(:title Suicide Attempts and Suicidal Ideation among Homosexuals and Bisexuals:) (:description Male homosexuals manifest elevated suicidal ideation and suicide attempts, but do not appear overrepresented among those that successfully commit suicide.:) (:keywords suicide attempts, borderline personality disorder, internalized homophobia, Paul Gibson, multiple personality disorder, MPD:) Evidence for increased suicide attempts and suicidal ideation among homosexuals and bisexuals, obtained from population-representative samples, has been extensively cited elsewhere within this section. This page is about there being no reliable evidence that nonheterosexuals are correspondingly relatively overrepresented among those that successfully commit suicide. Various considerations suggest that elevated suicide attempts and suicidal ideation among nonheterosexuals are additional manifestations of elevated psychiatric morbidity among them. !!The Paul Gibson paper In 1989, a task force established by the Secretary of the U.S. Department of Health and Human Services drafted a report on youth suicide. The report mentioned an estimate by homosexual activist Paul Gibson that up to 30% of annual youth suicide victims may comprise of homosexuals.[^Gibson P. Gay male and lesbian youth suicide. Report of the Secretary's Task Force on Youth Suicide, Vol 3: Prevention and Intervention in Youth Suicide. Washington, DC: US Department of Health and Human Services, 1989;110-42.^] Homosexuals have frequently cited this statistic even though the government disavowed this report and removed it from circulation. Gibson noted that homosexual youth are about 3 times as likely to attempt suicide compared to heterosexual youth, and believing that 10% of the population is homosexual, he estimated that 30% of youth who commit suicide are homosexual. Imagine a group, some members of which commit suicide and succeed on their first attempt. If one were to take a random sampling of this group and ask about suicide attempts in lifetime, one would come across a prevalence of 0% because anybody who attempted suicide died. Clearly, a 0% suicide attempt rate obtained herein does not imply a 0% suicide rate. However, if in the same group, those who commit suicide succeed on their first attempt, which immediately follows suicidal ideation, then a sampling of this group would reveal a 0% rate of both suicide attempts and suicidal ideation. May we suppose that none belonging to this group ever think about suicide? At the other extreme, a group, some members of which think about killing themselves but attempt suicide without success, would achieve a suicide rate of 0%. This should suffice to point out the mistake made by Gibson. Young women attempt suicide at rates 2-9 times higher than young men, but young men commit suicide at a rate 6 times higher than young women.[^Rotheram-Borus MJ, Bradley J. Evaluation of suicide risk. In: Rotheram-Borus MJ, Bradley J, Obolensky N, eds. Planning to live: Evaluating and treating suicidal teens in community settings. Tulsa, Oklahoma: National Resource Center for Youth Services, University of Oklahoma, 1990;109-36.^] The discrepancy between the prevalence of suicide attempts and actual suicides is greater among adolescents than adults. For instance, according to CDC estimates, approximately 86 Americans commit suicide everyday whereas 1,500 Americans attempt suicide everyday, i.e., suicide attempts are approximately 18 times more common than actual suicides.[^http://www.cdc.gov/safeusa/suicide.htm^] On the other hand, injurious suicide attempts by adolescents are about 100 times more common than actual suicides.[^Healthy People 2000 Review. Vol DHHS Publ. No. (PHS) 94-1232-1. Washington, DC: US Public Health Service, 1993.^] In short, a high prevalence of suicide attempts does not necessarily imply a high suicide rate. Do homosexuals constitute a great proportion of individuals that successfully commit suicide? !!Reports of suicide victims There are no clear finds that homosexuals are overrepresented among suicide victims: *Robins described 134 individuals aged 24 years or older that committed suicide; none of them were homosexual.[^Robins E. The final months. New York: Oxford University Press, 1981.^] *Shaffer et al. reported that in an examination of 120 (95 were men) out of 170 consecutive suicide victims less than age 20 years, 3 were male homosexuals judging by behavior or identification and 3 other men were somewhat behaviorally feminine.[^Shaffer D, Fisher P, Hicks RH, et al. Sexual orientation in adolescents who commit suicide. Suicide Life Threat Behav 1995;25 Suppl:64-71.^] None of the three homosexuals had committed suicide following a stigmatizing episode and all had psychiatric disorders. *Beskow reported that among 271 Swedish male suicides aged 15 years or older, 5 of 161 (3.1%) in the urban sample and 1 of 110 (0.09%) in the rural sample were homosexual.[^Beskow J. Suicide in mental disorder in Swedish men. Acta Psychiatr Scand Suppl 1979(277):1-138.^] *Rothberg et al. noted that 1.7% of 212 U.S. Army personnel that committed suicide in 1985-1986 were homosexual.[^Rothberg JM, Fagan J, Shaw J. Suicide in United States Army personnel, 1985-1986. Mil Med 1990;155(10):452-6.^] Some assume that the Army’s exclusionary policy toward homosexuals decreases the number of homosexuals in it. However, homosexuals and bisexuals appear to be relatively overrepresented in the U.S. army.[^Fay RE, Turner CF, Klassen AD, et al. Prevalence and patterns of same-gender sexual contact among men. Science 1989;243(4889):338-48.^]'^,^' [^Rogers SM, Turner CF. Male-male sexual contact in the USA: Findings from five sample surveys, 1970-1990. J Sex Res 1991;28(4):491-519.^] *Rich et al. reported that among 283 suicides in San Diego, from November 1981 to June 1983, consisting of 133 consecutive cases under age 30 years and 150 consecutive cases over age 30 years, 202 were men and 81 were women.[^Rich CL, Fowler RC, Young D, et al. San Diego suicide study: comparison of gay to straight males. Suicide Life Threat Behav 1986;16(4):448-57.^] No woman was homosexual. Among the men, 13 (6.4%) were homosexual. All 13 homosexual men were in the age range 21-42 years. There were 106 heterosexual men in this age range. Both the homosexual and heterosexual suicide victims in the age range 21-42 years could not be distinguished on various characteristics, although there appeared a tendency for the homosexuals to have manifested elevated psychotic disorders and elevated past suicide attempts. Of the 13 homosexuals, 12 had one or more DSM- III substance abuse diagnoses, and 11 had a DSM- III diagnosis other than substance abuse. *In a 1991 random Gallup poll of 1,152 teenagers, homosexual behavior or orientation was not cited by any teen as responsible for suicide attempts by themselves or their friends, and this was also true of a follow-up random poll of 1,612 teenagers in 1994.[^Teen suicide: a report on the 1991 Gallup survey among teens and the 1994 Gallup update survey: The Gallup Organization, 1995.^] One can say with reasonable confidence that even if one could show that homosexual men are somewhat relatively overrepresented among suicide victims, the discrepancy between attempted suicides and successful suicides would still be much greater among homosexual men than among heterosexual men. In Rich et al.’s study above, 67% of the deceased homosexuals had previously attempted suicide, whereas only 37% of the deceased heterosexuals in the same age range had previously attempted suicide; this discrepancy would have been statistically significant had the sample size been larger, and these figures suggest that the heterosexual group was more successful at committing suicide than the homosexual group. Besides, the authors did not find any homosexual among the deceased youth. Given such considerations, Paul Gibson’s 30% statistic is even more remarkable because the only way 30% of suicides could consist of homosexuals would be if a much greater proportion of homosexual suicide attempters were successful compared to heterosexual suicide attempters. !!Why are suicide attempts and suicidal ideation more common among nonheterosexuals? An oft-repeated claim is that elevated suicidality in homosexuals results from societal prejudice and rejection, leading to the internalization of homophobia. However, other parts of this section present plenty of data that argues against this notion, including results from studies that have statistically controlled for risk factors. One expects societal rejection to lead to sadness or depression, and depression, in turn, leads to hyposexual behavior in normal individuals. However, homosexuals manifest [[Sexuality/Promiscuity|increased promiscuity]]. In this regard, Durant et al. reported that among male adolescents reporting one or more same-sex partners; alcohol, marijuana, and smokeless tobacco use at school; not attending school because of fear; having been threatened or injured with a weapon at school; and weapon carrying at school accounted for 15.8% of the variance in the number of male sexual partners, or 17.2% of the variance after the inclusion of suicide attempts or cigarette smoking, i.e., more partners correlate with increased risky behaviors among male homosexuals.[^DuRant RH, Krowchuk DP, Sinal SH. Victimization, use of violence, and drug use at school among male adolescents who engage in same-sex sexual behavior. J Pediatr 1998;133(1):113-8.^] In a comparison of 59 mostly non-white male runaways between the ages of 12 and 18 years with 60 mostly non-white homosexual and bisexual males attending a community agency and within the same age range, both groups had initiated sexual activity at a mean age of 12.6 years and the runaways had had a median of 11 women sexual partners whereas the nonheterosexual youth had had a median of 7 male sexual partners.[^Rotheram-Borus MJ, Meyer-Bahlburg HF, Rosario M, et al. Lifetime sexual behaviors among predominantly minority male runaways and gay/bisexual adolescents in New York City. AIDS Educ Prev 1992;Suppl:34-42.^] One wouldn’t blame so-called homophobia for precocious sexuality and promiscuity among heterosexual runaway youth and caution is required before one does so for homosexual youth. On the other hand, homeless nonheterosexual adolescents are worse than homeless heterosexual adolescents with respect to frequency of leaving home, victimization, substance use, psychopathology, and promiscuity.[^Cochran BN, Stewart AJ, Ginzler JA, et al. Challenges faced by homeless sexual minorities: comparison of gay, lesbian, bisexual, and transgender homeless adolescents with their heterosexual counterparts. Am J Public Health 2002;92(5):773-7.^] Is their a simple relationship between prejudice plus discrimination and suicidality? African-Americans experience elevated discrimination, prejudice, incarceration, persistent poverty, social isolation and lack of community resources, yet have a lower suicide rate than whites.[^Gibbs JT. African-American suicide: a cultural paradox. Suicide Life Threat Behav 1997;27(1):68-79.^] Compared to the white suicide rate, the African-American suicide rate was 28% lower under Jim Crow laws in 1950 and 24% lower during 1995-1998.[^Health, United States. Washington, DC: National Center for Health Statistics, US Government Printing Office, 1999;192-94^] Likewise, Jan Smuts, South Africa’s Prime Minister for a few years during apartheid, commented on the care-free, good tempered nature of sub-Saharan Africans, the only happy people he came across.[^van Den Berghe P. South Africa: a Study in Conflict. Berkeley: University of California Press, 1970. [See http://www.cycad.com/cgi-bin/Brand/quotes/q24.html?nochoice=y].^] In addition, an American Association of University Women study concerning self-esteem among school children showed that African-Americans had the highest self-esteem; African-American girls had higher self-esteem than white boys, and African-American boys turned out to be the most confident and ambitious of all, exceeding white boys in their desire to become doctors, scientists, governors, and senators.[^Shortchanging girls, shortchanging America. Washington, DC: American Association of University Women, 1991.^]'^,^' [^Sommers CH. Who stole feminism? How women have betrayed women. New York: Simon & Schuster, 1994.^] The higher self-esteem of African-Americans compared to whites is a robust find;[^Gray-Little B, Hafdahl AR. Factors influencing racial comparisons of self-esteem: a quantitative review. Psychol Bull 2000;126(1):26-54.^]'^,^' [^Twenge JM, Crocker J. Race and self-esteem: meta-analyses comparing whites, blacks, hispanics, asians, and American Indians and comment on Gray-Little and Hafdahl (2000). Psychol Bull 2002;128(3):371-408.^] and this includes self-concept of physical attractiveness, physical ability and even competence in reading, science and social studies, but [in a few studies] not math.[^Tashakkori A. Race, gender, and pre-adolescent self-structure: a test of construct-specificity hypothesis. Personal Individ Diff 1993;14:591-8.^]'^,^' [^Tashakkori A, Thompson VD. Race differences in self-perception and locus of control during adolescence and early adulthood: methodological implications. Genet Soc Gen Psychol Monogr 1991;117(2):133-52.^] Obese individuals experience discrimination with respect to college admission, renting a residence, and have a harder time attracting mates.[^Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: the evidence report. National Institutes of Health, National Heart, Lung, and Blood Institute, June 1998.^] While some homosexuals can conceal their homosexuality, the obese cannot hide their obesity. In a sample of 8,889 individuals from 13,800 randomly selected individuals, ages 18-64 years, 31% were overweight and an additional 11% obese.[^Doll HA, Petersen SE, Stewart-Brown SL. Obesity and physical and emotional well-being: associations between body mass index, chronic illness, and the physical and mental components of the SF-36 questionnaire. Obes Res 2000;8(2):160-70.^] Increasing overweight worsened physical health but not emotional health. Among those with chronic illnesses, the additional presence of obesity significantly worsened physical but not emotional well-being. In short, prejudice plus discrimination do not have a simple relationship with suicidality. How about mood disorders? Homosexuals manifest elevated mood disorders and so do anorexic women. In an examination of death records representing over 5 million women, 571 deaths resulted from anorexia nervosa, and among the dead anorexic women, 1.4% had committed suicide compared to 4.1% among 1,713 age- and ethnicity-matched controls.[^Coren S, Hewitt PL. Is anorexia nervosa associated with elevated rates of suicide? Am J Public Health 1998;88(8):1206-7.^] Therefore, mood disorders do not necessarily correspond to successful suicides. Suicide attempts among adolescents and youth in the general population are associated with delinquency/criminality, or psychiatric illness in self or parents, or substance use,[^Christoffersen MN, Poulsen HD, Nielsen A. Attempted suicide among young people: risk factors in a prospective register based study of Danish children born in 1966. Acta Psychiatr Scand 2003;108(5):350-8.^] all of which are more prevalent among homosexuals. Surely, no one would blame so-called homophobia for such associations among heterosexuals. Additionally, in spite of American society becoming more accepting of homosexuality, the prevalence of suicide attempts among male homosexuals and bisexuals has remained constant across birth cohorts, and the mean age at initial attempts has declined.[^Paul JP, Catania J, Pollack L, et al. Suicide attempts among gay and bisexual men: lifetime prevalence and antecedents. Am J Public Health 2002;92(8):1338-45.^] Elevated suicidal ideation/attempts among homosexuals can be grouped along with other risky practices indulged in by homosexuals'^([[Sexuality/HomePage|sexual behaviors]], [[Psychiatry/Adolescents|Table 3 here]])^' that places them at greater risk for self-harm. The most common form of deliberate self-harm is self-poisoning.[^Hawton K, Fagg J, Simkin S, et al. Trends in deliberate self-harm in Oxford, 1985-1995. Implications for clinical services and the prevention of suicide. Br J Psychiatry 1997;171:556-60.^] In one study, only 41% of a sample of 34 individuals who had deliberately poisoned themselves claimed suicidal intent, and in only one case did a close friend or relative agree that the self-poisoning was motivated by suicidal intent.[^James D, Hawton K. Overdoses: explanations and attitudes in self-poisoners and significant others. Br J Psychiatry 1985;146:481-5.^] Given the considerable relative overrepresentation of homosexuals among individuals with [[Psychiatry/Patients|borderline personality disorder (BPD)]], which represents an extreme along a continuum,[^Haslam N. Categorical versus dimensional models of mental disorder: the taxometric evidence. Aust N Z J Psychiatry 2003;37(6):696-704.^]'^,^' [^Rothschild L, Cleland C, Haslam N, et al. A taxometric study of borderline personality disorder. J Abnorm Psychol 2003;112(4):657-66.^] and that one manifestation of this disorder is repeated suicide attempts,[^Zubenko GS, George AW, Soloff PH, et al. Sexual practices among patients with borderline personality disorder. Am J Psychiatry 1987;144(6):748-52.^] elevated suicidal ideation and attempts among homosexuals should be considered as another example of greater psychiatric morbidity among them that is not readily explicable in terms of societal prejudice. BPD is not the only mental disorder that manifests elevated suicidality. In an examination of 236 cases of multiple personality disorder (MPD), 72% had attempted suicide but only 2.1% had been successful.[^Ross CA, Norton GR, Wozney K. Multiple personality disorder: an analysis of 236 cases. Can J Psychiatry 1989;34(5):413-8.^] In this sample, the most common previous diagnoses were for affective disorders (63.7%), personality disorders (57.4%), anxiety disorders (44.3%) and schizophrenia (40.8%). Note that although MPD is typically a dubious diagnosis,[^Piper A, Jr. Hoax and reality: the bizarre world of multiple personality disorder: Jason Aronson, Inc., 1997.^] the psychiatric morbidity described as MPD correlates with elevated suicide attempts. In addition, in a 6- to 12-year follow-up study of 500 psychiatric outpatients, these individuals had an unnatural (suicide, homicide) death rate three and a half times higher than expected (conditions highly predictive of unnatural deaths were alcoholism, antisocial personality disorder, drug addiction, and homosexuality.), but in spite of a history of repeated suicide attempts, hysteria was not associated with elevated unnatural mortality.[^Martin RL, Cloninger CR, Guze SB, et al. Mortality in a follow-up of 500 psychiatric outpatients. II. Cause-specific mortality. Arch Gen Psychiatry 1985;42(1):58-66.^] One should note that very few sane individuals who decide to commit suicide and then attempt it would fail. I recall an attempted suicide by a friend of mine. He was distraught over his girlfriend having dumped him. He bought rat and roach poison, consumed the rat poison, then went to a friend’s house, told him about what had happened and what he had done, and then proceeded to drink the roach poison. His friend knocked away the canister of roach poison, grabbed him, and rushed him to a nearby hospital. The doctors managed to save him. It is noteworthy that this individual has an above average IQ and it should be obvious to even someone with below average IQ that had he gone deep inside the woods after consuming the rat poison, by the time they would have found him, his body would have been decomposing for a while. In another example, a young male homosexual had attempted suicide about 13 or 14 times and claimed to be no fool who didn’t know how to do it right.[^# Remafedi G. Adolescent homosexuality: psychosocial and medical implications. Pediatrics 1987;79(3):331-7.^] In one such attempt, he crashed his mother’s car at 150 mph into a guardrail. However, had he crashed the car into a thick concrete wall or an 18-wheeler, he would have sealed his fate. It appears that when suicidal decisions and attempts are made in a fit of insanity, they conflict with an innate attempt on the part of the organism to protect oneself, thereby leading to lame attempts at suicide, which are often unsuccessful. Consistent with elevated suicide attempts/ideation among homosexual and bisexual men as an example of psychiatric morbidity is the find that half of the suicide attempters in a probability sample of 2,881 MSM in four large American cities had attempted suicide repeatedly.[^Paul JP, Catania J, Pollack L, et al. Suicide attempts among gay and bisexual men: lifetime prevalence and antecedents. Am J Public Health 2002;92(8):1338-45.^] In this sample, 21% had made a suicide plan, 12% had attempted suicide, and most first-time suicide attempts were before age 25 years. !!References [^#^]