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Table.  
Suicide Risk Behaviors Among Sexual Minority Adolescents in the United States, 2015a
Suicide Risk Behaviors Among Sexual Minority Adolescents in the United States, 2015a
1.
Hatzenbuehler  ML.  The influence of state laws on the mental health of sexual minority youth.  JAMA Pediatr. 2017;171(4):322-324.PubMedGoogle ScholarCrossref
2.
Mueller  AS, James  W, Abrutyn  S, Levin  ML.  Suicide ideation and bullying among US adolescents: examining the intersections of sexual orientation, gender, and race/ethnicity.  Am J Public Health. 2015;105(5):980-985.PubMedGoogle ScholarCrossref
3.
Silenzio  VM, Pena  JB, Duberstein  PR, Cerel  J, Knox  KL.  Sexual orientation and risk factors for suicidal ideation and suicide attempts among adolescents and young adults.  Am J Public Health. 2007;97(11):2017-2019.PubMedGoogle ScholarCrossref
4.
Zaza  S, Kann  L, Barrios  LC.  Lesbian, gay, and bisexual adolescents: population estimate and prevalence of health behaviors.  JAMA. 2016;316(22):2355-2356.PubMedGoogle ScholarCrossref
5.
Brener  ND, Kann  L, Shanklin  S,  et al.  Methodology of the Youth Risk Behavior Surveillance System—2013.  MMWR Recomm Rep. 2013;62(RR-1):1-20.PubMedGoogle Scholar
6.
King  G, Tomz  M, Wittenberg  J.  Making the most of statistical analyses: improving interpretation and presentation.  Am J Pol Sci. 2000;44:341-355. https://web.stanford.edu/~tomz/pubs/ajps00.pdf. Accessed November 15, 2017.Google ScholarCrossref
Research Letter
December 19, 2017

Suicide Risk Behaviors Among Sexual Minority Adolescents in the United States, 2015

Author Affiliations
  • 1Wharton School, University of Pennsylvania, Philadelphia
  • 2University of California, San Diego, School of Medicine, La Jolla
  • 3Graduate School of Public Health, San Diego State University, San Diego, California
JAMA. 2017;318(23):2349-2351. doi:10.1001/jama.2017.16908

Sexual minority (lesbian, gay, bisexual, or questioning) adolescents are believed to have elevated suicide risks.1 Studies supporting this claim, however, rarely use nationally representative samples, which is a major limitation given that stigma and prevention resources vary across communities and may influence suicide risk behaviors.2 When nationally representative studies are available, they are not recent.3 Moreover, studies have ignored the diversity among sexual minorities, assuming all share the same risks.4 We estimated suicide risk behaviors of sexual minority adolescents using nationally representative data from 2015.

Methods

The 2015 National Youth Risk Behavior Survey uses a 3-stage, cluster sample of counties from all states, schools (including private schools) within counties, and classrooms within schools, yielding a nationally representative sample of high school students.5 Students responded privately on computer-scannable questionnaires (response rate = 60%). The US Centers for Disease Control and Prevention institutional review board approved the survey, requiring parental consent and student assent. Secondary analysis of these public data was exempt from further review.

To assess suicide risk behaviors, participants were asked whether, in the past year, they had (1) seriously considered suicide, (2) planned suicide, or (3) attempted suicide. Suicide risk behaviors of sexual minority adolescents, including gay or lesbian, bisexual, or not sure (hereafter referred to as questioning), relative to heterosexuals were estimated using descriptive statistics and logistic regressions including plausible and commonly used controls for sex, age, race/ethnicity, English language proficiency, and grades. Effect estimates were calculated for sexual minorities as a group, across subgroups (gay, bisexual, questioning), and across sexes (eg, gay males). Relative risks were described as risk ratios holding confounders at their mean using random draws from the logistic regression variance covariance matrix.6 Analyses were computed using the survey package for R (R Foundation), version 3.4.1, and a 2-sided α of .05.

Results

Participants (N = 15 624) reported their sexual orientation as heterosexual (overall, 88.8%; female population, 84.5%; male population, 93.1%), gay or lesbian (overall, 2.0%; female population, 2.0%; male population, 2.0%), bisexual (overall, 6.0%; female population, 9.8%; male population, 2.4%), or questioning (overall, 3.2%; female population, 3.7%; male population, 2.6%).

In the past year, seriously considering suicide was reported by 40% of sexual minority adolescents (95% CI, 36.4%-42.9%); planning suicide, 34.9% (95% CI, 31.1%-38.6%); and attempting suicide, 24.9% (95% CI, 21.5%-28.2%) compared with 14.8% of heterosexuals (95% CI, 13.7-15.9) seriously considering suicide; 11.9% (95% CI, 10.7-13.0) planning suicide; and 6.3% (95% CI, 5.5-7.2) attempting suicide (Table).

After adjusting for potential confounders, sexual minority adolescents were significantly more likely to consider, plan, or attempt suicide (risk ratio [RR]: 2.45 [95% CI, 2.12-2.81] for considering, 2.59 [95% CI, 2.18-3.04] for planning, and 3.37 [95% CI, 2.73-4.09] for attempting) than heterosexuals.

By subgroup, lesbian, gay, bisexual, and questioning adolescents were all at elevated risk for suicide relative to heterosexuals. For instance, bisexuals were more likely to consider (46.0% [95% CI, 41.5%-50.4%]; RR, 2.73 [95% CI, 2.32-3.18]), plan (40.8% [95% CI, 35.8%-45.8%]; RR, 2.85 [95% CI, 2.34-3.42]), or attempt (31.9% [95% CI, 27.7%-36.0%]; RR, 4.28 [95% CI, 3.34-5.35]) suicide than heterosexuals.

Differences persisted after stratifying by sex. Of lesbians, 40% (95% CI, 28.1%-52.2%) considered suicide vs 19.6% (95% CI, 17.7-21.6) of heterosexual females, and, of gay males, 25.5% (95% CI, 14.8%-36.1%) considered suicide vs 10.6% of heterosexual males [95% CI, 9.6%-11.7%]). Furthermore, the pattern held after controlling for confounders. For example, bisexual males (RR, 4.44 [95% CI, 2.88-6.15]) and bisexual females (RR, 2.27 [95% CI, 1.91-2.67]) were more likely to consider suicide than their heterosexual peers.

Discussion

Sexual minority adolescents were substantially more likely to report suicide risk behaviors.

This study is limited by the lack of data for suicide risks among transgender adolescents and a 60% response rate that may limit generalizability. Further study is also needed to understand the mechanisms underlying elevated suicide risk behaviors for sexual minority adolescents.

The substantial suicide risks among sexual minorities merits a comprehensive reaction. Policy makers should invest in research to understand and prevent suicide among sexual minorities. Clinicians should discuss sexual orientation with patients, and allocate appropriate mental health resources. Caretakers should watch for signs of suicide risk behaviors among sexual minority adolescents, and seek supportive help when warranted.

Section Editor: Jody W. Zylke, MD, Deputy Editor.
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Article Information

Accepted for Publication: October 11, 2017.

Corresponding Author: John W. Ayers, PhD, MA, 2967 Four Corners St, Chula Vista, CA 91914 (ayers.john.w@gmail.com).

Author Contributions: Mr Caputi had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: Caputi, Ayers.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Caputi, Ayers.

Obtained funding: Caputi, Smith.

Administrative, technical, or material support: All authors.

Supervision: All authors.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Funding/Support: This work was supported by the Joseph Wharton Scholar program and the George J. Mitchell scholarship program from the US-Ireland Alliance (both Mr Caputi) and by grant P30 AI036214 from the University of California, San Diego, Center for AIDS Research, a National Institutes of Health–funded program (Dr Smith).

Role of the Funder/Sponsor: The funder did not influence the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; nor the decision to submit the manuscript for publication.

Additional Contributions: We thank Keith Schnakenberg, MA, PhD (Washington University in St Louis), for his uncompensated statistical review.

References
1.
Hatzenbuehler  ML.  The influence of state laws on the mental health of sexual minority youth.  JAMA Pediatr. 2017;171(4):322-324.PubMedGoogle ScholarCrossref
2.
Mueller  AS, James  W, Abrutyn  S, Levin  ML.  Suicide ideation and bullying among US adolescents: examining the intersections of sexual orientation, gender, and race/ethnicity.  Am J Public Health. 2015;105(5):980-985.PubMedGoogle ScholarCrossref
3.
Silenzio  VM, Pena  JB, Duberstein  PR, Cerel  J, Knox  KL.  Sexual orientation and risk factors for suicidal ideation and suicide attempts among adolescents and young adults.  Am J Public Health. 2007;97(11):2017-2019.PubMedGoogle ScholarCrossref
4.
Zaza  S, Kann  L, Barrios  LC.  Lesbian, gay, and bisexual adolescents: population estimate and prevalence of health behaviors.  JAMA. 2016;316(22):2355-2356.PubMedGoogle ScholarCrossref
5.
Brener  ND, Kann  L, Shanklin  S,  et al.  Methodology of the Youth Risk Behavior Surveillance System—2013.  MMWR Recomm Rep. 2013;62(RR-1):1-20.PubMedGoogle Scholar
6.
King  G, Tomz  M, Wittenberg  J.  Making the most of statistical analyses: improving interpretation and presentation.  Am J Pol Sci. 2000;44:341-355. https://web.stanford.edu/~tomz/pubs/ajps00.pdf. Accessed November 15, 2017.Google ScholarCrossref
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