Content uploaded by R. Cameron Wolf
Author content
All content in this area was uploaded by R. Cameron Wolf on Jan 03, 2014
Content may be subject to copyright.
Sexual Orientation and Risk of Suicide Attempts
Among a Representative Sample of Youth
Robert Garofalo, MD; R. Cameron Wolf, MS; Lawrence S. Wissow, MD, MPH;
Elizabeth R. Woods, MD, MPH; Elizabeth Goodman, MD
Objective: To examine whether sexual orientation is
an independent risk factor for reported suicide at-
tempts.
Design: Data were from the Massachusetts 1995 Cen-
ters for Disease Control and Prevention Youth Risk Be-
havior Survey, which included a question on sexual ori-
entation. Ten drug use, 5 sexual behavior, and 5 violence/
victimization variables chosen a priori were assessed as
possible mediating variables. Hierarchical logistic regres-
sion models determined independent predictors of sui-
cide attempts.
Setting: Public high schools in Massachusetts.
Participants: Representative, population-based sample
of high school students. Three thousand three hundred
sixty-five (81%) of 4167 responded to both the suicide
attempt and sexual orientation questions.
Main Outcome Measure: Self-reported suicide at-
tempt in the past year.
Results: One hundred twenty-nine students (3.8%) self-
identified as gay, lesbian, bisexual, or not sure of their
sexual orientation (GLBN). Gender, age, race/ethnicity,
sexual orientation, and all 20 health-risk behaviors were
associated with suicide attempt (P,.001). Gay, lesbian,
bisexual, or not sure youth were 3.41 times more likely
to report a suicide attempt. Based on hierarchical logis-
tic regression, female gender (odds ratio [OR], 4.43; 95%
confidence interval [CI], 3.30-5.93), GLBN orientation
(OR, 2.28; 95% CI, 1.39-3.37), Hispanic ethnicity (OR,
2.21; 95% CI, 1.44-3.99), higher levels of violence/
victimization (OR, 2.06; 95% CI, 1.80-2.36), and more
drug use (OR, 1.31; 95% CI, 1.22-1.41) were indepen-
dent predictors of suicide attempt (P,.001). Gender-
specific analyses for predicting suicide attempts re-
vealed that among males the OR for GLBN orientation
increased (OR, 3.74; 95% CI, 1.92-7.28), while among
females GLBN orientation was not a significant predic-
tor of suicide.
Conclusions: Gay, lesbian, bisexual, or not sure youth
report a significantly increased frequency of suicide at-
tempts. Sexual orientation has an independent associa-
tion with suicide attempts for males, while for females
the association of sexual orientation with suicidality may
be mediated by drug use and violence/victimization be-
haviors.
Arch Pediatr Adolesc Med. 1999;153:487-493
W
ITHIN THE past 50
years, suicide rates
among adolescents
in the United States
have dramatically
increased.
1
In the 15- to 24-year-old age
group, the incidence of suicide has in-
creased from 4.5 per 100 000 in 1950 to
13.2 per 100 000 in 1990. In 1996, sui-
cide was the third-leading cause of death
among youth ages 15 to 19 years, repre-
senting approximately 5000 deaths per
year.
2
Data from the 1996 national Cen-
ters for Disease Control and Prevention
(CDC) Youth Risk Behavior Survey (YRBS)
indicate that approximately 9% of youths
reported a suicide attempt within the past
12 months.
3
History of an attempted sui-
cide is the most powerful predictor of an
eventual suicide.
4-7
Many studies have been conducted to
determine risk factors for suicide among
adolescents. Population-based research has
identified recognized risks for suicide at-
tempts, including gender, race/ethnicity,
history of depression, hopelessness, alco-
hol and other drug use, sexual activity, and
violence/victimization.
8-12
Factors that may
exacerbate these risks include underly-
ing psychological stresses, such as mar-
ginalization, isolation, and rejection.
13-15
Editor’s Note: Why is being G-BN more directly correlated with
suicide attempts than L-BN?
Catherine D. DeAngelis, MD
ARTICLE
From the Divisions of General
Pediatrics (Dr Garofalo) and
Adolescent/Young Adult
Medicine (Drs Woods and
Goodman), Children’s
Hospital/Harvard Medical
School, Cambridge, Mass;
JRI Health–Sidney Borum
Community Health Center,
Boston, Mass (Dr Garofalo);
and The Johns Hopkins School
of Hygiene and Public Health,
Baltimore, Md (Mr Wolf and
Dr Wissow).
ARCH PEDIATR ADOLESC MED/ VOL 153, MAY 1999
487
©1999 American Medical Association. All rights reserved.
at Tel-Aviv University, on January 9, 2008 www.archpediatrics.comDownloaded from
Homosexuality has also been suggested as a risk factor
for youth suicide.
16-19
Gay, lesbian, bisexual, and not
sure (GLBN) youth frequently encounter many of the
environmental stresses thought to exacerbate suicidal-
ity
16-22
; however, studies of suicidality among gay youth
have been difficult, because of the social stigma associ-
ated with both topics. With one exception, studies
examining the relationship of suicide with sexual orien-
tation have been limited to small samples that may not
be representative of nonheterosexual youth as a group.
Recently, an important population-based study by Re-
mafedi et al
22
showed sexual orientation to be a signifi-
cant risk factor for suicide attempts among youth; how-
ever, this 1987 data set lacked the ability to examine the
association between sexual orientation and suicide risk
within the context of other possible confounding and me-
diating variables, such as substance use, sexual activity,
and violence/victimization.
Although population-based studies have found an
association between sexual orientation, suicide risk, and
other health-risk behaviors, the complexity of these re-
lationships has not been well described.
22,23
Using a con-
ceptual model, our study examined whether sexual ori-
entation was an independent predictor of suicide attempts
in a population-based sample of adolescents (
Figure).
We hypothesized that sexual orientation would be asso-
MATERIALS AND METHODS
SURVEY DESIGN
The CDC designed the YRBS to measure the prevalence
of behaviors associated with leading causes of morbidity
and mortality among youth attending high school. The
YRBS is administered at a state level: a core group of
questions are provided by the CDC, but state authorities
can add questions to address topics of local or regional
interest. In 1995, Massachusetts added a question assess-
ing sexual orientation. This was the first time a sexual
orientation question had been added to the standardized
YRBS instrument. Data for this study were obtained from
the 1995 Massachusetts YRBS, which was administered
between February and May in representative public high
schools across the state. Fifty-nine (94%) of 63 selected
schools chose to participate. Within each school,
approximately 80 students were randomly selected from
3 to 5 classrooms of 9th to 12th graders, providing a
total sample of 4167 students.
The YRBS is a self-administered questionnaire con-
sisting of 91 multiple-choice questions. The question-
naire was available in English, Spanish, and Portuguese.
All participants were assured that the survey was anony-
mous and voluntary. Schools had the option of obtaining
parental consent for participation; fewer than 10 stu-
dents were denied parental permission. Of the selected
students who were in school on the days the question-
naire was administered, fewer than 15 chose not to com-
plete the survey. The 3365 students (81%) who
responded to both the suicide and sexual orientation
questions of the YRBS were chosen as the study popula-
tion. Ten percent (n = 428) did not respond to the sui-
cide question and 11% did not respond to the sexual ori-
entation question, but these 2 groups had only a small
overlap (n = 78 [1.9%]). Those who did not answer the
sexual orientation question were more likely to also not
answer the suicide attempt question than those who did
answer the sexual orientation question (17.3% vs 9.4%;
P,.001). There were no significant differences in age or
gender among those included vs excluded from this
study; however, students who self-identified as white
(84.6%) were more likely to have answered the suicide
and sexual orientation questions than those who self-
identified as black (68.3%), Hispanic (62.1%), or “other”
race (75%) (P,.001) and, hence, were more likely to
have been included in the study.
VARIABLES
In addition to the suicide and sexual orientation variables,
survey items assessing 20 health risks were identified a priori
as possible mediating variables. A description of all vari-
ables follows.
Suicide Attempt
To evaluate suicidal behavior, subjects were asked how
many times they had attempted suicide in the past 12
months. This variable was dichotomized into no suicide
attempts in the past 12 months vs 1 or more suicide
attempts in the past 12 months due to the small number
of youths who reported multiple attempts. Of note, 34.5%
of the 864 youths who had considered suicide actually
attempted suicide, compared with 1.2% of those who did
not report considering suicide (P,.001). Because suicidal
ideation was relatively common in this population and
suicide attempts is a more powerful predictor of future
attempts and completions, the dependent variable was
restricted to reported suicide attempt(s).
4-7
Sexual Orientation
Sexual orientation was determined by the question,
“Which of the following best describes you?” Responses
were heterosexual (straight), gay/lesbian, bisexual, not
sure, or none of the above. Students who self-identified as
gay/lesbian, bisexual, or not sure were selected as the
GLBN study population. Not sure respondents were
included in the GLBN study group since it was felt that
internal psychological conflict associated with question-
ing one’s sexual identity may contribute to predisposing
one to attempt suicide. In this sense, students questioning
their sexual orientation would be more similar to gay, les-
bian, and bisexual adolescents, who also experience sig-
nificant sexual identity conflict, than to their heterosexual
peers.
24,25
Respondents who answered “none of the above”
were excluded from the analysis.
Violence
Five violence-related behaviors were measured. An
example is, “During the past 12 months, how many
times were you in a physical fight?” This variable was
measured on an ordinal 8-point scale ranging from “0”
to “12 or more times.” Additional violence/victimization
variables included failure to attend school because the
ARCH PEDIATR ADOLESC MED/ VOL 153, MAY 1999
488
©1999 American Medical Association. All rights reserved.
at Tel-Aviv University, on January 9, 2008 www.archpediatrics.comDownloaded from
ciated with other known predictors of suicide attempts,
including drug use, sexual risks, and violence/vic-
timization, and would have an independent association
with suicide attempts when controlling for these other
known risk factors.
RESULTS
The 3365 (80.7%) of 4167 students responding to both
the suicide and sexual orientation question composed the
sample population; 49.6% were female and 78.6% were
white. The mean age of the respondents was 16.1 years.
A total of 9.9% of respondents reported 1 or more sui-
cide attempts within the past 12 months. On the sexual
orientation question, 17 self-identified as gay or lesbian
(0.5%); 67 as bisexual (2.0%); and 44 as not sure (1.3%),
giving a total of 129 students (3.8%) who self-identified
as having GLBN orientation. Among nonheterosexuals
only 1.7% of females self-identified as gay, lesbian, or bi-
sexual, compared with 3.8% of males (P,.002). Gay, les-
bian, bisexual, or not sure youths were more likely to re-
port same-gender experiences (30.9%) than heterosexual
youth (0.9%, P,.001); however, only 55% of those with
same-gender experiences self-identified as GLBN. Among
the overall population, the frequencies for the 10 drug
use, 5 violence-related, and 5 sexual risk behaviors are
student “felt unsafe,” “carried a weapon,” was “injured or
threatened with a weapon,” and had “ever had sexual
contact against your will.” These variables were measured
on similar ordinal scales. Ordinal responses were recoded
as dichotomous variables (having not engaged in the
behavior vs having engaged in the behavior 1 or more
times).
Drug Use
Ten substance use variables were examined. Subjects
were asked questions regarding their lifetime use of alco-
hol, marijuana, cocaine, crack, steroids, inhalants,
injectables, and other illegal drugs, such as LSD, PCP,
ecstasy, mushrooms, speed, ice, or heroin. A similar
question focused on the recent use (past 30 days) of
cigarettes and chewing tobacco or snuff. Responses were
measured on ordinal scales. In terms of “hard” drug
use—including cocaine, crack, steroids, inhalants,
injectables, and other illegal drugs—responses were
dichotomized into those who had ever used the drug vs
those who had not, since any use of these substances
was considered a high-risk behavior. The alcohol, snuff,
cigarette, and marijuana variables were also dichoto-
mized into low- and high-risk groups. Having had a
drink on 10 or more days in your life, having used chew-
ing tobacco or snuff on more than 2 of the past 30 days,
having used marijuana more than twice in your life, and
having used cigarettes on more than 9 of the past 30
days were classified as high-risk activities.
Sexual Behaviors
Five sexual risk behaviors were examined. Questions
asked whether a respondent had ever been sexually
active, and the number of partners with whom the
respondent had had sexual intercourse. Subjects were
asked whether alcohol or drugs were used at their last
sexual encounter and whether they had ever been preg-
nant or gotten someone pregnant. Same-gender sexual
experiences were also assessed by combining the stu-
dent’s gender with a variable that asked the gender of
persons with whom the student had had sexual contact,
with options of male(s), female(s), male(s) and female(s),
and “I have not had sexual contact with anyone.” Those
respondents with same-gender experiences were com-
pared with youths who did not report same-gender sexual
experiences. This was a separate variable from self-
identified sexual orientation.
RISK SCALES
Covariation or “clustering” among health-risk behaviors has
been well described.
23,26
We theorized that no one specific
behavior placed an individual at risk of attempted suicide
but rather that higher levels of risk behavior would be pre-
dictive of suicide attempts. To assess the level of sexual,
drug, and violence/victimization risk, the dichotomous vari-
ables assessing each of these areas that were statistically sig-
nificant in the bivariate analyses were summed into sexual,
drug, and violence/victimization indices. We had hypoth-
esized that because of the clustering of health risk behav-
iors an individual voluntarily engages in, the drug and sexual
behavior indices would have good internal consistency,
whereas the violence/victimization index would not. In fact,
the Cronbach a value for the drug index was 0.76; sexual
risk index, 0.61; and violence/victimization index, 0.48, in-
dicating that the violence/victimization index had poor in-
ternal consistency and therefore could not function as a scale.
This supports the hypothesis that these involuntary be-
haviors would not covary in the same way as the volun-
tary drug use and sexual behaviors. The drug index had a
possible range of 0 to 10, whereas the sexual and violence/
victimization indices had a possible range of 0 to 5.
STATISTICAL ANALYSIS
All analyseswere performed using weighted data. Weighting
the data reduces the possible bias from nonresponders and
reflects the likelihood of sampling each student. Weighting
also adjusts for the intentional oversampling of Boston stu-
dents that was done to coordinate the state YRBS with the city
YRBS. Since the YRBS uses a random complex survey design
and the statistical software used for this analysis (SPSS Inc,
Chicago, Ill) assumes data collection with a simple random-
sample design, hypotheses were tested at the P = .001. Thus,
the likelihood of committing type I error was very small. Pear-
son x
2
analysis examined the association between the 10 sub-
stance use, 5 sexual behavior, and 5 violence/victimization
variables; sexual orientation; and self-reported suicide attempts.
Nonparametric testing using the Mann-Whitney U test ex-
amined the relationship between the 3 risk indices and both
sexual orientation and suicide attempts. Hierarchical logis-
tic regression to determine independent predictors of suicide
attempts was based on our conceptual model (Figure). Age,
gender, and race/ethnicity were entered into the model simul-
taneously, followed by sexual orientation. Lastly, the 3 indi-
vidual risk behavior scales were added to the model. Odd ra-
tios (ORs) and 95% confidence intervals (CIs) are reported.
ARCH PEDIATR ADOLESC MED/ VOL 153, MAY 1999
489
©1999 American Medical Association. All rights reserved.
at Tel-Aviv University, on January 9, 2008 www.archpediatrics.comDownloaded from
presented in Table 1. The mean ± SD drug-risk index
score was 2.2 ± 1.9, with a range of 0 to 10. Twenty-two
percent had a score of 0; 22%, 1; 16%, 2; 18%, 3; 10%, 4;
and 12%, 5 or more. The mean ± SD sexual risk score was
0.75 ± 1.00, with range of 0 to 5. Fifty-six percent scored
a 0 on the sexual risk index; 22%, 1; 14%, 2; 7%, 3; and
1%, 4 or more. The mean ± SD violence/victimization score
was 0.79 ± 0.97, with a range of 0 to 5. Fifty percent had
no violence/victimization risks; 29%, 1 risk; 15%, 2 risks;
4%, 3 risks; and 2%, 4 or more risks.
Results of the x
2
analyses revealed that gender, age,
race/ethnicity, sexual orientation, and all 20 health risk
behaviors were significantly associated with a self-
reported suicide attempt within the past 12 months
(P,.001) (
Table 2). Those who classified themselves
as GLBN were 3.4 times more likely to report a suicide
attempt in the past year. Gay, lesbian, bisexual, or not
sure male students were 6.50 times more likely to re-
port a suicide attempt than heterosexual male students
(P,.001). Gay, lesbian, bisexual, or not sure female stu-
dents were 2.02 times more likely to report a suicide at-
tempt than their heterosexual female peers (P,.001).
Youths who were not sure of their sexual orientation were
2.49 times more likely to report a suicide attempt than
their heterosexual peers (22.7% vs 9.1%, P,.006) and
gay, lesbian, or bisexual youths were 3.88 times more
likely to report a suicide attempt than heterosexual youths
(35.3% vs 9.1%, P,.001). Students who reported using
cocaine in their lives or having sexual contact against their
will were 4 times more likely to have reported an at-
tempted suicide within the past year that those without
the risk factor. Those using alcohol or drugs before their
last sexual intercourse or who reported having missed
school because of fear about their safety were more than
3 times as likely to have attempted suicide. All 3 risk in-
dices were significantly associated with sexual orienta-
tion and a reported suicide attempt in the past year. Those
scoring higher on any of the 3 indices were more likely
to report GLBN sexual orientation and to report a sui-
cide attempt (P,.001).
When analyzed with hierarchical logistic regres-
sion (
Table 3) among the overall sample population,
gender, GLBN orientation, Hispanic ethnicity, higher rates
of violence/victimization, and more drug use remained
in the model as independent predictors of suicide at-
tempts among youth (P,.001). After controlling for other
factors, age and the sexual activity index were not sta-
tistically significant predictors within our model. Gay,
lesbian, bisexual, or not sure youth were 2.28 times as
likely as their peers to report a suicide attempt within
the past 12 months (95% CI, 1.39-3.37). Among males,
the OR associated with GLBN orientation increased to
3.74 (95% CI, 1.92-7.28), whereas among females, GLBN
orientation did not remain statistically significant within
the regression model. In addition, Hispanic ethnicity
seemed to be a significant predictor of suicide for fe-
males but not males.
COMMENT
The dramatic increase in the death rate from suicide
among youth makes the identification of significant risk
factors a matter of public health importance. Improving
the understanding of suicide risk assists in the identifi-
cation of vulnerable youth as well as in the develop-
ment of effective adolescent suicide prevention pro-
grams. Numerous factors have been identified as
mediating the risk for suicide among youth; however, de-
spite clinical suspicion and relative consistency among
previous studies, controversy continues to exist as to
whether sexual orientation is a significant risk factor for
GLBN
Sexual
Orientation
Suicide
Attempt
Drug and Alcohol
Use Risk
Sexual Activity Risk
Violence and
Victimization Risk
Conceptual model. GBLN indicates gay, lesbian, bisexual, or not sure.
Table 1. Demographics of Study Sample (N = 3365)
%
Characteristics
Age, y*
#16 60.3
.16 39.6
Female 49.6
Race/ethnicity
White, non-Hispanic 78.6
Black, non-Hispanic 5.4
Hispanic or Latino 6.3
Other 9.3
GLBN† sexual orientation 3.8
Suicide attempt 9.9
Behavioral Risks
Drug use behaviors
Cocaine 7.2
Crack cocaine 4.0
Steroids 3.9
Inhalants 19.7
Illegal drugs 17.5
Injectable drugs 2.4
Marijuana 41.4
Cigarettes 70.4
Alcohol 51.0
Smokeless tobacco 4.7
Violence-related behaviors
Missed school because felt “unsafe” 4.8
Threatened with a weapon 19.6
Sexual contact against will 8.7
Injured in a fight 7.2
Engaged in a fight 38.2
Sexual behaviors
Sexual intercourse 43.4
Been pregnant or gotten someone pregnant 3.7
Same-gender sexual experience 1.8
$4 Sexual partners 13.5
Alcohol/drug use with sex 12.6
*
SD, 16.1 years.
†
GLBN indicates gay, lesbian, bisexual, or not sure.
ARCH PEDIATR ADOLESC MED/ VOL 153, MAY 1999
490
©1999 American Medical Association. All rights reserved.
at Tel-Aviv University, on January 9, 2008 www.archpediatrics.comDownloaded from
youth suicide, in part due to a lack of carefully
designed, population-based studies examining the
issue.
27-30
When Massachusetts modified its version of the 1995
YRBS by including a question addressing sexual orien-
tation, it provided an opportunity to explore issues of sui-
cide risk among a representative, population-based sample
of self-identified GLBN youth. It also created an oppor-
tunity to examine suicide risk among youth within the
context of other possible confounding and mediating vari-
ables, such as age, gender, race/ethnicity, and risk be-
haviors. In the present study we used this data set to test
a conceptual model postulating that sexual orientation
has both direct and indirect effects on the likelihood of
attempting suicide. Our results support this empirical
model. In the overall population, after adjusting for other
confounding demographic variables and level of engage-
ment in health risks associated with an increased likeli-
hood of a suicide attempt, sexual orientation had the sec-
ond highest odds ratio for predicting a suicide attempt.
The findings also reveal that higher levels of engage-
ment in risk behaviors, such as using substances, engag-
ing in violent behaviors, or being victimized, seem to play
a role in mediating the increased suicide risk reported
by GLBN youth. These results are consistent with pre-
vious nonrepresentative and retrospective research that
examined the risks of GLBN youth as well as a recent
population-based study by Remafedi et al.
22
The study by Remafedi et al
22
also showed that, in
gender-specific analyses, sexual orientation was pre-
dictive among males but not females. Our study sup-
ports their findings. Gay, lesbian, bisexual, or not sure
orientation was predictive of reported suicide attempts
for males in both the bivariate and multivariate analy-
ses. In contrast, among females, the increased suicide
risk associated with GLBN orientation was evident
only in the bivariate, not the multivariate, analyses.
This may suggest that the increased suicide risk
among GLBN females does not reflect an independent
association with sexual orientation but rather reflects
possible confounding and mediating factors, such as
gender, race/ethnicity, and level of engagement in risk
behaviors. Among gay and bisexual male adolescents,
prior studies have correlated suicide rates with factors
such as self-identification as homosexual at younger
ages, female gender role, family dysfunction, interper-
sonal conflict regarding sexual orientation, and non-
disclosure of sexual orientation to others.
16,17,19,21
Issues such as gender nonconformity and other factors
directly related to self-identified homosexual or
bisexual orientation, such as isolation, social rejection,
or parental aspects of acceptance, may disproportion-
ately affect GLBN adolescent males in comparison
with females, thus contributing to the independent
association found in our study.
Table 2. Bivariate Associations Between Predicted Risk
Factors and Suicide Attempts in the Past 12 Months*
Risk Factors
Attempted
Suicide, %
Contingency
Coefficient
Risk
Factor(s)
No Risk
Factors
Female 13.4 6.4 0.12
GLBN† sexual orientation 31.0 9.1 0.14
Cocaine use 30.3 7.8 0.20
Crack cocaine use 46.3 8.1 0.25
Steroid use 45.8 8.4 0.24
Inhalant use 21.9 6.8 0.20
Illegal drug use 20.6 7.4 0.17
Marijuana use 14.1 6.2 0.13
Injection drug use 46.9 8.8 0.20
Cigarette use 12.1 3.6 0.12
Alcohol use 12.8 5.8 0.12
Smokeless tobacco use 19.6 9.2 0.07
Missed school because of fear 33.7 8.7 0.18
Threatened with a weapon 18.6 7.6 0.15
Sexual contact against will 30.0 7.5 0.22
Injured in a fight 33.3 7.9 0.22
Engaged in a fight 16.0 5.7 0.17
Sexual intercourse ever 13.6 6.1 0.13
Been pregnant or gotten
someone pregnant
30.6 9.1 0.13
Same-gender sexual experience 30.6 9.2 0.10
$4 Sexual partners 18.7 7.9 0.13
Alcohol/drug use with sex 16.0 5.7 0.17
*P,
.001.
†
GLBN indicates gay, lesbian, bisexual, or not sure.
Table 3. Logistic Regression Predicting a Reported Suicide
Attempt in the Past 12 Months
Odds Ratio
(95% Confidence Interval)
Total Sample (N = 3267)
Age (years) 0.89 (0.78-0.99)
Female 4.43 (3.30-5.93)
Race/ethnicity
Black, non-Hispanic 0.49 (0.23-1.01)
Hispanic or Latino 2.21 (1.44-3.99)
Other 1.29 (0.85-1.96)
GLBN* sexual orientation 2.28 (1.39-3.37)
Drug use scale 1.31 (1.22-1.41)
Sexual behavior scale 0.98 (0.85-1.12)
Violence/victimization scale 2.06 (1.80-2.36)
Girls Only (n = 1646)
Age (years) 0.87 (0.75-0.99)
Race/ethnicity
Black, non-Hispanic 0.41 (0.16-1.10)
Hispanic or Latino 2.66 (0.56-4.54)
Other 1.20 (0.71-2.00)
GLBN sexual orientation 1.42 (0.65-3.09)
Drug use scale 1.28 (1.16-1.41)
Sexual behavior scale 1.02 (0.86-1.21)
Violence/victimization scale 2.35 (1.97-2.80)
Boys Only (n = 1632)
Age (years) 0.90 (0.75-1.00)
Race/ethnicity
Black, non-Hispanic 0.68 (0.22-2.08)
Hispanic or Latino 1.66 (0.77-3.58)
Other 1.37 (0.65-2.89)
GLBN sexual orientation 3.74 (1.92-7.28)
Drug use scale 1.36 (1.23-1.51)
Sexual behavior scale 0.92 (0.74-1.15)
Violence/victimization scale 1.64 (1.32-2.05)
*
GLBN indicates gay, lesbian, bisexual, or not sure.
ARCH PEDIATR ADOLESC MED/ VOL 153, MAY 1999
491
©1999 American Medical Association. All rights reserved.
at Tel-Aviv University, on January 9, 2008 www.archpediatrics.comDownloaded from
In addition, age at self-identification may be an-
other factor mitigating the gender differences in the ef-
fect of sexual orientation on suicide risk.
16
Gay, lesbian,
bisexual, or not sure females typically self-identify as ho-
mosexual/bisexual at later ages than GLBN males.
25
The
findings of this study are consistent with this hypoth-
esis, as fewer females than males self-reported gay, les-
bian, or bisexual orientation; however, among those stu-
dents who self-identified as not sure of their orientation,
a higher percentage were female (1.7% vs 0.9%). Per-
haps a delayed “coming out” process among GLBN fe-
males decreases the stress associated with disclosure and
serves a protective function against suicide associated with
sexual orientation. Unfortunately, beyond individual be-
haviors, the YRBS instrument does not allow delineation
of suicide risk in areas such as depression, social margin-
alization, or age at self-identification. The development of
improved survey instruments that address these complex
issues will be useful to begin to address these concerns.
The prevalence of self-reported gay, lesbian, or bi-
sexual identity in surveys of teenagers is typically much
lower than the commonly quoted prevalence of 5% to 10%
in adults.
20,25
A period of confusion concerning sexual
orientation often precedes self-identification as gay, les-
bian, or bisexual and may preclude self-identification dur-
ing adolescence.
25
Adolescents also have a more fluid
sexual identity, so that same-sex experiences may not ac-
curately reflect self-identified sexual orientation. Among
the students who responded “not sure” in the current
study, there is no way of determining which students were
truly unsure of their sexual orientation vs which were
confused about the question itself or possible re-
sponses. Prior studies concluded that suicide attempts
in homosexual youth tended to occur in response to the
emotional distress associated with an emerging homo-
sexual identity or gender-atypical behavior.
16,31
Others
reported that suicides occurred after conflict regarding
sexual orientation, either distress over an undisclosed ho-
mosexual orientation or rejection following disclo-
sure.
19,32,33
The bivariate analyses in this study suggest that
questioning youth were more likely to attempt suicide
than their heterosexual peers, but the risk was lower than
for self-identified gay, lesbian, or bisexual youth.
Suicide and suicidal behavior fall along a con-
tinuum from suicidal ideation to a fatal, completed sui-
cide. Although suicide completers are a primary clinical
concern, the goal of prevention makes it important to ex-
amine nonlethal behaviors, such as suicide attempts.
4
While not all completers have a history of attempts, ap-
proximately one third of suicides and as many as 50% of
female completers have made a previous attempt.
4
Be-
cause data on suicide are often derived from mortality
statistics collected from death certificates, information
regarding the sexual orientation of adolescent suicide vic-
tims is minimal. This population-based information on
individuals who report an attempted suicide is relied on
for the examination of psychosocial risk factors.
As a secondary data analysis, this study was limited
by a lack of standardized measures of suicide attempts.
In addition, the data collected were part of a cross-
sectional survey, and therefore we can not draw conclu-
sions about causality. Although these data may be gen-
eralizable to most adolescents who attend public high
school, other high-risk youths, such as homeless or run-
away youths, who do not regularly attend school may not
be represented by our data. Further limitations include
regional limitations, for which studies of national data
may prove helpful in identifying differences. In addi-
tion, this analysis was based on self-reported behaviors,
and it cannot be determined whether respondents may
have overreported or underreported risk. The YRBS in-
strument was developed by the CDC, and the validity and
reliability of adolescent self-reported behaviors have been
discussed previously
34
; however, the validity and reli-
ability of the sexual orientation question remain un-
clear in part due to social stigma and other pressures of
the coming-out process. Embarrassment, regardless of ori-
entation, fear of discovery, and anxieties about sexual
questions in general may also affect an adolescent’s abil-
ity to answer such a question. As such, our sample of 129
GLBN respondents most likely does not represent all gay,
lesbian, and bisexual youths within the study popula-
tion. Clearly, the use of prospective studies and the de-
velopment of sensitive, specific, valid, and reliable ques-
tions regarding sexual identity and orientation are critical
areas in need of further work.
CONCLUSIONS
In support of prior anecdotal and nonrepresentative data,
this population-based study identifies GLBN sexual ori-
entation as an important independent predictor of sui-
cide attempts among adolescents. After adjusting for other
potential confounding and mediating factors, in this popu-
lation, our findings indicate that a nonheterosexual sexual
orientation significantly increases the odds of a suicide
attempt.
While most gay, lesbian, and bisexual youths cope
with stresses and become healthy, productive adults, un-
derstanding the interrelationships among demographic
variables, health risk behaviors, sexual orientation, and
suicide risk may aid in the recognition of vulnerable
youths and the identification of individuals at risk. Per-
haps the challenge is to move beyond statistical esti-
mates of risk to the exploration of more complex issues,
such as resiliency or the effects of marginalization on ado-
lescent development and well-being.
Accepted for publication September 9, 1998.
This work was funded in part by grant BRH 970155
for Special Projects of National Significance and project grant
MCJ-MA 259195 from the Maternal and Child Health Bu-
reau (Title V, Social Security Act), Health Resources and
Services Administration, Department of Health and Hu-
man Services, Washington, DC (Dr Goodman), and by the
Dyson Foundation of New York Inc, New York.
We thank the staff of the Sidney Borum Community
Health Center, Boston, Mass, and Steven Tierney, EdD, for
their comments and support.
Presented in part at the Pediatric Academic Societies
Annual Meeting, New Orleans, La, May 3, 1998.
Corresponding author: Robert Garofalo, MD, Sidney
Bowman Community Health Center, 130 Boylston St, Bos-
ton, MA 02116 (e-mail: rgarofalo@jrihealth.org).
ARCH PEDIATR ADOLESC MED/ VOL 153, MAY 1999
492
©1999 American Medical Association. All rights reserved.
at Tel-Aviv University, on January 9, 2008 www.archpediatrics.comDownloaded from
REFERENCES
1. Centers for Disease Control and Prevention. Programs for the prevention of sui-
cide among adolescents and young adults.
MMWR Morb Mortal Wkly Rep
. 1994;
43:1-7.
2. Guyer B, Martin JA, MacNorman MF, Anderson RN, Strobino DM. Annual sum-
mary of vital statistics—1996.
Pediatrics
. 1997;100:905-918.
3. Kann L, Warren CW, Harris WA, et al. Youth risk behavior surveillance—United
States, 1995.
MMWR CDC Surveill Summ.
1996;45:1-84.
4. Lewinsohn PM, Rohde P, Seeley JR. Adolescent suicidal ideation and attempts:
prevalence, risk factors, and clinical implications.
Clin Psychol Sci Pract
. 1996;
3:25-46.
5. Shaffer D. Suicide in childhood and early adolescence.
J Child Psychol Psychia-
try
. 1974;15:275-291.
6. Shafii M, Carrigan S, Whittinghill JR, Derrick A. Psychological autopsy of com-
pleted suicide in children and adolescents.
Am J Psychiatry
. 1985;142:1061-
1064.
7. Brent DA, Perper JA, Kolko DJ, Zelenak JP. The psychological autopsy: meth-
odologic considerations for the study of adolescent suicide.
J Am Acad Child
Adolesc Psychiatry
. 1988;27:362-366.
8. King CA, Hill EM, Naylor M, Evans T, Shain B. Alcohol consumption in relation to
other predictors of suicidality among adolescent girls.
J Am Acad Child Adolesc
Psychiatry
. 1993;32:82-88.
9. Crumley FE. Substance abuse and adolescent suicidal behavior.
JAMA
. 1990;
263:3051-3056.
10. Low BP, Andrews SF. Adolescent suicide.
Med Clin North Am
. 1990;74:1251-
1264.
11. Woods ER, Lin YG, Middleman A, Beckford P, Chase L, DuRant RH. The asso-
ciation of suicide attempts in adolescents.
Pediatrics
. 1997;99:791-796.
12. Beautrais AL, Joyce PR, Melder RT. Risk factors for serious suicide attempts
among youth aged 13 through 24 years.
J Am Acad Child Adolesc Psychiatry
.
1996;35:9:1174-1182.
13. Kienhorst KWM, deWilde EJ, Diekstra RFW, Wolters WH. Adolescents’ image of
their suicide attempt.
J Am Acad Child Adolesc Psychiatry
. 1995;34:623-628.
14. King RA, Apler A. Psychoanalytic perspectives on adolescent suicide.
Psycho-
anal Study Child
. 1996;51:491-511.
15. Negron R, Placentini J, Grace F, Davies M, Shaffer D. Microanalysis of adoles-
cent suicide attempters and ideators during the acute episode.
J Am Acad Child
Adolesc Psychiatry
. 1997;36:1512-1519.
16. Remafedi G, Farrow JA, Deisher RW. Risk factors for attempted suicide in gay
and bisexual youth.
Pediatrics
. 1991;87:869-875.
17. Remafedi G. Adolescent homosexuality: psychosocial and medical implica-
tions.
Pediatrics
. 1987;79:331-337.
18. Roesler T, Deisher RW. Youthful male homosexuality: homosexual experience
and the process of developing homosexual identify in males age 16 to 22 years.
JAMA
. 1972;219:1018-1023.
19. Gibson R.
Report of the Secretary’s Task Force on Youth Suicide: Prevention and
Intervention in Youth Suicide
. Rockville, Md: US Dept of Health and Human Ser-
vices; 1989.
20. Gonsiorek J. Mental health issues of gay and lesbian adolescents.
J Adolesc Health
Care
. 1988;9:114-122.
21. Savin-Williams R. Verbal and physical abuse stressors in the lives of lesbian,
gay male, and bisexual youths: associations with school problems, running away,
substance abuse, prostitution, and suicide.
J Consult Clin Psychol
. 1994;62:
261-269.
22. Remafedi G, French S, Story M, Resnick MD, Blum R. The relationship between
suicide risk and sexual orientation: results of a population-based study.
Am J
Public Health
. 1998;88:57-60.
23. Garofalo R, Wolf RC, Kessel S, Palfrey J, DuRant RH. The association between
health risk behaviors and sexual orientation among a school-based sample of
adolescents.
Pediatrics
. 1998;101:895-902.
24. Rotherman-Borus MJ, Fernandez MI. Sexual orientation and developmental chal-
lenges experienced by gay and lesbian youths.
Suicide Life Threat Behav
. 1995;
25:26-33.
25. Trodien R. Homosexual identity development.
J Adolesc Health Care
. 1988;9:
105-113.
26. Jessor R. Risk behavior in adolescence: a psychological framework for under-
standing and action.
J Adolesc Health
. 1991;12:597-605.
27. Remafedi G.
Death By Denial: Studies of Suicide in Gay and Lesbian Teenagers
.
Boston, Mass: Alyson Publications Inc; 1994.
28. Muehrer P. Suicide and sexual orientation: a critical summary of recent re-
search and directions for future research.
Suicide Life Threat Behav
. 1995;25:
75-81.
29. Shaffer D, Fisher P, Hicks RH, Parades M, Gould M. Sexual orientation in ado-
lescents who commit suicide.
Suicide Life Threat Behav
. 1995;25:64-71.
30.
Moscicki EK, Muehrer P, Potter LB, Maris RW. Recommendations for a research
agenda in suicide and sexual orientation: working groups, workshop on suicide
and sexual orientation.
Suicide Life Threat Behav
. 1995;25(suppl):82-94.
31.
Saghir MT, Robins E.
Male and Female Homosexuality: A Comprehensive Inves-
tigation
. Baltimore, Md: Williams & Wilkins; 1973.
32.
Schneider SG, Faberow NL, Kruks GN. Suicidal behavior in adolescent and young
gay men.
Suicide Life Threat Behav
. 1989;19:381.
33.
Rotherman-Borus MJ, Hunter J, Rosario M. Suicidal behavior and gay-related
stress among gay and bisexual male adolescents.
J Adolesc Res
. 1994;9:496-
500.
34.
Brener N, Collins J, Kann L, Warren C, Williams B. Reliability of the Youth Risk
Behavior Survey Questionnaire.
Am J Epidemiol
. 1995;141:575-580.
ARCH PEDIATR ADOLESC MED/ VOL 153, MAY 1999
493
©1999 American Medical Association. All rights reserved.
at Tel-Aviv University, on January 9, 2008 www.archpediatrics.comDownloaded from
