24

Research Trends
Suicidal Behaviors in Homosexual and Bisexual Males

Christopher Bagley, Pierre Tremblay

A stratified random sample of 750 males in Calgary, Canada, aged 1827 years, were given questions on sexual activity and orientation. Mental health questions included a measure of suicidality and of acts of deliberate self-harm. A computerized response format, which has been established as a good method for eliciting sensitive personal data, ensured anonymity. Almost 13% of the males were classified as homosexual or bisexual on the basis of being currently homosexually active or by self-identification. Significantly higher rates of previous suicidal ideas and actions were reported by homosexually oriented males than by heterosexual males. Homosexually oriented males accounted for 62.5% of suicide attempters. These findings, which indicate that homosexual and bisexual males are 13.9 times more at risk for a serious suicide attempt, are consonant with previous findings. The predominant reason for the suicidality of these young males may be linked to the process of coming out, especially for those who currently have high levels of depression. These results underscore the need for qualified services rarely available to homosexually oriented youth. Keywords: Homosexual males, Bisexual males, Suicidal behavior.

Introduction
Available evidence indicates that young homosexual and bisexual males have highly elevated rates of suicidal behavior. Lifetime rates of suicidal behavior (deliberate self-harm or attempted suicide) derived from 12 North American studies of homosexual and bisexual male youth (predominantly associated with gay community organizations) up to 20 years of age range from 20 to 50%, while the mean is 31.3% up to an average age of 19.3 years. The relevant studies are detailed in Table 1. Similar rates have also been reported for
Crisis, 18/1 (1997) 1997 Hogrefe & Huber Publishers

community-based samples of British gay youth [Plummer, 1989]. Of course, the special nature of the sample populations studied means that the very high rates of suicidal behaviors recorded may not be paralleled in general population studies that identify homosexuals. To date, the best general population study available is that by Bell and Weinberg [1978] for the Kinsey Institute. Bell and Weinberg analyzed data from a 1969 sample of 575 white, predominantly homosexual San Francisco males with a mean age of 37 years, reflecting the situation of American youth between the years 1930 and 1969. In the Kinsey study, results were compared with those from a stratified random sample of predom-

Research Trends
Table 1 Rates of Suicide Attempts in Community-Based Samples of Gay and Bisexual Male Youth
Study 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Mean Roesler and Deisher, 1972 Remafedi, 1987 Martin and Hetrick, 1988 Schneider et al., 1989 Remafedi et al., 1991 Magnuson, 1992 Rotheram-Borus, 1992 Uribe and Harbeck, 1992 Herdt and Boxer, 1993 Hammelman, 1993 DAugelli and Hershberger, 1993 Proctor and Groze, 1994 N Males 60 29 480 108 137 77 139 37 141 28 142 159 Mean age (years) 20.0 18.3 17.0* 20.6 23.5 19.6 17.0* 17.0* 18.0* 23.0* 19.2 18.5* 19.3 Suicide attempters (%) 31% 31% 21% 20% 30% 26% 39% 50%* 20% 20% 42% 40% 31.3% Suicide reattempts (%) 37% 20% 45% 44%

25

52% 52%

39.6%

*Exact figure is not given in studies; number represents the best possible estimate given the information supplied. These are predominantly gay community-based samples. Two samples (3 and 9) represents the total adolescent and youth population visiting an agency or youth group. One study (8) is high school based. One sample (7) is 89% youth of color. Suicide attempt definitions usually do not separate parasuicides from deliberate attempts at self-killing. If this were done, some of the attempted suicide rates might be lower.

inantly heterosexual males taken in the same area, controlling for age, education, and occupational level. By the age of 20 years, the homosexual males sampled were shown to have been at a 13.6 times greater risk for attempting suicide, based on the suicide attempt rates of 9.6% for homosexual males and 0.7% for heterosexual males. Bell and Weinberg [1978] also studied smaller samples of black homosexual and heterosexual males, as well as white and black homosexual and heterosexual females, all showing higher attempted suicide rates for homosexually oriented individuals. The probability that homosexually oriented youth are at a higher risk for suicidal ideas (or suicidality) has occasionally been noted in the media, with requests for study and intervention reaching the United States Congress. This led to a 1994 workshop, with papers published in a special issue of Suicide & Life-Threatening Behavior [Moscicki et al., 1995]. The major emphasis of these papers was on the potentially biased nature of all samples that indicate high suicidality levels for homosexually oriented people, apparently limiting the reliable conclusions that could be made [Moscicki et al., 1995; Moscicki, 1995; Muehrer, 1995]. While it is true

that most estimates of suicidality in homosexual youth give rates only for the special populations (e. g., those in gay youth centers or in clinic populations for those counseled following a suicide attempt), several studies have used unselected populations, such as high school students. Further analysis of these earlier studies, arguing that they do imply an elevated rate of suicidality in homosexually oriented males, is offered by Tremblay [1995]. Regardless of the methodological adequacy of the available studies, it is disappointing that the United States Task Force did not address the problems of adequate counseling for young people who are coming out, reducing homophobia, and the hatred and stigmatization of homosexuals. Despite suggestive evidence from community studies, homosexuality issues have been largely ignored in suicide intervention and prevention programs, as well as in youth suicidality research [Remafedi, 1994; Tremblay, 1995], reflecting a phenomenon that exists in almost all fields where youth problems have been studied [Herdt, 1989]. This lack of systematic training on issues concerning the emergence of homosexuality in young people also applies
Crisis, 18/1 (1997)

26

Research Trends
to mental health professionals [Murphy, 1992; Steel & Gyldner, 1993]. The stigmatization of gay men and women by most members of the US public is reflected in the behaviors of some educators and therapists [Harbeck, 1992 a; Steel & Gyldner, 1993]. Homophobia may be a major reason why the methodologically excellent study of Bell and Weinberg [1978] has been largely ignored by suicidologists, and why no attempt has been made to replicate the finding that homosexual males may be at much greater risk for experiencing suicidal crises. For purposes of this analysis, data in our study are given for several categories of males based on their either being currently sexually active (have had heterosexual or homosexual sexual contacts in the last six months) or their being currently celibate (see Table 2). Celibate males are then divided into two categories based on self-identification: predominantly homosexual and predominantly heterosexual. Presenting the data for these categories permits key comparisons to be made; our grouping approximates the categorization of males studied by Bell and Weinberg [1978]. Bell and Weinberg [1978] studied two groups of homosexual and heterosexual males (see Introduction), defined on the basis of the Kinsey [1948] seven-point scale ranging from exclusive heterosexuality (0) to exclusive homosexuality (6). Males in the white homosexual sample had a mean age of 37 years and almost three-quarters . . . considered themselves exclusively homosexual (or 6 on the Kinsey Scale) in their current sexual behavior [p. 54]. Nearly 90% of homosexual respondents were rated a 5 or a 6 on the combined behavior and feelings scale. Approximately three-quarters of Bell and Weinbergs San Francisco heterosexual male sample were rated 0 on the same scale. The mean age of our Calgary sample was 22.7 years. Out of this sample, the group best approximating the Bell and Weinberg sample of predominantly homosexual males includes: the 4.3% of males who in the past 6 months have been currently and exclusively homosexually active and are classified as homosexual (32 of 750); the 1.7% celibate self-identified homosexual males (13 of 750) who have been homosexually active in the past (a few also self-identifying as bisexual); and the 4.9% bisexual males (37 of 750) who are currently sexually active with both genders. This grouping produces a total of 10.9% of males (82 of 750) in the homosexual category, 55% (45 of 82) who are more or less exclusively homosexual, compared to 75% in Bell and Weinbergs homosexual male sample [Bagley & Tremblay, in press].

Antecedents of the Present Study

We have undertaken a secondary analysis of data from a previous study on self-harm behaviors and suicide attempts involving a stratified random sample of 750 men aged 1827 years residing in Calgary, Canada [Bagley, Wood, & Young, 1994]. The sampling was carried out in 1991 and 1992, census figures indicating that in 1991 Calgarys population was 742,000 [Alberta Statistical Review, 1992]. The research was originally designed as a community mental health study focusing on long-term sequels of physical, emotional, and sexual abuse in childhood [Bagley et al., 1994]. However, the questions on sexual behavior and orientation were sufficiently detailed to allow some estimates of the prevalence of male homosexuality and bisexuality to be made. Mental health questions also permitted estimates to be made of lifetime self-harm activity and suicidal attempts in homosexually and heterosexually oriented adolescents and young adults. The aims of this secondary analysis of the Canadian data set were: 1. To determine whether rates of self-harm and suicidal attempts vary significantly on the basis of sexual orientation. 2. To see whether the earlier results of Bell and Weinberg [1978] could be replicated using a random sample of a community not selected on the basis of sexual orientation. 3. To integrate our findings with those of other studies and so produce a clearer perspective on the North American youth suicidality problem.
Crisis, 18/1 (1997)

Research Methods and Instruments in the Original Study

Cluster analysis of census data for Calgary identified three types of neighborhoods containing high

27

R e s e a r c h Research Trends
proportions of young adults: (1) predominantly young families living in detached or row-houses (basically, middle class or upper class); (2) predominantly unmarried young adults living in apartments, usually with white collar jobs (basically, middle to lowermiddle class); and (3) predominantly single, married, or cohabiting adults, living in low rent and public housing. Two neighborhoods (defined by postal codes related to the census data used) within each of the three strata were randomly selected. The sampling area was restricted to the northern half of Calgary, but the regions sampled were representative in terms of demographic profiles of the types of neighborhoods in the southern half of the city as well. Respondents were randomly sampled within the six neighborhoods using the reverse telephone directory. An initial telephone call established whether anyone in the required 18 to 27 year age group was a resident; then a request was made for a personal interview in the respondents home for a study of childhood events, current adjustment, and outlook on life. The interviews took place in 1991 and 1992, and respondents were paid $ 20 for participating, regardless of whether or not they completed the computerized questionnaire. Sexual issues were not mentioned initially, and were only asked at the very end of the computerized questionnaire, because we thought that some types of mental health responses might be triggered if these questions followed those on sexuality. Sampling continued until approximately 75 individuals in each of the ten age groups (1827 years) were obtained. Sixteen individuals did not complete the computerized questionnaire. Of those in the requisite age groups, 72.9% agreed to participate and also completed the computerized questionnaire in their home; this took between 40 and 90 minutes. Within each neighborhood, we interviewed between 31% and 52% of the total population of males aged 1827 years identified in the 1991 Canadian Federal Census. Sampling continued until 750 completed questionnaires were obtained. Substituting newly sampled individuals for those declining an interview could have been a source of bias. However, the 27% of the sample who were recruited as substitutes did not differ on any of the demographic, childhood, or current behavioral and emotional profiles from the remainder of the sample. The districts sampled did not
Crisis, 18/1 (1997)

27

include Calgarys city center, where the highest concentration of homosexual males is located and which is referred to as the gay community area. Respondents were advised that no record of identity would be made, and that the responses were completely anonymous. After an initial tutorial on using the portable computer, questions appeared on the screen, and the computers track-ball was used to key in the chosen response. Data for each respondent were stored in a random block, so that the order in which questionnaire data were saved on the hard drive did not allow the researchers to identify any individual. The research assistants who introduced the computerized questionnaire were male, casually dressed, and in the same age range as the respondents. While the respondent completed the interactive program, the research assistant read a book or watched TV and declined to answer any specific questions about the response system because of the ethical requirement that researchers should be blind to individual responses. This was emphasized during the tutorial to increase the subjects confidence that the information given was truly anonymous. The measure of current sexual interests and activities consisted of selected items on heterosexual and homosexual activity (voluntary and involuntary) at various ages, devised by Langevin [1985], and included questions on whether the sexual activity was wanted or unwanted, taken from a national Canadian survey [Bagley, 1989 c]. Pilot testing of the computerized response format compared with a conventional penciland-paper format indicated that the computerized questionnaire yielded a higher proportion of young males who responded positively to questions on the sensitive theme of sexual abuse in childhood [Bagley & Genuis, 1991]. Using this method, 1% of the men reported having had sex with girls or boys less than 12 years of age, and 45% reported having desires of this kind [Bagley et al., 1994]. Open acknowledgment of such highly taboo sexual information would not be expected in telephone or face-to-face interviews, implying that the computerized method is probably the best available to date for eliciting guarded information. The homosexual contacts reported in this paper were, according to the respondents, all voluntary, regardless of the age at which these contacts occurred (12
Crisis, 18/1 (1997)

28

Research Trends
years and older). Unvoluntary contacts are discussed in Bagley et al. [1994]. The age of 12 years was chosen because at that age Canadian law allows a young person to exercise some degree of free choice in sexual relationships, both heterosexual and homosexual [Wells, 1989]. The measures included the frequency of sexual contact with someone of either sex and responses to the question: Do you consider yourself to be heterosexual (Yes or No) . . . homosexual (Yes or No) . . . bisexual (Yes or No)? Various measures of mental health were employed. The ones of concern here include patient suicidal ideas (in the past 6 months), patient suicidal behavior (in their lifetime), and patient depression (in the past 2 weeks). These measures are reported in this further analysis because, as inferred from previous studies, a high incidence of suicidal ideas and behavior occurs in adolescents and young men struggling with homosexual identity issues within an oppressive and stigmatizing climate of homophobia [Martin, 1982; Schneider, 1988; Herdt, 1989; Harbeck, 1992; Blumenfeld, 1992; Savin Williams, 1994; Unks, 1995]. The Suicidal Ideas and Behavior Scale was scored as follows: 0 = no suicidal thoughts or behaviors in the past 6 months; 1 = any thoughts or ideas about suicide in the past 6 months; 2 = plans for a suicide attempt in the past 6 months; 3 = any act of deliberate self-harm over the patients lifetime; 4 = any act of intentional (but failed) self-killing over the patients lifetime. The face validity of this scale in terms of its psychosocial correlates was established by Ramsay and Bagley [1985] and Bagley and Ramsay [1993]. In addition, respondents also completed the Centre for Epidemiological Studies Depression Scale [Radloff, 1977]. This scale is well-validated, and is widely used in epidemiological studies [Roberts & Vernon, 1983; Zimmerman & Coryell, 1994]. A score of 19 or higher on the scale indicates a degree of psychological distress which might benefit from counseling. (11.1%) and/or current homosexual activity (9.2%). A total of 115 of the 750 males (15.3%) reported consenting homosexual experiences at some point since the age of 12 years and/or identified themselves as homosexual or bisexual at the time of the survey. These results are presented and discussed in Bagley and Tremblay [in press]. We argue that these demographic estimates are likely to be more accurate than the estimates of 13% homosexually oriented males produced in recent studies such as those of Billy et al. [1993], Michael et al. [1994], and Binson et al. [1995], who used telephone or face-to-face interviews to collect data. The figures on suicidality and suicidal behaviors (see Table 2) confirm earlier findings that homosexual and bisexual males have a higher incidence of suicidal thoughts and actions than heterosexual males. Celibate heterosexual men also have a high score on the suicidality index and current depression, but no reported serious suicide attempts. The group most at risk in terms of actual suicidal behaviors, suicidal ideation in the past 6 months, and depression in the past 2 weeks is celibate self-identified homosexual males. They had the highest proportion of individuals in the self-harm category (46.1%; 6 of 13), followed by celibate heterosexual males (17.7%; 22 of 124), compared with their sexually active bisexual (10.8%; 4 of 37), homosexual (9.4%; 3 of 32), and heterosexual male (2.8%; 15 of 544) counterparts. Within the sexually active male groups, those males classified as homosexual and bisexual were nearly three times more likely (risk ratio 2.94:1) to have engaged in self-harm at some point in their lifetime compared with heterosexual males. Homosexual and bisexual men are 6 and 11 times (3.1 and 5.4% vs. 0.5%) more likely to have made a life-threatening suicide attempt than heterosexual males. Celibate homosexual men had the highest serious suicide attempt rate, at 15.5% (2 of 13). For the 10.9% of males classified as homosexually oriented (currently homosexually active males and celibate homosexual males), the risk ratio for a life-threatening suicide attempt was 13.86:1. In other words, these males were almost 14 times (5 of 82 or 6.1% vs. 3 of 688 or 0.44%) more likely to have made a serious suicide attempt at some point in their lives than their heterosexually oriented counterparts. The homosexually oriented males also accounted for 62.5% (5 of 8) of the serious suicide attempters (2 = 17.69, p < .001, df = 1).

Results
Table 2 indicates that in the stratified random sample of 750 young adult males an estimated 12.7% were homosexual or bisexual on the basis of self-identification
Crisis, 18/1 (1997)

Research Trends
Table 2 Sexual Status of Sexually Active and Celibate Homosexual, Bisexual, and Heterosexual Males at Interview and Past Histories of Suicidal Behavior
Category Homosexual sex 1 or more times in past 6 months Heterosexual sex 1 or more times in past 6 months Totals Homosexual, self-labeled Bisexual, self-labeled Heterosexual, self-labeled Suicidal ideas and behavior score Deliberate self-harm/attempted suicide in lifetime Attempted suicide in lifetime CES-Depression Score in past two weeks (SD) Active Active Active Homosexual Heterosexual Bisexual Yes No 32 of 750 4.3% 29 of 32 90.6% 5 of 32 15.6% 1 of 32 3.1% 0.93 3 of 32 9.4% 1 of 32 3.1% 14.6 (9.2) No Yes 544 of 750 72.6% 0 of 544 0.0% 10 of 544 1.8% 540 of 544 99.3% 0.67 15 of 544 2.8% 3 of 544 0.5% 13.7 (7.9) Yes Yes 37 of 750 4.9% 1 of 37 2.7% 25 of 37 67.6% 30 of 37 81.1% 1.25 4 of 37 10.8% 2 of 37 5.4% 15.7 (9.3) Celibate Celibate Homosexual Heterosexual No No 13 of 750 1.7% 13 of 13 100.0% 3 of 13 30.8% 0 of 13 0.0% 2.02 6 of 13 46.1% 2 of 13 15.5% 27.1 (16.5) No No 124 of 750 16.5% 1 of 124 0.8% 3 of 124 2.4% 123 of 124 99.6% 1.71 22 of 124 17.7%. 0 of 124 0.0% 23.6 (15.5)

29

Note: Some males declared more than one type of sexual orientation. Categorization of 13 celibate homosexual and 124 celibate heterosexual males is based on the predominant categories of self-declared sexual status. (a measure of relationship derived from analysis of variance across categories) is 0.18 (p < .001) for suicidal ideas and behavior score, and 0.34 (p < .001) for acts of deliberate self harm/attempted suicide. Bonferroni post hoc analysis for acts of self-harm and attempted suicide: heterosexual males significantly different (p < .01) from all other groups. Bonferroni analysis for attempted suicide, celibate heterosexual males versus all other groups, p < .01 > .005. for CES-D depression score across all groups: 0.16 (p < 01 > .005). Pearson r of CES-D and Suicidal Ideas and Behavior Scales: 0.41, 0.32, 0.45, 0.55, and 0.39, respectively, for the five sexual orientation and behavior categories above. In all cases, p < .05 or beyond.

Discussion
Bell and Weinberg [1978] obtained a sample of 3538 white, predominantly homosexual males, and random sampling was used within the many contact cells to produce a final stratified sample of 575 homosexual males, representative of all such males living in the San Francisco Bay area. The data collected were then compared with the data produced from a stratified random sample of predominantly heterosexual males living in the same area. In contrast, our samples of homosexually and heterosexually oriented males are subsets of a

randomly generated sample, where detecting sexual orientation was not part of the original sampling design. The Bell and Weinberg analysis produced a 13.6 times higher suicide attempt risk factor (to the age of 20 years) for predominantly homosexual males compared to predominantly heterosexual males, and our replication of this figure (13.9 times, to the average age of 22.7 years) is an important cross-validation. The differences between the 6.1% attempted suicide rate for our sample, compared to Bell and Weinbergs 9.6% estimate to the age of 20 years and the 31.3% estimate from additional, contemporary community-based samples (see Table 1), are probably the
Crisis, 18/1 (1997)

30

Research Trends
result of sampling differences. The Bell and Weinberg homosexual male sample represents a large urban gay community, while our suburban sample did not include gay and bisexual males living in the gay community area. Community-based samples of gay and bisexual male youth are (unlike our own sample) generally over-represented by males with attributes associated with high attempted suicide rates. In the Remafedi et al. [1991] sample of 137 males, 40% had been runaways, 39% had been sexually abused, 35% had been arrested, 23% were classified as gender nonconforming (feminine), and 17% had engaged in prostitution. The associated attempted suicide rates for males having these (often overlapping) attributes are 36%, 46%, 44%, 47%, and 52%, respectively, with an average for the sample of 30%. Gender nonconforming gay and bisexual males were estimated to be 3 times more at risk for a suicide attempt than other homosexual males [Remafedi et al., 1991], a risk factor also suggested by Harry [1987]. Most effeminate males are homosexually oriented [Bell, Weinberg, & Hammersmith, 1981; Green, 1987] and, as youth, these visibly gay males tend to live in gay community areas, often for safety reasons. The same applies to male youth engaged in prostitution. Their stroll is usually in the gay community area where they most often live. These males, as well as other at-risk homosexually oriented males living within the gay community area, are not represented (or would be greatly under-represented) in our subsample of homosexually oriented young men living generally stable lives outside the gay community area. Street youth, often with an adolescent runaway history, are not represented in our sample. Runaway youth have attempted suicide rates ranging from 15% to 29% [Stiffman, 1989; Rotheram-Borus, 1993], and gay and bisexual male youth form approximately 2040% of the homeless and street youth male populations [Savin-Williams, 1994]. In Calgary, youth and related services are concentrated in the city center, where one safe house reports that approximately 40% of their clients are homosexually oriented [Calgary Board of Education, 1996]. In addition to not sampling youth leading relatively unstable lives, our sampling excluded institutionalized youth at high risk for life-threatening suicide attempts [Memory, 1989]. On the basis of our results, it is, therefore, proposed that sampling youth in suburban areas of North American cities will produce relatively low suicide attempt rates, because
Crisis, 18/1 (1997)

male youth suicide attempters tend to be greatly overrepresented in populations concentrated in city centers, and often within gay community areas. Our results also imply that suicidality, as in the Remafedi et al. study [1991], is related to homosexuality issues, but these factors may be different from those identified by Remafedi. In our study, 80% (4 of 5) of homosexually oriented suicide attempters, and 77% (10 of 13) of homosexually oriented males in the selfharm category, were either celibate homosexuals or in the homosexually active bisexual category. Some of the celibate homosexual males in our sample may experience prolonged psychological problems because of the coming-out process. Comingout events occur in stages, and are usually tackled in a linear fashion [Troiden, 1988; Martin, 1992], but variations do occur (i. e., the first homosexual experience occurring before or after self-identification), and the youth may regress to a celibate status. These regressions may be related to self-acceptance problems, a factor also existing for some self-labeled bisexual males. When bisexuality is a transitional status [Gochros, 1989; Klein & Wolf, 1985], it is part of the coming-out process. Binson et al. [1995] report that approximately 50% of the bisexually active males aged 1829 years become exclusively homosexually active after the age of 30 years. In our study, the homosexually oriented young adult males (who are predominantly middle to lowerclass) were more likely to have experienced suiciderelated crises at some point in their lives than their heterosexual counterparts. Their 3-times greater likelihood of having engaged in some form of self-harm activity, and especially their 14-times greater risk of having engaged in the most serious form of self-harm (a deliberate attempt at self-killing), suggest their possible over-representation in hospitalizations (and possibly deaths) resulting from their suicide attempt(s). Their determination to die in suicide attempts is reflected in the results obtained by Remafedi et al. [1991]. For 45 out of a total 68 suicide attempts (carried out by 41 gay and bisexual males), for which the rescue was initiated by another person, 58% (26 of 45) of these cases received scores in the moderate to least rescuable range. In other words, the predictable likelihood of rescue was moderate to low, despite the actual occurrence of an intervention [Remafedi, 1991, p. 871]. Of the suicide attempts studied, 21% resulted

Research Trends
in medical or psychiatric hospitalization, sharply contrasting with the 12% rate in studies of all youth [Meehan et al., 1992; Centers for Disease Control, 1991]. These findings imply that homosexually oriented males may form the majority of male youth hospitalizations resulting from suicide attempts. This conclusion is also supported by the information related to the reattempted suicide rates for gay and bisexual male youth (2052%, with a mean of 39.6%; see Table 1). Given that the probability that males re-attempting suicide eventually commit suicide ranges from 10% to 14% [Spirito et al., 1989], and that gay and bisexual male youth have a very high re-attempt rate, it is possible that homosexually oriented males do feature disproportionately in populations of young males who have killed themselves. Only a small number of studies have estimated the proportion of homosexually oriented young males who commit suicide [Bagley, 1992; Shaffer et al., 1995]. All of these studies are beset by the problem that coroners and medical examiners may not be told about homosexuality, and that if parents have such information (or have reasons to suspect), they may suppress it. Some young males suffering from the psychological agony imposed by homophobia, may have told no one about their acute crises. Bagley [1992], after studying medical examiner records in Alberta, found that for 11 of 130 males (8.5%) aged 1030 years who committed suicide, homosexuality was identified as a background factor. Bagley notes that one male suicide victim in his series of completed suicides was known to have experienced an identity crises about coming out, but this was not recorded in the medical examiners records. Shaffer et al. [1995] only identified 3 of 95 male suicides (3%) as definitely homosexual, with some indication of homosexual orientation for nine more. There is some evidence that gay, bisexual, and lesbian youth have been ill-served by conventional mental health and counseling agencies, a reflection perhaps of the dont ask, dont tell ethos concerning homosexuality in North America. At the New York Institute for the Protection of Gay and Lesbian Youth for example, the situation of nine young people receiving therapy elsewhere for their suicide attempt was described as follows: [They] had not yet told their therapist either that they were homosexual or that that was a factor in their suicide attempt [Martin & Hetrick, 1988, p. 173]. These and other findings suggest that mental health professionals are poorly educated and trained about homosexual realities [Murphy 1992; Kourany, 1987], and that these issues continue to be ignored in most universities. At Vancouvers University of British Columbia, for example, homosexual realities are not included in counselor training [Abrams, 1996], in spite of Vancouver having the largest gay and lesbian community in western Canada. Homosexual youth are also often misunderstood and indeed harmed in substance abuse treatment programs [Simpson, 1994]. Substance abuse is a common problem among gay and bisexual male youth having coming out problems, especially stigmatization and hatred, and the low self-esteem that can result [Shifrin & Solis, 1992]. Remafedi et al. [1991] reported on the basis of a multiple logistic regression analysis that illicit drug use was one of the three most important factors implicated in the suicide attempts of gay and bisexual male youth, with age of self-identification and gender nonconformity being the other two. Gay and bisexual male youth have been at risk for a number of negative life experiences that are potentially linked to suicidal crises, including being physically, verbally, and emotionally abused in families, schools, and society; manifesting declining academic achievement and truancy; becoming throwaways, runaways, street youth, and delinquents; engaging in prostitution for survival purposes or as a way to act out learned negative stereotypes; and not being able to access qualified services when needed; or worse, being psychologically abused or neglected by professionals entrusted to help them [Remafedi, 1987; Boyer, 1989; Gibson, 1989; Hunter, 1990; Kruks, 1991; Remafedi et al., 1991; Galst, 1992; American Academy of Pediatrics, 1993; Savin-Williams, 1994; Pilkington & DAugelli, 1995]. Earlier sexual abuse might be a contributing factor for the psychological problems of homosexual youth. Certainly, our earlier analysis of the data from the Calgary survey indicates that sexual abuse (experiencing unwanted sexual acts before the age of 17 years) is a factor in suicidality problems [Bagley et al., 1994]. However, further analysis of the data from our sample of 750 Calgary males indicates that child sexual abuse is not significantly related to the self-harm behaviors reported by sexually active homosexual, bisexual, and heterosexual males. However, it is significant in the celibate groups who have the highest mean depression
Crisis, 18/1 (1997)

31

32

Research Trends
(CES-D) scores. Remafedi et al. [1991], on the basis of multivariate analysis, also did not find sexual abuse to be significantly implicated in the suicide attempts of sexually active gay and bisexual male youth when other factors were controlled. The struggles of a homosexual youth in the face of rejection by family and school peers is well illustrated by the following case. This 17-year-old boy sent the following message to a web site in Calgary, operated by the mother of a homosexual son:
My fight to live the life I want, and I see it in my gay friends lives, is so hard. My parents refuse to accept me. Their religion comes before me. I feel like they dont care about how I feel, or what I want to be when I become of age. It really gets lonely in North Carolina. I dont even know why Im writing this . . . I just saw post you left in the young gay/bi/les news site. My parents have told me if I live this life style they would rather be dead, theyre afraid of their own reputation. They are afraid of what my younger sisters life would be like. They are afraid of what my relatives would say. They told me that they wish that I was never born. Ive run away several times, Ive used drugs to satisfy my needs for love . . . but the drugs became overwhelming so I had to go to the hospital for a while. It helped me a lot. So now at the present date I have tricked my parents, they think Im now straight. But Im not. I cant love girls. Well, the type of love that you and I know. I have many girls that are friends, but its not the same as a guy. I really need someone to talk to. Next school year Im going back to my old school where everyone knows Im gay. Its gonna be so hard because most of my relatives are very conservative and like to express themselves. All of this pressure has drove me over the wall to where life seems meaningless. Im lying to my parents, grandparents, it all gets so confusing, I just dont know who to lie to . . . They have kicked me out of the house and sent me to the local YMCA for a night. Every time we have a fight, they end up by thinking that Im straight . . . so Im going in circles. I just want parents who should love me, to love me for what I am inside. But when does the lying end? They have already told me that if I live this life they will reject me as a son. Why cant they see that all this is slowly killing me? What a life your son [i. e., the son of the woman hosting the web site] must have, hes so lucky to have parents that love him even if he is gay. God, how much I wish for that . . . Ive lost all respect for god, Im so confused. Im on so much medication for depression and anxiety, Ive been to mental institutions for suicide . . . Its just the confusion that is getting to me. If God is Crisis, 18/1 (1997) real why cant he make my life better? Im trapped in a room with windows and doors. but theyre all locked and barred. God hasnt left me a window open for me to escape, no keys under the mat. So I walk in circles in that room. Im just so scared, what is going to happen when I get older, will my parents love me? How badly I want my parents love But I dont think that will ever happen if I live a gay life. Several months ago, I decided to live my life no matter what my parents think.

This young man sent no more messages to the web site. He might be dead. After reading this narrative, it is not difficult to understand why he might have killed himself. Or, he may have been successful in coming out and living an independent, gay life. But the hurdles to be overcome in doing this are daunting. He has to acquire a new and loving family of gay men, he needs nonhomophobic counseling, and he needs a nonhomophobic school environment. Gibson [1989] might have been writing about the internet boy (who came from a religiously conservative black family) when he said:
Homosexual youth . . . have tremendous fears of losing their extended family and being alone in the world. This fear is made greater by the isolation they already face in our society as people of color. These ethnic minority gay youth who are rejected by families are at risk of suicide because of the tremendous pressures they face being gay and a person of color in a white, homophobic society [p. 123].

Finally, it must be stressed that the Calgary study was not designed to investigate any links between suicidality and homosexual status; the risk ratios for suicidal behavior, though salient, need be verified in further research. New studies must be designed to investigate the hypotheses that our own study has implied. Given the probability that family and community reactions to an emerging homosexual identity may be an important etiological factor in adolescent suicide attempts (and perhaps also in completed suicides), new studies should be conducted as a matter of urgency.

References
Alberta Statistical Review. First Quarter, 1992. Bureau of Statistics, Alberta Treasury, 1992. American Academy of Pediatrics: Committee on Adolescence, Homosexuality and adolescence. Pediatrics 92:631634. Bagley C. Prevalence and correlates of unwanted sexual acts in

Research Trends
childhood: Evidence from a national Canadian study. Canadian Journal of Public Health 1989; 80:295296. Bagley C, Genuis, M. Sexual abuse recalled: Evaluation of a computerized questionnaire in a population of young adult males. Perceptual and Motor Skills 1991; 72:287288. Bagley C, Ramsay, R. Suicidal ideas and behavior in contrast generations: Evidence from a community mental health survey. Journal of Community Psychology 1993; 21:2634. Bagley C, Tremblay, P. On the prevalence of homosexuality and bisexuality in a random community survey of 750 men aged 18 to 27. Journal of Homosexuality 1997; in press. Bagley C, Wood M, Young L. Victim to abuser: Mental health and behavioral sequels of child sexual abuse in a community survey of young adult males. Child Abuse and Neglect 1994; 18:683697. Bell A, Weinberg M. Homosexuality: A study of diversity among men and women. New York: Simon and Schuster, 1978. Bell A, Weinberg M, Hammersmith S. Sexual preference. Bloomington, Indiana: Indiana University Press, 1981. Billy J, Tanfer K, Grady W, Klepinger D. The sexual behavior of men in the United States. Family Planning Perspective 1993; 25:52 60. Binson D, Michaels S, Stall R, Coates T, Gagnon J, Catania J. Prevalence and social distribution of males who have sex with males: United States and its urban centers. Journal of Sex Research 1995; 32:245254. Blumenfeld W. (Ed). Homophobia: How we all pay the price. Boston: Beacon Press, 1992. Boyer D. Male prostitution and homosexual identity. In G Herdt (Ed) Gay and lesbian youth (pp. 151184). New York: Harrington Park Press, 1989. Calgary Board of Education. Report to the regular meeting of the Board. June 11, 1996. Centers for Disease Control. Attempted suicide among high school students United States, 1990. Journal of the American Medical Association 1991; 266:19111912. DAugelli S, Hershberger S. Lesbian, gay, and bisexual youth in community settings: Personal challenges and mental health problems. Journal of Community Psychology 1993; 21:421448. Galst L. Throwaway kids. The Advocate (Los Angeles) 1992; December 29:5457. Gibson P. Gay and lesbian youth suicide. In M Feinlieb (Ed.) Prevention and intervention in youth suicide: Report of the Secretarys Task Force on Youth Suicide, Vol. III. Washington, DC: US Department of Health & Human Services, 1989, pp. 109142. Gochros H. When husbands come out of the closet. New York: Haworth, 1989. Green R. The sissy boy syndrome and the development of homosexuality. New York: Yale University Press, 1987. Hammelman T. Gay and lesbian youth: Contributing factors to serious attempts or considerations of suicide. Journal of Gay and Lesbian Psychotherapy 1993; 2:7789. Harbeck K. Introduction. In KM Harbeck (Ed.) Coming out of the classroom closet. New York: Harrington Park Press, 1992, pp. 17. Harry J. Parasuicide, gender, and gender deviance. Journal of Health and Social Behavior 1987; 24:350361. Herdt G. Introduction: Gay and lesbian youth, emerging identities, and cultural scenes at home and abroad. In G Herdt (Ed.) Gay and lesbian youth. New York: Harrington Park Press, 1989. Herdt G, Boxer A. Children of horizon: How gay and lesbian teens are leading a new way out of the closet. Boston: Beacon Press, 1993. Hunter J. Violence against lesbian and gay male youths. Journal of Interpersonal Violence 1990; 5:295300. Klein F, Wolf T (Eds.). Two lives to lead: Bisexuality in men and women. New York: Harrington Park Press, 1985. Kourany R. Suicide among homosexual adolescents. Journal of Homosexuality 1987; 13:111117. Kruks G. Gay and lesbian homeless/street youth: Special issues and concerns. Journal of Adolescent Health 1991; 12:515518. Langevin R. Erotic preferences, gender identity and aggression in males. Hillsdale, NJ: Lawrence Erlbaum, 1985. Magnuson C. Lesbian and gay youth in Ottawa: The importance of community Pink Triangle Services. Ottawa, Ontario: Masters thesis, Carleton University, 1992. Martin A. Learning to hide: The socialization of the gay adolescent. Adolescent Psychiatry: Development and Clinical Issues 1982; 10:52 65. Martin H. The coming out process for homosexuals. Hospital and Community Psychiatry 1992; 42:29. Martin A, Hetrick E. The stigmatization of the gay and lesbian adolescent. Journal of Homosexuality 1988; 15:163183. Meehan P, Lamb J, Saltzman I, OCarroll P. Attempted suicide among young adults: Progress toward a meaningful estimate of prevalence. American Journal of Psychiatry 1992; 149:4144. Memory J. Juvenile suicide in secure detention facilities. Correction of published rates. Omega: Journal of Death Studies 1989; 13:455 463. Michael R, Gagnon J, Laumann E, and Kolata G. Sex in America: A definitive survey. Boston: Little, Brown, 1994. Moscicki E. Epidemiology of suicidal behavior. Suicide and LifeThreatening Behavior 1995; 25:2235. Moscicki E, Muehrer P, Potter L. Introduction to supplementary issue: Research issues in suicide and sexual orientation. Suicide and Life-Threatening Behavior 1995; 25:13. Muehrer P.. Suicide and sexual orientation: A critical summary of recent research and direction for future research. Suicide and Life-Threatening Behavior 1995; 25:7281. Murphy B. Educating mental health professionals about gay and lesbian issues. In K. Harbeck (Ed.) Coming out of the classroom closet. New York: Harrington Park, 1992, pp. 229246. Pilkington N, DAugelli A. Victimization of lesbian, gay, and bisexual youth in a community setting. Journal of Community Psychology 1995; 23:3456. Plummer K. Lesbian and gay youth in England. In G Herdt (Ed.) Gay and lesbian youth. New York: Harrington Park Press, 1989, pp. 193223. Proctor C, Groze V. Risk factors for suicide among gay, lesbian, and bisexual youth. Social Work 1994; 39:504513. Radloff L. The CES-D scale: A self-report depression scale for research in the general population. Applied Psychological Measurement 1977; 1:385401. Ramsay R, Bagley C. The prevalence of suicidal behaviors, attitudes and associated social experiences in an urban population. Suicide and Life-Threatening Behavior 1985; 8:151160. Remafedi G. Adolescent homosexuality: Psychosocial and medical implications. Pediatrics 1987; 79:331337.

33

Crisis, 18/1 (1997)

34

Research Trends
Remafedi G, Farrow J, Deisher R. Risk factors for attempted suicide among gay and bisexual youth. Pediatrics 1991; 87:869875. Remafedi G. Introduction: The state of knowledge on gay, lesbian, and bisexual youth suicide. In G Remafedi (Ed.) Death by denial. Boston: Alyson Publications, 1994, pp. 714. Roberts R, Vernon S. The Centre for Epidemiological Studies depression scale: Its use in a community sample. American Journal of Psychiatry 1983; 140:4146. Roesler J, Deisher R. Youthful male homosexuality. Journal of the American Medical Association 1972; 219:10181023. Rotheram-Borus M, Hunter J, Rosario. Suicidal behavior and gayrelated stress among gay and bisexual male adolescents. Unpublished manuscript, Columbia University. Data and results summarized in Savin-Williams, 1994. Rotheram-Borus M. Suicidal behavior and risk factors among runaway youths. American Journal of Psychiatry 1993; 150:103107. Savin-Williams R. Verbal and physical abuse in the lives of lesbian, gay male, and bisexual youth: Associations with school problems, running away, substance abuse, and suicide. Journal of Consulting and Clinical Psychology 1994; 62:261269. Schneider M. Often Invisible: Counselling gay & lesbian youth. Toronto, Ontario: Central Toronto Youth Services, 1988. Schneider S, Farberow N, Kruks N. Suicidal behavior in adolescent and young adult gay men. Suicide and Life-Threatening Behavior 1989; 19:281394. Shifrin F, Solis M. Chemical dependency in gay and lesbian youth. In L Dava (Ed.) Lesbian and gay men chemical dependency issues. New York: Harrington Park, 1992, pp. 6776. Shaffer D, Vieland V, Garland A, Rojas M,Underwood M, Busner C. Adolescent suicide attempters. Journal of the American Medical Association 1990; 264:31513155. Simpson B. Opening doors: Making substance abuse and other services more accessible to lesbian, gay, and bisexual youth. Toronto, Ontario: Central Toronto Youth Services, 1994. Steel C, Gyldner C. Identifying and meeting the needs of gay and lesbian adolescents in family therapy. Canadian Journal of Human Sexuality 1993; 2:112. Stiffman A. Suicide attempts among runaway youths. Suicide and Life-Threatening Behavior 1989; 19:147159. Tremblay P. The homosexuality factor in the youth suicide problem. Presentation at the Sixth Annual Conference of the Canadian Association for Suicide Prevention, Banff, October, 1995. Available on the Internet at: http://www.qrd.org/qrd/www/ youth/tremblay/. yes Troiden R. Homosexual identity development. Journal of Adolescent Health Care 1988; 9:29. Unks G. The gay teen. New York: Routledge, 1995. Uribe V, Harbeck K. Addressing the needs of lesbian, gay, and bisexual youth: The origins of Project 10. In K Harbeck (Ed.) Coming out of the classroom closet. New York: Harrington Park, 1992, pp.9 22. Wells M. Canadas law on sexual abuse. Ottawa, Ontario: Department of Justice, Government of Canada, 1989. Zimmerman M, Coryell W. Screening for major depression in the community: A comparison of measures. Psychological Assessment 1994; 6:7174.

Christopher Bagley (to whom correspondence should be addressed) has a D. Phil. in social psychology from the University of Sussex, UK, and has conducted extensive research in adolescent and adult mental health. He has taught and researched in Canada, Britain, Hong Kong, India, and the Philippines. His most recent book, Children, sex and social policy: Humanistic solutions for problems of child sexual abuse, was published by Avebury in 1997. He was elected to a Fellowship of the Royal Society of Arts in 1996. Dr. Bagley is currently with the Department of Social Work Studies, University of Southampton, Southampton SO17 1BJ, England. Pierre Tremblay studied French literature at the University of New Brunswick, where he also obtained a degree in geology. He has worked in the oil exploration industry in Alberta, Canada, before studying education. He has worked as a teacher and counselor in Alberta, and is currently a community worker with gay and lesbian youth in Calgary.

Crisis, 18/1 (1997)