Suicide Risk and Prevention for

Lesbian, Gay, Bisexual, and

Transgender Youth

Suicide Prevention Resource Center

Education Development Center, Inc.
55 Chapel Street
Newton MA 02458
877-GET-SPRC (438-7772)
www.sprc.org
 Prepared by the Suicide Prevention Resource Center
for the Center for Mental Health Services
Substance Abuse and Mental Health Services Administration
U.S. Department of Health and Human Services
Supported by Grant No. 1 U79 SM57392-02

2008

Suggested citation:

Suicide Prevention Resource Center. (2008). Suicide risk and prevention for lesbian, gay, bisexual, and
transgender youth. Newton, MA: Education Development Center, Inc.

This publication is available for download: http://www.sprc.org/library/SPRC_LGBT_Youth.pdf

This publication was developed by the Suicide Prevention Resource Center (SPRC)
which is supported by the U.S. Department of Health and Human Services,
Substance Abuse and Mental Health Services Administration (SAMHSA), under
Grant No. 1 U79 SM57392-02. The opinions, conclusions, and recommendations
expressed are those of the authors and SPRC and do not necessarily reflect the
views of SAMHSA or any of the reviewers.
Acknowledgments
This paper was written by Effie Malley, Marc Posner, and Lloyd Potter with
editorial and reference assistance provided by Lori Bradshaw and additional staff
of the national Suicide Prevention Resource Center (SPRC).

Special thanks to the following people who contributed to this paper regarding the
Internet and online social networking by LGBT youth:

Vincent M. B. Silenzio, M.D., M.P.H., Assistant Professor of Family Medicine,

Psychiatry, and Community and Preventive Medicine, Center for the Study and
Prevention of Suicide, University of Rochester Medical Center

Paul R. Duberstein, Ph.D., Professor, Department of Psychiatry; Director,

Laboratory of Personality and Development; Co-Director, Center for the Study
and Prevention of Suicide, University of Rochester Medical Center

SPRC would like to acknowledge the following people for their reviews of drafts
of this publication:

Brenda Bruun, Special Assistant to the Director, Division of Prevention,

Traumatic Stress, and Special Programs, Center for Mental Health Services,
Substance Abuse and Mental Health Services Administration

Anthony R. D’Augelli, Ph.D., Professor of Human Development, Department of

Human Development and Family Studies, Pennsylvania State University

Mark A. Davis, M.A., Founding President of the Pennsylvania Mental Health

Consumers' Association and Philadelphia Pink & Blues

Nancy Davis, Ed.D., Public Health Advisor, Substance Abuse and Mental
Health Services Administration

Maria Dinger, R.N., M.S., Captain, U.S. Public Health Service, Branch Chief,
Suicide Prevention Branch, Division of Prevention, Traumatic Stress, and
Special Programs, Center for Mental Health Services, Substance Abuse and
Mental Health Services Administration

Ann P. Haas, Ph.D., Research Director, American Foundation for Suicide

Prevention

Anne Mathews-Younes, Ed.D., Director, Division of Prevention, Traumatic

Stress, and Special Programs, Center for Mental Health Services, Substance
Abuse and Mental Health Services Administration
 Lisa M. Millet, M.S.H., Program Manager, Injury and Violence Prevention
Program, State of Oregon

Jane Palmieri, School of Nursing, Linfield College

H. Jonathon Rendina, Bachelor of Philosophy, Schreyer Honors College,

Pennsylvania State University

Charles Robbins, Executive Director, The Trevor Project

Scott Salvatore, Psy.D., ABPP, Commander, U.S. Public Health Service, Senior
Program Officer, Suicide Prevention Branch, Division of Prevention, Traumatic
Stress, and Special Programs, Center for Mental Health Services, Substance
Abuse and Mental Health Services Administration

Pat Shea, M.S.W., M.A., Public Health Advisor, Center for Mental Health
Services, Substance Abuse and Mental Health Services Administration

Vincent M. B. Silenzio, M.D., M.P.H., Assistant Professor of Family Medicine,

Psychiatry, and Community and Preventive Medicine, Center for the Study and
Prevention of Suicide, University of Rochester Medical Center

We endeavored to address the issues that reviewers raised and to incorporate new
information they provided. The reviewers’ feedback and suggestions helped shape
this paper, and we are grateful for their guidance and assistance; however, they
bear no responsibility for any omissions, errors, or misjudgments.
Executive Summary
This paper highlights the higher risk of suicidal behavior among lesbian, gay, and
bisexual (LGB) youth. This higher risk may well extend to transgender (T) youth.
Additionally, the paper provides recommendations to reduce this risk by
addressing stigma and prejudice at the institutional and individual level; by
forming partnerships across youth-serving, suicide prevention, and LGBT youth
agencies; by building on recent advances in research; and by responding to the
issues of LGBT youth. To write the paper, the authors reviewed relevant up-to-
date literature and researched current services for LGBT youth. Youth, for the
purposes of this paper, is defined as between ages 15 and 24. Drafts of the paper
were reviewed by LGBT youth and experts with relevant interests.

LGB youth as a group experience more suicidal behavior than other youth. A
variety of studies indicate that LGB youth are nearly one and a half to three times
more likely to have reported suicidal ideation than non-LGB youth. Research from
several sources also revealed that LGB youth are nearly one and a half to seven
times more likely than non-LGB youth to have reported attempting suicide. These
studies do not include transgender youth.

For several reasons, little can be said with certainty about suicide deaths among
LGB people. Most mortality data do not include sexual orientation. However,
based on the higher rate of suicide attempts among LGB youth and the relative
seriousness of their suicide attempts, it is likely that LGB youth experience higher
rates of suicide deaths than their non-LGB peers. While limited information is
available on suicidal behavior among transgender youth, it is plausible to
hypothesize that transgender youth, in common with LGB youth, have elevated
risk and lower protective factors and higher rates of suicidal behavior.

Risk and protective factors help explain suicidal behavior and inform program and
practitioner approaches to reducing suicidal behavior. LGB youth generally have
more risk factors, more severe risk factors, and fewer protective factors than
heterosexual youth. For example, LGB youth often lack important protective
factors such as family support and safe schools, and more LGB young people
appear to experience depression and substance abuse. In addition, there is risk
unique to LGB youth related to the development of sexual orientation, for
example, disclosure at an early age raises risks.

It would be difficult to overstate the impact of stigma and discrimination against

LGBT individuals in the United States. Stigma and discrimination are directly tied
to risk factors for suicide. For example, discrimination has a strong association
with mental illness, and heterosexism may lead to isolation, family rejection, and
lack of access to culturally competent care.
While LGB youth are at higher risk for suicidal behavior, some groups of LGB
youth are at particular risk: those who are homeless and runaway, living in foster
care, and/or involved in the juvenile justice system. Although all youth in these
settings are vulnerable, many LGBT youth experience multiple risk factors and
have fewer supports than other youth.

Suicide prevention programs can be effective in diminishing risk factors and

especially in building protective factors, yet few target risk and protective factors
relevant to LGBT youth. Gatekeepers—those who have contact with youth and are
trained to recognize at-risk youth and refer them to services—as well as staff of
screening programs and crisis lines, need to understand LGBT risk for suicidal
behavior, know particular issues for these youth, and develop cultural
effectiveness to serve them. Gatekeepers and staff need to be aware of LGBT-
inclusive providers to use for referrals.

Other programs, whether they serve all youth or specifically LGBT youth, may not
explicitly address suicide prevention, but may reduce suicidal behavior by
strengthening protective factors, such as connecting youth with supportive adults,
and reducing risk factors, such as preventing violence and harassment.
Organizations serving LGBT youth can partner with statewide suicide prevention
groups to increase their expertise in suicide prevention and to ensure that suicide
risk among LGBT youth is addressed effectively.

Three venues for providing services to youth can make vital differences in the lives
of LGBT youth—schools, mental health and social services, and health care
services – by increasing safety and inclusion. This is accomplished not only by
having knowledgeable and culturally effective staff, but by having an environment
– including the setting, polices, and board – that supports safety and inclusion
comprehensively.

The authors assert the following recommendations to strengthen or increase

protective factors and to reduce risk factors among LGBT youth. Agencies that
serve youth – schools, health practices, suicide prevention programs, and youth
services – as well as funders, can help to reduce suicidal behavior among these
youth. The authors recommend that these agencies and individuals:

• Implement training for all staff members to effectively serve LGBT youth by
including recognition and response to warning signs for suicide and the risk
and protective factors for suicidal behavior in LGBT youth

• Include information about higher rates of suicidal behavior in LGBT youth

in health promotion materials
 • Assess and ensure that youth services and providers are inclusive,
responsive to, and affirming of the needs of LGBT youth, and refer youth to
these services and providers

• Develop peer-based support programs

• Include the topic of coping with stress and discrimination and integrate
specific activities for LGBT youth in life skills training and programs to
prevent risk behaviors

• Support staff advocacy for LGBT youth

• Incorporate program activities to support youth and their family members

throughout the development of sexual orientation and gender identity,
including awareness, identity, and disclosure. These programs must
address young children and adolescents.

• Promote organizations that support LGBT youth, such as Gay-Straight

Alliances and Parents, Families, and Friends of Lesbians & Gays (PFLAG)

• Institute protocols and policies for appropriate response if a client or

student is identified as at risk of self-harm, has made a suicide attempt, or
has died by suicide

• Make accurate information about LGBT issues and resources easily

available

• Use an LGBT cultural competence model that enables individuals and

agencies to work effectively with LGBT youth cultures

• Include LGBT youth in program development and evaluation

• Institute, enforce, and keep up to date non-discrimination and non-

harassment policies for all youth

• Implement confidentiality policies that are clear, comprehensive, and

explicit

• Assume that clients or students could be any sexual orientation or gender

identity and respond accordingly

• Address explicitly the needs of LGBT youth in school-based programs and

policies to prevent violence and bullying

Researchers and program developers, as well as funders, also play a role in

reducing suicidal behavior in LGBT youth. The authors recommend that they:
 • Use evaluation results, surveillance data, and research conclusions to
develop evidence-based programs to build protective factors and to prevent
suicide among LGBT youth

• Undertake large-scale epidemiological studies that include complex

measures of sexual orientation and gender identity and include research on
discrimination and mental illness

• Include LGBT youth in research development and evaluation

• In developing programs, emphasize protective factors for LGBT youth

• Develop research projects and funding for research on risk and protective
factors for suicidal behavior for youth generally and for LGBT youth
specifically and work with program staff to encourage getting research
results into program design

These recommendations will help not only to reduce the disparate rate of suicidal
behavior of LGBT youth but to promote the health, safety, and inclusion of LGBT
youth as visible and empowered members of our communities.
Contents
Introduction ...................................................................................................................... 11
Terminology...................................................................................................................... 12
Scope of the Problem: Suicide Deaths Among LGB Youth..................................... 13
Scope of the Problem: Suicide Attempts Among LGB Youth................................. 14
Overview of the Data on Suicide Attempts Among LGB Youth ................... 14
Limitations of the Data on Suicide Attempts Among LGB Youth .................. 16
Scope of the Problem: Suicidal Ideation Among LGB Youth ................................. 17
Overview of the Data on Suicidal Ideation Among LGB Youth ..................... 17
Limitations of the Data on Suicidal Ideation Among LGB Youth .................. 18
Conclusions About Suicidal Behavior Among LGB Youth .................................... 19
Risk and Protective Factors for Suicidal Behavior Among LGB Youth ................ 19
Social Environment .................................................................................................. 20
Family Support .......................................................................................................... 22
Internet Use ................................................................................................................ 23
AIDS/HIV Prevalence .............................................................................................. 24
Depression and Substance Abuse ......................................................................... 25
Gender Nonconformity ........................................................................................... 26
Ethnicity ...................................................................................................................... 26
Suicidal Behavior in Family and Friends ............................................................. 27
Suicidal Behavior and Transgender Youth ................................................................. 27
The Current State of Suicide Prevention for LGBT Youth ...................................... 28
Programs Serving LGBT Youth.............................................................................. 28
Youth Suicide Prevention Programs ..................................................................... 29
A Cultural Competence Approach to Preventing Suicide Among LGBT Youth 31
Suicide Prevention Programs: Other Considerations ............................................... 31
Strategic Venues for LGBT Youth Suicide Prevention ............................................ 32
Schools ........................................................................................................................ 32
Mental Health and Social Services ........................................................................ 35
Health Care Services ................................................................................................ 37
Working with LGBT Youth at Higher Risk ................................................................ 38
Homeless and Runaway Youth .............................................................................. 39
Youth in Foster Care ................................................................................................. 40
Youth in Juvenile Justice ......................................................................................... 41
Recommendations ........................................................................................................... 43
Conclusion ........................................................................................................................ 45
References ......................................................................................................................... 46
Appendix A: Resources on LGBT Issues .................................................................... 55
Appendix B: Resources on Cultural Competence ..................................................... 62
Introduction
Every year, suicide claims the lives of more than 800,000 people worldwide
(Peden, McGee, & Krug, 2002) and about 32,000 people in the United States alone.
Suicide is the third leading cause of death for people 15 to 24 years old, with more
than 4,000 youth dying by suicide each year (Centers for Disease Control and
Prevention, 2007). Many more youth consider suicide, make plans to kill
themselves, or attempt suicide.

In recent years, major national and international reports have drawn attention to
this tragedy. These reports include the World Health Organization’s Prevention of
Suicide: Guidelines for the Formulation and Implementation of National Strategies
(United Nations, 1996), The Surgeon General's Call to Action to Prevent Suicide (U.S.
Public Health Service, 1999), National Strategy for Suicide Prevention: Goals and
Objectives for Action (U.S. Department of Health and Human Services, 2001), and
the Institute of Medicine’s Reducing Suicide: A National Imperative (Goldsmith,
Pellmar, Kleinman, & Bunney, 2002).

Although all of these reports identify groups at risk for suicidal behavior, none
address in any depth issues relevant to one group generally thought to be at
higher risk for suicidal behavior: youth who are lesbian, gay, bisexual, or
transgender (LGBT). For example, National Strategy for Suicide Prevention (U.S.
Department of Health and Human Services, 2001) includes only a brief appendix
that refers to LGB youth as a special population at risk.

Fortunately, the field of suicide prevention is beginning to turn its attention to

LGBT youth. For example, the application guidelines for youth suicide prevention
programs authorized under the federal Garrett Lee Smith Memorial Act ask that
applicants address issues of sexual orientation and gender in at-risk populations.

The focus of this paper is on what is known about suicidal behavior among LGBT
youth. As defined in National Strategy for Suicide Prevention, suicidal behavior
includes suicidal thinking, suicide attempts, and completed suicides (U.S.
Department of Health and Human Services, 2001). For the purposes of this paper,
the term youth is roughly defined as people age 15 through 24. In developing this
paper, the authors reviewed the relevant literature published from 1996 through
2007, spoke with individuals in suicide prevention and mental health promotion
programs, and researched services for LGBT youth. After summarizing research
findings about the higher risk of suicidal behavior for LGBT youth, the paper
explores risk and protective factors for this group and provides recommendations
to the field that we hope will reduce suicidal behavior among LGBT youth.

11
Drafts of this paper were reviewed by LGBT youth and experts in sexual and
gender minority issues, suicide, and suicide prevention.

Terminology
The terms lesbian, gay, bisexual, and transgender are often used with minimal
consideration of the complexities of sexuality and gender. How and why sexual
orientation—affection and/or sexual attraction towards males, females, or both—
develops and changes over time remains the subject of both research and debate.
The relationships among sexual orientation, gender identity (whether a person
identifies as male or female), and gender conformity (whether a person displays
the emotional and behavioral characteristics culturally associated with a particular
gender) are extremely complex.

The term transgender refers to persons whose gender identity and/or expression is
inconsistent with cultural norms about their biological sex. Transgender is not a
sexual orientation; however, transgender people are sometimes included in
research on LGB people. Occasionally included in research are young people
identified as questioning—that is, those who are in the process of exploring the
nature of their sexual orientation or gender identity. Questioning often occurs
during adolescence, the developmental stage when many young people struggle
with issues of sexuality, gender, and identity. This struggle can be especially
difficult and prolonged for people exploring LGBT sexual orientations and gender
identities.

The somewhat ambiguous nature of these definitions and perhaps of human

sexuality in general complicates research about health problems associated with
sexual orientation and gender identity. For the most part, this paper will use the
terms lesbian, gay, bisexual, and transgender in their everyday sense. While the
authors acknowledge that these terms cannot reflect individuality, and sexuality
and gender may be more fluid than research can accommodate, this paper does
not attempt to reconcile these issues. However, it is important to remember the
diversity that exists within sexual orientations and gender identities. Additionally,
the underlying cultural conceptions of sexual and gender identity, not just the
terms used to describe these identities, change over time.

This paper uses the common abbreviation LGBT to refer to lesbian, gay, bisexual,
and transgender people. In discussing the research, the paper defers to each
study’s definitions and reports the results accordingly. For example, if the research
includes only lesbian, gay, and bisexual youth, we will use the abbreviation LGB,
not LGBT.

12
Scope of the Problem: Suicide Deaths Among LGB Youth
Suicide is the eleventh leading cause of death overall in the United States, and the
third leading cause of death for youth age 15 through 24, following unintentional
injuries and homicide. However, data on suicide rates—the number of suicide
deaths per 100,000 of population—reveal that the rate for this age group is 10 per
100,000, below the national rate of 11.01 per 100,000 for people of all ages (Centers
for Disease Control and Prevention, 2007).

Little can be said with any certainty about the extent of suicide deaths among LGB
youth. Sexual orientation is not usually included in a cause of death report or on a
death certificate. Even if information on sexual orientation was included in a police
or a medical examiner’s report, the National Vital Statistics System that aggregates
these reports at the state and national levels does not include this information. This
is a significant omission: the National Vital Statistics System is a primary source of
data for public health researchers studying any cause of mortality, including
suicide.

Newspaper obituaries rarely make reference to the sexual orientation of the

deceased or to the cause of death when suicide is involved. Families and friends
may not know—or be willing to discuss—the sexual orientation of a person who
died, especially by his or her own hand (Lebson, 2002).

Although hard data on suicide rates for young LGB people are lacking, research
has established that the most reliable indicators of suicide risk are suicidal ideation
and prior suicide attempts (American Psychiatric Association, 2003; Beautrais,
2001; Beautrais, 2004; Borges et al., 2006; Gibb, Beautrais, & Fergusson, 2005).

Citation of Scientifically Questionable Statements

A report on suicide among gay and lesbian youth provides a powerful illustration
of how statements derived from very limited hard data can acquire the aura of
fact. In 1989 the U.S. Department of Health and Human Services published Report
of the Secretary’s Task Force on Youth Suicide. The section “Gay and Lesbian Youth
Suicide” includes two often-quoted statements:
• Homosexual youth may represent up to 30 percent of youth suicide
deaths.
• Suicide is the leading cause of death for LGBT youth.

Ryan and Futterman (1998) have pointed out criticisms that these statements were
based on a review by Paul Gibson (1989) of non-random studies and agency
reports on diverse lesbian and gay populations. Unfortunately, the statements
have often been quoted as factual even though the scientific grounding behind
them is questionable.

13
Scope of the Problem: Suicide Attempts Among LGB Youth
A suicide attempt is a “potentially self-injurious behavior with a nonfatal outcome,
for which there is evidence that the person intended to kill himself or herself” (U.S.
Department of Health and Human Services, 2001, p.203). One of the strongest
predictors of suicide is one or more prior suicide attempts. Data from the National
Comorbidity Survey of people 15 through 54 years of age show a lifetime suicide
attempt rate of 4.6 percent (Kessler, Borges, & Walters, 1999)—that is, nearly one in
twenty people reported having attempted suicide at some point in their lives. The
Youth Risk Behavior Survey (YRBS) results from October 2004 to January 2006
indicated that 8.4 percent of all students in grades 9 through 12 reported having
attempted suicide at least once in the 12 months before the survey (Eaton et al.,
2006).

Overview of the Data on Suicide Attempts Among LGB Youth

Studies that compare the rate of suicide attempts among LGB youth with those
among heterosexual youth show significantly higher rates for LGB youth:

• Remafedi and colleagues (Remafedi, French, Story, Resnick, & Blum, 1998)
found that 28.1 percent of gay or bisexual males in grades 7 through 12 had
attempted suicide at least once during their lives, while only 4.2 percent of
heterosexual males in those grades had attempted suicide. The
corresponding percentages for females were 20.5 percent for lesbian or
bisexual females and 14.5 percent for heterosexual females.

• The Massachusetts Youth Risk Behavior Survey reported that LGB high
school students in Massachusetts were more than four times as likely as the
state’s non-LGB students to have attempted suicide in the last year
(Massachusetts Department of Education, 2006b).

• Safren and Heimberg (1999) reported that 30 percent of LGB youth versus
13 percent of heterosexual youth (mean age of about 18) had attempted
suicide at some point.

• Garofalo and colleagues (1999) found that high school students identifying
as either LGB or not sure of their sexual orientation were 3.4 times as likely
to have attempted suicide within the last 12 months as their heterosexual
peers.

• D’Augelli and Hershberger (1995) found that LGB youth were three times
as likely to have attempted suicide as heterosexual youth.

14
 • Russell and Joyner (2001) found that the risk of attempting suicide was
twice as high among LGB youth as among heterosexual youth.

• Eisenberg and Resnick (2006) found that LGB students in grades 9 and 12
were significantly more likely to have attempted suicide than their
heterosexual peers. 52.4 percent of LB females and 29.0 percent of GB males
had attempted suicide. The percentages of non-GLB females and males who
had attempted suicide were 24.8 and 12.6 percent respectively.

• A study in New Zealand found that 32.1 percent of LGB youth through age
21 had attempted suicide, whereas only 7.1 percent of same-age
heterosexual youth had made such an attempt (Fergusson, Horwood, &
Beautrais, 1999).

Several other studies reported dramatic suicide attempt rates among young LGB
people, but these studies do not include comparison groups. In such cases, it is
useful to compare the data with a range: population studies suggest that a range of
4 to 8 percent of all young people have attempted suicide by age 20 (Beautrais,
2003). In contrast, non-comparison studies of LGB youth found that the following
percentages of lesbian, gay, and/or bisexual youth had attempted suicide at some
point over the life course:

• 40.3 percent of LGB people up to age 21 (Proctor & Groze, 1994)

• 37 percent of LGB youth ages 14 to 21 (D’Augelli, 2002)

• 33 percent of GB males ages 15 to 25 (Remafedi, 2002)

• 30 percent of GB males ages 14 to 21 (Remafedi, Farrow, & Deisher, 1991)

The majority of literature reviews on LGB suicide attempts conclude that LGB
youth have a significantly higher rate of attempting suicide than heterosexual
youth. Furthermore, most suicide attempts among LGB people occur during
adolescence and young adulthood (Kulkin, Chauvin, & Percle, 2000; Proctor &
Groze, 1994; Remafedi et al., 1991). (The same holds true for people of all sexual
orientations; national hospital data show self-harm rates are highest for youth age
15 through 19 years old (Centers for Disease Control and Prevention, 2007)).

Some researchers have compared the seriousness of suicide attempts by LGB and
heterosexual youth by asking people about their intent to end their lives. Safren &
Heimberg (1999) found that 58 percent of LGB people who had attempted suicide
reported that they had really hoped to die. In contrast, only 33 percent of
heterosexuals who had attempted suicide reported that they had really hoped to
die. Another measure of seriousness is the lethality of the means used to attempt
suicide. For example, people who use firearms in a suicide attempt have a higher

15
rate of suicide deaths than people who use other means, simply because firearms
are more lethal than other means (Brent et al., 1991; Conwell et al., 2002; Brent &
Bridge, 2003; Shenassa, Catlin, & Buka, 2003; Miller, Azrael, Hepburn, Hemenway,
& Lippman, 2006). Remafedi and colleagues (1991) found in interviews with GB
males 14 through 21 years of age that 54 percent of suicide attempts in this group
could be classified as moderately to highly lethal. The study also reported that one
fifth of LGB youth who attempted suicide needed hospitalization, and three-fifths
were least or moderately rescuable (a measure of the seriousness of the attempt).

It is important to note that all suicide attempts should be taken seriously by those
responsible for the care of young people, including parents, school staff, and
health care providers.

Limitations of the Data on Suicide Attempts Among LGB Youth

The data on suicide attempts have limitations. Medical records seldom include
information on the sexual orientation of a patient, and often lack data on the cause,
much less the intent, of the injury. Many people who attempt suicide do not
receive medical or other health services. Much of the research on suicide attempts
depends on surveys in which people self-report both suicidal behavior and sexual
orientation. Given the stigma - widespread social disapproval and negative
attitudes - associated with both homosexuality and suicide, research participants
may be reluctant to answer questions about these issues honestly, even in a
confidential or anonymous survey.

Many studies on suicide among LGB young people ask participants to self-identify
as lesbian, gay, or bisexual. Some researchers add the category “questioning” (or,
less frequently, “not sure”) to describe adolescents who are still coming to terms
with their sexual identity (see, for example, Garofalo, Wolf, Wissow, Woods, &
Goodman, 1999; Medeiros, Seehaus, Elliott, & Melaney, 2004; Morrison &
L’Heureux, 2001; Savin-Williams & Ream, 2003). Asking participants to self-
identify in a survey assumes that they define their sexual orientation by one of the
categories offered by the survey and that these categories are meaningful in terms
of the range of sexual behavior, identity, and expression among young people.
Some researchers try to avoid these definitional questions by asking survey
respondents about their sexual behavior rather than their sexual orientation (see,
for example, Bontempo & D’Augelli, 2002; Botnick et al., 2002; Cochran & Mays,
2000b; DuRant, Krowchuk, & Sinal, 1998; Remafedi, 2002). Surveys using this
methodology might, for example, ask men if they have had sex with men in the
past year and ask women if they have had sex with women in the past year. This
approach assumes that sexual behavior is consistent with sexual identity and that
the respondents are sexually active.

16
Although many researchers postulate that studies underestimate the rate of
suicide attempts among young LGB people because of their low self-reporting of
both sexual orientation and suicidal behavior, some researchers speculate that self-
reports of these variables may inflate the reported rate of suicide attempts among
LGB youth. Cochran and Mays (2000b) suggest that LGB people willing to disclose
their sexual orientation in research studies may also be more willing to admit to
other socially stigmatized attributes—suicide attempts or mental health
problems—than LGB people who are reluctant to disclose their sexual orientation.
Savin-Williams (2001) contends that much of the discrepancy between the suicide
rates of LGB youth and their heterosexual peers can be attributed to the fact that
LGB youth tend to exaggerate the seriousness of their suicide attempts, “to
communicate the hardships of [their] lives or to identify with a gay community.”

Despite these limitations, the data on suicide attempts can be extremely useful in
investigating suicide risk. For further insight into this risk, researchers and
practitioners commonly turn to the third area of suicidal behavior, suicidal
thinking.

Scope of the Problem: Suicidal Ideation Among LGB Youth

Suicidal ideation has been defined as “self-reported thoughts of engaging in
suicide-related behavior” (U.S. Department of Health and Human Services, 2001,
Appendix E, Glossary). Ideation can range in severity from passing thoughts about
suicide to a detailed plan for attempting suicide. Suicidal ideation is often used as
an indicator of suicide risk in studies, based on the fact that many people who
seriously consider suicide go on to attempt or die by suicide. Suicidal ideation is
more widespread than either attempts or suicides, and its recognition can provide
an opportunity to intervene before more serious suicidal behavior develops.

Although not all youth with suicidal ideation go on to attempt or die by suicide,
ideation is disruptive to the individual and a matter for serious concern. Youth
considering suicide need emergency or outpatient mental health services or other
support (Gary Diamond, personal communication, November 21, 2007).

Overview of the Data on Suicidal Ideation Among LGB Youth

The National Comorbidity Survey reported that 13.5 percent of the U.S. population
(all gender identities and sexual orientations) ages 15 through 54 responded “yes”
to the question “Have you seriously thought about committing suicide?” (Kessler
et al., 1999). For youth, suicidal ideation is relatively common: the Youth Risk
Behavior Survey found that 16.9 percent of all students in grades 9 through 12
reported that they had “seriously considered attempting suicide” in the 12 months

17
before the survey was given (Eaton et al., 2006). Although this represents a
minority of youth, one in nearly six youth facing this risk is a significant share.

Research results generally confirm that LGB youth have much higher levels of
suicidal ideation than their heterosexual peers:

• Cochran and Mays (2000a) found that 41.2 percent of gay men ages 17 to 39
reported suicidal ideation, compared to only 17.2 percent of heterosexual
men of similar ages.

• The Massachusetts Youth Risk Behavior Survey reported that youth who
self-identified as gay, lesbian, or bisexual or who reported any same-sex
sexual contact were more than three times as likely as their heterosexual
peers to have seriously considered suicide in the last year (34 percent
compared to 11 percent) (Massachusetts Department of Education, 2006b).

• Eisenberg and Resnick (2006) found that 47.3 percent of GB adolescent boys
and 72.9 percent of LB adolescent girls reported suicidal ideation, compared
with 34.7 percent of non-GB adolescent boys and 53 percent of non-LB
adolescent girls.

• Remafedi et al. (1998) reported that 31.2 percent of GB male high school
students and 36.4 percent of LB female students reported suicidal ideation.
The proportions for heterosexual students were 20.1 percent and 34.3
percent respectively.

Comparable outcomes have been reported in international studies:

• A study of LGB people in New Zealand through age 21 found that 67.9
percent reported suicidal ideation, compared to 28 percent of similarly aged
heterosexuals (Fergusson et al., 1999).

• A study in Belgium found that suicidal ideation among LGB youth was
double that of heterosexual youth (van Heeringen & Vincke, 2000).

Limitations of the Data on Suicidal Ideation Among LGB Youth

Data on the prevalence of suicidal ideation are based on surveys in which

participants self-report. Thus, data on suicidal ideation among LGBT youth are
subject to many of the same limitations that apply to surveys on the frequency of
suicide attempts, including the following:

• respondent reluctance to admit suicidal thinking

• respondent reluctance to disclose sexual orientation or gender identity

18
 • possible respondent exaggeration of suicidal ideation

• difficulty in ascertaining the seriousness of suicidal thinking

• differences in definitions of sexual orientation

Differences in the results of these surveys may result from methodological issues
including the age of the sample, how respondents are recruited, and how ideation
is defined. It is also difficult to distinguish suicidal thoughts that put people at risk
of suicide or a suicide attempt from thoughts that do not.

Conclusions About Suicidal Behavior Among LGB Youth

Research indicates that LGB youth have significantly higher rates of suicide
attempts and suicidal ideation than their heterosexual peers. Data limitations make
it difficult to draw conclusions about higher rates of death by suicide among LGB
youth; however, the higher number of suicide attempts, as well as the seriousness
of attempts among LGB youth, make it probable that this group of youth has a
higher rate of suicide deaths than their heterosexual counterparts.

Risk and Protective Factors for Suicidal Behavior Among

LGB Youth
Risk and protective factors help explain suicidal behavior—including suicidal
ideation, suicide attempts, and suicide deaths. According to National Strategy for
Suicide Prevention, risk factors “make it more likely that individuals will develop a
disorder; risk factors may encompass biological, psychological or social factors in
the individual, family and environment” (U.S. Department of Health and Human
Services, 2001, p. 202). Risk factors include mental disorders, a lack of social
support, a sense of isolation, stigma associated with seeking help, loss of a
relationship, and access to firearms and other lethal means, along with many other
factors. Protective factors, such as access to effective care, restricted access to lethal
means, community support, coping skills, and strong family connections, make it
less likely that individuals will consider or attempt suicide (U.S. Department of
Health and Human Services, 2001).

Risk factors affect the likelihood of suicidal behavior in ways both dynamic and
synergistic—that is, a factor’s significance can change for an individual over time,
and the effect of a single factor is increased when an individual has additional risk
factors. Berman et al. (2006) grouped risk factors into themes such as mental
illness, negative personality attributes (such as aggression and impulsivity),
negative personal history (including previous self-harm and parental mental
illness), isolation and alienation, and availability of a method. Beautrais (2003)

19
reviewed the literature on risk factors for suicidal behavior in youth. She identified
a complex interplay of factors including adverse events (such as family discord,
abuse, and neglect), stresses (relationship losses or conflicts and legal or
disciplinary crises), personality traits (such as low self-esteem, impulsivity, and
hopelessness), and mental health problems. She found that youth who
demonstrated suicidal behavior may have had not only more stresses but also
more severe stresses and that a majority of youth attempting suicide has some
form of mental disorder at the time of the attempt (Beautrais, 2003).

The risk factors that apply to youth overall also apply to LGB youth. Kitts’s review
of the research literature (2005) confirms this. Kitts concludes that the elevated risk
of suicide attempts among LGB adolescents is a consequence of the psychosocial
stressors associated with being lesbian, gay, or bisexual, including gender
nonconformity, victimization, lack of support, dropping out of school, family
problems, suicide attempts by acquaintances, homelessness, substance abuse, and
psychiatric disorders. While heterosexual adolescents also experience these
stressors, they are more prevalent among LGB adolescents (Kitts, 2005).

In addition, stresses related to the awareness, discovery, and disclosure of being

gay—which researchers refer to as “gay-related stress”—are unique risk factors for
LGB youth (Bontempo & D’Augelli, 2002). Research indicates that LGB youth are
more at risk for suicide attempts if they acknowledge their sexual orientation at an
early age (Remafedi et al., 1991). Remafedi and his colleagues speculate that
“compared with older persons, early and middle adolescents may be generally less
able to cope with the isolation and stigma of a homosexual identity” (p. 874).

Social Environment

Although the social environment itself has not been defined as a risk factor for
suicide, widespread discrimination against LGBT people, heterosexist attitudes,
and gender bias can lead to risk factors such as isolation, family rejection, and lack
of access to care providers. Risk factors may interact in unhealthy ways—for
example, internalized homophobia or victimization may lead to stress, which is
associated with depression and substance abuse, which can contribute to suicide
risk. This risk may be compounded by a lack of protective factors that normally
provide resilience, such as strong family connections, peer support, and access to
effective health and mental health providers.

In the United States prejudice and discrimination against LGB people are
widespread among individuals, and in fact, supported by many religious, social,
and government institutions. Homophobia and heterosexism are terms that refer
to prejudice against LGB people and reflect prevalent social attitudes that most
people have internalized (McDaniel et al., 2001).

20
Morrow (2004) points out that “GLBT adolescents must cope with developing a
sexual minority identity in the midst of negative comments, jokes, and often the
threat of violence because of their sexual orientation and/or transgender identity”
(p. 91-92) and that, given the pervasive homophobia in our culture and in the
families of LGBT youth, “the internalization of homophobic and heterosexist
messages begins very early—often before GLBT youth fully realize their sexual
orientation and gender identity” (p. 92). Morrow also says that positive role
models for LGBT youth are hard to find.

Herek and colleagues (2007) describe a framework to understand the social

environment for sexual minorities. The framework integrates the sociological idea
of stigma with the psychological idea of prejudice. Through stigma, society
discredits and invalidates homosexuality relative to heterosexuality. Institutions
embodying stigma results in heterosexism, and heterosexual individuals
internalizing stigma results in prejudice. The United States legal system has faced
challenges by sexual minorities and sympathetic heterosexuals that have led to
significant changes. However, the legal system continues to reinforce stigma
through discriminatory laws and the absence of laws protecting sexual minorities
from discrimination in employment, housing, and services. A minority of states
had antidiscrimination laws as of 2005, and most of these only referred to
employment and not to housing or services. Most religious denominations
continue to condemn homosexuality as sinful and provide a rationale for
marginalizing LGB people.

Researchers suggest that this social environment puts stresses on LGBT people that
elevate the risk of substance abuse, depression, anxiety, and other emotional
problems. One study (with participants in their mid-twenties) found that
internalized homophobia was correlated with depression, although not directly
correlated with suicide (Igartua et al., 2003). Mays and Cochran (2001) found
growing evidence that experiences of discrimination can result in mental health
and general health disorders. Analyzing data from the National Survey of Midlife
Development in the United States (MIDUS), they compared LGB and heterosexual
people’s mental health and experiences with discrimination. The MIDUS asked
about the frequency of lifetime and day-to-day experiences of perceived
discrimination including being denied a scholarship, being denied a bank loan,
receiving poorer services at stores, and being called names. Mays and Cochran
found that homosexual and bisexual individuals reported more frequently than
heterosexual individuals both day-to-day and lifetime discrimination, and 42
percent attributed the discrimination at least in part to their sexual orientation.
LGB individuals were twice as likely as heterosexuals to have experienced
discrimination in a lifetime event and were five times more likely to indicate that
discrimination had interfered with having a full and productive life. Perceived
discrimination had a relatively robust association with mental disorders.

21
Meyer (2003) describes a social environment that is hostile and stressful for LGB
people. His review of research demonstrates that social stressors are significantly
associated with mental disorders and supports a model of minority stress that
theorizes the higher prevalence of mood, anxiety, and substance use disorders
among LGB people as “caused by excess in social stressors related to stigma and
prejudice” (p. 691). Another study relates minority stressors to suicidal behavior: a
study of gay men (with an average age of 38) found that three stressors—
internalized homophobia, stigma (related to expectations of rejection and
discrimination), and experiences of discrimination—were significantly associated
with five outcomes indicating psychological distress, including suicidal ideation
and behavior (Meyer, 1995).

Other studies find that internalized homophobia and conflict about sexual
orientation appear to contribute to suicide risk among LGB youth. One study
reported that LGB youth are at higher risk of suicide if they report high levels of
internal conflict about their sexual orientation (Savin-Williams, 1990). Another
study of gay men (with a median age in the twenties) found that internalized
homophobia was associated with depression and anxiety, which increased suicide
risk (Igartua, Gill, & Montoro, 2003). A third study indicated that positive role
models and high self-esteem are protective factors against suicide in young gay
men (Fenaughty & Harre, 2003).

A Research Agenda

Research on discrimination and sexual minority social stress (see Mays and Cochran, 2001;
Meyer, 2003; Meyer, 2007) suggest the need for large-scale epidemiological studies that
focus on discrimination and social stressors and negative mental health outcomes in the
LGB population. Meyer (2003) suggests that this research must use random sampling,
sophisticated measures of sexual orientation, a large number of respondents, and
hypotheses related to prevalence of disorders and their causes and the process through
which stressors work.

Family Support

Aspects of family dynamics—such as lack of support, conflict, and rejection as well

as connectedness —play an important role in suicide risk for LGB youth. Abuse
within the family (whether psychological, verbal, physical, or sexual) elevates the
risk of suicidal behavior by LGB young people (Gibson & Saunders, 1994; McBee-
Strayer & Rogers, 2002). Forty percent of the callers to the Trevor Helpline for
LGBTQ youth reported that they had difficulty with their families because of their

22
sexual orientation (Charles Robbins, personal communication, April 9, 2008).
Family conflict is also a contributing factor to homelessness of LGBT youth,
discussed below.

Family support plays an important role for LGB youth during the period in which
they identify and “come out,” or disclose their sexual orientation to their families.
LGB youth experience a rise in suicide attempts and ideation around the time of
disclosure (D’Augelli & Hershberger, 1993; Igartua et al., 2003; Remafedi et al.,
1991). D’Augelli, Hershberger, & Pilkington (1998) found that LGB youth who had
disclosed to their families were more than four times as likely to have attempted
suicide as LGB youth who had not disclosed. Researchers speculate that this is
related to the stress caused by coming out and fear of—or actual—rejection by
members of their families. A substantial proportion of youth who disclose an LGB
sexual orientation to their families are assaulted by members of their family, while
many others are threatened or verbally and emotionally abused (D'Augelli et al.,
1998).

Research findings generally agree that family and parental support are important
protective factors against adolescent suicide for LGB youth (Kidd et al., 2006;
Proctor & Groze, 1994). Eisenberg and Resnick (2006) measured protective
factors—specifically, family connectedness, other adult caring, and school safety—
based on youth self-reports. They found that lower levels of these protective
factors in LGB youth account for much of the increased risk of suicidal ideation
and attempts. In particular, family connectedness plays a vital role for LGB youth:
those with strong family connectedness are half as likely to experience suicidal
ideation as those with low family connectedness. They concluded:

Family connectedness, support from other adults, and school safety are all
characteristics that are amenable to change, and would be appropriate
targets for interventions aimed at protecting young people from self-harm.
Improving the ability of parents and other influential adults to connect with
and support adolescents grappling with issues of sexual identity may be a
critical component of mental health promotion and protection for these
young people (p. 667).

Internet Use

Use of the Internet by young people has grown astronomically in recent years, and
concerns about the potential benefits and harm of this technology have been
raised. More than half of all online American youth ages 12 to 17 use an online
social networking site (Lenhart & Madden, 2007). Public attention has focused on
social networking sites for potential unwanted sexual solicitation and harassment
of youth; however, the majority of youth who are online are not victimized, and

23
online victimization seems to occur less frequently on social networking sites than
in other Internet applications such as instant messaging. (Ybarra & Mitchell, 2008).
About half of teens use social networking sites at least once a day. Nine-tenths use
the sites to stay in touch with friends they see frequently, while half use the sites to
make new friends (Lenhart & Madden, 2007).

Internet use by youth also raises questions about targeted messages to influence
suicidal behavior. Sites that promote suicide and describe specifics of methods, as
well as chat rooms that may facilitate suicide pacts, exist in cyberspace alongside
health- promoting and suicide prevention sites. The influence of the Internet on
suicidal behavior is not well understood (Biddle et al., 2008) although the influence
of other media reporting of suicides – particularly specific content about methods
– has been shown to raise the risk of suicide clusters or contagion (Biddle et al.,
2008; Gould, Petrie, Kleinman, & Wallenstein, 1994; Gould, Wallenstein, &
Davidson, 1989; Gould, Wallenstein, Kleinman, 1990; Gould, Wallenstein,
Kleinman, O’Carroll, & Mercy, 1990; Gould, 2001; Gould, Jamieson, & Romer,
2003).

LGBT youth rely on the Internet and related technologies to a greater degree than
their peers in order to find an accepting peer group and social support (Hillier,
Kurdas, & Horsley, 2001; McFarlane et al., 2002; Brown, Maycock, & Burns, 2005).
This reliance has been attributed to the relative social isolation of these youth, the
privacy that these media are perceived to provide, and the ready access to a
supportive environment (Hillier et al.). Social networking sites such as MySpace
and Facebook have been rapidly embraced by adolescents and young adults and
particularly by young LGBT individuals (Hillier et al.; Koblin, 2006; Egan, 2000).
Virtual and online spaces are seen as sites where youth can explore their identities
and interact with others (Maczewski, 2002).

Not enough is known yet about the potential protection or risks posed by online
social networking among LGBT youth. Online contacts may decrease isolation and
build positive relationships. Such networks offer the potential to disseminate
suicide prevention or other targeted health messages to audiences of LGBT
individuals. Further research is needed on how social networking and other
Internet applications can raise—or lower—risks of suicide among LGBT and other
adolescents.

AIDS/HIV Prevalence

Little research exists on the relationship of HIV and AIDS status to suicide. Most
research on the topic does not target LGB people per se, although studies of
HIV/AIDS and suicide tend to include a substantial portion of gay men. Some
research indicates that being infected with HIV or having AIDS may elevate the

24
risk of suicide. A study of Swiss homosexual and bisexual males found that a
sample of HIV seropositive gay men (all ages) had significantly higher suicide risk
than did the HIV seronegative sample (Cochand & Bovet, 1998). A study of a very
small sample of HIV seropositive gay men in New York City found that 17 percent
either had made plans or had given serious consideration to ending their own lives
because of their HIV status (Goggin et al., 2000). A study of HIV seropositive men
in Texas over the age of 18 (80 percent of whom identified as gay) revealed that 59
percent had thought about suicide and 30 percent had attempted it (Shelton et al.,
2006). A study of HIV seropositive men and women in North Carolina (64 percent
were gay) found that two thirds had exhibited suicidal ideation at some point
since their diagnosis and one-third were currently exhibiting ideation. Half of the
individuals in the sample had made suicide plans and one quarter had attempted
suicide (Robertson, Parsons, Ven Der Horst, & Hall, 2006). A study of primarily
ethnic minority women in New York City (all ages and sexual orientations) found
those who were HIV seropositive were significantly more likely to have
experienced suicide attempts or ideation (Cooperman & Simoni, 2005).

HIV seropositive status has also been found to be associated with elevated rates of
depression, a risk factor for suicide, among gay men (Hedge & Sherr, 1995) as well
as among men and women of all sexual orientations (Williams et al., 2005).

At least one review of the literature on HIV/AIDS and suicide points out that this
research is compromised by the fact that many of the participants in these studies
are GB men and people who have abused substances—two groups at elevated risk
for suicidal behavior (Komiti et al., 2001). The research on the relationship of
HIV/AIDS and suicide is also complicated by the fact that people with HIV/AIDS
who attempt suicide tend to have additional risk factors that can confound the
relationship between HIV/AIDS and suicide (including younger age, a family
history of suicidal behavior, and depression) (Roy, 2003).

Depression and Substance Abuse

Although the majority of young people who are clinically depressed or who abuse
alcohol or other drugs do not attempt or die by suicide, both depression and
substance abuse are risk factors for suicide among people of all ages, sexual
orientations, and gender identities. Among LGB youth, suicide and suicidal
ideation are associated with depression (Proctor & Groze, 1994; Russell & Joyner,
2001; Savin-Williams & Ream, 2003; van Heeringen & Vincke, 2000) and with
substance abuse (Remafedi et al., 1991; Russell & Joyner, 2001; Savin-Williams &
Ream, 2003). LGB young people have an elevated risk for both depression (Gilman
et al., 2001; Russell & Joyner, 2001; Safren & Heimberg, 1999) and substance abuse
(Bagley & Tremblay, 2000; DuRant et al., 1998; Garofalo et al., 1999; Gilman et al.,
2001; Russell & Joyner, 2001). Safren and Heimberg (1999) found that when

25
substance abuse, depression, and related psychosocial factors are taken into
account, the difference in suicide rates between LGB and heterosexual people is
greatly reduced.

Recent research from Silenzio and others found that some risk factors for suicidal
ideation and attempts differed for LGB and non-LGB youth responding to the
National Longitudinal Study of Adolescent Health. Consistent with earlier
findings, LGB youth had higher rates of suicidal ideation and attempts than non-
LGB youth. There was a surprising finding, however: drug use was not associated
with increased risk of ideation for LGB respondents, and problem drinking, drug
use, and depression were not associated with increased risk of suicide attempts for
LGB respondents. The authors call for further research on other mediating risk and
protective factors for LGB youth (Silenzio et al., 2007).

Gender Nonconformity

Fitzpatrick, Euton, Jones, and Schmidt (2005) conclude that cross-gender role
(often called gender nonconformity)—that is, “personality traits associated with
the opposite sex”(p. 35)—accounts for almost all of the variation in suicidal
behavior between heterosexuals and LGB people. An earlier study identified that
gender nonconformity in gay and bisexual males was predictive of self harm
(Remafedi et al., 1991). Some research—for example, the review of the literature in
Lippa (2000)—indicates that gender nonconformity is more prevalent among
LGBT people than among heterosexuals. Although research on the issue is lacking,
the social disapproval of gender nonconformity 1 might result from its association
(whether real or perceived) with an LGB sexual orientation.

Ethnicity

Research indicates that some ethnic and cultural groups (such as first-generation
immigrants from Latin America) are less accepting of children who do not
conform to standard gender roles than are families that have been in the United
States for several generations (Ryan, 2004). Other researchers maintain that the
question of whether particular ethnic minority cultures in the United States are
less accepting of LGB people remains open (Herek & Gonzalez-Rivera, 2006). Some
researchers theorize that LGB youth who are members of ethnic groups with
particularly strong prohibitions against homosexuality may be subject to levels of
stress that can lead to increased risk of depression, anxiety, or suicidal ideation
(Balsam, Huang, Fieland, Simoni, & Walters, 2004; Kulkin et al., 2000; Lebson,
2002; Morrison & L’Heureux, 2001; Morrow, 2004; Pinhey & Millman, 2004;
Rotheram-Borus, Rosario, Van Rossem, & Reid, 1995).
1
The term gender nonconformity is not used as a pejorative by any of the researchers whose work is cited in
this section or by the authors of this report.

26
Suicidal Behavior in Family and Friends

Exposure to suicide or suicide attempts by family members or friends is a risk

factor for suicidal behavior. Research also indicates that LGB youth who reported
suicidal ideation and attempts were more likely to report that a member of their
family or close friend has attempted or died by suicide (D’Augelli, Hershberger, &
Pilkington, 2001; Russell & Joyner, 2001). More LGB youths know of peers who
have attempted or died by suicide: more than half of LGB youth in one study
knew of a suicide attempt by a close friend, while for adolescents generally
another study estimates 20 percent knew of a friend’s suicide attempt (D’Augelli,
Hershberger, & Pilkington, 2001).

Suicidal Behavior and Transgender Youth

There is a paucity of research on suicide, suicide attempts, and suicidal ideation
among transgender youth. A recent study focused on transgender youth age 15 to
21. Of transgender youth participating in the study, 45 percent had thought
seriously of killing themselves, and half of these said their thoughts were related to
their transgender status. When comparing transgender youth who reported
having attempted suicide with those who had not, researchers found that the
youth who had attempted suicide had experienced more physical and verbal
abuse from their parents (Grossman and D’Augelli, 2007).

One study that was not restricted to young people found that 83 percent of
transgender people had thought about suicide and 54 percent had attempted it
(Dean et al., 2000). In another study that surveyed transgender people of all ages,
about one third (30.1 percent) of respondents reported at least one suicide attempt
(Kenagy, 2005). A study of transgender people over the age of 18 found that 32
percent had attempted suicide. This study found that the risk factors associated
with attempted suicide among transgender people were younger age (under 25),
depression or a history of substance abuse, forced sex, and gender-based
victimization and discrimination (Clements-Nolle, Marx, & Katz, 2006). Although
these studies were not restricted to youth, all of them found high attempt rates for
transgender people.

While little research exists on transgender people and suicidal behavior, it is

reasonable to hypothesize that transgender youth—in common with LGB youth—
have elevated risk and lower protective factors for suicidal behavior. Transgender
youth often exhibit gender nonconformity and are presumed by others to be LGB
even if they do not identify as such. Transgender youth also experience high rates
of rejection and physical and verbal abuse at the hands of their parents (Grossman,
D’Augelli, Howell, & Hubbard, 2005). Grossman and D’Augelli (2007) have
summarized the experiences of transgender youth as indicated in recent

27
research—victimization by their peers, negative parental reactions, substance
abuse, and family violence—as similar to those of their LGB counterparts, who
have higher rates of suicidal behavior.

The Current State of Suicide Prevention for LGBT Youth

The staff members of the Suicide Prevention Resource Center (SPRC) have
identified LGBT youth programs that explicitly incorporate components of suicide
prevention as well as suicide prevention programs that specifically focus on LGBT
youth by (a) searching the World Wide Web; (b) posting queries to LGBT advocate
and provider e-mail lists and to suicide prevention e-mail lists; (c) asking SPRC’s
collaborators and contractors about suicide prevention services for LGBT youth;
and (d) reviewing the medical, psychological, and social science literature.

SPRC identified only one program with a primary focus on preventing suicide by
LGBT youth. The Trevor Project operates the nation’s only 24-hour toll-free suicide
prevention helpline for LGBT and questioning youth (1-866-4-U-TREVOR).

Programs Serving LGBT Youth

SPRC staff found that most programs serving LGBT youth do not offer services
explicitly related to suicide prevention but give priority to other issues, such as
school safety, health promotion, violence and harassment prevention, civil rights,
peer education, emergency support, and HIV and AIDS prevention and support
services. Many of these organizations offer services that contribute to suicide
prevention by strengthening protective factors, even if suicide prevention is not
among their explicit organizational goals. Training in life skills, enhancing peer
relationships, connecting LGBT young people with supportive adults, and helping
parents and teachers provide support to LGBT youth are all activities that
contribute to preventing suicide.

Several youth suicide prevention state coalitions include state chapters of Parents,
Families, and Friends of Lesbians and Gays (PFLAG) or other organizations
serving LGBT people. Many of these organizations explicitly acknowledge the
importance of suicide prevention and actively pursue this work along with other
issues. Cooperation among these organizations has reciprocal benefits: LGBT
organizations can ensure that statewide coalitions include LGBT youth in
developing public awareness, training, data, and interventions, and statewide
coalitions can provide resources and suicide prevention expertise to LGBT
organizations. Some organizations with a broad focus on public health provide
specific suicide prevention resources for LGBT youth—for example, the King
County (Washington) Public Health Department features a suicide prevention
page focusing on LGBT youth on its Web site.

28
Youth Suicide Prevention Programs

SPRC also considered the scope of youth suicide prevention programs and
whether they explicitly included LGBT youth. A summary of suicide prevention
programs for all youth found that most are implemented in three settings—
schools, communities, and health care systems—and follow one of two broad
goals: case-finding with referral and treatment or reduction of risk factors (Gould,
Greenberg, Velting, & Shaffer, 2003).

Case-finding programs include school-based suicide awareness curricula,

gatekeeper training, screening, and crisis centers and hotlines. School-based
awareness programs are generally designed to heighten student awareness of
adolescent suicide, increase recognition of signs of and risk factors for suicide,
change attitudes about getting help, and publicize resources. Gatekeeper training
teaches people who come into contact with youth—teachers, peers, school staff,
and others—to identify warning signs and to refer youth at risk for suicide to
treatment or other services. Screening, which can include questions about mood,
suicidal thoughts, and substance abuse, identifies high-risk youth for further
assessment and treatment. Risk-factor reduction includes lethal-means restriction,
media training, youth life skills training, and postvention (that is, interventions
that follow suicidal behavior) (Berman, Jobes, & Silverman, 2006).

Rather than only reducing risk factors, many suicide prevention programs
emphasize building protective factors, as recommended by The Surgeon General’s
Call to Action to Prevent Suicide. Programs to enhance protective factors or resilience
are as important as programs for risk reduction (U.S. Public Health Service, 1999).
A study of American Indian and Alaska Native youth suicide attempts found that
increasing protective factors was more effective for reducing attempt probability
than decreasing risk factors. Protective factors included ability to discuss problems
with family or friends, connectedness to family, and emotional health (Borowsky,
Resnick, Ireland, & Blum, 1999).

The Garrett Lee Smith Memorial Act funds state and tribal youth suicide
prevention and early intervention programs across the country. Substantial work
has been underway since 2005 to develop programs that address at-risk youth and
to evaluate the effectiveness of interventions. Several grantees have decided to
focus on LGBT youth as an at-risk population, mostly by training parents of LGBT
youth and staff from schools and agencies that serve youth. The higher risk of
suicidal behavior by LGBT youth, as well as risk and protective factors for LGBT
youth, are discussed in training sessions. The Maine Youth Suicide Prevention
Program and the Tennessee Department of Mental Health are grantees that work
directly with LGBT youth when developing training, awareness, and resource
materials. Other grantees offer clinicians the Suicide Prevention Resource Center

29
training “Assessing and Managing Suicide Risk” which identifies LGBT youth as a
group at higher risk for suicidal behavior.

Most states have suicide prevention coalitions with plans that follow the goals of
the National Strategy for Suicide Prevention. Some plans specifically refer to LGBT
people as a risk group to address. Many statewide coalitions oversee the
implementation of the state plan and hold yearly conferences for providers,
survivors, and agencies involved in suicide prevention. Conferences frequently
include workshops on such topics as the higher risk for suicidal behavior among
LGBT youth and recent research on risk and protective factors for LGBT youth. In
addition, the largest national conference on suicide prevention, hosted yearly by
the American Association of Suicidology, has featured sessions in recent years on
topics related to suicidal behavior and LGBT people. National organizations
including the Suicide Prevention Action Network USA and the American
Foundation for Suicide Prevention, and the federal agency Substance Abuse and
Mental Health Services Administration, have also featured the topic in national
meetings and conferences.

Suicide prevention programs can increase their capacity to serve the specific needs
of LGBT youth by taking the following steps:

• Providing information about LGBT youths’ risk of suicidal behavior to the

staff of case-finding programs, including gatekeepers, crisis line staff, and
screening program staff

• Including information about LGBT youths’ risk of suicidal behavior in

school-based and public awareness material

• Identifying LGBT-inclusive services and providers to use for referrals of

youth from screening programs, crisis lines, or gatekeepers

• Including LGBT youth in program development and evaluation

• Developing peer-based support programs

• Including in life skills training and programs to reduce risk behaviors the
topic of coping with stress and discrimination

• Supporting parents or guardians and other family members of LGBT youth

• Emphasizing protective factors relevant to LGBT youth

Russell (2003) reports that there are no published studies of the efficacy of suicide
prevention programs for sexual minority youth. Since LGBT youth are at higher

30
risk for suicidal behavior, it is imperative that programs that address this
population be developed, implemented, and evaluated.

A Cultural Competence Approach to Preventing Suicide

Among LGBT Youth
One way in which service providers—whether they work for an agency that serves
all youth or LGBT youth only—can better serve LGBT youth is by using a cultural
competence model. Cultural competence encompasses a set of behaviors, attitudes,
and policies that enables a system, agency, or professional to work effectively in
cross-cultural situations (Messinger, 2006). Many providers already use cultural
competence to ensure that their services are effective for ethnic and racial
minorities. Given that LGBT youth are a minority dealing with negative social
forces, a cultural competence approach for LGBT people can help address service
disparities.

Awareness of and sensitivity to LGBT people can be promoted through training. A

key role for instructors is to create a nonjudgmental and supportive learning space
with safety guidelines developed by the group being trained. This approach allows
for open exploration and discussion. Training begins with comprehending the
existence of LGBT people, learning and becoming comfortable with LGBT
terminology, and developing an initial awareness of one’s own biases and
assumptions. Values clarification and empathy development is an important part
of sensitivity training. Instructors explore the group’s values about LGBT people,
policies, and civil rights. Participants are asked to imagine the stresses that sexual
and gender minority people face. Competency training allows participants to
rehearse skills and often uses case studies and exercises in which participant
groups develop LGBT-inclusive policies and programs (Turner, Wilson, & Shirah,
2006)

The National Center for Cultural Competence has created a checklist (Dunne,
Goode, & Sockalingam, 2003) of the core functions necessary for programs to
effectively serve culturally and linguistically diverse groups of children and youth
with special needs. The checklist, adapted here by staff of the national Suicide
Prevention Resource Center for programs seeking to effectively serve LGBT youth,
is in Appendix B. Lack of support and barriers to care appear to be risk factors for
LGBT youth; more inclusive and aware providers, fostered by cultural
competence, can serve as a protective factor.

Suicide Prevention Programs: Other Considerations

Family connectedness—including the ability of youth to talk with parents, youth
feeling cared about and understood, and the family having fun together—has been

31
shown to reduce the risk of suicidal ideation and suicide attempts for some LGB
groups by half (Eisenberg & Resnick, 2006). Thus, programs that build family
support are important, especially for LGBT young people. Supporting the
development of PFLAG groups, LGBT youth support groups, family agencies that
provide culturally sensitive services to families with LGBT youth, and gay-straight
alliances may help to reduce the isolation of LGBT youth and create the social
supports that operate as a protective factor against suicidal behavior.

A review of studies on adolescent health, risk behavior, and sexual orientation

revealed that the initiation of some risk behaviors for suicide before age 13 was
correlated with LGB identity (Garofalo, Wolf, Kessel, Palfrey, & DuRant, 1998).
One study reported that many LGB youth make their first attempt before
disclosing their identity (D’Augelli et al., 2001). A study of LGB adults found that
the average age for first disclosure was 29, with a range of ages for first disclosure
from age 10 to 68 (D’Augelli & Grossman, 2001). These findings suggest that
suicide prevention for LGB youth should begin at the age range in which they are
considering disclosing their identity to their parents. Because LGB people often
become aware of their orientation at very young ages, it is important to direct
some suicide prevention interventions at younger adolescents and their parents.

Gatekeeper training teaches people to recognize youth at risk for suicide and to
refer them for help. Peer gatekeeping programs may be an effective intervention
with LGB youth: youth often first confide their problems to peers (Berman et al.,
2006) and for many LGB youth, a gay or lesbian friend may be the most important
person in their lives (Garofalo et al., 1998).

Strategic Venues for LGBT Youth Suicide Prevention

Efforts to reduce suicidal behavior in LGBT youth need to identify promising
venues through which to reach them as well as optimal features for each venue.
Practitioners seeking to develop prevention efforts within schools, health care
services, and mental health and social service agencies should give highest priority
to staffing and the overall program environment. As important as knowledgeable
and sensitive staff members are, they cannot work in isolation but need an
environment—physical setting, policies and procedures, colleagues and board—
that supports safety and inclusiveness.

Schools

Adolescents spend a substantial amount of time in school. School provides much

of the context for the social, intellectual, emotional, and sexual development of
young people.

32
Many students feel unsafe at school. The 2005 National School Climate Survey of
middle and high school students concluded that “anti-LGBT language, as well as
bullying and harassment on the basis of sexual orientation or gender
identity/expression remain common in America’s schools” (p. xii). Nearly two-
thirds of the respondents felt unsafe at school because of their sexual orientation.
Slightly more than 64 percent of students responding said they had been verbally
harassed, and 17.6 percent said they had been physically assaulted because of their
sexual orientation (Kosciw & Diaz, 2006). Because the National School Climate
Survey is not a scientific survey, results may not be representative of the entire
LGBT youth population; however, this does not lessen the fact that hundreds of
LGBT students reported being harassed in school.

A study of ninth- and twelfth-grade students indicated that approximately one in

seven LB females and one in five GB males report feeling a high degree of safety in
school (Eisenberg & Resnick, 2006). In a study of high school students, LGB youth
were almost five times as likely as non-LGB youth to have missed school because
of fears about their safety and more than four times as likely to have been
threatened with a weapon on school property (Garofalo et al., 1998). LGB youth
report school avoidance at higher rates than other students in the Massachusetts
2005 Youth Risk Behavior Survey. Thirteen percent of LGB students reported
having skipped school in the previous month because of feeling unsafe at or en
route to school, compared to only 3 percent of non-LGB students (Massachusetts
Department of Education, 2006a).

Victimization—violence, bullying, and verbal harassment—is a risk factor for

suicide attempts and suicidal ideation (Bagley & Tremblay, 2000; Bontempo &
D’Augelli, 2002; Huebner, Rebchook, & Kegeles, 2004; Rivers, 2001; Russell &
Joyner, 2001) as well as for mental health issues that increase the risk of suicide,
including substance abuse and low self-esteem among LGB youth (Bontempo &
D’Augelli, 2002; Huebner et al., 2004). Studies suggest that LGB students are
victimized by other students at higher rates than are their heterosexual peers
(Bagley & Tremblay, 2000; Bontempo & D’Augelli, 2002; D’Augelli, 2002; DuRant
et al., 1998; Garofalo et al., 1999).

Aside from explicit victimization, many adolescents who identify as LGBT

experience social isolation, ostracism, and stressed interpersonal relationships at
school. Many school staff members are not prepared and sometimes unmotivated
to intervene on behalf of LGBT youth (Elze, 2006). In a 1991 study, only one fifth of
guidance counselors had received training on serving gay and lesbian students,
and two-thirds had negative feelings toward non-heterosexual people
(Prezbindowski & Prezbindowski, 2001).

Research emphasizes that school safety seems to be a critical protective factor

against suicidal ideation and attempts for LGBT youth. Schools can play an

33
important role in preventing suicidal behavior among LGBT youth by taking the
following steps:

• Ensuring that the school is a safe and supportive environment for LGBT
youth by instituting and enforcing policies that prohibit harassment and
discrimination

• Including specific content about the needs of LGBT youth in trainings for
staff, teachers, and parents on youth development, mental health issues,
gatekeeper skills, and violence prevention

• Including material on LGBT youth in curricula and resources in the library

related to sexuality

• Integrating specific activities on and for LGBT youth in evidence-based

programs that help all youth to develop life skills and critical-thinking
skills, and to resist violence, substance abuse, and other risk behaviors

Box 1. Model School Program: Out for Equity

Out for Equity is a program within the St. Paul (Minnesota) Public Schools that is
committed to:
• Reducing high-risk behavior among lesbian, gay, bisexual, and transgender
students
• Reducing harassment and violence against lesbian, gay, bisexual, and
transgender students, staff, and families
• Fostering school environments that value diversity

Staff dedicated to speaking out against harassment and supporting LGBT students are
called Safe Staff and commit to activities including the following:
• Be accurately informed and continue learning about LGBT issues
• Examine personal attitudes and beliefs
• Challenge speech and actions that harass or are violent against LGBT people
• Be comfortable talking with LGBT people and about LGBT issues
• Respect confidentiality
• Be aware of services for LGBT people
• Help set a school climate of safety and support for all students

Furthermore, Out for Equity has developed a list of ways for staff to end homophobia
in schools:
• Do not assume heterosexuality.
• Guarantee equality. Include sexual orientation and gender identity in non-
discrimination and harassment policies as well as diversity statements.
• Create a safe environment that does not tolerate physical violence or harassing
language.
• Diversify library and media holdings—often the first place students go to for

34
 accurate sexuality and gender information.
• Provide training for faculty and staff to develop understanding of LGBT youth
and children from LGBT families.
• Provide appropriate health care and education. Counselors and health staff
need to make their sensitivity to LGBT issues clear.
• Be a role model. Demonstrate respectful language, intervene in harassment
instances, and bring diverse images into the classroom.
• Provide support for students. Gay-straight alliances are one way to help build
peer support and acceptance as well as promote equality and school change.
• Reassess the curriculum to integrate LGBT issues.
• Broaden entertainment and extracurricular activities to include content that
reflects diversity.

Finally, educators can play an important role in making their schools inclusive and safe
for sexual and gender minorities by adapting forms, classroom materials, and
textbooks; redesigning counseling services, school activities, and student resources; and
adopting anti-harassment policies and procedures (Horowitz and Loehning, 2005).

Mental Health and Social Services

It can be especially damaging for young LGBT people to receive less-than-

supportive services from mental health care providers. Some mental health care
providers still consider an LGB orientation pathological (Morrison & L’Heureux,
2001), despite the fact that the American Psychiatric Association removed
homosexuality from its list of psychiatric disorders in 1973 (Ryan & Futterman,
2001). Other providers may simply lack experience and training in supporting
LGBT people. All mental health providers need to ensure that their practice
responds to the needs of LGBT young people.

Morrow (2006) has developed guidelines for social work practice with LGBT youth
that could be applied to other types of providers. These include the following:

• Assess the degree of LGBT identity development and the degree to which
youth have developed a positive or negative self-identity.

• Assess the level of disclosure of sexual orientation to others (including

parents, friends, and schoolmates), and help young people explore the
advisability and consequences of disclosure.

35
 • Assess safety, since LGBT youth can be at risk of violence from family and
classmates as well as of suicidal ideation, substance abuse, self-harm, and
depression.

• Provide accurate educational information on sexual orientation and gender

identity, given that such material is often excluded (or presented
inaccurately) in health classes.

• Establish an LGBT-supportive work area, for example, by hiring and

training staff supportive of LGBT youth and by displaying LGBT-
supportive literature.

• Advocate for enhanced social services, a more supportive school

environment, and civil rights and social change.

Working with transgender children, youth, and their parents raises additional
challenges for which child welfare workers and other professionals need guidance.
Research based on focus groups of transgender people indicates that some felt they
were treated poorly by psychotherapists and attributed this poor treatment to the
provider’s lack of experience with transgender people or the provider’s belief that
transgenderism is an illness. Some members of the focus groups reported that
participating in peer support groups was helpful (Xavier & Bradford, 2005).
Mallon and DeCrescenzo (2006) recommend that practitioners work with
transgender clients to develop strategies for expressing gender variance and
dealing with discrimination and prejudice. They also emphasize that practitioners
should closely monitor the safety of the youth, as sexual violence toward
transgender youth is prevalent.

Meyer (2007) emphasizes the need to address the social stressors faced by sexual
minority individuals at both the structural and individual levels, in prevention and
intervention. It is important for providers to work to eliminate sources of stress in
the social environment by working to reduce antigay violence, eliminate
discrimination, and create a supportive social environment. There are many
national organizations to support this work. Individual-level interventions must
acknowledge the importance of individual agency and resilience. Prevention
programs can build LGB youth sense of self, while clinical interventions can focus
on issues of internalized homophobia, antigay violence, and rejection and
discrimination. He concludes:

“Ignoring the social environment would erroneously place the burden on

the individual, suggesting that minority stress is only a personal problem
for which individuals must be treated” (p. 259).

36
Health Care Services

Many youth seek help for emotional issues such as depression or substance abuse
from their primary health care providers. Health care providers are in a position to
respond to suicidal behavior in youth even if young people do not readily
volunteer information about these problems.

Unfortunately, LGBT people report hostile treatment and substandard care as well
as denials of care by health care providers (Elze, 2006). LGBTQ youth in one study
reported bad clinical interactions and said that they value what all youth value in
health care—competence, cleanliness, respect, and honesty. (“Q” designates youth
who are “questioning”.) LGBTQ youth repeatedly emphasized the importance of
confidentiality. They also valued specific knowledge of LGBTQ issues and
sensitivity (Ginsburg et al., 2002).

Frankowski and the Committee on Adolescence of the American Academy of

Pediatrics have developed guidelines for pediatricians working with LGB youth
that are also appropriate for other types of health care providers. These
recommendations include raising issues of sexual orientation and behavior with all
adolescent patients, since many LGB youth will not bring up their sexual
orientation voluntarily. The guidelines recommend that the provider give factual,
current, and nonjudgmental information while maintaining confidentiality.
Professionals who feel unable to provide care to LGB youth are advised to refer
these patients to other providers (Frankowski & American Academy of Pediatrics
Committee on Adolescence, 2004).

The GLBT Health Access Project in Massachusetts has developed comprehensive

standards of practice for quality health care services for LGBT clients. The
standards address administrative practice and service delivery in personnel, client
rights, intake and assessment, service planning and delivery, confidentiality, and
community outreach and health promotion. The standards, funded by the
Massachusetts Department of Public Health, include indicators to assess progress
and help providers meet the standards (Gay, Lesbian, Bisexual, and Transgender
Health Access Project, 2006).

37
Box 2. Model Health Care Program: Fenway Community Health

Fenway Community Health in Boston, Massachusetts provides medical and mental health
care to LGBT individuals, raises awareness about LGBT health issues, and hosts a national
LGBT helpline. Fenway offers primary and specialty health care, mental health and
addiction services, alternative therapies, health promotion and community activities,
violence prevention and recovery, and family and parenting services. Fenway has the
broad goal of improving the health of the larger local and national community through
education and training, policy and advocacy, and research and evaluation. Since its
beginning decades ago, Fenway has been a leader advocating for sexual minority health
care needs.

Fenway staff members are trained to address depression and suicide and work with the
GLBT Health Access Project, which offers training and technical assistance to health care
providers. Fenway’s Peer Listening Line and GLBT Helpline are anonymous and
confidential phone lines that offer LGBT adults and youth information, referrals, and
support.

The Fenway Institute at Fenway Community Health is an interdisciplinary center whose

research aims to better understand the needs of the LGBT community and to create
programs and policies based on that knowledge. In 2007, the National Institutes of Health
awarded Fenway Institute a federal population center grant, and the Institute became the
first federally funded research center to focus specifically on sexual minority population
research. Research will focus on the diversity of LGBT individuals, families, and
households; demographic features of LGBT health, illness, disability and mortality; and
behavioral issues in HIV transmission.

Working with the American College of Physicians, the Fenway Institute published the
nation’s first medical textbook focused on LGBT people, The Fenway Guide to Lesbian, Gay,
Bisexual and Transgender Health. The Guide is a comprehensive textbook that aims to
eliminate disparities in health care for sexual and gender minorities. It includes content
about health promotion for LGBT patients, basic issues for transgender and intersex
patient health, and unique clinical issues for LGBT populations.

Fenway is a leading example of LGBT health centers across the country that offer models
of inclusive and effective ways to provide LGBT people with services that reduce the risk
of suicidal behavior.

Working with LGBT Youth at Higher Risk

Although LGBT youth in general are at higher risk for suicidal behavior, certain
subpopulations of LGBT youth are at especially high risk. For purposes of
planning suicide prevention services, LGBT youth who are not living at home—
homeless and runaway youth as well as youth in foster care and juvenile justice

38
settings—face similar challenges. The issues of family conflict and rejection, cycles
of abuse and neglect, and juvenile criminal offenses are often closely related, and
many young people may experience all of them.

Homeless and Runaway Youth

Although family conflict is the primary reason that youth leave or are expelled
from their homes, LGB youth are at higher risk of being told to leave—or feeling
that they need to leave—their homes than young heterosexual people. Once out of
the home, LGB youth are more likely to end up on the streets than their
heterosexual peers, often because of the hostile environment they face in foster or
group homes and shelters for runaway and homeless youth (Ray, 2006). Studies
have found that gay and lesbian youth make up 11 to 35 percent of homeless and
runaway youth (Cochran, Stewart, Ginzler, & Cauce, 2002). The percentage may be
larger in big cities perceived as welcoming to LGBT people: a study in Seattle
found that 40 percent of homeless youth identified as LGB (Ray, 2006).

Life on the street represents risks for all homeless youth. Homeless and runaway
youth have elevated rates of mental illness, violence, sexual exploitation, and
substance abuse (Van Leeuwen et al., 2006). They also have a high rate of suicide
attempts: one study found that 76 percent of homeless youth reported attempting
suicide at least once, and 86 percent of that group reported more than one attempt
(Van Leeuwen et al.).

For LGB youth, these risks are amplified. One study found that 62 percent of LGB
homeless youth reported having attempted suicide, compared to 29 percent of
non-LGB homeless youth (Van Leeuwen et al., 2006). A study of homeless youth in
eight Midwestern cities found higher rates of suicidal ideation and previous
suicide attempts for LGB youth (73 percent and 57.1 percent respectively) than for
heterosexual youth (53.2 percent and 33.7 percent respectively) (Whitbeck, Chen,
Hoyt, Tyler, & Johnson, 2004). A study comparing homeless LGBU youth (“U”
designates youth who stated they were “unsure” about their sexual orientation)
and heterosexual youth found that LGBU youth had a higher rate of recent
depression (and of recent suicide attempts for females) and a higher rate of lifetime
history of suicide attempts (Noell & Ochs, 2001). Studies have also found that
LGBT homeless youth have higher rates of depression, posttraumatic stress
disorder, and psychopathology than do other homeless youth (Cochran et al., 2002;
Whitbeck et al., 2004). A recent study reports that LGBTQ homeless youth
compared to other homeless youth have almost twice the rate of sexual
victimization and higher rates of HIV infection (Van Leeuwen et al., 2006). As
many as one in five transgender people need or are at risk of needing homeless
assistance, yet transgender youth face difficulties—in most shelters youth are
housed by birth sex rather than by gender identity (Ray, 2006).

39
Families in conflict relating to a youth’s sexual orientation may benefit from family
therapy and other forms of support to reduce family stress and the likelihood that
LGBT adolescents will leave the home (Cochran et al., 2002). Programs serving
homeless and runaway youth may be more effective if they work to ensure that
relevant staff members are informed about the particular risks of LGBT youth—
risks that include more frequent victimization, higher rates of highly addictive
drug use, and more sexual partners (Cochran et al.).

The National Gay and Lesbian Task Force report on LGBT homelessness (Ray,
2006) makes the following recommendations for practitioners:

• Agencies receiving funds to serve homeless youth should be required to

demonstrate LGBT cultural competence and to adopt nondiscrimination
policies for LGBT youth.

• Providers who seek professional licenses should be required to take LGBT

awareness training and to demonstrate cultural competence.

• LGBT cultural competence training should be mandatory for all state

agency staff who work in child welfare or juvenile justice.

These recommendations could reduce the stressors to LGBT youth and make
services more accessible, thus preventing homelessness and reducing suicide risk.

Youth in Foster Care

Trauma, disruption, and isolation typify the lives of many foster children, a
substantial proportion of who were abused by their families or come from families
that were unable to provide care for them. Youth living in out-of-home settings
have higher rates of emotional disorders and substance abuse and often lack the
protective factors of youth with a more permanent family life. Adolescents in
foster care have higher rates of past-year suicidal ideation (26.8 percent versus 11.4
percent) and higher rates of suicide attempts (15.3 percent versus 4.2 percent) than
those who have not been in foster care (Pilowsky & Wu, 2006).

LGBT youth in foster care face significant challenges. Although abuse and neglect
of LGBT youth in the foster care system have been documented, a recent survey
found that no state child welfare agency had policies prohibiting discrimination
based on sexual orientation or requiring training for staff or foster parents on the
needs of LGBT youth (Elze, 2006). LGBT youth in foster care receive fewer services
than their non-LGBT counterparts and are often labeled as difficult. They
experience fears about their safety, rejection at intake, harassment, and violence.
They have longer stays out of their homes, more frequent placement changes, and
difficulties accessing appropriate physical and mental health services (Hunter,

40
Cohall, Mallon, Moyer, & Riddel, 2006). Foster care providers might assess how
well they follow the guidelines for serving LGBT youth outlined below in Box 3.

Youth in Juvenile Justice

The juvenile justice system—which includes probation, diversion programs,

courts, residential detention facilities, and group and foster care homes—addresses
the rehabilitation of youth and the prevention of criminal acts by youth. Young
people enter the juvenile justice system due to either crimes or status offenses (that
is, offenses that apply only to youth, such as skipping school or running away
from home). The juvenile justice system almost by definition deals with at-risk
youth, many of whom are at elevated risk of suicide because of mental or
substance abuse disorders, legal issues, and family conflict.

The pressures that cause LGBT youth to run away or be thrown out of their homes
can also lead to their becoming involved with juvenile justice. Although some of
these young people enter the system for reasons unrelated to their sexual
orientation or gender identity, others enter the system because of behaviors
directly related to conflicts with family or peers over their sexual orientation or
gender identity. Many runaway youth living on the street—including LGBT
youth—commit crimes related to their homelessness, including crimes committed
while trying to support themselves on the street, such as robbery, prostitution,
shoplifting, and selling drugs.

41
A study of LGBT youth in New York suggests they were overrepresented in the
juvenile justice system, where they experienced widespread discrimination, abuse,
and mistreatment. The authors of this study say that “even at its best, the system is
widely ignorant of the existence and needs of LGBT youth” (p. 6). Although the
report often notes suicide as a risk for these young people, none of the
recommendations refer specifically to suicide prevention (Feinstein, Greenblatt,
Hass, Kohn, & Rana, 2001). Staff members at juvenile justice residential services
might assess how well they follow the guidelines for serving LGBT youth outlined
below in Box 3.

Box 3. The Model Standards Project for LGBT Youth in Child Welfare and Juvenile
Justice Systems and CWLA Best Practice Guidelines: Serving LGBT Youth in Out-Of-
Home Care

Legal Services for Children, which provides free legal and social services to youth in the
San Francisco Bay Area, and the National Center for Lesbian Rights, a national legal
resource center for LGBT people, undertook the Model Standards Project (MSP) in 2002.
The goal of the MSP is to improve practices to benefit LGBT youth in foster care and
juvenile justice out-of-home care.

The Model Standards Project calls for:

1. A safe and inclusive environment that prohibits slurs based on race, culture, religion,
gender, gender identity, sexual orientation, or any other difference
2. Displaying posters and other visuals that demonstrate an LGBT-friendly environment
3. Using respectful inclusive language and intervening when youth show disrespect for
LGBT differences
4. Training about LGBT youth for all staff, caregivers, and service providers as well as
ongoing supervision and evaluation after this training
5. Policies prohibiting harassment and discrimination that apply to all levels of an
institution as well as private contractors
6. Ensuring that potential caregivers practice nondiscriminatory, inclusive care and
provide a safe home
7. Ensuring safety in residential agencies through close staff supervision, an emphasis on
relationship between staff and residents, and high-quality programming (Wilber, Reyes, &
Marksamer, 2006).

The recommendations of the MSP were used to develop CWLA Best Practice Guidelines:
Serving LGBT Youth in Out-of-Home Care, published by the Child Welfare League of
America (Wilber, Ryan, & Marksamer, 2006). See Appendix A for more information about
the Best Practice Guidelines.

42
Recommendations
The authors assert the following recommendations to strengthen or increase
protective factors and to reduce risk factors among LGBT youth. Agencies that
serve youth – schools, health practices, suicide prevention programs, and youth
services – as well as funders, can help to reduce suicidal behavior among these
youth. The authors recommend that these agencies and individuals:

• Implement training for all staff members to effectively serve LGBT youth by
including recognition and response to warning signs for suicide and the risk
and protective factors for suicidal behavior in LGBT youth

• Include information about higher rates of suicidal behavior in LGBT youth

in health promotion materials

• Assess and ensure that youth services and providers are inclusive,
responsive to, and affirming of the needs of LGBT youth, and refer youth to
these services and providers

• Develop peer-based support programs

• Include the topic of coping with stress and discrimination and integrate
specific activities for LGBT youth in life skills training and programs to
prevent risk behaviors

• Support staff advocacy for LGBT youth

• Incorporate program activities to support youth and their family members

throughout the development of sexual orientation and gender identity,
including awareness, identity, and disclosure. These programs must
address young children and adolescents.

• Promote organizations that support LGBT youth, such as Gay-Straight

Alliances and Parents, Families, and Friends of Lesbians & Gays (PFLAG)

• Institute protocols and policies for appropriate response if a client or

student is identified as at risk of self-harm, has made a suicide attempt, or
has died by suicide

• Make accurate information about LGBT issues and resources easily

available

43
 • Use an LGBT cultural competence model that enables individuals and
agencies to work effectively with LGBT youth cultures

• Include LGBT youth in program development and evaluation

• Institute, enforce, and keep up to date non-discrimination and non-

harassment policies for all youth

• Implement confidentiality policies that are clear, comprehensive, and

explicit

• Assume that clients or students could be any sexual orientation or gender

identity and respond accordingly

• Address explicitly the needs of LGBT youth in school-based programs and

policies to prevent violence and bullying

Researchers and program developers, as well as funders, also play a role in

reducing suicidal behavior in LGBT youth. The authors recommend that they:

• Use evaluation results, surveillance data, and research conclusions to

develop evidence-based programs to build protective factors and to prevent
suicide among LGBT youth

• Undertake large-scale epidemiological studies that include complex

measures of sexual orientation and gender identity and include research on
discrimination and mental illness

• Include LGBT youth in research development and evaluation

• In developing programs, emphasize protective factors for LGBT youth

• Develop research projects and funding for research on risk and protective
factors for suicidal behavior for youth generally and for LGBT youth
specifically and work with program staff to encourage getting research
results into program design

These recommendations will help not only to reduce the disparate rate of suicidal
behavior of LGBT youth but to promote the health, safety, and inclusion of LGBT
youth as visible and empowered members of our communities.

44
Conclusion
The greater risk of suicidal behavior among LGBT youth may be seen as largely a
function of our social environment, including discrimination and stigma. Social
stressors are associated with mental illness, isolation, victimization, and stressful
interpersonal relationships with family, peers, and community. The effect of this
stress is compounded by the fact that many youth-serving professionals and
institutions are not effectively meeting the needs of LGBT youth.

The good news is that we know enough about many of these risk and protective
factors to do something to change them. To accomplish this, we urgently need to
build the capacity of agencies that specifically serve LGBT youth and youth in
general, all the while keeping our eye on the goal of reducing the disparity in
suicidal behavior between LGBT youth and their peers. There is a tremendous
opportunity for school staff, mental health providers, social service agency staff,
and health care providers, as well as suicide prevention program staff, to take
steps at the individual and institutional level to increase safety and inclusion, and
further to advocate for LGBT youth so that all can recognize their potential.

The steps we take to reduce suicidal behavior among LGBT youth can have the
additional benefit of reducing the social stigma and discrimination against LGBT
people in our families, schools, and communities. Our ultimate goal is not to
merely help lesbian, gay, bisexual, and transgender youth survive but to support
them to thrive as healthy, productive, and vibrant youth welcomed and
empowered in their communities.

45
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Appendix A: Resources on LGBT Issues
Appendix A contains items in the following categories: Schools, Health Care
Providers and Consumers, Telephone and E-mail Help, Data and Research, and
Other Resources. For resources on cultural competence, please refer to Appendix
B.

Schools

Beyond the Binary A Toolkit for Gender Identity Activism in Schools (2004)
www.gsanetwork.org/BeyondtheBinary/toolkit.html

Beyond the Binary was produced by the Gay-Straight Alliance Network, Transgender Law
Center, and the National Center for Lesbian Rights. It has practical information to assist
teachers and students in creating a safe space within the school for transgender and
gender nonconforming students.

The Gay, Lesbian, and Straight Education Network (GLSEN)

www.glsen.org

This organization provides free and inexpensive tools to help establish school Gay-
Straight Alliances, including Jump-Start Activity Guides, Safe Schools policies, stickers,
do-it-yourself training kits, and results from the National School Climate Survey of LGBT
students.

Out for Equity

http://outforequity.spps.org/index.html

This organization, which is part of Saint Paul [Minnesota] Public Schools, offers resources
about creating a safe school environment, including a Safe Schools Manual.

Health Care Providers and Consumers

Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling

(ALGBTIC)
www.algbtic.org/resources/listing.htm

A division of the American Counseling Association, this organization provides a variety

of resources about the counseling of LGBT individuals, including a list of therapists.

55
Gay and Lesbian Medical Association (GLMA)

www.glma.org

This association offers extensive references and resources for providers and patients as
well as for advocates.

GLBT Health Access Project

www.glbthealth.org/index.html

This project, funded by the Massachusetts Department of Public Health, works with GLBT
populations and the health care providers who serve them. The project offers a variety of
resources, including community standards of practice for quality health care services, with
indicators for both administrative practices and service delivery.

Healthy People 2010: Companion Document for Lesbian, Gay, Bisexual, and
Transgender Health (2001)

www.glma.org/_data/n_0001/resources/live/HealthyCompanionDoc3.pdf

This document, co-written by the Gay and Lesbian Medical Association and the National
Coalition for LGBT Health, contains quantitative and qualitative research and information
specific to LGBT health and discusses the overall health status of LGBT people.

Transgender Health Access in Virginia: Focus Group Report (2005)

www.vdh.virginia.gov/epidemiology/DiseasePrevention/Programs/HCPC/documents
/TG Focus Group Report final 1.3.pdf

This detailed report presents findings on both mental and physical health issues facing
transgender individuals.

NAMI Multicultural Action Center’s Gay, Lesbian, Bisexual, and Transgender (GLBT)
Mental Health Resources
www.nami.org/Content/NavigationMenu/Find_Support/Multicultural_Support/Resou
rces/GLBT_Resources.htm

This Web page contains research, fact sheets, training materials, and other resources on
GLBT mental health.

The National Coalition for Lesbian, Gay, Bisexual, and Transgender Health

www.LGBTHealth.net

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This coalition is committed to improving the health and well-being of lesbian, gay,
bisexual, and transgender individuals and communities through public education,
coalition building, and advocacy. The Web site has health updates and information about
events.

Provider’s Introduction to Substance Abuse Treatment for LGBT Individuals (2001)

www.kap.samhsa.gov/products/manuals/pdfs/lgbt.pdf

This publication from the Center for Substance Abuse Treatment of the Substance Abuse
and Mental Health Services Administration (SAMHSA) presents information to assist
providers in improving substance abuse treatment for LGBT clients by raising awareness
about issues unique to LGBT clients.

Recommended Framework for Training Mental Health Clinicians in Transgender Care

(2006)

www.vch.ca/transhealth/resources/library/tcpdocs/training-mentalhealth.pdf

This document, a collaboration between Transcend Transgender Support and Education

Society and Vancouver Coastal Health’s Transgender Health Program, presents
recommendations for community mental health professionals about working with
transgender individuals.

World Professional Association for Transgender Health (WPATH)

www.wpath.org

Formerly known as the Harry Benjamin International Gender Dysphoria Association,

WPATH is a professional organization devoted to the understanding and treatment of
gender identity disorders. Its Web site contains information about WPATH activities and a
number of resource links.

Telephone and E-mail Help

Fenway Community Health’s Gay, Lesbian, Bisexual, and Transgender Helpline and
The Peer Listening Line
www.fenwayhealth.org

These anonymous and confidential phone lines offer gay, lesbian, bisexual, and
transgender adults and youths from all over the United States a safe place to call for

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information, referrals, and support. Trained volunteers address topics such as locating
local GLBT groups and services as well as issues including coming out, HIV/AIDS, safer
sex, and relationships.

Fenway Gay, Lesbian, Bisexual and Transgender Helpline

617-267-9001
Toll-free - 888-340-4528

Fenway Peer Listening Line

617-267-2535
Toll-free - 800-399-PEER

GLBT National Help Center

www.glnh.org

This center offers free telephone and e-mail peer counseling, information, and local
resources for GLBTQ callers throughout the United States.

GLBT National Hotline:

Toll-free 1-888-THE-GLNH (1-888-843-4564)

HOURS:

Monday through Friday from 1 pm to 9 pm, Pacific Time

Saturday from 9 am to 2 pm, Pacific Time

Email: [email protected]

GLBT National Youth Talkline

Toll-free 1-800-246-PRIDE (1-800-246-7743)

HOURS:
Monday through Friday from 5 pm to 9 pm, Pacific Time
Email: [email protected]

The Trevor Project

www.thetrevorproject.org

Trevor operates the nation’s only 24-hour toll-free suicide prevention helpline for gay,
lesbian, bisexual, transgender, and questioning youth (1-866-4-U-TREVOR).

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Data and Research

Family Acceptance Project

http://familyproject.sfsu.edu/overview

This project, directed by Caitlin Ryan at San Francisco State University, is the first major
study of the families of lesbian, gay, bisexual, and transgender youth. Findings will be
available to policymakers, families, and providers to inform policy and practice and to
change the way that systems of care address the needs of LGBT adolescents.

GayData.org

www.gaydata.org/

This Web site, maintained by Randall L. Sell at Drexel University, provides extensive
research summaries and links for data, and promotes the collection of sexual orientation
data and further analysis of data sources that have already collected such data.

LGBT Youth: An Epidemic of Homelessness (2007)

www.thetaskforce.org/reports_and_research/homeless_youth

This report from the National Gay and Lesbian Task Force discusses the reasons so many
LGBT youth are homeless and the risks they face in shelters and on the street.

Living in the Margins: A National Survey of LGBT Asian and Pacific Islander
Americans (2007)

http://thetaskforce.org/reports_and_research/api_study

This report from the National Gay and Lesbian Task Force discusses the discrimination
that Asian and Pacific Islander American LGBT persons face.

Other Resources

Creating Safe Space for GLBTQ Youth: A Toolkit (2006)

www.advocatesforyouth.org/publications/safespace/safespace.pdf

A resource for youth-serving professionals, Creating Safe Space provides tips and strategies
for assessment, inclusive programming, lesson plans, and addressing harassment.

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Child Welfare League of America’s Best Practice Guidelines: Serving LGBT Youth in
Out-of-Home Care (2006)

www.cwla.org/pubs/pubdetails.asp?PUBID=10951

This book, by Shannan Wilber, Caitlin Ryan and Jody Marksamer describes best
practices for providing services to LGBT youth in foster care or juvenile justice residential
care and can be ordered from the CWLA web site.

The Gay, Lesbian, Bisexual, and Transgender Youth Support Project

www.hcsm.org/glys/glys.htm

This program, part of Health Care of Southeastern Massachusetts Inc., provides tools,
training, and ongoing support for educators and health and human service providers. The
Web site contains assessment tools, legal and policy statements, and other information.

The National Center for Transgender Equality (NCTE)

www.nctequality.org

This social justice organization is dedicated to advancing the equality of transgender

people through advocacy, collaboration, and empowerment. Its Web site contains news
and resources.

National Gay and Lesbian Task Force

www.thetaskforce.org

The mission of the National Gay and Lesbian Task Force is to build the grassroots power
of the lesbian, gay, bisexual, and transgender (LGBT) community. The Task Force trains
activists, develops the organizational capacity of the movement, and equips state and local
organizations with the skills needed to organize broad-based campaigns to defeat anti-
LGBT referenda and advance pro-LGBT legislation.

Parents, Families, and Friends of Lesbians & Gays (PFLAG)

www.pflag.org/

This group promotes the health and well-being of gay, lesbian, bisexual, and transgender
persons and their families and friends. PFLAG’s Web site contains sections on support,
education, and advocacy.

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Transgender Law Center

www.transgenderlawcenter.org

This organization works to make California a state in which people can freely express
gender identities. The organization’s web site has comprehensive collections of resources
on transgender law and current work in education, health care, employment, and
business.

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Appendix B: Resources on Cultural Competence
NCCC Cultural Competence Resources

The National Center for Cultural Competence (NCCC) provides a 2004 resource titled
Planning for Cultural and Linguistic Competence in State Title V Programs, which addresses
cultural and linguistic competence in programs serving children and youth with special
health care needs and their families. The resource, which includes a checklist and
guidelines, can be found at
http://www11.georgetown.edu/research/gucchd/nccc/documents/NCCC%20Title%20
V%20Checklist%20(CSHCN).pdf The NCCC checklist was adapted for LGBT youth by
staff at the national Suicide Prevention Resource Center.
To serve the needs of LGBT youth effectively, an organization should:

• Perform needs and asset assessments with LGBT groups

• Develop and administer policies in partnership with consumers, including LGBT

youth

• Design services and supports to meet the needs of LGBT youth (for example,
consumer-driven and community-based services, culturally based advocacy, and
participatory action research)

• Use appropriate strategies to address barriers to the design and delivery of services
and supports (for example, staff attitude and manner, service location, lack of
insurance, and fear and distrust of the service system)

In the area of human resources and staff development, an organization should:

• Employ a diverse, culturally competent workforce, including LGBT staff

• Provide pre-service and in-service training and professional development activities

for governing boards and all staff to ensure understanding and acceptance of
program values, principles, and practices governing cultural competence

• Provide orientation training, mentoring, and other supports for all volunteers to
ensure understanding and acceptance of program values, principles, and practices
governing cultural competence

• Incorporate areas of awareness, knowledge, and skills in cultural competence into

position descriptions and performance evaluations for all staff

Furthermore, a culturally competent organization has policies and sufficient fiscal

resources to support and sustain the above activities. The requirements and objectives for
cultural competence should be incorporated into contracts as well.

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Other Cultural Competence Resources

Family & Children’s Service has been providing counseling, family and school support,
violence reduction, and community development programs in the Twin Cities
[Minnesota] for more than 125 years. The FCS checklist for organizations seeking to be
more culturally competent for LGBT youth can be found at http://tinyurl.com/yoljxu.

Seattle and King County [Washington] Public Health has a Web site that provides tips for
providers on how to give culturally competent care to GLBT patients at
http://www.metrokc.gov/health/glbt/providers.htm#tips.

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