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Youth suicide risk and sexual orientation - Statistical Data Included
Philip A. RutterSmith and Crawford (1986) studied suicide intent among 313 Midwestern high school students. Of the 62% who reported some degree of suicidal ideation or intent, 8.4% had actually made an attempt. Given the nonclinical sample, this percentage is alarmingly high.
Neiger and Hopkins (1988) explored the relationship between demographics, etiology, and adolescent suicide. They found that depression, low self-esteem, self-dislike, and self-criticism were important predictors of suicidal ideation. Indicators of actual suicidal intent included previous suicide attempts, frequent discussion of death, making plans for death, purchasing or carrying deadly weapons, and certain criminal behavior. Finally, suicidal teenagers also reported external concerns: family violence, loss of a parent through divorce or death, and history of parents or siblings who had either attempted or committed suicide.
Brent and colleagues (1993) studied completed youth suicides by comparing victims with a history of previous psychiatric disturbances to those without such history. Although the latter group had fewer of the personal and familial risk factors associated with completed suicide, they nonetheless exhibited higher rates of familial psychiatric disorder, past suicidal ideation or behavior, legal or disciplinary problems in the past year, and loaded firearms in the home.
According to research conducted in the past two decades, sexual minority youth (gay, lesbian, and bisexual) exhibit more suicidal ideation than do their heterosexual peers. Estimated rates of suicidal ideation range from 50% to 70%, and actual suicide attempt rates range from 30% (Gibson, 1989) to 42% (D'Augelli & Hershberger, 1993), or three times that of heterosexual youth (D'Augelli & Hershberger, 1995; Rotheram-Borus, Reid, Rosario, Van Rossen, & Gillis, 1995). For racial minorities who are also gay or lesbian (Smith & Crawford, 1986), rates of suicidal activity are suspected to be even higher, and may reflect prejudice toward both sexual orientation and race. The youth in these studies were seeking assistance from community mental health centers or refuge at shelters, and they typically exhibit greater pathology than the mainstream gay, lesbian, or bisexual youth, an issue that may present a confound (Savin-Williams, 1990).
Furthermore, studies assessing suicide risk among youth have not included the full spectrum of sexual orientation. Several researchers suggest that bisexual and questioning youth may be at higher risk for suicidal behavior than self-identified homosexual youth (D'Augelli & Hershberger, 1993; D'Augelli, Hershberger, & Pilkington, 1996; Rotheram-Borus, Piacentini, Miller, Graae, & Castro-Blanco, 1994).
The literature on adolescent suicide has increased with the increase in suicidal behaviors, particularly among certain adolescent groups where suicidal ideation and behavior are higher. However, the predictive validity of suicide assessments has received mixed reviews. Several instruments display a high false positive rate, that is, overpredicting suicide risk (Muehrer, 1995). Because previous suicide attempters are at greatest risk for suicidal behavior, assessments are needed that not only produce lower false positive rates, but also identify those who have made attempts or have a suicide plan. This group can then be targeted for prevention and intervention efforts.
Another limitation of adolescent suicide research is that suicidal behavior and suicidal ideation are different constructs (Muehrer, 1995), and cross-study comparison of youth who experience fleeting thoughts of suicide with those who have actually made a suicide attempt and have been hospitalized is problematic. Thus, assessment of youth suicide risk should include the full range of suicide risk: low risk (fleeting suicidal ideation with no plan) to high risk (suicide plan, selection of lethal method, and previous attempt history).
Research suggests that some sexual minority youth are depressed and may consider suicide as an escape, not from issues related to their sexual orientation, but as a result of challenges they encounter in the broader social context (Savin-Williams, 1994; Rotheram-Borus, Hunter & Rosario, 1994; D'Augelli & Hershberger, 1995). Consequently, assessment of psychopathology and suicidality in the entire adolescent population, across the spectrum of sexual orientation, may be more appropriate (D'Augelli & Hershberger, 1995; Rotheram-Borus et al., 1994).
To summarize, several methodological problems hinder the ability to draw conclusions from previous youth suicide research. The studies used to predict suicide risk measured different constructs and employed different instruments. In addition, samples of gay, lesbian, bisexual, and questioning youth often were taken from community mental health and crisis centers and then compared with youth from the general high school population. Finally, studies of adolescent suicide used different definitions of suicidal ideation, intent, and behavior, making cross-comparisons of results difficult (Muehrer, 1995).
The purpose of this study was to assess suicide risk in a nonclinical sample of adolescents of homosexual, bisexual/questioning, and heterosexual orientation, and to investigate the potential relationship between sexual orientation and suicidal behavior.
METHOD
Participants
This study used a convenience sample recruited from a community support agency and an urban university. Participants were 50 males and 50 females. They ranged in age from 17 to 19 years, as follows: 17 (14%), 18(37%), and 19(49%). Twenty-six percent of the sample identified as homosexual, 24% as bisexual/questioning, and 50% as heterosexual. Fifty-three percent were Caucasian, 25% African American, 6% Asian, 3% Hispanic, and 13% indicated "other" for ethnic background (i.e., biracial or Native American).
Procedure
Participants were informed of the focus of the study, that their involvement was voluntary, and that they could enter a drawing for a $50 gift certificate to a record store. They were offered counseling contact information and informed that the principal investigator would be available to discuss any of their concerns after completion of the survey packet.
Measures
In order to prevent participants from recognizing that the study focused on any specific relationship between suicide risk and sexual orientation (Remafedi, Farrow, & Deisher, 1991), the survey packet was compiled in the following order: the Beck Hopelessness Scale, the Suicide Probability Scale, the Suicide Questionnaire, and the demographics form. These measures were chosen because they provide a comprehensive assessment of suicide risk (i.e., ideation, behavior, planfulness, and hostility). In addition, the scales overlap only minimally and use language understandable to youth.
The Beck Hopelessness Scale (BHS) is a self-report measure that has 20 true-false statements to assess negative beliefs about the future. Scores range from 0 to 20, with higher scores indicating greater levels of hopelessness. Research indicates that the BHS has strong internal consistency and reliability, with the Kuder-Richardson formula 20 coefficient ranging from .82 to .93 across a variety of clinical and nonclinical groups. The test-retest reliability for the BHS was .69 after one week and .66 after six weeks (Beck, Weissman, Lester, & Trexler, 1974).
The Suicide Probability Scale (SPS) is a self-report measure that assesses suicide risk in adolescents aged 14 years and older. Subjects are asked to rate the frequency of certain thoughts, feelings, and behaviors on a 4-point Likert scale ranging from "none or a little of the time" (1) to "most or all of the time" (4). The SPS includes 36 questions which, when scored, reveal an overall suicide risk profile comprised of four subscales: Hopelessness, Suicidal Ideation, Negative Self-Evaluation, and Hostility. The SPS displayed strong test-retest reliability of .92 after three weeks and .94 after ten days. Internal consistency was found to range from .62 to .89 for the individual scales and was .93 for the total instrument. Split-half reliability ranged from .55 to .88 for the subscales and was .93 for the total instrument (Zachary, Roid, Cull, & Gill, 1983).
The Suicide Questionnaire (SQ) incorporates items from a standard clinical interview (Meehan, Lamb, Saltzman, & O'Caroll, 1992). Although the questionnaire exhibits high face validity and offers a nonthreatening method of assessing the history and lethality of suicidal ideation, plans, and attempts (Muehrer, 1995; Gibson, 1989), its reliability and validity have not yet been assessed.
A demographics form was used to obtain information about socioeconomic, cultural, and educational background. The demographics form included questions about the amount of support the participant receives from friends, family, and school staff, as well as questions about the participant's sexual orientation.
Because research indicates bisexual and questioning youth have more limited social support and may be confused about their sexual identity, the first hypothesis predicted that bisexual and questioning youth would exhibit greater levels of suicidal ideation than would the other groups (i.e., heterosexuals and homosexuals). These factors have been shown to increase levels of hopelessness and suicidality (Hollander, 2000; Rotheram-Borus et al., 1994; Savin-Williams, 1994; Schneider & Tremble, 1986). Specifically, bisexual/questioning youth were expected to score significantly higher on the BHS and the Hopelessness, Negative Self-Evaluation, and Suicidal Ideation subscales of the SPS.
Research by Coleman and Remafedi (1989) suggests that homosexual male youth and heterosexual male youth are similar in terms of suicidal thoughts and behaviors. Accordingly, the second hypothesis predicted that suicide risk among homosexual and heterosexual male participants would be similar. Specifically, they were expected to obtain similar scores on the Suicidal Ideation and Hostility subscales of the SPS and similar levels of lethality on the SQ.
Research underscores the importance of support for young people's psychological well-being. Youth who receive counseling or peer support exhibit healthier coping mechanisms and maintain a more positive outlook about their future (De Wilde, Kienhorst, Diekstra, & Wolters, 1993), in contrast to youth who lack support, with their greater likelihood of becoming truant or engaging in criminal behavior or substance abuse (Berndt & Savin-Williams, 1993; Himmelman, 1993). The third hypothesis proposed that youth who feel supported by friends, groups, counselors, or family members would express less suicidal ideation than those who do not feel supported. Specifically, youth who perceived themselves as having adequate social support were expected to have significantly lower BHS scores and lower Negative Self-Evaluation and Hostility subscale scores on the SPS than youth who did not perceive themselves as having adequate social support.
RESULTS
Table 1 groups participants by sexual orientation and displays their mean scores on the various scales. A multivariate analysis of variance was performed to analyze these data. Wilks's lambda was .87; F(2, 94) = .12 (not significant at the .05 level). Results of this analysis revealed that sexual orientation did not have a significant main effect on suicide risk scores in this sample (i.e., BHS score; SPS Hopelessness, Negative Self-Evaluation, and Suicidal Ideation subscale scores), and therefore the first hypothesis was not supported. Thus, bisexual and questioning youth exhibited no greater suicide risk than did the other groups.
The second hypothesis predicted that the level of suicide risk among heterosexual and homosexual males would be similar. The scores on the Suicidal Ideation and Hostility subscales of the SPS and levels of lethality in suicidal thoughts and attempts as determined by responses to the Suicide Questionnaire were used to test this hypothesis. The participants' mean scores are listed by sexual orientation in Table 2. A multivariate analysis of variance was performed on these data. No significant differences emerged between the homosexual and heterosexual male participants in terms of level of suicide risk. Wilks's lambda was .98; F(1, 39) = .26. The results of the analysis revealed that sexual orientation had no effect on male participants' suicide risk scores. Thus, the second hypothesis was not refuted.
The third hypothesis predicted that youth who report feeling supported by friends, school staff, or family would exhibit less suicidal ideation than would those youth who do not feel supported. Table 3 shows the correlations between support and suicide risk scores. As expected, all risk scores correlated negatively with support, several significantly: SPS Hopelessness, Hostility, Suicidal Ideation, and Negative Self-Evaluation, and BHS. Thus, support was negatively related to suicide risk, as hypothesized.
DISCUSSION
This study had several limitations. First, it utilized a convenience sample comprised of youth from a community organization and from a university, which diminishes the generalizability of the results. Second, because of the low number of participants (especially in the analysis comparing risk among males), only the most significant effects could be detected. Therefore, the findings should be viewed conservatively as an initial exploration of youth suicide risk across the spectrum of sexual orientation.
The bisexual/questioning youth of this study showed no greater suicide risk than did the others. This finding challenges previous studies and suggests that not all bisexual/questioning youth are at increased risk for suicidal behavior. Social support may be a mitigating factor in the two variables that are highly correlated with youth suicide risk--isolation and hopelessness (Savin-Williams, 1992; Rotheram-Borus et al., 1995). As is the case for the majority group, supportive peers may in fact reduce the level of suicide risk for bisexual/questioning youth.
The findings for heterosexual and homosexual males challenge previous research and bring elements of the current approach to youth suicide risk assessment into question. Specifically, are homosexual youth predisposed to greater suicidal behavior simply because of their sexual orientation? The results of this study suggest that this is not the case.
Support appeared significantly related to lower scores on the BHS and the SPS Negative Self-Evaluation and Hostility subscales, suggesting it may indeed have a positive effect on reducing suicide risk. Further youth suicide research should explore the importance of support as a potential mitigating variable.
Conclusions and Clinical Implications
By questioning the assumption that sexual minority youth are at increased risk for suicide, this study challenges several notions regarding youth suicide risk. In addition, by examining a range of suicide risk behaviors and psychosocial variables related to suicide risk, this project offers an alternative to the current risk-category perspective, namely that certain psychosocial variables relate more closely to suicide risk than any particular demographic variable. Future work could use a larger and more representative youth sample to expand upon this psychosocial variables premise.
This study posits that the current method of youth suicide risk assessment could be more efficient. If we rely on historical trends and assume that only certain groups are at risk, we may overlook others that are at substantial risk. Epidemiologists, clinicians, and researchers need to explore the variables related to a young person's membership in a risk category (Tharinger & Wells, 2000). Rather than focusing upon demographic variables, Rutter (1998) and Soucar (1983) recommend the use of a psychosocial construct approach to investigate youth suicide risk. By exploring underlying psychosocial stressors related to youth suicide risk, clinicians may offer more appropriately targeted interventions, thereby potentially reducing youth suicide attempts and completions. Future youth suicide research could further assess the psychosocial correlates of suicide risk across the spectrum of sexual orientation.
This study involved a broad assessment of youth suicide risk. By including a range of risk factors and assessing youth across the spectrum of sexual orientation, the study expands our knowledge. Future work on youth suicide risk could refine the assessment of support and include other variables historically related to risk in the adult population, such as substance abuse and family mental health history (Jordan, 2000).
The current project questioned the current risk-category approach and determined that demographic criteria, such as sexual orientation, do not automatically imply suicide risk. In order to develop more effective prevention and intervention strategies, future research should account for underlying psychosocial variables that may prove to be more salient.
Table 1
Mean Scores on the Beck Hopelessness Scale and the Suicide Probability
Scale (Hopelessness, Suicidal Ideation, and Negative Self-Evaluation)
Across Three Sexual Orientations
Homo Hetero Bisexual/
sexual sexual Questioning
Scale M SD M SD M
BHS 4.81 3.26 3.90 3.03 5.00
SPS Hopelessness 20.85 7.75 17.08 7.47 23.80
SPS Suicidal 14.31 8.65 12.38 6.30 14.95
Ideation
SPS Negative 14.46 4.68 13.54 4.11 15.95
Self-Evaluation
Bisexual/
Questionin
g
Scale SD
BHS 3.26
SPS Hopelessness 8.45
SPS Suicidal 5.82
Ideation
SPS Negative 4.15
Self-Evaluation
Note. n = 26 for homosexual youth; n = 50 for heterosexual youth; n = 24
for bisexual/questioning youth.
Table 2
Mean Scores on SPS Hostility, SPS Suicidal Ideation, and SQ Lethality
for Homosexual and Heterosexual Males
Homosexual Male Heterosexual Male
Scale M SD M SD
SPS Hostility 12.50 3.29 13.28 5.01
SPS Suicidal Ideation 13.19 7.41 13.44 6.84
SQ Lethality 0.69 0.48 0.76 0.44
Note. n = 16 for homosexual males
n = 25 for heterosexual males.
Lethality denoted as either lower risk (less than 0.49) or as higher
risk (more than 0.50).
Table 3
Intercorrelations Among Support and Suicide Risk Scores for the Total
Sample
Scale 1 2 3 4 5 6
1. BHS - .34 ** .64 *** .56 ** .50 * .53 **
2. Lethality - .54 ** .40 * .32 * .57 **
3. SPS Hopelessness - .73 *** .58 * .69 ***
4. SPS Hostility - .37 * .68 ***
5. SPS Negative - .40 *
Self-Evaluation
6. SPS Suicidal -
Ideation
7. Support
Scale 7
1. BHS -.23 *
2. Lethality -.11
3. SPS Hopelessness -.35 ***
4. SPS Hostility -.22 *
5. SPS Negative -.34 ***
Self-Evaluation
6. SPS Suicidal -.18 *
Ideation
7. Support -
Note. n = 100
* p < .05
** p < .01
*** p < .001.
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This study was supported, in part, by the Fahs-Beck Fund for Dissertation Research. The authors wish to thank Elisabeth Sherman-Slate for her editorial assistance.
Emil Soucar, Counseling Psychology Program, Temple University, Philadelphia.
Reprint requests to Philip A. Rutter, University of Colorado at Denver, North Classroom 4032-A, Campus Box 173364, Denver, Colorado 80217. Electronic mail may be sent to phil_rutter@ceo.cudenver.edu.
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