The US government's Report of the Secretary's Task Force on Youth Suicide, which appeared in 1989, sparked a controversy that continues to the present day. In his chapter on gay and lesbian youth suicide, Gibson projected that "gay youth are 2 to 3 times more likely to attempt suicide than other young people. They may comprise up to 30% of completed youth suicides annually."1 Some experts rejected the conclusions as being drawn from biased samples.2 Considerable work since then has addressed the putative association between sexual orientation and suicide.
The problem of suicide first surfaced as an incidental finding in pioneering research on homosexuality that identified a high prevalence of such attempts among young men.3 Two of the earliest studies of gay youths revealed that as many as 1 in 3 had attempted suicide.4,5 The next generation of research specifically studied suicidality and sexual orientation in convenience samples.3,6- 14 Ten such studies found consistently high rates of attempts among homosexual youths—in the range of 20% to 42%. Six of the studies involved both women and men.7,9- 11,13,14 Three found women's attempt rates to be as high as or higher than those of boys.9,13,14
Of the 10 studies, 6 explored risks for suicide by comparing attemptors and nonattemptors. They found that suicide attempts were neither universal nor attributable to homosexuality per se, but they were significantly associated with gender nonconformity,3 early awareness of homosexuality,3,8,11,14 stress,12 violence,14 lack of support,8,11,14 school drop-out,12 family problems,8 acquaintances' suicide attempts,12 homelessness,12 and substance abuse3 or other psychiatric symptoms.6,11,14
While providing valuable descriptive information, the prior studies were limited by potential sample biases, the absence of comparison groups, or both—problems recently surmounted by controlled, population-based surveys. Five of 6 such studies involved representative samples of US secondary school students15- 19 and one, a community sample of young men from Calgary, Canada.20 All found higher rates of attempted suicide among homosexual youths compared to their heterosexual peers. Surveys large enough to examine sex differences among Minnesota15 and Massachusetts students19 found a significant association between homosexuality and suicidality in males only. Suicide risk factors such as gender nonconformity may be particularly detrimental to boys.15,19
A unifying explanation for the prevalence of suicidality among homosexual youths remains to be determined, as does the extent to which attempts end in death. Two psychological autopsy studies21,22 have tried to unearth the sexual orientation of suicide victims. One found that 11% (13/119) of the young men who died from suicide in San Diego from 1981 to 1983 were known to be gay, but of the women, none were known to be lesbians.21 A second New York suicide study involved adolescent suicides from 1984 to 1986 and found that 3.2% (3/95) of male suicides and none of the living controls were found to have had homosexual experiences.22 Studies of this type can be limited in their ability to ascertain sexual behavior and orientation posthumously.
Although the understanding of gay, lesbian, and bisexual youth suicide is increasing, many questions remain regarding sex and ethnic differences, predisposing social and psychiatric conditions, protective factors, and constructive interventions. Future population-based surveys should routinely inquire about sexual orientation to retest prior findings in diverse settings. Prospective, longitudinal studies are needed to examine the evolving risk of suicide across the lifespan of homosexual persons. As we continue to assess the problem, existing data are sufficiently compelling to teach clinicians about the association between suicidality and sexual orientation and to plan preventive interventions.
Remafedi G. Sexual Orientation and Youth Suicide. JAMA. 1999;282(13):1291-1292. doi:10.1001/jama.282.13.1291-JMS1006-6-1