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Suicide among gay* adolescents is a major public health concern, but it is still under-emphasized within mainstream healthcare. This article brings together information garnered from past studies, articles, and experiences to create a more in-depth understanding of why gay adolescents are at a higher risk for suicide. By creating a better understanding, this article attempts to push forward the significance of this issue and encourages physicians to take a more active role in suicide prevention. The article initially explores why issues involving homosexuality are seldom discussed and provides evidence for an increased risk in suicide among gay adolescents. By addressing major psychosocial issues faced by gay adolescents, it spends the majority of time facilitating an understanding of the increased risk.
A Familiar but Unfamiliar Case
This article explores why issues involving homosexuality are seldom discussed, provides evidence for an increased risk of suicide among gay adolescents, and attempts to facilitate an understanding of why these individuals are at such increased risk. With this understanding, a physician is more likely to adequately approach the issue of sexuality with an adolescent and ultimately play a more significant role in suicide prevention.
When considering possible reasons for patients' suicidal ideation or attempts, is their sexuality brought up? And if so, is it dismissed based on an assumption? "They are not gay because they have a girl/boyfriend."
Why is it Seldom Discussed?
There is still a stigma attached to being openly gay even in the medical field. During a small conference on gay issues at my former medical university, one of the deans referred to the medical environment as not being the most open-minded and cautioned students to be careful about revealing their sexuality. For some people, not just gays, there is the fear that if one brings up a gay issue or gives a lecture on it, one will be assumed to be gay, especially if one is not married. Unless it is my "gay paranoia," I would not be surprised if readers of this article assumed I was gay. This was a risk I was hesitant to take. Unfortunately, it is a risk that some physicians are not willing to take out of fear jeopardizing their careers. This fear hinders important gay issues from being discussed in the mainstream. Goldfried (2001) stated that despite the growing literature on gay issues, mainstream psychology has tended to ignore much of the work that has been done in this area. Thus, important issues, such as suicide among gay adolescents, remain invisible not only to mainstream psychology, but to mainstream healthcare.
During a lecture at the same university noted, a public health physician asked, "What are some risk factors for adolescent suicide?" After waiting for everyone else's response, I finally said, "homosexuality." The physician was unsure about this answer and turned to the psychiatrist who currently held a fellowship in child and adolescent psychiatry. To my surprise, he stated, "I do not think so."
An Increased Risk
How many suicides occur without learning whether the person was gay? People commit suicide leaving family and friends asking, "Why?" Could it be because of a secret they could not bear revealing--such as being gay? One study involving 350 gay adolescents between the ages of 14 and 21 reported that 54% made their first suicide attempt before coming out to others, 27% made the attempt during the same year they came out, and 19% made the attempt after coming out (D'Augelli et al., 2001).
Since being a gay adolescent is a risk factor for suicide, it needs to be addressed within the medical community. Physicians can help by raising the issue when appropriate on rounds, in case conferences, or during lectures. Addressing the issue of sexuality with adolescents can be made easier and more effective if the physician understands why it is so unbearable for some adolescents to reveal their sexuality or to live with being gay.
Understanding the Association
By noting the changes taking place in the media and the law, it is apparent that being gay is somewhat more accepted and tolerated by today's society. However, gays are still being discriminated against and victimized (Goldfried, 2001; Heimberg & Safren, 1999; Paul et al., 2002; Hart & Heimberg, 2001; DuRant et al., 1998; Russell et al., 2001; Bontempo & D'Augelli, 2002; McDaniel et al., 2001; Savin-Williams, 1994). Russell et al. (2001) reported a study involving 500 gay and lesbian adolescents in which it was found that 41% had experienced violence, and 46% of that violence was reported as being related to being gay. In a study by Bontempo and D'Augelli involving over 9,000 9th through 12th graders, 24% of gay/bisexual males reported at-school victimization ten or more times per year as compared with 2.7% of their heterosexual counterparts, and 10.1% of lesbian/bisexual females compared with 1.1% of their female counterparts (Bontempo & D'Augelli, 2002). These negative experiences can result in mood disorders, lower self-esteem, posttraumatic stress symptoms, substance abuse, and suicide (Gould et al., 2003; Paul et al., 2002; Nelson, 1997; Russell et al., 2001; Savin-Williams, 1994).
An adolescent does not need to be directly victimized to be affected by discrimination against gays. Matthew Shephard, a University of Wyoming student, was brutally murdered in 1998 because he was gay. What impact did this devastating event have on young individuals who were beginning to realize that they too were gay and living in the same society in which the murder was praised. What messages are protestors and politicians, including our President, who are against gay marriage sending to gay adolescents? How does living in a society where people can be rejected, disapproved of, or hated for their sexuality affect a gay adolescent's self-esteem or identity development? (Nelson, 1997).
Further, what may be even worse than being hated by society because of one's sexuality is being rejected, humiliated, and victimized by one's own family or peers. Gay adolescents have a much greater incidence of being thrown out of or opting to leave their homes (Nelson, 1997; Cochran et al., 2002). In a study involving 194 gay adolescents between the ages of 14 and 21, D'Augelli et al. (1998) reported that 26% of fathers, 10% of mothers, and 15% of siblings rejected their gay children when they came out. Goldfried (2001) reported that one out of every three were verbally abused by family members, one out of ten were physically assaulted by a family member, and one out of four had experienced physical abuse at school. The fear of experiencing such outcomes can be a tremendous stressor (Heimberg & Safren, 1999; Hart & Heimberg, 2001). How does a gay, closeted child feel when living with parents who adamantly reject gay marriage? Only 10 to 14% of gay adolescents who had not come out to their parents predicted parental acceptance (D'Augelli et al., 1998). How do these negative outcomes or fear of such negative outcomes also affect an adolescent's self-esteem or identity development? Nelson (1974) points out that gay adolescents who report a history of a suicide attempt score significantly lower on scales of family support, self-perception and self-esteem, and extra-familial social support when compared to similar adolescents without a reported history of suicidal ideation or suicide attempts.
Physicians can help by strengthening the support structure needed by some gay adolescents. Physicians should have information about such resources as PFLAG (Parents, Family, and Friends of Lesbians and Gays) and community gay centers so that they can refer patients and their families for assistance. National associations such as the Gay and Lesbian Medical Association, Association of Gay and Lesbian Psychiatrists, and the Lesbian and Gay Child and Adolescent Psychiatric Association have openly gay physicians who welcome referrals.
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