Current Challenges in the Management of LGBT Suicide

Reports of elevated risk of suicide in the LGBT community have existed for four decades. LGBT youths are four times more likely, and questioning youths are three times more likely, to attempt suicide compared with their heterosexual peers (1). Racial minority (African American and Hispanic) LGBT youths are more severely affected, at nearly twice the suicide attempt rate (2). Given that death records do not routinely mention the deceased's sexual orientation, the actual numbers are likely to be higher. Additionally, gay and lesbian individuals are twice as likely to experience suicidal ideation compared with their heterosexual counterparts. It is noteworthy that gay/bisexual men attempt suicide more than lesbian/bisexual women, contrary to gender patterns in the heterosexual population (3).

Risk Factors

There is a limited understanding of which facets of sexual orientation are most related to suicidal behavior. Data suggest that mood and anxiety disorders (which are potential harbingers of suicidal behavior) are more strongly associated with an LGBT identity rather than any particular sexual behavior (4). This is echoed by the finding that adolescents who experience same-sex attraction or behavior yet self-identify as heterosexual do not manifest an elevated risk of suicidal behavior compared with their peers (5).

Although some studies suggest that LGBT suicide follows the national trend of occurring more frequently in adolescents and young adults (6), there is some evidence that suicide in sexual minorities is more widely distributed across the lifespan, suggesting that suicidal attempts are more closely associated with the ages at which gay men and women acknowledge and disclose their sexual orientation (“come out”), rather than their chronological age (7). An association exists between suicidal attempts in LGBT individuals and major depression, generalized anxiety disorder, and alcohol/substance use disorders (8). Nonetheless, psychiatric diagnoses alone do not fully explain the elevated risk of suicidal behavior in the LGBT population. The risk remains elevated (two- to threefold) compared with heterosexual individuals, even after controlling for psychiatric morbidities.

Minority Stress

The prejudice faced by sexual minorities is posited to account, at least in part, for their elevated risk of suicidal behavior. Literature on minority stress (9) broadly separates the stressors to which minorities are exposed into objective (discriminatory or prejudice events) and subjective, (i.e., when stigma and negative attitudes seep into the self-image of an LGBT individual, for example, internalized homophobia, a state that has been linked to suicidal ideation) (10). The distinction between these two types of stressors serves to delineate institutional remedies on a societal level (such as awareness campaigns and policy changes) and individual remedies that address, among other things, cognitive appraisal of stress and stress-coping techniques. Among objective stressors, rejection at home proves to be the most dangerous and therefore merits a special focus by clinicians and researchers. LGBT young adults (ages 21–25) who experience frequent rejecting behaviors by their parents or caregivers during adolescence are over eight times more likely to attempt suicide than those with accepting parents (11). The long-term repercussions of parental rejection are most elucidated by the fact that up to 40% of homeless youths in the United States are LGBT (12). This is particularly harmful when combined with the effects of bullying at school and on social media, as well as victimization by hate-crime violence. While data suggest that LGBT individuals are more likely to be consumers of mental health services, several hurdles exist that affect the provision of adequate care in this population. Negative attitudes of some providers toward LGBT patients and lack of providers knowledgeable in LGBT lifestyle and mental health issues are major contributors to health disparities noted in these patients (13). Combatting discrimination against sexual minorities therefore emerges as a matter of public health.

Transgender Issues

Information on the suicidal risk in transgender individuals tends to focus on those who seek hormonal treatment and/or gender confirmation surgery, due to greater access of researchers to this subgroup of the transgender population. However, the rates of suicide attempts appear to be somewhat comparable between transgender people seeking surgery (19%–25%) (14) and self-identified transgender individuals (with one in three reporting at least one lifetime attempt) (15). The factors underlying the suicidal risk in transgender individuals are not dissimilar from those in gay and lesbian people. These include an association with depression, anxiety, and substance use (16), as well as parental rejection, in transgender youths (17). Most troubling is the weight of stigma and discrimination in this group. One in two transgender individuals will experience an adverse job action because of transgender status. This includes being denied employment, being denied a promotion, or being fired. Transgender members of communities of color are especially vulnerable. The majority of transgender people are likely to experience verbal abuse or being referred to as the wrong gender at the workplace on purpose. Overall, transgender individuals are twice as likely to be unemployed as the general population (18).

Positions on Therapy

The American Psychiatric Association has taken a clear stance against conversion/reparative or any therapy aimed at changing sexual orientation, stating that it “opposes any psychiatric treatment, such as reparative or conversion therapy which is based upon the assumption that homosexuality per se is a mental disorder or based upon the a priori assumption that the patient should change his/her sexual homosexual orientation,” (19) and further recommending that “ethical practitioners refrain from attempts to change individuals' sexual orientation, keeping in mind the medical dictum to first, do no harm” (19). The American Psychological Association has adopted a similar position, given that efforts to change orientation are unlikely to succeed and carry a risk of psychological harm (20). For children experiencing gender discordance, the American Academy of Child and Adolescent Psychiatry has asserted that whether treatment modalities aim to limit or to tolerate gender-discordant feelings and behaviors, further evidence on the long-term risks and benefits of these interventions is needed before any treatment can be endorsed (American Academy of Child and Adolescent Psychiatry assessment principles can be accessed online [http://www.lgbthealtheducation.org/wp-content/uploads/SO.GD_.MH-in-Children-and-Adolescents.pdf]). However, for adolescents and adults who experience persistent gender dysphoria, the goal of treatment ought to focus on helping them make developmentally appropriate decisions about sex reassignment and managing any associated psychiatric morbidity (21).

Interventions

The broad initiative launched by the American Foundation for Suicide Prevention has yielded expert consensus and recommendations on addressing the suicide risk in LGBT individuals (22). It underscores the paucity of existing initiatives aimed at improving help seeking in LGBT people and the need for provision of culturally appropriate mental health services tailored for this population. In this regard, the Trevor Project represents a unique model incorporating the only national crisis and suicide prevention hotline for LGBT and questioning youths, as well as in-school workshops, online educational resources, and advocacy work for public policy changes to combat LGBT stigma. Mainstream suicide prevention interventions still have ways to go in order to become more LGBT inclusive. Other national organizations serving the LGBT population and offering important resources for LGBT patients include GLSEN [the Gay, Lesbian and Straight Education Network], SAGE [Services and Advocacy for Gay, Lesbian, Bisexual and Transgender Elders], and PFLAG [Parents, Families and Friends of Lesbian, Gay, Bisexual and Transgender People] (23). Certain initiatives such as the Family Acceptance Project based at San Francisco State University are focusing on addressing parental rejection of gay youths by using evidence-based family interventions. New efforts in some European countries are engendering LGBT-specific behavioral health interventions that are fostered by LGBT community organizations.

Therefore, physicians and other clinicians are positioned to make important contributions to mitigating the psychiatric vulnerabilities of LGBT patients. Patients require clinicians that are not only clinically competent in screening, diagnosis, and treatment planning, but also mindful at managing any countertransference they might have toward LGBT patients.

From a training perspective, the management of psychiatric morbidities and suicidal risk in LGBT patients is not a standard item in clinical and didactic teaching in psychiatry residencies. The Group for the Advancement of Psychiatry developed an LGBT mental health syllabus for psychiatry residents, which is available online (www.aglp.org/gap). It includes a brief history of the relationship between psychiatry and homosexuality. It also covers clinically relevant topics such as sexual history taking in LGBT patients. It addresses medical issues and psychotherapy concerns, as well as ethical considerations in daily practice. The Association of American Medical Colleges has produced a landmark comprehensive resource for medical educators and students titled “Implementing Curricular and Institutional Climate Changes to Improve Health Care for Individuals Who Are LGBT, Gender Nonconforming, or Born with DSD” (difference of sex development), which is available online (http://offers.aamc.org/lgbt-dsd-health). Finally, the Gay and Lesbian Medical Association has compiled a guide for fostering an inclusive environment at schools of health professions titled “Recommendations for Enhancing the Climate for LGBT Students and Employees in Health Professional Schools,” also available online (http://www.glma.org/index.cfm?fuseaction=Page.viewPage&pageId=1027&grandparentID=534&parentID=1010&nodeID=1).

Key Points/Clinical Pearls