targeted in suicide research. In response to this gap, we conducted ethnographic research in a wealthy U.S. town that, over a recent 10-year period, witnessed at least four youth suicides and seven more youth accidental deaths. Our interviews (n = 30) explored community values and stressors, interpersonal relationships, and high school experiences on participant perceptions of community deaths. Youth participants characterize their affluent community as having (1) perfectionist standards; (2) permissive and sometimes absent parents; (3) socially competitive and superficial relationships; and (4) a "bubble" that is protective but also exclusionary. Our qualitative findings reveal network influence in teen suicides and accidental deaths in a wealthy community. Greater attention paid to the negative effects of subcultural values and stressors in affluent communities is warranted. Further, our work promotes the value of ethnographic, community-based methodologies for suicidology and treatment.

Minority Stressors, Social Provisions, and Past-Year Suicidal Ideation and Suicide Attempts in a Sample of Sexual Orientation and Gender Identity/Expression Minority People in Canada

Purpose: Mental health disparities in sexual orientation and/or gender identity and/or expression (SOGIE) minority groups are well-documented, with research consistently showing higher levels of suicidality, even in Canada, considered one of the world's most accepting countries of SOGIE minority groups. Adverse outcomes in these groups are often framed using minority stress theory, with social support frequently studied as an integral buffer to these outcomes. This analysis explores facets of minority stress and social support associated with past-year suicidal ideation and suicide attempts. Methods: A cross-sectional internet survey of SOGIE diverse people in Canada (n = 1542) was conducted. Binary logistic regression calculated bivariate and multivariate factors associated with past-year suicidal ideation and suicide attempts. Backward elimination (retaining sociodemographic factors and self-rated mental health) identified salient minority stress and social support (provisions) factors. Results: Over half (56.72%) of participants had ever thought of dying by suicide, with 24.84% having attempted suicide. During the past year, 26.80% had thought of dying by suicide, with 5.32% having attempted suicide. Victimization events, and guidance (e.g., someone to talk to about important decisions) and attachment (e.g., close relationships providing emotional security) social provision subscales remained salient after backward elimination procedures. Conclusion: Our findings emphasize that a fulsome, multilevel approach considering structural, community, and individual strategies to address overt discrimination, integrating social connections and guidance, is necessary to prevent dying by suicide.

Suicide Risk Assessments: A Scientific and Ethical Critique

There are widely held premises that suicide is almost exclusively the result of mental illness and there is "strong evidence for successfully detecting and managing suicidality in healthcare" (Hogan and Grumet, 2016). In this context, 'zero-suicide' policies have emerged, and suicide risk assessment tools have become a normative component of psychiatric practice. This essay discusses how suicide evolved from a moral to a medical problem and how, in an effort to reduce suicide, a paternalistic healthcare response emerged to predict those at high risk. The evidence for the premises is critiqued and shown to be problematic; and it is found that strong paternalistic interventions are being used more often than acknowledged. Using a Principles approach, the ethics of overriding autonomy in suicide prevention is considered. Ethical concerns are identified with the current approach which are potentially amplified by the use of these risk assessments. Furthermore, it is identified that the widespread use of risk assessments in health settings is equivalent to screening without regard to the ethical principles of screening. The essay concludes that this is unethical; that we should abandon the use of standardized suicide risk assessments and 'zero-suicide' policy; and that this may improve outcomes.

The Googlization of Health: Invasiveness and corporate responsibility in media discourses on Facebook's algorithmic programme for suicide prevention

Big tech companies increasingly play a role in the domain of health. Also called the "Googlization of Health", this phenomenon is often studied by drawing on the notion of 'hostile worlds', where market values and common goods are incommensurable. Yet, the 'hostile worlds' theory is not uncontested; scholars for instance argue that the justifications of big tech companies are important analytical considerations as well. Building on this literature, in this paper I report on a case study of Facebook employing AI for suicide prevention, moving beyond Facebook's justifications only to study the ways in which media commentators and their audiences discussed Facebook's programme and the values they saw as being at stake. In the results, I show how invasiveness was, in different ways and forms, a main theme in thinking about Facebook using AI to do suicide prevention. Commentators and readers alike discussed how: 1) Facebook takes corporate responsibility with this initiative, or alternatively Facebook only has commercial interests and uses the notion of 'public good' to transgress spheres and sectors even further, thus being invasive; 2) Facebook's AI suicide prevention programme is invasive in relation to privacy and privacy laws, or, instead, people give up their privacy willingly in exchange for entertainment; 3) The programme undermines, rather than enhances, safety; 4) Suicide prevention in itself is already invasive. These different forms of invasiveness, I argue in the conclusion, also imply responsibility for different actors, from AI itself to Facebook through to medical professionals. Moreover, they show what values are at stake in, and transformed through, Facebook's AI suicide prevention programme, going beyond the frames of privacy and surveillance capitalism.

Correlates of suicidal ideation related to the COVID-19 Pandemic: Repeated cross-sectional nationally representative Canadian data

OBJECTIVE

With significant levels of mental distress reported by populations, globally, the magnitude of suicidal ideation during and beyond the COVID-19 pandemic is a central concern. The goal of this study was to quantify the extent of pandemic-related suicidal ideation in the Canadian population during the first ten months of the pandemic and identify sociodemographic and pandemic-related stressors associated with increased risk of ideation.

METHOD

Data were derived from three rounds of a mental health monitoring survey, nationally representative by age, gender, household income, and region, delivered online in May 2020, September 2020, and January 2021. Bivariate analyses were used to quantify the proportion of respondents in Canada reporting suicidal ideation by sociodemographic factors and pandemic-related stressors. Unadjusted and adjusted multivariable logistic regression was used to study the association between suicidal ideation and correlates within four pandemic-related stressor categories (financial, relationship, substance use, COVID-19 exposure).

RESULTS

Of the 7002 respondents, 6.2% (n = 433) reported experiencing suicidal thoughts or feelings as a result of the pandemic within the two weeks prior to taking the survey. In terms of sociodemographic factors, suicidal ideation was more commonly reported among those who were not cisgender, <65 years-old, single, Indigenous, LGBT2Q+, and who experience a pre-existing mental health condition. After adjusting for sociodemographic factors, indicators across all four pandemic-related stressor categories were associated with two or more times the odds of suicidal ideation.

CONCLUSION

Disparities in COVID-19 related suicidal ideation have persisted throughout the first year of the pandemic for specific sociodemographic sub-groups and those who have faced stressors related to finances, relationships, increased substance use, and COVID-19 virus exposure. To best address these disparities and to prevent a transition from suicidal ideation to action, appropriate planning, resources, and policies are needed to ensure health and well-being for everyone.

" … I felt completely stranded": liminality and recognition of personhood in the experiences of suicidal women admitted to psychiatric hospital

Purpose: The purpose of this study is to explore how patients experience their suicidality and how they experience being in a psychiatric hospital.

Methods: This is part of a field study, and the article is based on data collected in interactions with 11 women who were admitted to a psychiatric hospital and were struggling with suicidality. Data were collected through interviews, conversations, and participatory observation. We analysed the data by means of Systematic Text Condensation, followed by a deductive process where the data and preliminary findings were interpreted in light of the theory of liminality.

Results: We found that the patients’ experiences of suicidality and being a patient in a psychiatric acute ward involve “Liminality and weakened sense of personhood,” and from their perspective, “Recognition of personhood” is an important aspect of care.

Conclusion: Our study indicates that suicidality and psychiatric hospitalization involve liminality and weakened sense of personhood, aspects that are important to consider in the care of the patients. Professionals need to acknowledge more the importance of recognition of personhood in care, since this can strengthen the patient’s self-worth and empower the person. Lack of recognition may increase the patient’s suffering and suicidality.