'Striking' Risk for Suicidality, Depression in Gay Teens

Caroline Cassels

April 07, 2011

April 7, 2011 — Gay and lesbian teens are 3 times more likely to report a history of suicidality and more than twice as likely to report symptoms of depression than their heterosexual counterparts, new research suggests.

In what is reportedly the first systematic review and analysis of suicidality and depressive symptoms in sexual minority youth (SMY), a large meta-analysis conducted by investigators at the University of Pittsburgh School of Medicine in Pennsylvania showed 28% of gay teens reported a history of suicidality compared with 12% of heterosexual teens.

Dr. Michael Marshal

"Gay youth report being 3 times more likely to have a history of suicidality than heterosexual youth, which is a striking difference. We had 18 studies and a total of 105 odds ratios (ORs) that we examined and, as a whole, 104 of 105 leaned in the direction of gay youth being at higher risk — so these results were tremendously robust," principal investigator Michael Marshal, PhD, told Medscape Medical News.

Dr. Marshal also noted that as the severity of suicidality increased the disparity between gay and straight youth also increased.

"When we're talking about suicidal ideation, the odds ratio was about 2. But as we worked our way up the suicidality scale, we found that gay youth were more than twice as likely to have suicidal plans, over 3 times more likely to have attempted suicide, and, very depressingly, more than 4 times more likely to have made a suicide attempt that required medical attention.

These results speak to the urgency of the problem and underline the fact that we need to do something about it so we can prevent gay youth from completing suicide.

"These results speak to the urgency of the problem and underline the fact that we need to do something about it so we can prevent gay youth from completing suicide," he said.

The study was published online April 4 in the Journal of Adolescent Health.

The Big Picture

Dr. Marshal undertook this research due to his empirical observation that a disproportionate number of his patients attending a youth mental health clinic specializing in the treatment of depressed and suicidal teens were gay or lesbian.

"I started to wonder what the literature said about the best ways to work with gay youth in the clinical setting and discovered there are no published studies examining intervention programs tailored to this population and I was struck by that.

"I also started to look at the disparities literature and found there were these really large effect sizes, which got me thinking that we should compile and analyze all of this literature and see what it says as a whole."

To examine disparities between SMY and heterosexual youth in rates of suicidality and depressive symptoms, the investigators analyzed data from 19 studies that included a total of 122,955 participants.

Studies were included in the analysis if they had a sample with mean age of 18 years or younger and an upper age limit of 21 years and if suicidality or depression symptoms were compared across SMY and heterosexual youth.

Even after controlling for important explanatory variables, SMY were still almost 3 times as likely to report a history of suicidality as heterosexual youth.

The results revealed that "SMY reported significantly higher rates of suicidality (OR, 2.92) and depression symptoms (standardized mean difference, d = 0.33) than did heterosexual youth.

Disparities increase as the severity of suicidality increased (ideation OR, 1.96; intent/plans OR, 2.2; suicide attempts OR, 3.18; suicide attempts requiring medical attention OR, 4.17). Effects did not vary across sex, recruitment source, and sexual orientation definition," the investigators report.

The investigators also note that "104 of the 105 odds ratios for the association between sexual orientation and suicidality were greater than 1.00 and over 25% were larger than 4.00.

"Finally," they add, "the studies showed that even after controlling for important explanatory variables, SMY were still almost 3 times as likely to report a history of suicidality as heterosexual youth."

Is Bullying a Catalyst?

Although the investigators were not able to examine the underlying reasons for this increased risk in gay teens, Dr. Marshal said there are a couple of potential hypotheses.

The first, known as the minority stress theory, postulates that gay and lesbian individuals experience much more violence, discrimination, and victimization than heterosexual teenagers, which in turn leads to increased stress and feelings of helplessness and hopelessness that can develop into depression and suicidality.

Dr. Marshal noted that on March 31 the Institute of Medicine released a report on the health of lesbian, gay, bisexual, and transgender (LGBT) individuals, which endorses the minority stress hypothesis.

We believe poor mental health outcomes are a function of teasing and bullying and discrimination that happens at all levels of our society but which starts in the playground.

There is also what he described as a "secondary hypothesis," where gay teens are socially marginalized and ostracized from mainstream social groups and, as a result, they gravitate to "fringe" social groups, where there tends to be more risky behavior, including drug and alcohol use.

"Deviant peer affiliation is one of the strongest predictors of poor health outcomes in kids, especially for substance use, but also there is this notion when you hang around depressed kids there may be a 'depression contagion,' where depressive behavior encourages depressive behavior," he said.

Interestingly, said Dr. Marshal, there is research that shows that teens who report being straight but who are perceived as gay and suffer the negative consequences of that, such as bullying, have similar mental health outcomes as self-reported gay youth.

"We believe poor mental health outcomes are a function of teasing, bullying, and discrimination that happens at all levels of our society, but which starts in the playground," he said.

Call to Action

Dr. Marshal pointed out there is a need for more research into mental health issues in LGBT youth, including preventive and intervention studies. However, he also noted, such an undertaking is associated with significant challenges.

He pointed out that research in youth that have not reached age of majority often requires parental consent and the inherent risk of being "ostracized and/or thrown out of the family home because they disclose their sexual orientation is a risk most [LGBT] kids just aren't willing to take," said Dr. Marshal.

It is important, said Dr. Marshal, that clinicians find a way to communicate to their young patients that their practice is a safe place to discuss their sexual orientation. Something as simple as posting a gay pride "rainbow" sticker in the office or clinic will get the message across.

In addition, the Gay Lesbian Straight Education Network offers a Safe Space Kit for a nominal charge to organizations that want to support LGBT youth.

"It is imperative clinicians do everything they can to ensure their office or clinic is a supportive environment where kids can talk about their sexual orientation without being outed to their parents," said Dr. Marshal.

Finally, he said, physicians need to directly ask their young patients about suicide.

There is a growing body of research indicating SMY are often the targets of peer aggressors.

"All too often this is topic that is ignored or avoided because it is hard to discuss. But when you do ask kids about it they are surprisingly open to answering the question."

Next research steps for Dr. Marshal and his team include examining factors that make LGBT youth resilient to the effects of homophobia and bullying.

Such work would help them develop intervention programs that target protective factors.

"We already have some unpublished data showing a strong positive relationship between gay youth and their parents mitigates the risk for suicide — it just wipes it out. So if we can help parents and kids establish good relationships there could be a very positive benefit," said Dr. Marshal.

'Excellent' Research

Dr. Allison Dempsey

Asked by Medscape Medical News to comment on the study, Allison Dempsey, PhD, assistant professor, educational psychology, University of Houston in Texas, said she was surprised.

Like Dr. Marshal, Dr. Dempsey said the results indicate a need for further research to explain this increased risk.

"Specifically, previous research has indicated that negative peer experiences, particularly peer victimization and bullying, increase risk for suicidal ideation and attempts. There is also a growing body of research indicating SMY are often the targets of peer aggressors.

"It will be important to determine the degree to which experiencing bullying and peer victimization accounts for the increase in depressive symptoms and suicidal ideation/attempts," Dr. Dempsey said.

Equally important, she added, is the need to identify social factors that may provide a buffer against depression and suicidality. That is, what social supports can be put into place that reduces risk for depression and suicidality among SMY?

Overall, said Dr. Dempsey, the article by Dr. Marshal and colleagues was "excellent" and took a "sophisticated approach" in examining question of depression and suicidality in this population.

Dr. Marshal and Dr. Dempsey have disclosed no relevant financial relationships.

J Adolesc Health. Published online April 4, 2011.

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