Dr Delaney Skerrett, Australian Institute for Suicide Research & Prevention: Suicidal behaviour in...

Suicidal behaviour in LGBTI populations in Australia

Dr Delaney Michael SkerrettDr Kairi KõlvesProf. Diego De Leo Australian Institute for Suicide Research and Prevention

WHO Collaborating Centre for Research and Training in Suicide Prevention

National Centre of Excellence in Suicide Prevention

Life Promotion Clinic

Overview

• AISRAP• Introduction• International research• Australian research• Risk & protective factors• Limitations & implications for research• Queensland Suicide Register (QSR) study

AISRAP, National Centre of Excellence in Suicide Prevention

Australian Institute for Suicide Research and Prevention The Institute conducts research in all aspects of suicide prevention and

manages the Queensland Suicide Register since 1990. AISRAP was officially established in 1997.

AISRAP, located at Griffith University's Mt Gravatt campus, became a World Health Organization Collaborating Centre for Research and Training in Suicide Prevention in July 2005.

Apart from research activities, AISRAP provides education and training for health and allied professionals. Offering postgraduate programs in suicidology in 2001 was a world first for further information contact [email protected]

In 2004, the Institute opened the Life Promotion Clinic. This was the first outpatient facility in Australia focused on providing specialised treatment to people with a history of suicidal behaviour.

In 2008 AISRAP was established as the National Centre of Excellence in Suicide Prevention, funded by the Commonwealth government’s Department of Health and Ageing.

Introduction

• LGBT(IQ) = lesbian, gay, bisexual, transsexual, (intersex, queer/questioning)

• Same-sex attraction ubiquitous, however…– Sexuality and gender identity as complex and not stable or

essential characteristics• Complicated to study

– Little information on actual feelings or practices (usually relies on self-report or common belief)

– Especially problematic with older studies and psychological autopsies• One Danish study based on partnership register (still approximate

indication only)AISRAP, National Centre of Excellence in Suicide Prevention

Introduction (cont.)

• Nothing inherently suicidogenic about sexuality/gender minority status

• Continued societal stigma, particularly for adolescents, has led to belief in greater risk of suicidal behaviour– Early research inconsistent and often non-representative

(e.g., prisoners, psychiatric inpatients)


Introduction (cont.)

• LGBTI recognised as high risk groups by Australian Senate Committee report (2010)– “Targeted approach” to prevention and awareness– Commonwealth Government acknowledged the

heightened risk and supported the recommendations for targeted approaches

• DoHA’s LIFE framework lists gay and lesbian people as among the “highest risk” groups– MindOUT! project

Aim

• In light of international research (to follow) and Australian government agency recommendations, establish the evidence base for heightened risk in the Australian context– No review of the Australian research has so far been

published

Method

• Scopus, Medline, and Proquest– Articles in English in peer-reviewed academic journals– Title/key words/abstract: suicid* AND gay OR lesbian OR

bisexual OR transsexual AND Australia


INTERNATIONAL RESEARCH


Studies on non-fatal suicidal behaviours: North American adults• Paul et al (2002): 2,881 gay and bisexual men (USA)

– Lifetime prevalence for suicide plan 21%– Suicide attempt 12% (almost half multiple attempters)

• Bolton & Sareen (2011): 34,653 adults, nationally-representative survey (USA)– Males: G 9.8%, B 10%, unsure 8.5%, non-GB 2.1% (lifetime attempt)– Females: L 10.9%, B 24.4%, 9.9% unsure, non-LB 4.2% (lifetime

attempt)• Mathy (2002): 38,204 respondents to online survey from 5

continents (93% USA; 83% male)– Lifetime suicidal ideation sig higher for LGB only in Asia, Nth America,

Sth America (not Australia or Europe)– Suicide attempt significantly higher on all continents except Europe


Studies on non-fatal suicidal behaviours: North American adolescents

• Hatzenbuehler (2011): 31, 852 11th graders in Oregon (4.4% LGB) – 12-month attempt LGB 21.5% vs. 4.2% non-LGB

• Eisenberg & Resnick (2006): 83,731 high schoolers from Minnesota– LGB 47.3% males & 72.9% females lifetime suicidal ideation (34.7% & 53% non-LGB)– LGB 29.0% males & 52.4% females lifetime suicide attempt (12.6% & 24.8% non-

LGB)– ORs (male & female): 1.60 & 1.92 (ideation); 2.49 & 2.63 (attempt)

• Russell & Joyner (2001): 12,000 high schoolers (USA)– ORs (male & female): 2.45 & 2.48 (suicide attempt)

• Silenzio et al (2007) nationally-representative longitudinal study of adolescents (USA)– aOR: 2.94 (12-month ideation)

• Marshal et al (2012): 527 female 17 yrs. high schoolers in USA– ORs: 2-week suicidal ideation 4.17, 12-month suicidal ideation 4.93, and 12-month

self-harm 7.20


Studies on non-fatal suicidal behaviours: non-North American

• Wichstrøm & Hegna (2003): 2,924 high-schoolers (representative; Norway)– Same-sex sexual behaviour predictive of previous attempt (males & females) and

future attempt (females) independent of depressed mood, early sexual debut, parental monitoring, social support

• Pinhey & Millman (2004): 1,381 high-schoolers (random sample from 95% of population; Guam)– ORs (male & female): 5.0 & 2.6 (12-month attempt)

• Plöderl & Fartacek (2005): 358 LGB & 267 non-LGB adults (convenience sample; Austria)– LGB 28%, non- LGB 13% (current ideation)– LGB 14%, non-LGB 1% (lifetime attempt)

• Skegg et al (2003): 946 participants in longitudinal study in NZ– Lifetime self-harm: OR 5.5 males, 1.9 females

• The greater the degree of same-sex attraction, the greater the likelihood of self-harm

– 12 month suicidal ideation: OR 3.1 males, 2.9 females– Lifetime suicide attempt: OR 3.2 males, 1.4 females


Recent research on fatal suicidal behaviour

• Mathy et al (2011): nested case-control study using national cross-referencing civil partnership and suicide data (Denmark)– Significant for males only: age-adjusted mortality risk approx. 8-times

higher for men in registered partnerships with other men vs. ever married and approx. 2-times higher than never married


Suicidal behaviours and minority gender role

• Fitzpatrick et al (2005): 77 UG psych students, cross-gender role uniquely predicted suicidality, accounting for more variance than sexuality

• Clements-Nolle (2006): 392 MtFs, 123 FtMs (San Fransisco):– 32% lifetime suicide attempt


AUSTRALIAN RESEARCH


Studies on non-fatal suicidal behaviours: Australia

• Buhrich & Loke (2005): first study identified– Greater proportion of GB than non-GB men presenting to Sydney hospital ER

for suicidal behaviours (n.s.)• Barbeler (1991): convenience sample 200 Ls aged 14-28 in Sydney

– 14-18yrs: 63% suicidal ideation (lifetime); 46% because of sexuality– 19-21yrs: 51% (24%)– 22-25yrs: 51% (33.5%)– Suicide attempt (lifetime; all ages): 47.5% (31%)

• Kelly et al (1998): 65 HIV-, 164 HIV+ GB men– Symptomatic HIV+ men significantly higher suicidal ideation than

asymptomatic HIV+ and HIV- men– HIV+ 21%, HIV- 29% (lifetime attempt, n.s.)



• Jorm et al (2002): 4,824 from electoral roll 20-24yrs & 40-44yrs (Canberra)– “Suicidality” (measured on 5-pt scale) significantly higher for LG, and higher

still for B• Moller et al (2013) from wave three of the same study as Jorm et al

(4,160 participants)– Bisexuality predictive of self-harm (12-month): OR 2.65


• Nicholas & Howard (1998): 57 G and 54 non-G men from Sydney (snowball sample)– Higher lifetime suicidal ideation, thoughts of suicide, intrusive thoughts of

suicide, thoughts about methods• Rogers et al (2004): 542 G (34% HIV+) from Adelaide

– 14% HIV+, 17% HIV- (2-week) suicidal ideation (n.s.)– 25% lifetime attempt (overall)

• Hillier et al (2005): 1,749 SSA 14-21yrs– 35% lifetime self-harm due to sexuality: 14-17yrs 41%; 18-21yrs 31%)

• Hillier et al (2010): “strong relationship” between homophobic abuse and thoughts about self-harm, self-harm, thoughts about suicide, and suicide attempt


• Pitts et al (2006): 5,476 LGBTI (65% male, 35% female) online, broadly geographically representative of all States and Territories– 15.7% males, 14.6% females, 15.7% overall “better off dead” in previous 2

weeks• Abelson et al (2006): 656 G, 115 B, non-GB men in Sydney & Melbourne,

18-50 yrs.– Frequency of “feeling suicidal” (0 never to 3 often): G .61, B .62, non-GB .31

• Thorpy et al (2008): online 12-20yrs LGB in Qld– 68% “thought about” self-harm (12 months)– 59% had self-harmed (12 months)– 82% suicidal ideation (12 months)– 37% attempt (12 months)

Studies on fatal suicidal behaviours: Australia

• There were no studies identified on fatal suicidal behaviours among LGBT people, except:– QSR report 2005-2007 (De Leo & Sveticic, 2012) identified only 12

suicides of same-sex orientation• de Leo et al (2010) note that sexuality is seldom recorded at

death in Australia


RISK & PROTECTIVE FACTORS


Common risk factors with non-LGBT

• Substance abuse– G more likely to have tried a variety of drugs; L more likely alcohol

abuse (McDaniel et al, 2011)


Specific risk factors

• Developmental stressors– “Coming out” in adolescence/early adulthood

• Prejudice & discrimination (homophobia & heterosexism)– Internalisation of homophobia: shame

• Higher risk of being bullied & of sexual assault• Precocious development of minority sexual orientation & subsequent

maltreatment (Corliss et al, 2009)• Russel & Joyner (2001): suicide risk mediated by depression,

hopelessness, alcohol abuse, recent suicide attempt of family member or friend, victimisation

• Clements-Nolle et al (2006): independent predictors of suicide risk in transsexual people are age under 25 yrs, depression, history of substance abuse treatment, history of forced sex, discrimination, & victimisation


Protective factors

• Talking about & acceptance of one’s sexuality:– Suicide attempts tend to occur before “coming out” and first same-sex

experience (Nicholas & Howard, 1998)• Supportive family, esp. father (Nicholas & Howard, 1998)• Feeling safe at school, having supportive teachers, having a

high self-esteem (Saewyc, 2007)• Exposure to media positively portraying gay characters

(McKee, 2000)• Tolerant societal environment: rates in US states with anti-

discrimination legislation decreased after coming into law


LIMITATIONS & IMPLICATIONS FOR RESEARCH


Limitations

• Keyword search limited to article titles given the large amount of international research on the topic


Implications for research

• No representative studies have been carried out in Australia– Jorm et al (2002) carried out on 8,824 people from the

electoral role did identify elevated risk– Abelson et al (2006) found statistically significant

differences in “feeling suicidal” between G, B, and non-G/B men, but control group not matched

• No studies on completed suicide among LGBT• Need for representative, controlled studies as well as

studies on completed suicide in Australia


QUEENSLAND SUICIDE REGISTER (QSR) STUDY FOR BEYONDBLUE


The Queensland Suicide Register

• The QSR is a comprehensive suicide database maintained by the Australian Institute for Suicide Research and Prevention (AISRAP).

• The QSR holds records of all suicides in Queensland since 1990 and is currently the only database of suicides in Australia.

• Information comes from a variety of sources including– the Queensland Office of State Coroners – the Queensland Health

• The QSR provides information on a wide range of demographic, psychosocial, psychiatric, medical, contextual and behavioural aspects of suicide death cases

QSR

Causes of death are scrutinised in the QSR following the Suicide Classification Flow Chart, developed by AISRAP

All suicide cases in the QSR are classified into one of the following categories:

• Beyond reasonable doubt, or• Probable, or • Possible.

This method of assessment might lead to a lower threshold for classifying a death as a suicide, since it is based on health research criteria rather than on an assessment from Coroner’s findings as applied by the ABS (De Leo et al., 2006).

Queensland Suicide Register (QSR) study

• Part one of two-part study for beyondblue– Part two is a psychological autopsy study with next-of-kin (NOK) of

approx. 25 LGBTI suicides, with 2-3 live LGBTI controls (or NOKs)• All cases 2000-2009 were reviewed for mention of LGBTI

identification or status– Only “beyond reasonable doubt” and “probable” were included (i.e.,

“possible” was excluded)• First study on fatal suicidal behaviours in Australia

– Likely the first study in some 30 years to explore the characteristics of LGBT completed suicides to determine whether or not LGBT individuals who die by suicide constitute a unique subpopulation of those at risk for suicide

Queensland Suicide Register (QSR) study

• 35 cases identified (L=11(10); G=22; B=1(2); T=1; I=0)– Underreporting: sexuality no longer including on “Form 1”;

approx. 550 suicides per year in Qld• 3 controls matched for date of suicide (closest

possible), age (+/- 2 years), and gender were compared with conditional logistic regression (or Fisher’s exact test for n < 4) for demographic, psychosocial, psychiatric, medical, contextual, and behavioural aspects – T case matched for identified gender (psychosocial vs.

biological/medical approach)

Conclusion

• Early studies found no significant increased risk of suicide among LGBT but more recent work, including representative studies (US, Canada, Norway, and Denmark), has identified increased risk of suicidal ideation, suicide attempt, and completed suicide.

• Outstanding need for methodologically rigorous work on this important topic in Australia– Our work with beyondblue go towards addressing this

need


THANK YOU!


Copyright © Australian Institute for Suicide Research and Prevention, 2013

[email protected](07) 3735 3393

mailto:[email protected]

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