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The Relationship of Cumulative Stressors, Chronic Illness and Abuse to the Self-Reported Suicide Risk of Black and Hispanic Sexual Minority Youth

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Abstract

Sexual minority youth [SMY] are a population who experience considerable stress related to their sexual identities. Previous investigations have identified individual risk factors that contribute to suicide among SMY, yet little research has focused on cumulative stressors that may exacerbate negative outcomes for multiethnic sexual minority youth [MSMY]. This study used hierarchical logistic regression to explore the relationship between cumulative risks and their relationship to self-reported suicide risk for MSMY. The community-based clinical sample (n = 137) reported high co-occurrence of risks, with an average of 9. Overall, MSMY with a higher number of cumulative risk factors were twice as likely to express self-reported suicide risk. Specifically, experiencing chronic illness and physical or sexual abuse resulted in threefold higher odds of self-reported suicide risk among MSMY. These findings address a gap in the literature about the relationship of cumulative and specific stressors to the self-reported suicide risk for an understudied, vulnerable population.
ARTICLE
THE RELATIONSHIP OF
CUMULATIVE STRESSORS,
CHRONIC ILLNESS AND ABUSE TO
THE SELF-REPORTED SUICIDE RISK
OF BLACK AND HISPANIC SEXUAL
MINORITY YOUTH
Shelley L. Craig and Lauren McInroy
University of Toronto
Sexual minority youth [SMY] are a population who experience
considerable stress related to their sexual identities. Previous investigations
have identified individual risk factors that contribute to suicide among
SMY, yet little research has focused on cumulative stressors that may
exacerbate negative outcomes for multiethnic sexual minority youth
[MSMY]. This study used hierarchical logistic regression to explore the
relationship between cumulative risks and their relationship to self-reported
suicide risk for MSMY. The community-based clinical sample (n =137)
reported high co-occurrence of risks, with an average of 9. Overall, MSMY
with a higher number of cumulative risk factors were twice as likely to
express self-reported suicide risk. Specifically, experiencing chronic illness
and physical or sexual abuse resulted in threefold higher odds of
self-reported suicide risk among MSMY. These findings address a gap in
the literature about the relationship of cumulative and specific stressors to
the self-reported suicide risk for an understudied, vulnerable population.
C2013 Wiley Periodicals, Inc.
We acknowledge the staff of the Alliance for GBLTQ Youth for their energetic work on behalf of this population,
as well as The Children’s Trust of Miami for their support of that organization. We dedicate this manuscript
to the youth that fight every day not only to survive but to also make their schools safer for their peers. This
research was partially supported by a Social Sciences and Humanities Research Council (SSHRC) Institutional
Grant from the University of Toronto.
Please address correspondence to: Shelley L. Craig, Factor-Inwentash Faculty of Social Work, 246 Bloor Street
W, Toronto, Ontario, M5S 1A1. E-mail: shelley.craig@utoronto.ca
JOURNAL OF COMMUNITY PSYCHOLOGY, Vol. 41, No. 7, 783–798 (2013)
Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jcop).
C
2013 Wiley Periodicals, Inc. DOI: 10.1002/jcop.21570
784 rJournal of Community Psychology, September 2013
INTRODUCTION
Sexual minority youth [SMY] are a population at particular risk for suicidal ideation
and suicide attempts (Haas et al., 2011; King et al., 2008). SMY also disproportion-
ately experience discrimination (Meyer, 2003), school failure (Murdock & Bolch, 2005),
familial rejection (Davis, Saltzburg, & Locke, 2009), violence, and mental health problems
(Russell, Franz, & Driscoll, 2001). Despite this increased understanding of individual risk
factors, little research has explored the relevance of a cumulative risk model for SMY or
attended to the cumulative risks of multiethnic sexual minority youth [MSMY]. Further,
there is a lack of knowledge regarding the particular risk and protective factors associ-
ated with suicidality for lesbian, gay, bisexual, transgender, and questioning (LGBTQ)
subgroups (Haas et al., 2011), despite recent calls for increased attention to the role of
culture and racial/ethnic identity in such investigations (Rutter, 2008).
Cumulative Risk
Cumulative risk may be defined as an accumulation of risk factors, or stressors, which col-
lectively increase the likelihood of negative outcomes or behaviours (Price & Hyde, 2009).
The study of multiple risks utilizes an ecological model (Bronfenbrenner, 1979), stressing
that individual, family, community, institutional, and societal factors interact to influence
the functioning of an individual in multiple settings. The cumulative risk framework was
utilized for this study, as it accounts for the community, social, and environmental condi-
tions youth experience as a result of their marginalization (Haas et al., 2011; Morrison &
L’Heureux, 2001).
Recent studies have utilized this model with SMY (Hong, Espelage, & Kral, 2011) and
have demonstrated the need to consider risk factors cumulatively (Gerard & Buehler,
2004b), as risks rarely occur in isolation or are solely responsible for negative outcomes
(Prelow & Loukas, 2003; Roberts, Roberts, & Xing, 2010). Cumulative risk has also been
used in previous studies with adolescents, including with ethnic minority adolescents
(Gerard & Buehler, 2004a; Mitchell et al., 2007), to predict outcomes such as substance use
(Griffin, Scheier, Botvin, & Diaz, 2000; Vega, Zimmerman, Warheit, Apospori, & Gil, 1993),
early sexual behaviour (Mitchell et al., 2007), truancy and delinquency (Rutter, 2008),
academic outcomes, behaviour patterns and adjustment, and general well-being. The
cumulative risk framework has also been specifically recommended to evaluate suicidality
for MSMY (Rutter, 2008), yet to our knowledge this is the first study to do so.
A crucial assumption of the model is that the number of risk factors experienced is
the most influential determinant of an adolescent’s overall level of risk, rather than any
one combination of factors (Gerard & Buehler, 2004b). It should also be noted that a
simultaneous criticism of cumulative risk is that all risk factors are assumed to have an
equal effect on the lives of adolescents (Gerard & Buehler, 2004a). Yet the importance
of considering risk factors across multiple domains cannot be overlooked, as stressors
in multiple areas of an adolescent’s life may leave youth without a secure space for
“psychological retreat” (Gerard and Buehler, 2004b, p. 703), resulting in diminished
coping abilities, increased likelihood of depression, and poor development.
This study contributes to the literature by (a) providing a review of the risks of MSMY
in critical ecological domains, (b) exploring the utility of a cumulative risk index for
this understudied population, and (c) testing the relationship of the accumulation of
these risks to their self-reported suicide risk. To provide context, literature that examines
the relevant risk factors for MSMY is briefly described. This review is organized into
Journal of Community Psychology DOI: 10.1002/jcop
Cumulative Stressors and Suicide Risk for Sexual Minority Youth r785
four related domains suggested by previous research (Gerard & Buehler, 2004b): (a)
demographic; (b) school, community, and social environment; (c) family; and (d) health
and mental health.
Demographic Risk Factors
Gender and race/ethnicity are potential risk factors for SMY. Female SMY may be at
particular risk for maladjustment, including depression, anxiety, low self-esteem, and
substance use (Bauermeister et al., 2010; King et al., 2008; Teasdale & Bradley-Engen,
2010). Gender based analyses indicate sexual orientation is a stronger predictor of suicide
attempts for young males, while suicidal ideation is more prevalent among females (Haas
et al., 2011). Strong racial/ethnic identities may buffer youth by providing culturally
specific coping (Kiang, Yip, Gonzales-Backen, Witkow, & Fuligni, 2006) and the ability to
deal with racial/ethnic stigma (Meyer, 2003). Yet, for MSMY, their multiple identities may
potentially compound minority stress (Fisher et al., 2008; Meyer, 2003). Multiple minority
status, resulting in isolation from both one’s community of origin and the sexual minority
community, may increase MSMYs suicide risk (Morrison & L’Heureux, 2001). Recent
studies have found elevated suicide attempts among African American gay males (Haas
et al., 2011). This complexity and lack of knowledge illuminates the need for research
specific to MSMY (Homma & Saewyc, 2007).
School, Community, and Social Environment Risk Factors
SMY are at increased risk for an array of school-related problems (Craig & Smith, 2011),
including being up to five times more likely to skip school as a result of safety concerns
and having double the chance of no postsecondary school plans (Fisher et al., 2008).
SMY also frequently experience harassment and discrimination in their neighbourhoods
and communities (Fisher et al., 2008; Ray, 2007; Tharinger and Wells, 2000), and may
experience stress from social environments hostile to their sexuality (Baiocco, D’Alessio,
& Laghi, 2010). Low community socioeconomic status [SES] may increase risk factors for
SMY (Lock & Steiner, 1999), while assertion of SMY identity has been found to be positively
related to higher socioeconomic status (SES) and parental education (Remafedi, Resnick,
Blum, & Harris, 1992). Although research is lacking on SMY, among sexual minority male
adults, suicide attempts are highest among those with low SES (Haas et al., 2011). Thus,
school and community contexts may be important to understanding MSMY suicide risk.
Family Risk Factors
SMY are more likely to experience rejection and decreased familial support (Needham &
Austin, 2010; Ryan, Russell, Huebner, Diaz, & Sanchez, 2010; Tharinger & Wells, 2000).
SMY rejected by parents are eight times more likely to report a suicide attempt than
peers whose parents were accepting (Haas et al., 2011). Unsupportive families may also
be more likely to commit violence against SMY, while supportive families may protect
SMY from violence (Homma & Saewyc, 2007). SMY report high levels of physical and
sexual violence (Homma & Saewyc, 2007), including violence from family (Tharinger &
Wells, 2000), which is associated with suicide for SMY (Detrie & Lease, 2008; Morrison &
L’Heureux, 2001; Rutter, 2008).
Family substance use also impacts adolescents, though data are lacking regarding
SMY specifically. Children and grandchildren of substance users are at increased risk for
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786 rJournal of Community Psychology, September 2013
maladaptive behaviours, psychological, social, and emotional problems, and other health
issues. A range of environmental issues may also be related to parental substance use,
which contributes to poor family functioning and parenting practices, such as poverty,
violence, and family dysfunction (Francis, 2011; Leventhal, Pettit, & Lewinsohn, 2011).
Growing up in families not headed by two parents has been linked to many poor
outcomes, including poverty, lower educational achievement, substance use, and poor
self-image (Aguilar-Vafaie, Roshani, Hassanabadi, Masoudian, & Afruz, 2011). Although
unstudied for SMY, and while the advantages of two-parent families are not equally experi-
enced, children living with both biological and married parents do better overall (Musick
& Meier, 2010). Evidence also suggests that SMY may be a disproportionately represented
in foster care, though reliable estimates prove challenging; many SMY do not disclose
their sexuality, often because of hostile organizational climates (Gallegos et al., 2011).
SMY in foster care are frequently placed into unstable settings that may expose them to
violence and discrimination (Freundlich & Avery, 2004; Gallegos et al., 2011).
SMY also disproportionately experience homelessness, comprising 20%–40% of
homeless youth (Fisher et al., 2008), with many citing conflicts about their sexuality
as the primary cause (Ray, 2007). Over 50% of homeless adolescents experience suicidal
ideation, while more than 25% have attempted suicide in the previous year (Ray, 2007).
Children in immigrant families are more likely to live in poverty, as well as in larger
households (Hernandez, Macartney, & Blanchard, 2010). While research demonstrates
that many positively adapt, “not all immigrant adolescents adjust equally well” (Hernan-
dez et al., p. 428). Immigrant SMY may also have lower self-esteem and higher depression
than nonimmigrant SMY peers (Russell, Ryan, Toomey, Diaz, & Sanchez, 2011).
Health and Mental Health Risk Factors
SMY may experience poorer overall health outcomes (Detrie & Lease, 2008; Needham
& Austin, 2010), as well as higher levels of psychological distress and mental health
problems, including anxiety and depression, often as a result of difficulties with their
sexuality (Bauermeister et al., 2010; Teasdale & Bradley-Engen, 2010). Additionally, SMY
are almost twice as likely to abuse substances and develop adult substance issues (Marshal,
Friedman, Stall, & Thompson, 2009). Substance use among SMY has been linked to
suicidal ideation and attempts (Rutter, 2008).
Suicide Risk
Suicide is one of the foremost causes of death among SMY, with research indicating that
up to 40% have attempted suicide, while SMY may account for up to 30% of adolescent
suicides per annum (Fisher et al., 2008; Hegna & Wichstrøm, 2007). Suicide attempts
range from two to seven times higher for SMY than straight youth (Haas et al., 2011).
Mental health issues, sexuality-related victimization, and substance use are critical predic-
tors of increased SMY suicide risk (Rutter, 2008). The prevalence of suicide among this
population indicates a critical need for investigation.
This study will examine (a) the risk profile of MSMY participating in a case manage-
ment program, (b) the utility of a cumulative risk index for research involving MSMY, and
(c) the relationship of an accumulation of risks in the multiple ecological domains of de-
mographics, school, community, and social environment, family, and health and mental
health on the self-reported suicide risk of MSMY. We expected that that the family and
Journal of Community Psychology DOI: 10.1002/jcop
Cumulative Stressors and Suicide Risk for Sexual Minority Youth r787
health and mental health domains, as well as overall cumulative risk, would be associated
with higher rates of self-reported suicide risk.
METHODS
Procedure & Participants
This study was conducted among participants in a clinical case management program
at a community organization for SMY in a large, urban city in the Southeastern United
States. The program, developed as part of a response to an extensive community needs
assessment (Craig, 2011), provides individualized guidance, support, and connections to
services for SMY. Typically participants received services over a period of four to six weekly
sessions of approximately 90 minutes. The duration of the program was determined to
provide focused services to as many interested SMY as feasible, as well as to comply with
funder requirements. Many participants attended a second period of case management,
consideration for which was based on participant request after case manager consultation
and was determined by inadequate resolution identified issues.
The program was founded on a strengths-based model, which has been
used with numerous vulnerable populations (Arnold, Walsh, Oldham, & Rapp,
2007; Rapp, 1998); its implementation with MSMY has been detailed elsewhere
(Craig, 2012). Case management involved creation of an individualized care plan to
aid youth in negotiating a variety of challenges. Five integrated components were carried
out: (a) an in-depth assessment involving an evaluation of risks and strengths in multiple
domains, (b) development of a care plan based upon the findings of the assessment,
(c) referrals to relevant resources/services, (d) monitoring and goal adjustment, and (e)
advocacy on behalf of the individual youth.
While some participants in the community-based program were referred by guid-
ance counsellors/helping professionals (20%) or family members (6%), the majority
(74%) self-referred, most learning about the program from their peers. To participate in
case management youth had to reside in the Dade County, Florida catchment area and
state that they needed help with a problem. The most prevalent reasons for participa-
tion included family, school, and stress management issues. Data were collected between
February 2009 and February 2011. Study inclusion criteria comprised (a) participation
in the case management program, (b) identification as a sexual and/or gender minor-
ity, and (c) residence in a low income community (identified by zip code). Participants
completed an informed consent form that fully described the study purpose and confi-
dentiality procedures and were assured that their participation had no bearing on service
delivery. The study was covered under a University of Toronto Research Ethics Board
protocol.
Participant (n =137) ages ranged from 14–21 years (mean [M]=17.20, stan-
dard SD =1.62). As a result of the demographic composition of the city where the
research was undertaken, most participants identified as White Hispanic (26.3%), His-
panic no/other race (27.7%), Black Hispanic (5.1%), as well as Black non-Hispanic
(38.7%). Participants’ sexual orientation included lesbian (35.0%), gay (29.9%),
bisexual (24.1%), queer/pansexual (1.5%), and straight (3.6%). Participants identified
their gender identity as female (60.6%), male (34.3%), or transgender and other (5.1%).
Because of low group frequencies and problems in interpretation, those who identified
as queer/pansexual, straight, transgender, or other were removed from analyses. Missing
Journal of Community Psychology DOI: 10.1002/jcop
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data ranged from 0 to 6% for retained variables, except immigration status (15%). For
data identified as missing, a multiple imputation approach was used with five imputed
data sets (Jaccard, 2001) using the expectation-maximization method with importance
re-sampling as described in King, Honaker, Joseph, and Scheve (2001).
Measures
Comprehensive psychosocial assessments were created for this study and completed by
participants. A thorough review of the measurements available in the literature was com-
pleted; all were deemed to be too time intensive by the community organization delivering
the program. Although this presents obvious challenges because of the lack of an estab-
lished, reliable measure, this presented an opportunity for insight into the complex nature
of the risks experienced by SMY. Thus, the assessments were developed in cooperation
between researchers and the community organization and were designed to assess multi-
ple dimensions of participants’ lives as comprehensively as possible given the constraints
of short assessments. Assessments items were determined during four iterative researcher
and community meetings. The resulting Youth Brief Psychosocial Assessments (YBPA)
included questions about demographics, presenting problems, school and community
safety, health and mental health concerns, family supports and stressors, and personal
goals. Questions were a combination of multiple-choice questions (with a write-in “other”
option) and qualitative questions requiring more detailed descriptions of risks and con-
cerns. Participants completed the assessments verbally during their first meeting with the
case manager.
Based on ecological systems theory (Bronfenbrenner, 1979), and previous studies
of SMY (Elze, 2002), risk factors were categorized into the following: (a) demographic
(gender identity, race/ethnicity); (b) school, community and social environment (prob-
lems with school, problems with community/neighbourhood); (c) family (problems with
family, live with other than with two parents, homelessness, sexual or physical abuse,
child protective services involvement, immigrant parent(s), family substance use, family
violence); and (d) health and mental health (problems with health, chronic illness, men-
tal health, substance use) factors. The presence of chronic illness was identified with a
question about whether they had a chronic illness (yes/no). For those that indicated the
existence of chronic illness, an open-ended question was asked about the condition and
its effect. Although chronic illness included a variety of both physical and psychological
conditions (e.g., ADHD, diabetes, anxiety), participants identified that the struggles of
dealing with long-term illness were similar across types.
Self-reported suicide risks were identified through a question that stated, “Are you
concerned about your suicide risk?” Previous research has found single item self-reported
suicide risk assessments to be in agreement with structured clinician interviews over 80%
of the time (Yigletu, Tucker, Harris, & Hatlevig, 1994), as well as particularly useful for
adolescent services (Muehlenkamp & Gutierrez, 2007).
The next step was to construct a cumulative risk index (CRI) in a manner previously
utilized for other studies of adolescent populations (Gerard & Buehler, 2004b). The par-
ticular strengths of CRIs are their high face validity, “consistency in predicting adjustment,
and recognition that risk factors often occur in conjunction with one another” (Gerard &
Buehler, 2004b, p. 704). The CRI was constructed via three steps: (a) categorical measures
were dichotomized into any risk (1) or no risk (0); (b) continuous responses were scored
using a 75th percentile cut point (Gerard & Buehler, 2004b); and (c) total scores were
added to create a CRI.
Journal of Community Psychology DOI: 10.1002/jcop
Cumulative Stressors and Suicide Risk for Sexual Minority Youth r789
RESULTS
SPSS 19 was utilized for all analyses. In addition to the challenges that may be experi-
enced by being ethnic/racial and sexual minorities, the youth in this study experienced
high levels of risk (Table 1). Although participants could have reported zero risks, the
risks ranged from 4–13 with a mean score indicating the presence of many risks (M=
9, SD =2.1). A majority of youth (62%) had risks in more than two domains. The data
were not significantly skewed or kurtotic and no outliers were present. Biserial correla-
tions were calculated and revealed several interesting relationships (Table 2). Greater
cumulative risk was positively correlated with experiencing homelessness (.218). Black,
non-Hispanic identities significantly (p<.05) reported more cumulative risk (.201) than
Hispanic participants. In addition, cumulative risk was negatively correlated with younger
age compared to being older than 18 years of age (–.173). At the p<.01 level, higher cu-
mulative risk was positively correlated with being female compared with male (.279) and
being lesbian (.258), as well as reporting suicide risk (.285), problems with family (.394),
problems with health (.401), chronic illness (.376), mental health issues (.331), substance
use (.462), being physically or sexually abused (.462), immigrant parent(s) (.257), family
substance use (.482), and violence (.433).
An initial logistic regression was conducted to identify the contribution of the CRI
to self-reported suicide risk using the total calculated scores. Overall, for every one-
unit increase in total cumulative risk the odds of self-reported suicide risk were twice
as high (odds ratio [OR] =1.9; 95% confidence interval [CI] =1.1, 2.3). To isolate
the contribution of groups of variables, a hierarchical logistic regression was conducted
through forced block entry (Aiken & West, 1991). Variables were entered by domains in
the following order (demographics, school and social environment, health and mental
health, and family) to identify their relationships to the self-reported suicide risk of MSMY.
A test of the full model against a constant-only model was statistically significant, indicating
that associations between the self-reported suicide risk for those with cumulative factors
and those without were significant (χ2=14.443/ 7, p <.05), reflecting a mild relationship
(Nagelkerke’s R2=.276). Table 3 presents the detailed results of the regression analysis.
Demographic and school and social environments did not have a significant relationship
to suicide risk. The domains of health and mental health (p <.05) and family (p <.05)
made a significant contribution to self-reported suicide risk. Using the EXP(B) value,
the odds of MSMY self-reported suicide risk were almost four times higher for each unit
increase in chronic illness, (OR =3.8; 95% CI =1.8, 4.6) and physical or sexual abuse
(OR =3.8; 95% CI =2.2, 5.4).
DISCUSSION
Suicide has been identified as a significant health concern for SMY (King et al., 2008).
This study provides meaningful information about the self-reported suicide risk of Black
and Hispanic SMY, as well as the relevance of a cumulative risk index. In addition to their
identities as low-income, racial/ethnic minority youth, the MSMY experienced multiple
risks, with an average of nine factors. Consistent with expectations that the number of
risk factors experienced is a particularly influential determinant of an adolescent’s overall
level of risk (Gerard & Buehler, 2004b), our findings indicate that MSMY with greater
cumulative risk were nearly twice as likely to have reported suicide risk. Additionally,
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790 rJournal of Community Psychology, September 2013
Table 1. Risks Factors by Sexual Orientation for a Sample of MSMY (n =137)
Of those at risk:
At risk Lesbian Gay Bisexual
Risk variable Risk status criterion youth n(%) n(%) n(%) n(%)
Family
Problems with
family
Reported problems with
home/family
110 (80.3) 39 (35.5) 34 (30.9) 26 (23.6)
Other than two
parents
Lived other than with both
parents
Mother only; father only; mother &
other; father & other;
grandparent(s); other relative &
other
106 (77.4) 36 (34.0) 32 (30.2) 27 (25.5)
Homelessness Reported having ever been
homeless, thrown out, or run
away
63 (46.0) 25 (39.7) 20 (31.7) 13 (20.6)
Child protective
services
Reported having ever been in
foster care or ever having had a
child protection case
35 (25.5) 8 (22.9) 10 (28.6) 10 (28.6)
Immigrant
parent(s)
At least one parent/caregiver
born outside the U.S.A
92 (67.2) 35 (38.0) 28 (30.4) 21 (22.8)
Family substance
use
Reported alcohol/substance use
concerns within family
41 (29.9) 15 (36.6) 11 (26.8) 13 (31.7)
Family violence Reported violence-related
concerns within family
(Youth not target) physical abuse;
domestic violence; & sexual abuse
41 (29.9) 17 (41.5) 12 (29.3) 10 (24.4)
Physical and/or
sexual abuse
Reported experienced abuse
Physical abuse & Sexual abuse
34 (24.8) 18 (52.9) 7 (20.6) 8 (23.5)
Demographic
Gender identity Other than male
Female; Transgender; Intersex; other
90 (65.7) 48 (53.3) 4 (4.4) 25 (27.8)
Race/ethnicity Other than White;
Black, Hispanic; Black,
non-Hispanic; White, Hispanic;
American Indian/Alaskan; Asian;
Pacific Islander; multiracial; &
other
137 (100.0) 48 (35.0) 41 (29.9) 33 (24.1)
Health and mental health
Problems with
health
Reported problems with health 65 (47.4) 25 (38.5) 20 (30.8) 14 (21.5)
Chronic illness Reported experiencing chronic
illness
32 (23.4) 14 (43.8) 6 (18.8) 8 (25.0)
Mental health Had mood/mental health issues
Anger; hopelessness; sadness;
depression & helplessness
66 (48.2) 21 (31.8) 20 (30.3) 19 (28.8)
Substance use Reported having
alcohol/substance use concerns
36 (26.3) 19 (52.8) 6 (16.7) 8 (22.2)
Suicide risk Reported having suicide risk 42 (30.7) 19 (45.2) 9 (21.4) 9 (21.4)
School & social environment
Problems with
school
Reported problems with school 84 (61.3) 27 (32.1) 28 (33.3) 19 (22.6)
Problems with
community/
neighbourhood
Reported problems with
community or neighbourhood
14 (10.2) 2 (14.3) 5 (35.7) 6 (42.9)
Journal of Community Psychology DOI: 10.1002/jcop
Cumulative Stressors and Suicide Risk for Sexual Minority Youth r791
Table 2. Biserial Correlations of Demographics and Risk Factors for Multiethnic Sexual Minority Youth
123456789 101112131415161718192021222324
1. Hispanic 1.00
2. Black 1.00 1.00
3. Male .065 .085 1.00
4. Female .069 .068 .895** 1.00
5. Lesbian .145 .169*.531*.592*1.00
6. Gay .088 .099 .770*.680*.480*1.00
7. Bisexual .076 .065 .119 .140 .414*.368*1.00
8. Age .260** .262** .064 .087 .023 .068 .090 1.00
9. Problems with family .094 .079 .048 .062 .018 .043 .059.099 1.00
10. Other than two parents .219*.223** .021 .028 .042 .011 .031 .109 .039 1.00
11. Homelessness .047 .066 .074 .035 .090 .037 .125 .067 .052 .026 1.00
12. Child protective services .081 .065 .036 .041 .150 .017 .166 .053 .046 .123 .070 1.00
13. Immigrant parent .463** .429** .018 .008 .090 .016 .105 .069 .044 .118 .041 .053 1.00
14. Family substance use .164 .172 .036 .070 .021 .044 .021 .149 .244** .066 .197** .054 .050 1.00
15. Family violence .131 .141 .037 .030 .088 .009 .079 .238** .083 .104 .027 .092 .016 .130 1.00
16. Problems with health .070 .090 .102 .048 .068 .017 .085 .044 .140 .010 .033 .020 .073 .113 .209*1.00
17. Chronic illness .019 .005 .108 .128 .101 .135 .029 .018 .100 .092 .010 .007 .019 .016 .016 .132 1.00
18. Mental health .022 .043 .103 .089 .065 .008 .057 .009 .074 .033 .048 .072 .021 .136 .040 .126 .262** 1.00
19. Substance use .240** .245** .187*.142 .222** .173*.056 .207*.171*.073 .081 .084 .135 .225** .189*.130 .062 .022 1.00
20. Abuse .252** .256** .131 .152 .216 .117 .103 .175*.200*.255** .012 .143 .114 .399** .289** .232** .042 .013 .156 1.00
21. Suicide risk .034 .067 .147 .115 .142 .123 .024 .013 .069 .094 .073 .046 .074 .119 .015 .029 .194*.056 .071 .204*1.00
22. Problems with school .132 .097 .069 .119 .076 .094 .014 .032 .054 .000 .109 .087 .115 .103 .005 .056 .128 .106 .002 .133 .122 1.00
23. Problems with commu-
nity/neighbourhood
.027 .018 .061 .073 .147 .043 .106 .101 .107 .048 .070 .087 .175*.095 .201*.066 .099 .061 .072 .141 .037 .070 1.00
24. Total cumulative risk .211*.201*.319** .279** .258** .256** .058 .173*.394** .021 .218*.164 .257** .482** .433** .401** .376** .331*.456** .462** .285** .123 .215*1.00
Note. *p<.05. **p<.01.
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792 rJournal of Community Psychology, September 2013
Table 3. Regression Analysis Summary for Domains Associated With Suicide Risk for Black and Hispanic
Sexual Minority Youth (N =137)
Var iabl e B SE B β
Demographic factors
Age: 18+years (compared with younger than 18 years of age) .399 .502 1.491
Black (compared with Hispanic) .203 .412 .131
Male (compared with female) 1.685 1.219 .185
Bisexual (compared with lesbian) 1.018 1.162 2.766
Gay (compared with lesbian) 1.10 .971 3.00
School and community factors
Problems with school .473 .468 .623
Problems with community/neighbourhood .093 .770 .911
Family factors
Problems with family .181 .590 .307
Other than two parents .258 .545 .773
Homelessness .611 .463 .543
Child protective services .686 .547 1.986
Immigrant parent .659 .537 .517
Family substance use .639 .548 1.894
Family violence (not directed at youth) .475 .533 .622
Physical and sexual abuse 1.326 .615 3.865***
Health and mental health factors
Problems with health .559 .481 .572
Chronic illness 1.332 .540 3.788**
Mental health .173 .469 1.189
Substance use .468 .516 1.597
CRI
Total cumulative risks .279 .088 1.922 ***
Note. R2=.09 (Hosmer & Lemshow) .045 (Cox and Snell) .064 (Nagelkerke) for Step 1 (p<.564)
R2=.10 (Hosmer & Lemshow) .059 (Cox and Snell) .083 (Nagelkerke) for Step 2 (p<.028)
R2=.14 (Hosmer & Lemshow) .152 (Cox and Snell) .177 (Nagelkerke) for Step 3 (p<.028)
R2=.18 (Hosmer & Lemshow) .183 (Cox and Snell) .276 (Nagelkerke) for Step 4 (p<.008)
*p<.05. **p<.01. *** p<.001.
CRI =Total score on the cumulative risk index.
experiencing (a) physical and/or sexual abuse from family members or (b) chronic
illness strongly and directly contributed to self-reported suicide risk.
This study found high rates of self-reported suicide risks for non-Hispanic, Black,
and Hispanic sexual minority adolescents (31%). Most previous research has compared
suicidality between Whites and racial/ethnic minority populations (Meyer, Dietrich, &
Schwartz, 2007; Remafedi et al., 1992), yet the absence of Whites in this study was reflective
of the racial/ethnic composition of the study location. Within a larger, older sample (aged
18–59 years) of sexual minority individuals, Meyer et al. (2007) found that Blacks and
Latinos had higher rates of suicide attempts, most before the 20 years of age, compared
with Whites. Conversely, mental health issues, such as depression, which are generally
predictive of suicide attempts, were more prevalent among Whites. Similar to a recent
study of adults (O’Donnell, Meyer, & Schwartz, 2011), this study found there was not a
significant relationship between depression or substance use and suicide risk, indicating
it may not be the central feature of suicide risk for this population.
Recent studies of sexual minority adults have found that across all sexual minority
groups, traumatic events may be particularly influential on suicide risk (House, Van
Horn, Coppeans, & Stepleman, 2011). This is a key element of this study, as abuse and
Journal of Community Psychology DOI: 10.1002/jcop
Cumulative Stressors and Suicide Risk for Sexual Minority Youth r793
chronic illness, considerable traumatic events, figured most prominently in suicide risk.
Overall, SMY experience increased violence both from families (Rutter, 2008) and in
general (Tharinger & Wells, 2000). Literature has indicated that a familial history of
abuse or experience of sexual abuse may elevate the risk of suicide in SMY (Morrison
& L’Heureux, 2001). Similarly, large-scale adolescent studies have found that adverse
childhood experiences, such as abuse and household dysfunction, are associated with
higher suicide risk (Dube et al., 2001).
There is less research linking chronic illness and suicide risk for adolescents, yet
youth with chronic conditions have been found to have significantly increased risk of
suicide attempts (Greydanus, Patel, & Pratt, 2010; Miauton, Narring, & Michaud, 2004).
Further, research has indicated SMY may have poorer health outcomes overall and are
at increased risk for more health-related problems (Detrie & Lease, 2008; Needham &
Austin, 2010). It is important to note that the chronic illness described by participants
was not end-stage, but indicated a variety of long-term health and mental health issues
that required management, including some psychiatric issues (e.g., anxiety). Overall,
both chronic illness and experiencing physical and/or sexual abuse were associated with
suicide risk for MSMY, while higher levels of cumulative risk were also associated with
greater suicide risk.
Implications for Practice in Community Settings
Understanding the relationship of risks to one another, and to suicide, is critical in com-
munity contexts (Haas et al., 2011). The myriads of risks facing MSMY suggest that clinical
and community settings should also assess for other concerns. Mitchell et al. (2007) sug-
gests that adolescent service needs may be best determined by the number of risk factors
present, rather than particular problems occurring in the adolescent’s life. Although iden-
tifying those at risk of suicide poses particular challenges (Dube et al., 2001), this study
would suggest that histories of abuse and trauma, family stress, and chronic illness should
be included in assessments (as in the case of the organization where the research was
undertaken) to contextualize and evaluate the presenting problems in combination with
the overall level of risk. Practitioners should make efforts to probe more deeply in order
to determine which risk factors, either individually or in collaboration, are causing issues
for their particular client(s). This study found that the MSMY participants are struggling
with multiple risks, and research has demonstrated that experiencing cumulative risk
factors without intervention increases susceptibility for more severe, long-term difficulties
(Luthar & Cicchetti, 2000).
The typical approach to service delivery for SMY is community programs, such as the
one examined in this study, which try to reduce high-risk behaviors (Padilla, Crisp, & Rew,
2010). As this was a community-based sample of youth that voluntarily participated in the
program, this study captured a particularly under-researched group of SMY, as almost none
were accessing other services and/or reported a psychiatric diagnosis. Research suggests
that over 10% of completed suicides do not have a mental-health related diagnosis (Miller,
Eckert, & Mazza, 2009); qualitative evidence would suggest that this proportion may be
even higher for SMY, who are less likely to have sought help because of stigma and
discrimination (Craig, 2012). These implications create an even more crucial need for
community-based services and research initiatives.
A community-based continuum of care ranging from preventative to targeted pro-
grams is critical for marginalized populations that are likely to experience health dis-
parities, including suicide (Gay and Lesbian Medical Association, 2010). There is some
Journal of Community Psychology DOI: 10.1002/jcop
794 rJournal of Community Psychology, September 2013
evidence that providing information to adolescents about suicide and teaching them to
enhance their coping and problem-solving skills while reinforcing their assets, as seen
in the strengths-based program discussed in this study and elaborated upon elsewhere
(Craig, 2012), may lead to increased self-efficacy, problem solving, and reductions in sui-
cidal ideation (Miller et al., 2009). Finally, personalized programs, such as the subject
of this research, that address similarities in underlying risks while educating youth and
their families about typical developmental concerns may protect against stressors (Roberts
et al., 2010), and have been suggested to have the potential to be particularly helpful for
SMY (Morrison & L’Heureux, 2001).
LIMITATIONS AND DIRECTIONS FOR FUTURE RESEARCH
This study has several limitations. The community-based clinical sample consisted of par-
ticipants in a voluntary case management program, and thus the findings from this study
are not generalizable to a broader SMY population. Findings are also not generalizable
to all SMY because of the geographic focus and the racial/ ethnic composition of the
sample. Further, youth that participated in this study self-referred to the program and
may represent a highly motivated segment of the MSMY population. This study also uses
a measures developed by the community organization and, consequently, does not have
established reliability and collects only the self-reported risks and concerns of MSMY.
Further, youth self-report the presence of chronic illness, with conditions comprising
a wide variety of health and mental health issues. Despite this challenge, adolescents
may be in the best position to appraise their relationships and experiences, and their
self-assessment may provide a more individualized understanding of the influence of
particular risk factors on their functioning than an objective clinical assessment (Call
& Mortimer, 2001). Although preliminary analysis did not uncover significant concerns,
there may be also confounding population factors that influence the results of this study.
In addition, the variables used to construct the CRI may not be the best indicators of
the constructs, and there is a need for more precise measurement with multiple indicators.
Binary variables were used because that is how many of the risks were assessed during the
clinical services, as well as analysed in the construction of previous CRI analyses (Gerard
& Buehler, 2004a). Causality also cannot be assumed because of the cross-sectional nature
of the data.
Finally, it should also be noted that much cumulative risk research assumes all risk
factors to be equal and does not clearly define linearity (Gerard & Buehler, 2004b). While
most studies indicate a linear relationship between increasing risk factors and decreasing
adolescent well-being, few consider the possibility of nonlinearity, which could indicate
the possibility of either a risk threshold or an acceleration of problems at a critical level of
risk. Regardless, this study represents an important step toward understanding cumulative
risks and their contribution to self-reported suicide risk.
Research efforts extending this cumulative risk model should examine both pro-
tective and promotive factors (Luthar & Cicchetti, 2000). For example, social support,
particularly parental acceptance (Padilla et al., 2010), has been established as a protective
factor for suicide and should be further investigated in studies of MSMY (Miller et al.,
2009). In addition, the potential of a risk balancing effect (Gerard & Buehler, 2004),
which may decrease negative outcomes and enhance competence (Stouthamer-Loeber,
Loeber, Wei, Farrington, & Wikstrom, 2002), could enhance programs for MSMY. Addi-
tional practice-based studies involving youth already enrolled in intervention or research
Journal of Community Psychology DOI: 10.1002/jcop
Cumulative Stressors and Suicide Risk for Sexual Minority Youth r795
initiatives should be undertaken because they supplement critical current research ef-
forts based on large-scale population surveys (Haas et al., 2011). Such efforts may provide
knowledge that can be quickly integrated into practice, a critical need for youth at risk of
suicide. It could also, as with our study, be conducted at fairly low cost. This article has
explored a model of cumulative risk to understand the self-reported suicide risk of MSMY,
who report many complex risks beyond sexual orientation. A targeted cumulative risk
approach to assessment, evaluation, and treatment of factors that may specifically con-
tribute to suicide risk among MSMY may assist in addressing the unique vulnerabilities of
this population.
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... Furthermore, the private room feature is also attractive for those 151 who would like to explore their gender/sexual identities through online discussions 152 (Gonel, 2013). Clarifying the differences in victim experience by gender/sexual 153 minority status among Japanese LGBTQIA individuals could extend the findings of 154 7 VIRTUAL COMMUNITIES AND GENDER/SEXUAL MINORITIES previous studies that have been conducted, primarily with Western participants in 155 physical communities (Craig & McInroy, 2013;Paceley et al., 2017Paceley et al., , 2020Scheer et al., 156 2019), to East Asian populations and virtual communities (Chong et al., 2015). 157 1.1 | Minority stress model 158 Our first aim focused on multiple minority statuses. ...
... 166 According to the minority stress model, people with multiple minority statuses 167 have a higher risk of victimization than those with a single minority status because they 168 are likely to be victimized in more situations (Bowleg et al., 2003). In fact, LGBT 169 individuals with ethnic minority status are more victimized than those without one 170 (Balsam et al., 2011;Craig & McInroy, 2013). Recent studies have also implied that 171 people with multiple gender/sexual minority statuses have a higher risk of victimization 172 than people with a single gender/sexual minority status (Meyer, 2015). ...
... These findings indicate that virtual communities can serve as a platform that encourages 590 the free exchange of ideas among people with gender/sexual minority status while 591 decreasing the risk of victimization (Hillier et al., 2012;Ybarra et al., 2015;Ybarra & 592 Mitchell, 2016). Although victim experiences among LGBTQIA individuals is a serious 593 human rights issue (Carpenter, 2016;Craig & McInroy, 2013;Gwang-Jo, 2011; P. J. 6.759 *** .010 o < g+s+ i+g+s+ < g+s+ Community×Minority status c 8.447 *** .012 ...
Article
Full-text available
This study clarified the advantages of virtual communities on non‐victim experiences among lesbian, gay, bisexual, transgender, questioning, intersex, and asexual (LGBTQIA) individuals in Japan. A total of 3504 Pigg Party users, including 1390 LGBTQIA individuals, reported their experiences of victimization, perceived emotional support, and concealment of their gender/sexual identity in both physical and virtual communities. Japanese individuals with multiple minority statuses had more victim experiences than those with a single or without minority status. Furthermore, differences in victim experiences by gender/sexual minority status were lower in the virtual community than in physical communities. Similar tendencies were also confirmed on perceived emotional support and concealment. Virtual communities provided a more bias‐free social resource to Japanese LGBTQIA individuals than physical communities.
... Other nationally representative survey research, however, points to Latino/a people being uniquely empathetic toward LGBTQ+-based discrimination (Cox et al., 2017). Nonetheless, navigating an LGBTQ+ identity can be difficult for young people living in unaccepting family environments, as family rejection is linked to mental health challenges such as depression and suicide ideation among LGBTQ+ Latino/a young people (Craig & McInroy, 2013;Ryan et al., 2009). Ethnographic studies also highlight the role of familial gender beliefs and their impact on constraining LGBTQ+ Latino/a people's gender expansiveness when they do not conform to stereotypical societal standards (Acosta, 2013;Ocampo, 2012;Robinson, 2018). ...
... These intersecting family system processes were influential in shaping youth's experiences across age, gender, sexuality, race, and ethnicity. Perceptions of family rejection and conflict often have significant influence on LGBTQ+ young people of color's mental health (Craig & McInroy, 2013), and this impact can be salient for Latino/a LGBTQ+ individuals in the context of familism (Muñoz-Laboy et al., 2015). Specifically, LGBTQ+ Latina participants described the distinctive ways family members sought to regulate their sexualities, which aligns with previous work highlighting the influence of gender in how family and societal norms restrict Latina youth's sexual autonomy (Acosta, 2013;García, 2009). ...
Article
Objective We developed an intersectional family systems framework to examine how lesbian, gay, bisexual, transgender, and queer (LGBTQ+) Latino/a youth experience stressors stemming from familial resistance to their marginalized LGBTQ+ identities. Background Anti‐LGBTQ+ sentiments surrounding LGBTQ+ young people of color's multiple marginalized identities shape stressors. Specifically, LGBTQ+ Latino/a youth navigate distressing family experiences, yet how such family dynamics influence their well‐being remains unclear. Method By qualitatively analyzing in‐depth interviews with 41 LGBTQ+ Latino/a young adults between 18 and 25 years of age who were either born in or had moved to the United States as children, we developed an intersectional family systems approach. Results Anti‐LGBTQ+ familial derogation shaped youth's stressors. Further, familial religious pressure constrained young people's identity expression. Finally, participants navigated their mental well‐being through familial identity management strategies. Conclusion By advancing an intersectional family systems approach, we explicate the diverse ways LGBTQ+ youth of color perceive and respond to intersecting sources of oppression within their family systems. Implications These findings may inform service providers working with LGBTQ+ Latino/a young people and their families to improve mental health outcomes.
... Moreover, Black and Latinx LGBTQ youth experience signi cantly more mental health problems, like increased suicidal behaviors and hopelessness, compared to White LGBTQ youth (Russell, Sinclair, Poteat, & Koenig, 2012). Additionally, Black LGB youth report greater stressors that increase the likelihood of depression, anxiety, and suicide risk compared to Latinx LGB youth (Craig & McInroy, 2013). Thus, data indicate that LGBTQ PoC youth start experiencing mental health disorders from the adolescent period, and these negative experiences are cumulative over time, extending well into their young adult years and beyond. ...
Chapter
Social oppression (in the form of discrimination) takes a toll on the health of individuals. Indeed, extensive disparities in physical and mental health outcomes are evident for oppressed people, particularly sexual and gender and racial/ethnic communities. Despite their growing presence, racial/ethnic LGBTQ experience greater psychosocial stress from society’s marginalization. Arguably, many of these experiences become salient in adolescence for racial/ethnic LGBTQ given development of these identities during this period. Therefore, adolescence represents a critical period in the development of mental health issues for LGBTQ PoC. This chapter draws from the minority stress theory as it relates to mental health disparities among racial/ethnic LGBTQ. Additionally, the chapter focuses on the importance of stigma and discrimination during the critical period of adolescence, and how these experiences may lead to deterioration in mental health across the life span for LGBTQ PoC.
... There is a particular lack of research with female-identified SGMY, who report higher rates of HIV-related risk behaviors than their male-SGMY and non-SGMY peers [28][29][30][31][32][33][34][35][36][37]. These risks include sex with multiple partners [28,29], unprotected vaginal intercourse [30], injection drug use [31], and pregnancy [32,33]. ...
Article
Full-text available
Background: Sexual and gender minority youth (SGMY, aged 14-29 years) face increased risks to their well-being, including rejection by family, exclusion from society, depression, substance use, elevated suicidality, and harassment, when compared with their cisgender, heterosexual peers. These perils and a lack of targeted programs for SGMY exacerbate their risk for HIV and other sexually transmitted infections. Cognitive behavioral therapy (CBT) interventions support clients by generating alternative ways of interpreting their problems and beliefs about themselves. CBT, tailored to the experiences of SGMY, may help SGMY improve their mood and coping skills by teaching them how to identify, challenge, and change maladaptive thoughts, beliefs, and behaviors. Based on the promising results of a pilot study, a CBT-informed group intervention, AFFIRM, is being tested in a pragmatic trial to assess its implementation potential. Objective: The aim of this study is to scale-up implementation and delivery of AFFIRM, an 8-session manualized group coping skills intervention focused on reducing sexual risk behaviors and psychosocial distress among SGMY. Our secondary aim is to decrease sexual risk taking, poor mental health, and internalized homophobia and to increase levels of sexual self-efficacy and proactive coping among SGMY. Methods: SGMY are recruited via flyers at community agencies and organizations, as well as through Web-based advertising. Potential participants are assessed for suitability for the group intervention via Web-based screening and are allocated in a 2:1 fashion to the AFFIRM intervention or a wait-listed control in a stepped wedge wait-list crossover design. The intervention groups are hosted by collaborating community agency sites (CCASs; eg, community health centers and family health teams) across Ontario, Canada. Participants are assessed at prewait (if applicable), preintervention, postintervention, 6-month follow-up, and 12-month follow-up for sexual health self-efficacy and capacity, mental health indicators, internalized homophobia, stress appraisal, proactive and active coping, and hope. Web-based data collection occurs either independently or at CCASs using tablets. Participants in crisis are assessed using an established distress protocol. Results: Data collection is ongoing; the target sample is 300 participants. It is anticipated that data analyses will use effect size estimates, paired sample t tests, and repeated measures linear mixed modeling in SPSS to test for differences pre- and postintervention. Descriptive analyses will summarize data and profile all variables, including internal consistency estimates. Distributional assumptions and univariate and multivariate normality of variables will be assessed. Conclusions: AFFIRM is a potentially scalable intervention. Many existing community programs provide safe spaces for SGMY but do not provide skills-based training to deal with the increasingly complex lives of youth. This pragmatic trial could make a significant contribution to the field of intervention research by simultaneously moving AFFIRM into practice and evaluating its impact.
... Specifically, previous research has documented the adverse health and social outcomes for Latino/a-identified LGBTQ1 youth, such as increased family rejection (Ryan et al. 2009) and elevated rates of suicide ideation (Craig and McInroy 2013). The present study sheds light on the meaning-making processes LGBTQ1 Latino/ a young people engage in as they interpret intersecting stigmatizing societal messages. ...
Article
Lesbian, gay, bisexual, transgender, and/or queer (LGBTQ+) young people of color encounter interlocking systems of social prejudice and discrimination. However, little is understood about how subjective meanings of perceived structural stigma associated with multiple marginalized social statuses influence mental health. We document how perceived stigma can shape mental health inequalities among multiply marginalized individuals if they also encounter stigmatizing societal frameworks. Data come from in-depth interviews with 41 LGBTQ+ Latino/a young adults in the Rio Grande Valley collected from 2016 to 2017. Utilizing an intersectional minority stress framework, we qualitatively examine how young people conceptualize structural stigma, their multiple social locations (e.g., sexuality, gender, race/ethnicity, age), and their mental health. Findings highlight how LGBTQ+ Latino/a young adults experience structural racism, gender policing, and anti-LGBTQ+ religious messages in relation to their mental health. This study showcases the importance of an intersectional minority stress framework for documenting processes that can shape mental health inequalities.
... There is a particular lack of research with female-identified SGMY, who report higher rates of HIV-related risk behaviors than their male-SGMY and non-SGMY peers [28][29][30][31][32][33][34][35][36][37]. These risks include sex with multiple partners [28,29], unprotected vaginal intercourse [30], injection drug use [31], and pregnancy [32,33]. ...
Article
Full-text available
Background: Sexual and gender minority youth (SGMY, aged 14-29 years) face increased risks to their well-being, including rejection by family, exclusion from society, depression, substance use, elevated suicidality, and harassment, when compared with their cisgender, heterosexual peers. These perils and a lack of targeted programs for SGMY exacerbate their risk for HIV and other sexually transmitted infections. Cognitive behavioral therapy (CBT) interventions support clients by generating alternative ways of interpreting their problems and beliefs about themselves. CBT, tailored to the experiences of SGMY, may help SGMY improve their mood and coping skills by teaching them how to identify, challenge, and change maladaptive thoughts, beliefs, and behaviors. Based on the promising results of a pilot study, a CBT-informed group intervention, AFFIRM, is being tested in a pragmatic trial to assess its implementation potential. Objective: The aim of this study is to scale-up implementation and delivery of AFFIRM, an 8-session manualized group coping skills intervention focused on reducing sexual risk behaviors and psychosocial distress among SGMY. Our secondary aim is to decrease sexual risk taking, poor mental health, and internalized homophobia and to increase levels of sexual self-efficacy and proactive coping among SGMY. Methods: SGMY are recruited via flyers at community agencies and organizations, as well as through Web-based advertising. Potential participants are assessed for suitability for the group intervention via Web-based screening and are allocated in a 2:1 fashion to the AFFIRM intervention or a wait-listed control in a stepped wedge wait-list crossover design. The intervention groups are hosted by collaborating community agency sites (CCASs; eg, community health centers and family health teams) across Ontario, Canada. Participants are assessed at prewait (if applicable), preintervention, postintervention, 6-month follow-up, and 12-month follow-up for sexual health self-efficacy and capacity, mental health indicators, internalized homophobia, stress appraisal, proactive and active coping, and hope. Web-based data collection occurs either independently or at CCASs using tablets. Participants in crisis are assessed using an established distress protocol. Results: Data collection is ongoing; the target sample is 300 participants. It is anticipated that data analyses will use effect size estimates, paired sample t tests, and repeated measures linear mixed modeling in SPSS to test for differences pre- and postintervention. Descriptive analyses will summarize data and profile all variables, including internal consistency estimates. Distributional assumptions and univariate and multivariate normality of variables will be assessed. Conclusions: AFFIRM is a potentially scalable intervention. Many existing community programs provide safe spaces for SGMY but do not provide skills-based training to deal with the increasingly complex lives of youth. This pragmatic trial could make a significant contribution to the field of intervention research by simultaneously moving AFFIRM into practice and evaluating its impact. International registered report identifier (irrid): DERR1-10.2196/13462.
... Disclosure of an LGBTQ+ identity can be dangerous in an unaccepting family environment, as rejection has been linked to increased illicit substance use among LGBTQ+ Latinx young people (Ryan et al. 2009). Research has also identified elevated rates of suicide risk among Latinx sexual minority youth (Craig and McInroy 2013). ...
Article
Lesbian, gay, bisexual, transgender and queer/questioning (LGBTQ+) young people of colour are exposed to intersecting dynamics of social prejudice and discrimination related to sexuality and gender as well as race/ethnicity. In particular, Latinx-identifying LGBTQ+ young people face unique challenges in their lives, due to cultural stressors that stigmatise expansive gender and sexual identities. While it is crucial to examine the effects of multiple stressors on the well-being of LGBTQ+ young people of colour, this risk-based focus can overshadow the resilient capacities of multiply marginalised groups. Guided by an intersectional minority stress resilience framework, we asked: how do self-identified LGBTQ+ Latinx young adults manage cultural messages of prejudice and discrimination in relation to their health? Findings underscore how LGBTQ+ Latinx young adults established a strong sense of health autonomy to resist cultural stigma related to their intersecting identities. Young people actively educated themselves on health-related concerns, engaged in health-promoting tactics, and practised cultural negativity management to effectively navigate exposure to prejudice and discrimination.
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Suicide is the second leading cause of death for adolescents in the United States, yet remarkably little is known regarding risk factors for suicidal thoughts and behaviors (STBs), relatively few federal grants and scientific publications focus on STBs, and few evidence-based approaches to prevent or treat STBs are available. This “decade in review” article discusses five domains of recent empirical findings that span biological, environmental, and contextual systems and can guide future research in this high priority area: (1) the role of the central nervous system; (2) physiological risk factors, including the peripheral nervous system; (3) proximal acute stress responses; (4) novel behavioral and psychological risk factors; and (5) broader societal factors impacting diverse populations and several additional nascent areas worthy of further investigation.
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Despite increasing scholarship on sexual minority youth (SMY), little is known about the experiences and outcomes of those who identify as asexual. This study investigates how internal and external stressors, mental health, and health risk behaviours differ between asexual youth and other SMY. The study uses a sub-group analysis (n = 5,314) of an online survey of self-identified sexual and gender minority youth (SGMY). Descriptive and inferential statistics compare asexual (n = 669) to non-asexual (n = 4,645) respondents across two developmental phases—adolescence (age 14-19) and young adulthood (age 20-25)—while accounting for gender minority (e.g., transgender) self-identification. Results indicate that asexual youth had significantly higher internalised LGBTQ-phobia and tended to have poorer mental health (e.g., higher rates of depression), while having experienced less interpersonal discrimination/prejudice and having engaged in fewer health risk behaviours (e.g., substance use). Findings have implications for clinical practice. Future research should continue to investigate the impact of risk and protective factors on outcomes for asexual young people.
Article
Full-text available
Abstract Background: Lesbian, gay and bisexual (LGB) people may be at higher risk of mental disorders than heterosexual people. Method: We conducted a systematic review and meta-analysis of the prevalence of mental disorder, substance misuse, suicide, suicidal ideation and deliberate self harm in LGB people. We searched Medline, Embase, PsycInfo, Cinahl, the Cochrane Library Database, the Web of Knowledge, the Applied Social Sciences Index and Abstracts, the International Bibliography of the Social Sciences, Sociological Abstracts, the Campbell Collaboration and grey literature databases for articles published January 1966 to April 2005. We also used Google and Google Scholar and contacted authors where necessary. We searched all terms related to homosexual, lesbian and bisexual people and all terms related to mental disorders, suicide, and deliberate self harm. We included papers on population based studies which contained concurrent heterosexual comparison groups and valid definition of sexual orientation and mental health outcomes Results: Of 13706 papers identified, 476 were initially selected and 28 (25 studies) met inclusion criteria. Only one study met all our four quality criteria and seven met three of these criteria. Data was extracted on 214,344 heterosexual and 11,971 non heterosexual people. Meta-analyses revealed a two fold excess in suicide attempts in lesbian, gay and bisexual people [pooled risk ratio for lifetime risk 2.47 (CI 1.87, 3.28)]. The risk for depression and anxiety disorders (over a period of 12 months or a lifetime) on meta-analyses were at least 1.5 times higher in lesbian, gay and bisexual people (RR range 1.54-2.58) and alcohol and other substance dependence over 12 months was also 1.5 times higher (RR range 1.51-4.00). Results were similar in both sexes but meta analyses revealed that lesbian and bisexual women were particularly at risk of substance dependence (alcohol 12 months: RR 4.00, CI 2.85, 5.61; drug dependence: RR 3.50, CI 1.87, 6.53; any substance use disorder RR 3.42, CI 1.97-5.92), while lifetime prevalence of suicide attempt was especially high in gay and bisexual men (RR 4.28, CI 2.32, 7.88). Conclusions: LGB people are at higher risk of mental disorder, suicidal ideation, substance misuse, and deliberate self harm than heterosexual people.
Article
Full-text available
In this article the author reviews research evidence on the prevalence of mental disorders in lesbians, gay men, and bisexuals (LGBs) and shows, using meta-analyses, that LGBs have a higher prevalence of mental disorders than heterosexuals. The author offers a conceptual framework for understanding this excess in prevalence of disorder in terms of minority stress— explaining that stigma, prejudice, and discrimination create a hostile and stressful social environment that causes mental health problems. The model describes stress processes, including the experience of prejudice events, expectations of rejection, hiding and concealing, internalized homophobia, and ameliorative coping processes. This conceptual framework is the basis for the review of research evidence, suggestions for future research directions, and exploration of public policy implications.
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Risk and promotive effects were investigated as predictors of persistent serious delinquency in male participants of the Pittsburgh Youth Study (R. Loeber, D. P. Farrington, M. Stouthamer-Loeber, & W. B. van Kammen, 1998), living in different neighborhoods. Participants were studied over ages 13-19 years for the oldest sample and 7-13 years for the youngest sample. Risk and promotive effects were studied in 6 domains: child behavior, child attitudes, school and leisure activities, peer behaviors, family functioning, and demographics. Regression models improved when promotive effects were included with risk effects in predicting persistent serious delinquency. Disadvantaged neighborhoods, compared with better neighborhoods, had a higher prevalence of risk effects and a lower prevalence of promotive effects. However, predictive relations between risk and promotive effects and persistent serious delinquency were linear and similar across neighborhood socioeconomic status.
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This study investigated the risk factors associated with internalizing and externalizing problems among 169 gay, lesbian, and bisexual adolescents, ages 13 to 18, in northern New England, who were recruited through multiple methods. Data were gathered on individual, family, and community risk factors and youths' mental health and behavioral functioning. The youths did not differ on internalizing or externalizing problems by gender or by sexual orientation. Multivariate analyses demonstrated that risk factors unrelated to sexual orientation explained 18 percent and 19 percent of the variance in internalizing and externalizing problems, respectively. Risk factors related to sexual orientation explained an additional 4 percent of the variance in youths' internalizing problems and 1 percent in youths' externalizing problems. The results suggest that adolescent service providers should carefully assess gay, lesbian, and bisexual adolescents for concerns related and not directly related to their sexual orientation, as well as concerns specific to their identity. Even youths with positive feelings about their sexual orientation may be at risk.
Article
Context Suicide is a leading cause of death in the United States, but identifying persons at risk is difficult. Thus, the US surgeon general has made suicide prevention a national priority. An expanding body of research suggests that childhood trauma and adverse experiences can lead to a variety of negative health outcomes, including attempted suicide among adolescents and adults.Objective To examine the relationship between the risk of suicide attempts and adverse childhood experiences and the number of such experiences (adverse childhood experiences [ACE] score).Design, Setting, and Participants A retrospective cohort study of 17 337 adult health maintenance organization members (54% female; mean [SD] age, 57 [15.3] years) who attended a primary care clinic in San Diego, Calif, within a 3-year period (1995-1997) and completed a survey about childhood abuse and household dysfunction, suicide attempts (including age at first attempt), and multiple other health-related issues.Main Outcome Measure Self-reported suicide attempts, compared by number of adverse childhood experiences, including emotional, physical, and sexual abuse; household substance abuse, mental illness, and incarceration; and parental domestic violence, separation, or divorce.Results The lifetime prevalence of having at least 1 suicide attempt was 3.8%. Adverse childhood experiences in any category increased the risk of attempted suicide 2- to 5-fold. The ACE score had a strong, graded relationship to attempted suicide during childhood/adolescence and adulthood (P<.001). Compared with persons with no such experiences (prevalence of attempted suicide, 1.1%), the adjusted odds ratio of ever attempting suicide among persons with 7 or more experiences (35.2%) was 31.1 (95% confidence interval, 20.6-47.1). Adjustment for illicit drug use, depressed affect, and self-reported alcoholism reduced the strength of the relationship between the ACE score and suicide attempts, suggesting partial mediation of the adverse childhood experience–suicide attempt relationship by these factors. The population-attributable risk fractions for 1 or more experiences were 67%, 64%, and 80% for lifetime, adult, and childhood/adolescent suicide attempts, respectively.Conclusions A powerful graded relationship exists between adverse childhood experiences and risk of attempted suicide throughout the life span. Alcoholism, depressed affect, and illicit drug use, which are strongly associated with such experiences, appear to partially mediate this relationship. Because estimates of the attributable risk fraction caused by these experiences were large, prevention of these experiences and the treatment of persons affected by them may lead to progress in suicide prevention.
Article
Lesbian, gay, bisexual, transgendered, and questioning (LGBTQ) students are likely to be in every classroom in every secondary school in the United States; yet, their needs are often overlooked. LGBTQ students are at risk for developing academic, social, and emotional problems due to harassment and bullying experienced at school. Although schools have an ethical and legal duty to provide a safe educational experience for all students, few schools implement policies and programs to support LGBTQ students. School psychologists, with training in adolescent development, counseling, consultation, and systems change, are in a unique position to help schools be more responsive to the needs of LGBTQ students. By adopting a public health framework that focuses on primary, secondary, and tertiary levels of prevention and intervention for LGBTQ students, school psychologists can implement strategies and make recommendations for school-wide changes to promote positive development for all students. This article highlights challenges faced by LGBTQ students and presents methods for responding to the needs of this minority group using the public health framework.