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Co-sponsors of the Conference:U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau and Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; Comprehensive Health Education Foundation; HRSA Region VIII and X Field Offices; University of Washington, Division of Adolescent Medicine, and Harborview Injury Prevention and Research Center.

INTRODUCTION

In 1993, the American Academy of Pediatrics reviewed the GLB adolescent research data and concluded that these youth were at risk for having many problem, including suicidal problems, thus warranting concern by pediatricians (6). A similar concern, however, has not been manifested by mainstream researchers of youth suicide. Sexual orientation issues have generally been ignored in their studies of adolescents and young adults (7). The same applies for other helping professions, even after related papers were published in their journals (8), but the situation is slowly improving.

Meanwhile, the empirical data has continued to indicate that homosexual/bisexual adolescents are at risk for suicide problems, but most studies have either focused only on males, or the larger part of studied samples was male. At least for GB males, the evidence indicating their overrepresentation in male youth problems has become compelling, especially with respect to suicide problems and associated risk factors. Major changes are therefore warranted in mainstream youth suicide research and in adolescent/youth suicide prevention and intervention programs.

THE HOMOSEXUAL/BISEXUAL RISK FACTOR IN SUICIDE

Two North American studies (18-19) have nonetheless attempted to establish the sexual orientation of suicide victims after their death but the studies have been plagued by methodological problems (16, 17). To date, a study has not been conducted of gay/bisexual individuals who have made serious suicide attempts to learn how, if at all, their sexual orientation could have been determined had their deaths occurred, but some related information exists. In one study of GB youth, only four out of the 21 suicide attempters (19%) reported that they "had disclosed their sexuality to any key support before the first attempt" (21). Without such knowledge and other relevant information poor research methodology will continue to be used and significant underestimates are likely.

THE HOMOSEXUAL/BISEXUAL FACTOR IN MALE YOUTH SUICIDAL BEHAVIORS

Bell and Weinberg's 1978 study of a 1969 sample of 575 predominantly homosexual males and 284 predominantly heterosexual males (24) - matched on the basis of age, education, and occupational level - produced data indicating that homosexual males were 13.6 times more likely to have attempted suicide by the age of 21 years (9.5% vs 0.70%). Homosexual males have therefore continued to be at risk for having suicide problems during adolescence as the recent studies indicate. Furthermore, 6 of the 12 recent studies reported the percentage of suicide attempters who were repeat attempter, and the 39.6% average (16, 17) replicates the Bell and Weinberg homosexual male suicide reattempter rate of 38.9%.

It was only recently, however, that three large study samples produced suicide attempt and sexual orientation data indicating that homosexually oriented adolescents have been at greater risk for suicidal behaviors than their heterosexual counterparts. In 1997, the result of a 1996 Seattle school study of 8,406 adolescents in grades 7 to 12 (5% GLB) became internationally available via the Internet (25). The study produced important one-year problem prevalence results for self-identified GLB adolescents versus heterosexual adolescents (followed by the risk ratio): (1) made a suicide plan (31.1% vs 15.7% / 2:1), (2) attempted suicide (20.6% vs 6.7% / 3:1), and (3) attempted suicide resulting in medical attention (9.4% vs 2.2% / 4:1). Remafedi et al. (26) studied a 1987 Minnesota sample of 36,254 grades 7 to 12 adolescents from which a subsample of 175 GB males and 165 heterosexual male adolescents was taken, controlling for a number of social attributes. GB males were about 7 times more at risk for a suicide attempt than heterosexual males given their respective 28.1% and 4.2% attempted suicide rates. (Note 1: Result of the Massachusetts and Vermont school-based studies.)

Bagley and Tremblay (1997) studied a 1991-92 stratified random sample of 750 Calgary males aged from 18 to 27 years and reported that the 10.9% of the sample - classified to be homosexual or bisexual on the basis of self- identification (11.1%) and/or being currently homosexually active (9.2%) - had been 13.9 times more likely to attempt suicide (an attempt at self-killing) than heterosexual males (16, 17). This result (to the average age of 22.7 years) replicated the Bell and Weinberg "13.6 times" homosexual higher risk factor to the age of 21 years for a first-time suicide attempt. It was also reported that homosexual and bisexual males were 3 times more likely to have engaged in self-harm activities and they accounted for 26% of the self-harm cases, thus replicating the results of a 1983 study. A survey of the literature over a 20-year period revealed that homosexual individuals accounted for 15 of the 56 (27%) self-harm cases reported (27).

The Bagley and Tremblay data on self-harm behaviors and suicide attempts revealed, for the first time on the basis of random sampling, that gay/bisexual male youth were at risk for the most serious form of self-harm (an attempt at self-killing), thus placing them at greater risk for the most serious consequences of suicide attempts: being hospitalized, maybe being injured for life, and even dying as indicated by the data in another study (28). By 1996, the Seattle school study noted above had also produced data replicating the trend for homosexually oriented adolescents to be overrepresented in the most serious forms (and probably the most serious results) of suicidal attempts. Compared to heterosexual adolescents, GLB (gay, lesbian, and bisexual) adolescents were three times more at risk for a suicide attempt than heterosexual adolescents, but they were four times more at risk for a suicide attempt requiring medical attention.

THE "CHILD SEXUAL ABUSE" RISK FACTOR IN MALE YOUTH SUICIDAL BEHAVIORS

To date, as noted by Garnefski and Diekstra (32), almost all the research reporting a relationship between suicidal problems and child sexual abuse has been done on female samples. Research on the effects of child sexual abuse on males has been lacking, and one assumption having been that "male victims are less adversely affected than female victims." Therefore, they explored the effect of sexual abuse on boys by studying a large representative sample of 12- to 19-year-old adolescents. Sexually abused girls were 4.8 times more likely to report suicidal thoughts/behaviors than non-abused girls, but boys were 10.8 times more likely to have been suicidal than non-abused boys, thus essentially replicating the results of the Bagley et al. study (30). Boys were also more likely than girls to manifest other problems (eg. emotional and conduct disorders), although this was not the case in the Bagley et al. (1995) study. In conclusion, Garnefski and Diekstra noted that child sexual abuse is strongly associated with "the existence of a multiple problem pattern in both sexes," and that "the aftermath for boys might be even worse or more complex than for girls" (32).

HOMOSEXUAL/BISEXUAL MALES AT HIGH RISK FOR ATTRIBUTES AND EXPERIENCES ASSOCIATED WITH HIGH RATES OF SUICIDALITY.

To date, the two studies requesting sexual orientation information from adolescents have reported that GLB adolescents (25: 5% of adolescents), or self-identified GB male adolescents (26: 2% to 3% of males) to be at higher risk for suicide attempts. These adolescents, however, only represent the ones acknowledging their homosexual orientation who were also willing to come out, at least anonymously, to someone else: the self-disclosure to researchers via answers on a questionnaire. Many soon-to-be self-identified or "coming-out" GLB adolescents may have reported suicide attempts possibly related to their unwanted homosexual orientation, but they had not yet reached the stage of accepting their sexual desires nor being able to acknowledge this. These studies may therefore greatly underestimate the magnitude of GLB adolescent suicide problems and the proportion of adolescent suicide attempters who are homosexually oriented, but these errors may be corrected with studies of older individuals. The first such study reported that more than half (62.5%) of young adult males with a suicide attempt history are homosexually oriented (16, 17), and that they account for about 25% of males reporting self-harm behaviors. The results also suggest that these males have been also overrepresented in factors associated with male suicide and suicidal behaviors, as recent research results have been indicating.

The GB Male Overrepresentation in Mental Disorders

These studies, and others without psychiatric histories (48, 49), have generally reported rates of current depressive mental health problems (often measured over a six-month period) to not be elevated compared to rates in the average male population, and the same applies for one sample of HIV+/HIV- African American men (50). A larger sample of homosexual, bisexual and heterosexual HIV+/HIV- African American men, however, reported elevated rates of lifetime mental disorders as well as elevated current rates (51), and the same applies for a study of men with or at risk for HIV which was not differentiated on the basis of sexual orientation (44). The latter results, when combined with the current GB male higher risk for personality disorders and other related problems (46, 47), indicate that a significant sector of the GB adult male population has ongoing mental health problems. The Bell and Weinberg study reported "first-time" attempted suicides to occur in all age groups at about the same rate for GB males, and at elevated rates compared to heterosexual males also studied: 4.9%/.35% to age 17 years; 4.6%/.35% from age 18 to 21 years; 4.9%/1.77% from age 22 to 25 years; and 4.0%/.70% from age 26 to the age subjects were interviewed, the average age of the samples being 37 years (24).

Therefore, as a group, GB males have had ongoing serious problems which may be resolved at a young age for some, but they are being experienced at a later age by others. Celibate homosexuals males (forming about 15% of the GB male population) have been identified to have ongoing problems (17, 24), and one study reported an association with child sexual abuse (17). Stigmatization-related negative life events predict psychological dysfunction in gay men (52) and "minority stress" negatively affects their mental health, even increasing their risk for suicidal problems (53). About 30% of gay men report suicidal ideation occurring within a 6-month period (54). Internalized homophobia, sometimes associated with sexual dysfunction (55), is also linked to many problems (49, 56, 57), and its negative effects are especially pronounced in adolescents. Internalized homophobia or socially induced self-hatred (existing in degrees) and its resolution/elimination is represented by the "self-acceptance" stage of the coming-out process. For some individuals, however, socially indoctrinated homo-negativity is never overcome and related mental health problems last a lifetime.

The GB Male Overrepresentation in Alcohol and Drug Use Problems.

GB males have been at high risk for contracting HIV and related studies have reported high rates of substance use or abuse disorder when their psychiatric histories were taken. For samples of predominantly white well educated GB males (n = 68 to 208, mean ages = 30 to 40 years), lifetime rates of alcohol use or abuse disorder are 38.0%, 58.7%, and 36.5% (40-42) compared to lifetime rates of 19.1% to 32.5% in the adult male population (44). Lifetime rates of drug use or abuse disorder are 27.9%, 54.3%, and 48.6%, compared to lifetime rates of 6.5% to 14.6% in the adult male population (44). Rates of substance use or abuse disorder are 70.6% and 55.1% (41, 46), compared to lifetime rates of 35.4% in the adult male population (44). Therefore, the GB male risk for having had substance abuse problems as adolescents and/or as young adults is about 1.5 times that of heterosexual males, but their risk for developing drug problems is about two- to three-times the risk for heterosexual males. The situation may also be more serious for young African American GB males (n = 252) given that the lifetime rates of substance use disorder is apparently not significantly different than the rate for heterosexual African American males (n = 250) at risk for contracting HIV mostly because of their drug use. In this sample, "61.1% [of males] reported a history of regular use of one or more illicit drugs at some time in their lives (51)."

The GB Male Overrepresentation in Child Sexual Abuse

From these data and assuming that 20 to 30 percent of North American GB males have been subjected to "unwanted" sexual acts before the age of 17, it is probable that GB males have been more at risk for CSA than heterosexual males and the risk may be even higher for nonwhite GB males. International lifetime prevalence estimates for CSA in boys ranges from 2 to 11 percent, and these rates are similar to North American statistics, with Canada having prevalence rates of up to 16% (69). A recent major Canadian study produced a male CSA rate of 4.3% for "unwanted" sexual acts having occurred while males were growing up (69), the rate being 9.8% in an Alberta school-based study of adolescents (30), 15.6% in an Alberta stratified random sample of young adult males (29), and 1% in a large Minnesota school-based sample of adolescents (31). An underreporting problem may have occurred in the latter study given that the problem has been common in studies requesting sensitive sexual information related either to CSA or sexual orientation, especially from adolescents but also for older individuals (1, 16, 17).

SPECIFIC GB MALE RISKS FOR MENTAL HEALTH PROBLEMS AND SUICIDALITY.

Coming Out, Effeminacy, and Family Problems

Highly "feminine" boys (most of whom are or will be GB males: 75-77) have also been at higher risk for suicide attempts (28) because they are the ones believed to be homosexual as children and adolescents, and they are therefore more likely to receive the brunt of society's traditional disapproval (hatred-related abuses via peers, adults, and even professionals) for homosexual males. GB adolescent males have been more likely to be assaulted by parents than heterosexual males, and effeminate homosexually active adolescent GB males have been the most at risk for such assaults (78). GB adolescents have also been at risk for only being tolerated or even rejected in their families (79-80). One study of 221 GLB youth (suicide attempt rate = 40.3%) reported family problems to be in second place, after the youth's self-perception, with respect to risk for a suicide attempt (81).

The GB male high risk for social abuse and violence

The GB Male High Risk for Becoming Runaway/Homeless/Street Youth and Engaging in Prostitution

Runaway youth have elevated suicide attempt rates ranging from 15% to 29% (88, 89), and homeless gay youth were estimated to be three times more at risk for suicide attempts than their heterosexual counterparts (90); one sample of 53 GB male street youth had a 53% attempted suicide rate (84). Runaway GB male youth in a GB male youth sample had a suicide attempt rate of 36%, and GB males who had engaged in prostitution had a rate of 43% (28). A 1995 Los Angeles study of street youth (85) reported that GB males were the most likely to engage in survival sex (p less than .001), and a 1989 study of male youth prostitutes (70% GB males) reported them to more depressed compared to a control group of males; 26% of male prostitutes scored in the clinically depressed range on the Beck Depression Inventory compared to 6% of males in the control group (91).

Both depression and drug use has been implicated in youth suicidality, and greater drug use has been reported for male prostitutes (91). Sweeny et al. 1995 reported that, in the part of their sample obtained from homeless youth centers, 18.2% of the teenage males reporting "male-to-male sex" also reported intravenous drug use, and that these males formed 35% of the teenage male reporting intravenous drug use from homeless centers (92). Another risk factor for male youth prostitutes is their greater likelihood for having been sexually abused. In a 1989 study of 46 male youth prostitutes (average age of 16.2 years, 70% GB males), 72% of the GB males had been sexual abused compared to 43% of heterosexual males, 43% of GB males had been raped compared to 21% of heterosexual males, and 85% of the rapes had not been related to their street life (93). These experiences increase the risk for suicidal problems, and GB male prostitutes would likely be at the greatest risk.

Little research work has been done to understand the suicidal problems of male street youth in general and GB male street youth in particular, especially for GB males engaging in prostitution for a number of reasons, including as a part of coming out (64, 93). Tremble (1993) reports that the hopes of these males are high with respect to getting off the streets and that for some, these hopes may involve finding a "sugar daddy" to take care of them. Kruks (1991) described the situation for "many youth" coming to the Los Angeles Youth Service Center. They "have long histories of being involved in a succession of 'sugar daddy' relationships." These youths were always dumped, the "whole cycle lasting an average of 1-2 months, and the youth often becomes extremely suicidal at the end of each cycle (84)."

IMPLICATIONS FOR YOUTH SUICIDOLOGY

In the special issue of Suicide and Life-Threatening Behavior titled "Suicide Prevention Toward the Year 2000" (94) the two papers addressing suicide prevention in adolescents and young adult (95, 96) were silent about homosexuality issues, and another paper (22) did not confer much validity to the hypothesis that GB males are overrepresented in suicide problems. The same applies for the Suicide and Life-threatening Behavior issue on "sexual orientation" and suicide problems (39). If, however, the hypothesis supported by recent research results is correct, a major counterproductive oversight has occurred in the quest of mainstream suicidologists to understand and thereby effectively address youth suicide issues, especially male youth suicide problem given that males account for about 80% of adolescent deaths from suicide.

Some of the recent suicidality research has solicited sexual orientation information from adolescent and young adult subjects (16, 17, 25, 26), and the results have revealed the importance of soliciting such information in mainstream suicidality research. In fact, the data has been needed to begin disentangling the suicidal behavior risk factor problem so often mentioned by suicidologists. As a recent longitudinal study of children and adolescent has demonstrated, even an attribute most likely to apply to GB males (but not all of them), such as gender nonconformity detected at the age of 5 or 6 years, is related to not only depression problems in adolescence (97), but also to a likelihood for suicide attempts (98). The result therefore confirms the link between "feminine" GB males and a high risk for suicide attempts reported in a major comprehensive study of the GB male youth suicide attempt problem (28).

Generally, youth suicide prevention and intervention programs have either ignored or marginalized sexual orientation issues, and society's traditional homo-negativity may be implicated, thus exacerbating the serious often life-threatening problems this social attribute inflicts on homosexually oriented adolescents and youth. Studies have indicated that the highest risk GB adolescents, such as runaways needing shelter and the ones seeking substance abuse treatment, are not only poorly served by professionals supplying related services, but they are often harmed by the ones apparently working to help all youth (52, 99, 100). Causally implicated in these problems is the widely reported homo-negativity of many professionals and their general lack of a formal education about homosexuality, the coming out process, and related problems.

Given the GB male high risk for suicide problems, especially at a young age, and the general lack of related knowledge and understanding which has dominated mainstream suicidology, nothing less than a major educational remediation effort is needed to begin effectively addressing the problem. Furthermore, major changes will be required not only in prevention strategies focused on reducing adolescent suicidal behaviors, but in communication strategies used to inform highly distressed suicidal adolescents that help is available.

At best, the silence about homosexuality issues in many adolescent suicide prevention programs has been 'telling' suicidal GB adolescents what they likely feel about their problems: no one will understand and be able to help them, and they may greatly fear revealing their homosexual orientation to anyone. The results of this situation may be catastrophic, and harmful consequences may also result from programs which either marginalized homosexuality issues or do not address these issues in a comprehensive manner.

The most important question each director of suicide youth suicide prevention programs must ask is: "How different would our program be if it was known that the majority of the adolescent males attempting suicide in the most serius ways (and possibly committing suicide) are homosexually oriented?" They must then begin amending their programs in the direction indicated by the answer to the question, given the facts of the case.

BIBLIOGRAPHY

NOTES

Note 1: Results for the two 1995 school-based studies cited below were obtained from the paper, Sexual Orientation and Youth Suicide, presented by Lynn Levine and Linda Beeler at the Third Bi-Regional Adolescent Suicide Prevention Conference, September 21-23, 1997, at Breckenridge, Colorado.

Vermont "1995 Youth Risk Behavior Survey:" Grades 8-12 GLB (gay, lesbian, and bisexual) students were over 2.5 times more likely to have attempted suicide in the past year than heterosexual-identified students. GLB adolescents were over 4 times more likely to have made a suicide attempt requiring medical treatment.

The GLB Adolescent Section of The 1995 Massachusetts Youth Risk Behavior Survey Results

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