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To: The Table of Content - The Social Construction of Male Homosexuality and Related Suicide Problems...

By Pierre J. Tremblay in Collaboration with Richard Ramsay
Faculty of Social Work, University of Calgary.

The Paper  was Presented by Pierre Tremblay at The 11th Annual Sociological Symposium: "Deconstructing Youth Suicide," San Diego State University - March, 2000 (Cover Page). A part of the present updated paper was presented at the Gay Men's Health Summit in Boulder, Colorado - July, 2000 (Cover Page).

Male Youth Suicide Problems: Worsening Since 1950, Higher Rates for Homosexually Oriented Males, and Greater Risk for Suicide.

The male youth suicide problem for 15- to 24-year-old males increased 3-fold from 1950 to 1990 (Table 1), the increase being the greatest (5-fold) for males aged 15- to 19 years. Since 1950, males have also accounted for 88.5 percent of the additional deaths by suicide in the male and female 15- to 19-year-old category, and 95.5 percent of additional deaths in the 20- to 24-year-old group, meaning that the increase in youth suicides since 1950 has been almost exclusively a male problem. A number of general ideas have been given to explain the increasing adolescent male suicide problem, and Gibson (1989) was one of the first to suggest that homosexually oriented youth may account for about one-third of these deaths, but "some experts rejected the conclusions as being drawn from biased samples" (Remafedi, 1999, p. 1291; Remafedi 1999a).
Table 1 - American Youth Suicide Rates: 1950 to 1990
Increasing Youth Suicides: A 90% Male Problem
Age Range
Suicide Rate
[% Male]
Suicide Rate
[% Male]
Suicide Rate
[% Male]
15 to 19
M - 3.5
F - 1.8
M - 18.1
F - 3.70
M: 14.6 ( 5.2X) 
F: 1.90 (2.1X)
20 to 24
M - 9.3
F - 3.3
M - 25.7
F - 4.10
M: 16.4 (2.8X)
F: 0.8 (1.2X)
15 to 24
M - 6.5
F - 2.6
M - 22.0
F - 3.9
M: 15.5 (3.4X)
F: 1.3 (1.5X)
M = Males, F = Females, X = Suicide Rate Increase Multiple.
Suicide Rates: Deaths per 100,000 individuals per year.
Data Source: CDC, 1994, Table 1, p. 3.

Tremblay (1995) proposed that up to 50 percent of male youth suicide deaths may involve homosexually oriented males. This proposal contrasted with the results from two methodologically flawed postmortem studies (Rich et al., 1986; Shaffer et al., 1995) commonly used to suggest that homosexually oriented adolescents are not at greater risk for suicide than their heterosexual counterparts (Muehrer, 1995; Moscicki, 1995). On the basis of suicide risk indicators, however, including their research results, Bagley and Tremblay (1997a) speculated that more than half of male suicide deaths may involve homosexually oriented males. Given that the greatest increase in suicides has been in the 15- to 19-year-old category, that males form the vast majority of additional youth deaths from suicide since 1950, and that the greatest amount of male suicidality information based on sexual orientation criteria for this age group is available, a survey of the available information and related implications is warranted.

The trend in mainstream youth suicidology to assume that sexual orientation factors are not significantly different in suicide rates or suicide problems has created a general lack of awareness that homosexually oriented males may be greatly overrepresented in the worsening suicide problems (Gibson, 1989; Remafedi, 1994; Savin-Williams, 1994; Tremblay, 1995). This assumption persists in spite of the Bell and Weinberg (1978) study data indicating that white predominantly homosexual males, by the age of 20 years, were 14 times more at risk for a "first time" suicide attempt than their heterosexual counterparts. Bagley and Tremblay (1997) replicated this factor (to the average age of 22.7 years) for a large random sample of 18- to 27-year-old Calgary males, and a further analysis of the "suicide attempt" data for males 17 to 29 years of age in the Cochran and Mays (2000) NHANES III (National Health and Nutrition Examination Survey) study produced Odds Ratios similar to the two previously noted studies (OR range for the three studies: 12-15, Note 8). Given the average age of the Bell and Weinberg (1978) sample (37 years), the suicidality results for homosexual males best represent the situation existing in the early 1950s. At that time, "first time" suicide attempt incidence to the age of 17 years for white predominantly homosexual males was 4.9% percent: 28/575 (Bell and Weinberg, 1978).

The studies reporting on the suicidality of homosexually oriented male youth have used varied methodologies, thus creating interpretation problems and making it difficult to be absolute about the numbers, but a general trend is apparent from the available data and reported results. The lifetime suicide attempt incidence for homosexually oriented male adolescents has greatly increased over the years (about 6 times) given the Bell and Weinberg (1978) data (a 4.9% "first time" suicide attempt incidence by the age of 17), and the more recent study results. Studies based on varied North American volunteer community samples of gay and bisexual males report lifetime suicide attempt incidences averaging 30 percent (Bagley and Tremblay 1997), with a range of 20 to 42 percent for ten published American studies (Remafedi et al., 1999). These results have also been replicated in school based random sampling YRBS (Youth Risk Behavior Surveys, or similar surveys), and two of these studies specifically report suicidality results for male adolescents based on sexual orientation.

Based on a 1987 Minnesota study of grade 7 to 12 students, Remafedi et al. (1998) report a lifetime suicide attempt incidence of 28.1 percent for males identified as gay or bisexual by the average age of about 15 years, compared to 4.2 percent for heterosexual identified males. Using the same sample data, Saewyc et al. (1998) report that older gay and bisexual male adolescents (15- to 19-years-old) have a lifetime suicide attempt incidence of about 33% by the average age of about 17 years. Garofalo et al (1999) does not specifically give the suicide attempt rate (based on a 12-month period) for males identified as gay, bisexual, and "not sure" about their sexual orientation (GBN), but an estimate of 33 percent was determined on the basis of the information given (Note 6). Other studies (some not yet published, but the data is available) report similar results on average for homosexually oriented adolescents not differentiated on the basis of gender (Table 2).

Table 2 - GLB Youth: Increasing "At Risk" Status
For The More Serious Suicide Problems:
Youth Risk Behavior Survey Results

Suicidality Category

Mass 952
GLBN (Gay, Lesbian, 
Bisexual, Not Sure)  vs
Mass 971
GLB* and/or Homo-sex 
Active vs 
Seattle 951
Identified vs 
Vermont 952
Males &
Females: Homo-
sex active vs
Mass '93
Males & Females: Homo-sex active vs Hetero-sex
Considered Suicide
46.4% vs
54% vs 
34.2% vs 16.7%
59.2% vs 
41.7% vs
Planned Suicide
40.5% vs
41% vs 
31.1% vs 15.7%
52.8 vs 
 29.7% vs
36.0% vs
37% vs 
20.6% vs 6.7%
40.7% vs 
27.5% vs 13.4%
Medical Care
Associated with
Suicide Attempt 
19% vs 
9.4% vs 
26.5% vs 
20.0% vs 
"A" VS "B" 
"A" VS "B" 
Medical or Psychiatric Hospitalization Associated with Suicide Attempt
"A" VS "B" 
"A" VS "B" 
1. Unpublished Studies - 2. Published Studies but relevant data not given. Information obtained from other sources. 3. **More at Risk Factor for GLB Adolescents Compared to Heterosexual Adolescents.4. Defined by Ramsay and Bagley (1985) and Bagley and Ramsay (1985), and used by Bagley and Tremblay (1997): Note 7 - *GLBN = Gay, Lesbian, or Bisexual Identification; N = "Not Sure." 

Result from Youth Risk Behavior Surveys have also repeatedly indicated that homosexually oriented male and female adolescents are generally more at risk for the more serious suicide behavior: (1) considered suicide, (2) planning a suicide, (3) attempting suicide, and (4) attempting suicide with resulting medical attention (Table 2). In the category of "suicide attempt associated with having received medical attention," it is assumed that, as a rule, the most life threatening suicide attempts, or suicide attempts with a definite intent to die, would have a greater likelihood of resulting in the individual having receiving medical attention, but this may not always be the case, at least for gay and bisexual males (Remafedi et al. 1991).

The YRBS study results listed in Table 2 include homosexually oriented females, and female data tends to reduce major differences existing between males as indicated from the Garofalo et al. (1999) and Remafedi et al. (1998) study results. In the two studies, statistical significance was eliminated between homosexual and heterosexual female suicide attempters in the multivariate analysis, but great differences for suicide attempts incidence were reported for homosexually oriented males compared to their heterosexual counterparts. In the Garofalo et al. (1999) study, LBN females are 2.0-times more likely to report a suicide attempt than heterosexual females, while the factor is 6.5-times for GBN males compared to heterosexual males. In the Remafedi et al. (1998) study, the higher risk factor is 1.4 times for LB females and 7-times for GB males compared to their heterosexual counterparts. Therefore, it is suspected and predicted that an analysis of only the male data in other YRBS studies would likely show more serious suicidal behaviors than their heterosexual counterparts, compared to results generated from the combined male and female data (Table 2).

An indication of the magnitude of differences in suicidality of males based on sexual orientation was reported by Bagley and Tremblay (1997) on the basis of a large random sample of males ranging in age from 18- to 27-years-old. Their suicidality results are presented in two categories of self-harm behaviors based on previous epidemiological studies: "self-harm" (often called suicide attempts by adolescents, but without the intent to die, and the behavior is usually not life threatening), and "suicide attempts" representing a definite attempt at self-killing (Note 7). Compared to heterosexual males, homosexually oriented young adult males were 3 times more likely to report "self-harm" in their lifetime; this is remarkably similar to the reported differences, based on sexual orientation, for "suicide attempts" reported in YRBS studies (Table 2). For strictly defined "suicide attempts," however, Bagley and Tremblay (1997) reported that young adult homosexually oriented males were 14 times more likely to have attempted suicide than their heterosexual counterpart; and the magnitude of risk increases four to five times from their relative risk for for having engaged in "self-harm" activities, to their relative risk for a "suicide attempt" (Note 8).

Homosexually oriented male adolescents are also at risk for serious suicide attempts as reported by Remafedi et al. (1991) from their sample of 137 gay and bisexual male youth ranging in age from 14- to 21-years-old : "Fifty four percent of all suicide attempts (37/68) received risk scores in the 'moderate to high' lethality range." In the 45 attempted suicide cases where the rescuer was not the victim (76% of cases), 58% "received scores in the 'moderate to least' rescuable range. In other words, the predicted likelihood of rescue was moderate to low despite the actual occurrence of an intervention" (p. 871). Unfortunately, since 1991, studies reporting on the suicidality of homosexually oriented youth have only reported "suicide attempts" (with a related analysis) without investigating their degree of  lethality, nor were "suicide attempts" rigorously evaluated to separate the ones best classified as "self-harm" from the ones best classified as deliberate attempts to take one's life (Note 7). The Remafedi et al. (1991) and YRBS data (Table 2), however, suggests that maybe more than 25 percent of suicide attempts by gay or bisexual identified adolescent males result in medical interventions, thus indicating a higher likelihood for suicide for these males.

The high proportion of homosexually oriented male adolescents who attempt suicide places them at higher risk for an eventual suicide either as adolescents or later in life  (Lewinsohn et al., 1993; Kotila and Lonnqvist, 1989; Sellar et al., 1990; Shafii et al., 1985; Otto, 1972). In this respect, Garland and Ziegler (1993) reported that the "best single predictor of death by suicide is probably a previous suicide attempt" (p. 172).  Community samples of homosexually oriented youth have also produced high rates for repeat suicide attempters, six study samples producing a 44.2 percent average for the proportion of gay and bisexual male suicide attempters who became repeat suicide attempters (Table 3), the suggestion being that suicide is an ongoing problem for many of these youth.  A similar percentage (39.9%) resulted from the Bell and Weinberg (1978) data, thus indicating consistency in this respect over time. Unfortunately, published studies have not been located on the risk for an eventual suicide by adolescents with a history of repeated suicide attempts. It is possible that such individuals, especially males, are at much higher risk for committing suicide than males with a history of only one suicide attempt.

Table 3: - G(L)B Youth Lifetime "Suicide Attempt" DATA
Published Studies (American)
Roesler & Deisher, 1972
GB Males
Remafedi, 1987
GB Males
Schneider et al. 1989
GB Males
Remafedi et al. 1991
GB Males
Rotheram Borus, 1994
Visiting Hetrick & Martin 
Institute (N.Y.)
GB Males
+/- 17
Grossman & Kerner, 1998
GLB Youth
+/- 18
(6 Studies)
1. A variety of community-based volunteer samples.

2. Sample of gay/bisexual/lesbian individuals with suicide attempt prevalence given for entire group.

The lifetime incidence of "suicide attempts" for homosexually oriented male adolescents has increased about 6-fold since 1950, from about 5 to 30 percent. Of significant  interest are the YRBS study result producing a "suicide attempt" average about about 30 percent for a 12-month period: 32.3% for the 5 studies (Table 2). Given that these rates coincide with lifetime estimates from community samples (Table 3), this similarity likely reflects, at least in part, the possibility that adolescents in school define a "suicide attempt" in a more liberal way; a minor injury may be interpreted to be a suicide attempt. Another possible contributing factor is the high likelihood of homosexually oriented adolescents to be repeat suicide attempters (Table 3). It is important to recognize, however, that the random sampling YRBS studies likely solicits data from a wider spectrum of homosexually oriented adolescents than the representation obtained from volunteer community based samples. If this applies, the suicide problems of homosexually oriented adolescents may actually be more serious than proposed in the worst case hypotheses.

At issue, however, has been their representation in youth suicide problems, and especially their representation in suicide statistics. Mainstream suicidologists have often criticized suicidality results from gay community based samples because of their assumed biased nature (Moscicki, 1995Muehrer, 1995), and always to counter efforts to have homosexuality issues addressed in youth suicide education and prevention programs where indifference to homosexuality was the rule, as it had been in mainstream youth suicidality research (Remafedi, 1994; Savin-Wiliams,1994; Tremblay, 1995). Tremblay (1995) also suggested that a mean spirited objective had motivated the production of the 1995 Suicide and Life Threatening Behavior special issues on "Sexual Orientation" edited by Muehrer, Moscicki, and Potter (1995) who are from the National Institute of Mental Health (NIMH) and the Centers for Disease Control (CDC).

Tremblay (1995) felt that the document was not created by individuals who really wanted to see homosexuality issues addressed in mainstream youth suicidality education and prevention programs, and that maybe mainstream youth suicidality researchers were not to be encouraged to begin soliciting sexual orientation information in their research. By 1999-2000, this outcome was the ongoing research behavior that the CDC was modeling as a part of its boldly emphasized "Leadership Role." Apparently, the CDC's role is "to ensure the availability of accurate and current information on health risk behaviors among young people, [to provide] funding and technical support to states and major cities to conduct a Youth Risk Behavior Survey" (CDC, 1999), but it is not to model any research behavior such as soliciting "sexual orientation" information from adolescents.

The CDC's official YRBS questionnaire does not solicit "sexual orientation" information (CDC, 1999a), meaning that the CDC does not recognize this factor in adolescent problems in spite of the wealth of information indicating otherwise, nor does the CDC apparently believe that such information should be solicited. Although the questionnaire does solicit information about "sexual intercourse," generally assumed to mean "penis-vagina" sex, anyone thinking the requested information may apply to same-sex sexual intercourse would be in error given the confirmation of its heterosexist definition in Question #63. "The last time you had sexual intercourse, what one method did you or your partner use to prevent pregnancy?" Therefore, to the year 2000, the CDC has continued to ignore "sexual orientation" issues in youth suicide problems, which can have only one result. When any "at risk" group of adolescents are ignored, their concerns are also ignored, and the ones responsible for this are essentially working to maintain a maximum casualty status in the ignored sector of the adolescent population.

In spite of the ongoing modeling of indifference to homosexuality issues in youth problems by the CDC, results from relatively rare school-based studies which had solicited "sexual orientation" were being peer reviewed and published: Remafedi et al. (1998) and Saewyc et al., (1998) for a 1987 Grade 7 to 12 Minnesota student sample, Garofalo et al. (1998, 1999) for a 1995 Grade 9 to 12 Massachusetts student sample; Faulker et al. (1998) for a 1993 Grade 9 to 12 Massachusetts student sample; and Durant et al. (1998) for a 1995 Grade 8 to 12 Vermont student sample. It was only for the Garofalo et al. (1999) study, however, that information was made available to permit an estimate of the proportion of male suicide attempters who are homosexually oriented.

Given the 12-month period 33 versus 5.1 percent attempted suicide rate for GBN (gay, bisexual, and "Not Sure" about their sexual orientation) males forming 4.7% of the male population, it was then possible to calculate that about one quarter (24.3%) of male suicide attempters are in the GBN category (Note 6). Therefore, 4.7% of the students of GBN males account for about 25% of the male suicide attempt problem. Given, however, that the study is based on an amended form of the pencil-and-paper Youth Risk Behavior Survey questionnaire from the Centers for Disease control (CDC, 1999a), and that these surveys likely underestimate the numbers of homosexually oriented individuals by a factor of 3 to 4 (Bagley and Tremblay, 1998; Turner et al., 1998), it is therefore postulated that all homosexually oriented male adolescents, had they been identified by Garofalo et al. (1999), would account for maybe 60 to 80 percent of male suicide attempters. This estimated correction would be consonant with the Bagley and Tremblay (1997) results: 62.5% of young adult male suicide attempters (lifetime incidence) were in the homosexual or bisexual category, defined on the basis of self-identification and/or being currently homosexually active.

The probability that homosexually oriented male youth account for at least 50 percent of suicide attempters, and the fact that these males are more at risk than heterosexual males for the more serious suicide behaviors, such as more serious forms of suicide attempts (Bagley and Tremblay, 1997, 1997a; Remafedi et al., 1991; Table 2), leads to the informed proposition that more than 50 percent of male youth suicides (maybe up to 75 percent) involve males for whom homosexuality issues are, or have been, a significant factor in their lives. It is also known that some males do commit suicide for reasons expressed by Nicolas and Howard (1998) in their study, "Better Dead Than Gay!" and as outlined by Tremblay (1998-1999) in a web page titled "Better to be Dead Than Gay."

Homosexually Oriented Male Youth: Ongoing Suicide Problems?

The Bell and Weinberg (1978) report that, out of 105 homosexually oriented males who had attempted suicide at least once, 62 percent reported that "homosexuality" was associated in their first suicide attempt, a percentage replicated in a 1993 study (Note 9), and 43 percent of these suicide attempts were related to problems in a homosexual relationship. These "first time" attempts were also distributed over given age ranges, with half (52%) occurring by the age of 20 years. Twenty-seven percent (27%) of the attempts had occurred by the age of 17 years, 25 percent between the ages of 18 to 20 years, 27 percent between the ages of 21 and 25 years, and 22 percent after the age of 25 years.

In addition, 39 percent of the male suicide attempters (7% of the sample) were repeat attempters, thus indicating consistency over the last 50 years given that, in recent studies, 44.2 percent of homosexually oriented male youth who attempted suicide (13.3 percent of the sample populations) are repeat attempters (Table 3). The doubling of the percentage of repeat suicide attempters is indicative of increasing ongoing suicide problems, likely of the most serious kind, with implication yet to be studied. My experience in gay communities has revealed that male suicides and suicide attempts remain as a fact of life after homosexually oriented youth have made contact with gay communities. However, researchers have not explored this aspect of the problem, except for Bell and Weinberg (1978) reporting that homosexual relationship problems were associated with about 27 percent of first time suicide attempts.

The Remafedi et al. (1991) study of 137 gay and bisexual male (14- to 21-years-old) reports data indicating that 39 percent of studied youth had been runaways, 39 percent sexually abused, 35 percent arrested, and 20 percent had engaged in prostitution. The associated attempted suicide incidences for males having these often overlapping attributes are 37 (20/54), 47 (25/53), 44 (21/48), and 43 (12/28) percent respectively, the average for the sample being 30 percent. With respect to gender attributes, 23 percent of the males were classified "feminine," 26 percent were "undifferentiated," 31 percent were "androgynous," and 20 percent were rated as "masculine," and their respective suicide attempt incidences are 48 (15/31), 34 (12/35), 26 (11/42), and 11 (3/28) percent. There is therefore a general "suicide attempt" risk decrease from males being feminine, to males being masculine, the former having a 4.4 times greater likelihood for having attempted suicide than their "masculine" counterparts (48% vs 11%).

Many gay and bisexual identified adolescent males with a history of being runaways or throwaways, and especially the ones venturing into prostitution, form a sector of the more visible "gay communities" given that they are relating sexually with homosexually oriented men; Bell and Weinberg (1978) reported that 27 percent of predominantly homosexual males studied had paid for sex, and 25 percent had been paid for sex (p. 311). Not all gay and bisexual male adolescents making contact with gay communities, however, are in these categories, and little had been studied or written about their experiences and problems, including their ongoing risks for suicide problems and suicide. Real life story segment are nonetheless occasionally encountered within the context of researchers reporting on significant problems for which gay and bisexual male adolescents are at risk:

...[Y]outh who received the intervention [a lengthy safer sex education program] said that they would engage in unsafe sex when they felt particularly distressed because they thought it was hopeless for them to protect themselves from becoming HIV positive. In addition, youths who were overwhelmed by emotional distress would bring to the group problems regarding their latest crisis, for example, being involved with a partner who was suicidal or who was being threatened by a previous partner; for these youth these problems took precedence over making behavior changes toward less unprotected sex (Rotheram-Borus, 1995, p. 593).
A significant number of homosexually oriented male adolescents are attracted (commonly enough "only attracted") to older males and they will seek to have sexual relationships with them, often with the hope that love will be a major part of the relationship. This aspiration for love is an integral part of the adolescent male prostitution world, and "many youth" who have ventured into the Los Angeles Youth Service Center are described by Gabe Kruks.
The "sugar daddy" usually present himself to the youth in a loving caretaker manner. For street youth who have a past history of rejection and/or abuse, the promise to be loved and cared for is a compelling one. [These youth usually have many of these relationships and] each of these is a cycle of falling in love, believing that life will now be wonderful forever and that this older adult truly loves the young person, discovering that in fact it is just sex that the adult wants, feeling the impact of one more betrayal, and ending up on the streets again. This whole cycle lasts an average of 1-2 months, and the youth often becomes extremely suicidal at the end of each cycle (Kruks, 1991, p. 518).
Gay and bisexual male adolescents and young adults engaging in prostitution are reported to be at higher risk for suicide attempts (Nicholas and Howard, 1998), but they have not been the only ones attracted to older males and acting accordingly. Others have also been seeking sex (with the hope of love) relationships with older males as illustrated in the special "Love" issue of San Francisco's gay youth XY Magazine:
But when I came out, the closeness I was looking for wasn't what I found. Instead, I fell into the gay community's 'if you're gay, young and cute, you have to be one of those guys who sleeps around' stigma... And I learned from all the wonderful people I met that sex was just sex and that the whole closeness thing was merely a pipe dream - certainly unattainable [if not via sex]... My problem arises when people just coming out see our community as only sexual. That affects me. They learn, like young people in every culture, from their peers and elders. What they see, hear and experience is what they are going to assume the gay community is. With this type of base, they are going to have a very difficult time making their love lives flourish... There are some people who want more than sex and don't feel "sex is just sex" (Weldon, 1997, p. 53).
Marc describes his encounters from the age of 17 when he illegally ventured into gay clubs on a quest to find the males he was most attracted to: the ones about 10 years older than himself.
[By the age of 19, he had] had two "official" relationships... lasting no more than a couple of months, [and he has not been impressed with what he learned.] Maybe this pattern simply indicates bad choices on my part. I guess I can see why older men think 19-year-olds have nothing more than sex to offer. But it surprises me that the older crowd want shallow, detached physical contacts while their younger counterparts are searching so very,  very hard for something more substantial (Foster, 1997, p. 21).
The attraction of young gay males for older males is described in the "Older Partner" section of the report, Dangerous Inhibitions: How America is letting AIDS become an epidemic of the young. The section begins with: "Many young people find older partners attractive. All the young men and women participating in one series of PMI focus groups said that they prefer their sexual partners to be at least five years older than them" (Collins, 1997). Rotheram-Borus et al. (1995) reports that "many homosexual male adolescents have sexual relationships with homosexual men..., the group with the highest prevalence for AIDS" (p. 589), but most researchers have not been up front about this reality. For example, the Povinelli et al. (1996) study reports on a sample of 501 males aged 13 to 21 years "who self-identified as homosexual or bisexual or as having sex with men" (p. 33), the implication being that 13- to 16-year-old males are "men." The Remafedi (1994) study sample of 239 males aged 13 to 21 years uses similar terminology. The males in the sample were "self-identified as gay or bisexual and/or had sex with men... High risk sex between men account for the largest proportion of AIDS cases among adolescents (13 to 21 years of age)" (p. 163).  More honestly, however, Morris et. al. (1995) reported "that younger gay men with older partners are the leading edge of the [HIV-AIDS] epidemic in their cohort" (p. 24), and this problem would have begun early adolescence for some of the youngest males in the sample who were 18 years of age when studied.

Adolescent males who identify as gay or bisexual at the youngest age are at the greatest risk for suicide attempts (Remafedi et al., 1991; Schneider et al., 1989; D'Augelli et al., 1993; Hershberger et al, 1997; Nicholas and Howard, 1998), and they are most likely to be the youngest individuals becoming associated with some aspect of gay communities such as youth groups from which many study samples are obtained (Schneider et al., 1989; D'Augelli et al., 1993; Hershberger et al, 1997; Proctor and Groze, 1994). For many homosexually oriented male adolescents, however, their first contacts is with a well known part of gay communities known as the "public sex" or "anonymous sex" arena which has been participated in by about 50 percent of gay and bisexual males (Tewsbury, 1996). Uribe and Harbeck (1992) report on the related experiences of adolescent males:

Of the 37 males [in high school ranging in age from 16- to 18-years-old], 35 were already sexually active with other males. The average for the first sexual experience was 14 years, and in the majority of the cases this was with an unknown male... None of the males in this sample had his first sexual experience in a 'safe' manner, and none was still with his first sexual partner. [Furthermore], half of the study participants acknowledged engaging in suicide attempts in the year prior to the interview... Fifteen of these boys were living with friends, two admitted to living with 'sugar daddies,' and three were in residential or foster homes for gay adolescents (p. 21-22).
Family problems, reported to be almost universal for these males, is a factor significantly associated with suicide attempts (Schneider et al., 1989:Nicholas and Howard, 1998). Family problems and lack of services for these adolescents often result in a "lack of support" situation also linked to suicide attempts (Schneider et al., 1989; D'Augelli et al., 1993; Hershberger et al, 1997). Associated factors such as becoming homeless, dropping out of school, stress, and having friends who attempted suicide, have been linked to suicide attempts by gay and bisexual male youth visiting the Hetrick and Martin Institute in New York (Rotheram-Borus, 1994). About 25 to 40 percent of male street youth may be homosexually oriented (Kruks, 1991; Savin-Williams, 1994; Kipke et al., 1995). Runaway youth have elevated lifetime suicide attempt incidences ranging from 15 to 29 percent (Stiffman, 1989; Rotheram-Borus, 1993), and homeless gay youth were estimated to be three times more at risk for suicide attempts than their heterosexual counterparts (Gibson, 1989). One sample of 53 GB male street youth had a 53 percent lifetime suicide attempted incidence (Kruks, 1991).

Remafedi et al. (1991) reported high rates of sexual abuse for gay and bisexual male youth (39%), but also noted that sexual abuse generally postdated sexual identification as gay or bisexual. The unspoken implication is that the sexual abuse likely occurred after they made themselves available for sexual experiences often occurring via making contact with some gay community attribute such as the "public sex" arena, as most of the first sexual experiences occurred for the teenage gay males studied by Uribe and Harbeck (1992). Sexual assault and rape after adolescent males have made contact with gay communities, however, remain hidden in all studies reporting such experiences, often assumed to be "child sexual abuse" having occurred before the individual made contact with gay communities. This assumption may be incorrect.

About 20 to 39 percent of homosexually oriented males have experienced unwanted sexual acts (sexual abuse, sexual assault) by the age of 17 (Doll et al., 1992; Caballo-Dieguez and Dolezal, 1995; Holmes, 1997, Lenderking, 1997, Remafedi et al., 1991), and such experiences have been linked to a lifetime higher incidence of suicidal behaviors, including suicide attempts, in adolescent and young adult males (Bagley et al., 1994; Bagley et al., 1995), and in young adult gay males (Nicholas and Howard, 1998). The international incidences for boys being sexually abused ranges from 2 to 11 percent, with up to 16 percent results in Alberta, Canada (MacMillan et al., 1997). Homosexually oriented males may also be at greater risk for sexual abuse at younger ages given that one study reported that boys sexually abused before the age of 13 were 4 times more likely to be homosexual than boys not sexually abused (Finkelhor, 1979).

Substance abuse is also associated with suicide attempts of gay and bisexual male youth (Remafedi et al., 1991), as is alcohol abuse (D'Augelli and Hersberger, 1993), and both these problems are well recognized risk factors for both suicide attempts and suicides in mainstream youth populations (Brent, 1995; Mazza, 1997). Youth Risk Behavior Survey studies have reported that homosexually oriented adolescents (self-identified as gay, lesbian, or bisexual and/ or being homosexually active) are many times more at risk for multiple drug and/or alcohol use and abuse than their heterosexual counterparts (Garofalo et al. 1998; Faulkner et al., 1998; Note 10). Psychiatric symptoms such as depression have also been linked to suicide attempts for homosexually oriented youth (Nicholas and Howard, 1998; Hershberger et al, 1997; D'Augelli et al., 1993), and depression has been linked to suicide attempts and suicide in mainstream adolescent and youth population (Brent, 1995; Mazza, 1997). For homosexually oriented adolescents, however, psychiatric symptoms are likely related to, or exacerbated by, many of their most unfavorable life outcomes, and these symptoms should not be deemed "biological" in origin.

The Seal at al. (2000) qualitative study of seventy-two 16- to 25-year old young men who have sex with men (YMSM) from two midwest American cities reports on the multifaceted socially imposed problems of these youth. "Low self-esteem and self-worth, a lack of self-care and self-love, hopelessness and depression and teen suicide factors were believed to underlie unsafe sexual behavior:

There are time when I wished to God I would have just been dead. I couldn't go through the pain of who I was or the pain of trying to live my life. There was so much hurt. It wouldn't have mattered if I had gotten HIV. To be that would have been the simplest solution. I wouldn't have had to do a thing. I just would have had to lay there. I wouldn't have had to slit my wrists or commit suicide any other way. It's a more painful way, but if you're on a suicide mission it doesn't matter.
Participants further pointed out that may YMSM, and particularly YMSM of Color, lived with a pervasive sense of hopelessness in multiple aspects of their lives. Consideration of adverse long-term consequences of behavior was difficult for men who lived with daily violence, poverty, and despair and who held few expectations about a lengthy life:
When it comes down to it, the guys I talk to just don't care about life. They say life has nothing to offer them. A lot of times their mothers and fathers have disowned them and their family won't deal with them anymore because they are gay. They have no life, no family no future (p. 10).
...Some YMSM derived excitement from conscious unsafe sex: 'There's times with anonymous pickups that I won't use a condom. The thrill of not knowing whether he (an anonymous pickup) is gay or straight makes it difficult for me to stay safe.' Several respondents reported that more and more YMSM found sexual excitement in the 'Fuck of Death', that is, conscious unprotected receptive anal sex with a known HIV-positive partner or 'bug giver'" (p. 11).

An association between a history of suicide attempts and practicing unsafe sex by gay males was reported by Lewis (1988), but individual cases of gay males contracting HIV as a way to commit suicide had been reported as early as 1985 (Frances et al., 1985; Flavin et al., 1986). By the late 1990s, the phenomenon was reported in association with gay youth (Tompkins-Rosenblatt, 1997:  "Intentional HIV contraction: implications for direct child and youth care"), and from an analysis of Vancouver's Vanguard Project cohort of young men who have sex with men ranging in age from 18 to 30 years. A history of attempting suicide was the second most statistically significant association differentiating males who were "risk takers" compared to males who were not risk takers with respect to placing themselves at risk for contracting HIV (Martindale, 1997). Seal et al. (2000) report a similar phenomenon as noted above, but another factor is apparently also associated with desires for death by young men who have sex with men (YMSM):

They [YMSM] figure that they will have as much fun as they can now because they see old guys sitting in Venue X who like 40 and 50 and 60 years old and who haven't done anything with their life. Or, if they have, they're single and sitting in Venue X hitting on the young guys. The [YMSM] figure if they die young they wouldn't have to worry about that. It's the fear of age that many kids don't want to face - that they will get old. They figure that they have do do lots of things before their beauty fades (Seal et al., 2000, pp. 10-11).
In a Salon magazine interview, Edmund White commented on the gay community ageism factor possibly implicated in a conscious desire to contract HIV as a form of suicide, which could also be more unconscious for some gay males:
If you say you're going to be dead by 40, they say, "So what? There's no gay life after 40, anyway." Especially in France, but even here. You can easily be a gay in his 20s and never meet a gay over 40 because you don't see them in the bars. They don't go out, they're not part of your world, and if you do see them, you consider them pathetic (Reitz, 1997).
The above data basically renders a part of the story related to suicide problems for many homosexually oriented male adolescents, with one high risk attribute likely being an important factor in early identification as gay or bisexual, possibly dropping out of school, and venturing into the identifiable parts of gay communities at an early age. This common attribute of gay and bisexual identified male adolescents is a high level of "femininity" which, on the basis of mutlivariate analysis, resulted in "feminine" males having a 3-times greater risk for a suicide attempt than their counterparts (Remafedi et al., 1991).

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