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Bisexuality and Suicide: A Systematic Review of the Current Literature Maurizio Pompili, MD, PhD,* David Lester, PhD,† Alberto Forte, MD,* Maria Elena Seretti, MD,* Denise Erbuto, PsyD,* Dorian A. Lamis, PhD,‡ Mario Amore, MD,§ and Paolo Girardi, MD* *Department of Neurosciences, Mental Health and Sensory Organs, Suicide Prevention Center, Sant’Andrea Hospital, Sapienza University of Rome, Rome, Italy; †The Richard Stockton College of New Jersey, Galloway, NJ, USA; ‡ Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA; § Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Section of Psychiatry, University of Genova, Genova, Italy [Correction added on 16 June 2014, after first online publication: David Lester, Dorian A. Lamis, and Mario Amore’s affiliations were corrected.] DOI: 10.1111/jsm.12581

ABSTRACT

Introduction. Many studies of lesbian, gay, and bisexual youth have demonstrated that individuals reporting a bisexual orientation have a particularly high risk of suicidal behavior and substance abuse. It has been also suggested that bisexual individuals (both men and women) have higher rates of depression and anxiety compared with homosexual and heterosexual groups. Aim. The aim of the present article was to determine whether or not an association between bisexuality and suicidal behavior exists and to analyze risk factors for suicidal behavior in bisexual individuals. Main Outcome Measures. The combined search strategies yielded a total of 339 records screened from PubMed, Scopus, and Web of Knowledge. Duplicate articles, articles that were not in English, and those that did not analyze bisexuality separately from homosexuality were excluded. A quality assessment was performed for each study included. Methods. A careful systematic review of the literature was conducted investigating the potential bisexuality-suicidal behavior link. A total of 77 articles from peer-reviewed journals were considered, and the most relevant (N = 19) were selected for this review. Results. Individuals reporting a bisexual orientation had an increased risk of suicide attempts and ideation compared with their homosexual and heterosexual peers. Risk factors included related victimization, peer judgments, and family rejection. Bisexual individuals also reported higher rates of mental illness and substance abuse. Conclusions. Bisexual individuals may experience more psychological distress and mental health problems than individuals who identify with a homosexual or heterosexual orientation. Clinicians should consider the potential for suicidal behaviors in bisexual individuals and be alert for increased mental health problems and poor social integration. Pompili M, Lester D, Forte A, Seretti ME, Erbuto D, Lamis DA, Amore M, and Girardi P. Bisexuality and suicide: A systematic review of the current literature. J Sex Med 2014;11:1903–1913. Key Words. Bisexuality; Suicide; Prevention; Sexual Orientation

Introduction

S

exual orientation has at least three different dimensions: sexual self-identification, sexual behavior, and sexual attraction or fantasy [1,2]. The transition from childhood to adulthood that adolescents face can be challenging for any adolescent, but adolescents who belong to a sexual © 2014 International Society for Sexual Medicine

minority may experience increased social stigma, victimization, and discrimination. According to several research studies, lesbian, gay, and bisexual (LGB) individuals have higher rates of depression, anxiety disorders, self-harm, and suicidal behavior [3,4], and LGB individuals are often stigmatized [5] and more likely to experience physical violence, verbal abuse, and ostracism [6,7]. Homophobia J Sex Med 2014;11:1903–1913

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Pompili et al.

and victimization have negative effects on the mental health of LGB youth [8], made worse by rejection from family members and peers, particularly at school [9]. Gender discomfort in adulthood could be related to childhood gender variance. It was shown that the report of adulthood homosexual orientation was 8–15 times higher for subjects with a history of gender variance in childhood, compared with participants without a history of childhood gender variance [10]. Faulkner and Cranston [11] found that bisexual and homosexual youth had experienced more violence than heterosexual youth, and they often experienced these difficulties at school including feeling unsafe, being injured with a weapon, and being involved in physical fights. According to the youth risk behavior surveillance system (2001– 2009), the prevalence of feelings of sadness or hopelessness in the 12 months preceding the survey ranged from 19.3% to 29.0% (median: 24.8%) in the heterosexual students, from 28.8% to 52.8% (median: 41.3%) among lesbian and gay youth, and from 47.2% to 62.9% (median: 56.3%) among bisexual youth [12]. Many research studies have reported a higher incidence of serious suicidal behavior in LGB youth than heterosexual youth [12] and, in addition, a greater frequency of substance abuse [11], a major risk factor for suicidal behavior. King et al. [13] found that depression, anxiety disorders, and substance use disorders were 1.5 times more common in LGB people than in heterosexuals. Many studies of LGB youth have demonstrated that individuals reporting a bisexual orientation have a particularly high risk of suicidal behavior [14–17] and substance abuse [18], even when compared with homosexual youth. Moreover, it has been suggested that bisexual individuals (both men and women) have higher rates of depression, anxiety, and negative affect compared with homosexual and heterosexual groups [14].

ality and suicide, we performed a careful MedLine, Excerpta Medica, PsycLit and PsycInfo, and Index Medicus search to identify all papers and book chapters in English for the period 1987–2012. The following search terms were used: suicide OR suicide attempt OR ideation AND bisexuality; suicid* AND bisexuality. Only articles published in the English language were considered in this review. When a title or abstract seemed to describe a study eligible for inclusion, the full article was obtained and examined for relevance based on our predetermined inclusion criteria. Any discrepancies between the two reviewers who, blind to each other, examined studies for the possible inclusion were resolved by consultations with senior authors. In addition, we also examined reference lists and contacted experts in the field. Abstracts that did not explicitly mention suicide and bisexuality were excluded. We also excluded metaanalyses and systematic reviews.

Aims

Study Design and Quality Assessment A quality assessment was performed as shown in Table 1. Studies were rated for quality using the following criteria: (i) representativeness of the sample to the general population (1 point); (ii) presence of a control group (1 or 2 points); (iii) n > 1,000 subjects/treatment group (1 or 2 points); (iv) duration >1 year/follow-up group (1 or 2 points); (v) evidence-based measures of assessment (1 or 2 points); (vi) data presentation (1 or 2 points); and (vii) evidence-based measures

Given this research, the aim of the present article was to examine the relation between bisexuality and suicidal behaviors in current research and to ascertain specific risk factors associated with a bisexual orientation. Methods

In order to provide a new and timely systematic review examining the association between bisexuJ Sex Med 2014;11:1903–1913

Main Outcome Measures

The combined search strategies described above yielded a total of 339 records screened from PubMed, Scopus and Web of Knowledge. We removed 123 records as duplicate articles. Abstracts that did not explicitly mention suicide and bisexuality were also excluded, and after a complete analysis of the title and abstract, 89 fulltext articles were excluded. Moreover, we removed 14 articles that were not in English and 58 full-text articles that did not examine bisexuality separately from homosexuality. We also excluded 13 review articles and 23 articles with no original contribution (Letters, Editorials, Dissertations, Conference Papers, and Notes). Three reviewers, blind to each other, examined the full-text articles, including studies that added an original contribution to the literature. Finally, 19 studies met our inclusion criteria and were included in the present review.

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Bisexuality and Suicide Table 1

Most relevant studies about suicide risk and bisexuality FollowSample up Method

Study

Quality score*

Aim and study design

Jessup et al. [19]

I=1 II = 1 III = 0 IV = 0 V=1 VI = 1 VII = 1 Total score = 5 I=1 II = 1 III = 2 IV = 1 V=1 VI = 2 VII = 2 Total score = 10

Examine substance abuse and mental illness in 371 elders 74 were sexual minorities Observational study

371 No

Evaluate the association between social stressor (discrimination, victimization) and suicidal behaviors Cross-sectional study

92,470 No

I=1 II = 1 III = 2 IV = 1 V=2 VI = 2 VII = 1 Total score = 10 I=1 II = 2 III = 2 IV = 1 V=1 VI = 2 VII = 1 Total score = 10 I=1 II = 1 III = 2 IV = 0 V=1 VI = 1 VII = 1 Total Score = 7 I=1 II = 0 III = 0 IV = 0 V=1 VI = 1 VII = 1 Total score = 4

Evaluate whether the social environment leads to increase the rates of suicide attempts in lesbian, gay, and bisexual youth. Cross-sectional study

31,852 No

Examine the association between sexual orientation and health risk behaviors in young students (9–12) Cross-sectional study

156,145 No

Assess how and if family acceptance plays a role of a protective factor for lesbian, gay, bisexual, and transgender (LGBT). Observational study

Mustanski et al. [24]

I=1 II = 1 III = 0 IV = 1 V=1 VI = 2 VII = 1 Total score = 7

Needham et al. [25]

I=1 II = 1 III = 1 IV = 1 V=1 VI = 2 VII = 1 Total score = 8 I=1 II = 1 III = 2 IV = 2 V=1 VI = 1 VII = 1 Total Score = 9

Blosnich et al. [20]

Hatzenbuehler et al. [21]

Kann et al. [12]

Brennan et al. [22]

Ryan et al. [23]

Conron et al. [16]

Evidence the effect of sexual orientation on health conditions Cross-sectional study

49,901 No

Self-administrated questionnaires and clinical interview

Results

Conclusion

Bisexual reported significantly Bisexuality is associated with higher rates of depression, higher risk of mental illness anxiety, and suicidality either and should considered than heterosexual and gay separately from the group of and lesbian gay and lesbian

American College Sexual minorities reported Sexual minorities have a Health Association’s more often victimization, higher risk of suicidal (ACHA’s) National discrimination, and suicidal behaviours than the College Health behaviors (P < 0.05) heterosexual probably due Assessment Bisexual group had a great to social stressors (NCHA) survey association with suicide periods of Fall ideation, suicide attempt, 2008 and Spring and intentional self-harm 2009 than the gay and lesbian group The data were 22% of young bisexuals had The social environment leads obtained from the attempted suicide at least to an additional risk of Oregon Healthy once in the last 12 months, suicide attempts in addition Teens (OHT). while among heterosexuals to the individual-level risk only 4%. In addition, young factors. LGB also had higher levels of known risk factors for suicide attempts. Self-administrated In the 12 months before the Sexual minorities have an questionnaire survey: the 3.8–9.6% of increased risk of suicide. heterosexual, 15.1–34.3% of Between these minorities gay or lesbian, 20.6–32.0% the bisexual group have an of bisexual had attempted higher risk of suicide than suicide. gay or lesbian groups

Medical questionnaires (Canadian Community Health Survey data)

In comparison with heterosexual men, gay and bisexual reported an history of lifetime suicidality: gay OR 4.13 P value < 0.01 bisexual OR 6.32 P value < 0.01

Sexual orientation is an important factor to consider because is related to the mental health of these patients

245 No

Individual in-depth interviews of 2–4 hours.

Family acceptance has a positive effect on the state of mental and physical health of LGBT.

Evaluate associations of sexual orientation, gender, and race with various mental disorders among LGBT youths. Cross-sectional study

246 No

The data were obtained from individual interviews.

Examine the link between parental support in gay, lesbian, and bisexual youth and their worse health-related outcomes Cross-sectional study

11,153 No

Examine patterns of self-reported health in heterosexual compared with sexual minorities Cross-sectional study

67,359 No

Social support, self-esteem, and general health status improved thanks to family acceptance. In addition decreased significantly the cases of depression, substance abuse, and suicidal behaviors. Bisexual population was the one with lesser prevalence of each mental disorders diagnosis. The disorders most frequently encountered were conduct disorder (17%) and major depression (15%) while suicide attempts in the previous 12 months were 7%. Lesbian 12.6 (1.76), bisexual12.4 (2.19), and gay12.9 (1.82) reported lower parental support than the heterosexual 13.4 (1.69). LGB presented suicide thoughts more frequently than the heterosexual. Bisexuals had more barriers to health care, feelings of sadness, suicidal ideation in the past year, and cardiovascular risk. Binge drinking and lifetime physical intimate partner victimization were more common among bisexual women.

Audio computer assisted self-interview (ACASI) Center for Epidemiological Studies-Depression Scale (CES-D) Anonymous telephone survey

LGBT youth have a higher prevalence of diagnosed mental disorders compared to young controls.

Parental support is associated with a lower risk of negative health-related outcomes and represent a protective factor during the transition from adolescence to adulthood

Sexual minorities have an increased risk of victimization and mental illness. They have higher rates of suicidal ideation particularly in bisexual population.

J Sex Med 2014;11:1903–1913

1906 Table 1 Study

Pompili et al. Continued Quality score*

Langhinrichsen- I = 1 Rohling II = 1 et al. [15] III = 1 IV = 1 V=1 VI = 1 VII = 1 Total score = 7 Saewyc et al. [1]

Koh et al. [26]

Hidaka et al. [27]

Abelson et al. [28]

I=1 II = 1 III = 2 IV = 2 V=1 VI = 2 VII = 1 Total score = 10 I=1 II = 1 III = 1 IV = 1 V=1 VI = 1 VII = 1 Total score = 7 I=1 II = 1 III = 1 IV = 0 V=1 VI = 1 VII = 1 Total score = 6 I=1 II = 1 III = 1 IV = 0 V=1 VI = 2 VII = 1 Total score = 7

Balsam et al. [29]

I=1 II = 1 III = 0 IV = 1 V=1 VI = 1 VII = 1 Total score = 6

Warner et al. [30]

I=1 II = 1 III = 1 IV = 1 V=1 VI = 2 VII = 1 Total score = 8

Aim and study design Examine the relationship between sexual orientation and suicidal behaviors Cross-sectional study

FollowSample up Method 1,533 No

Self-complete questionnaire

Assess the prevalence 879,591 No and differences in suicidality among bisexual vs. gay/lesbian and heterosexual teens. Cross-sectional study

The data were obtained from the large-scale school-based surveys.

Evaluate the mental health issues in bisexual lesbian and heterosexual women. Cross-sectional study double-keyed entry

1,304 No

Self-administrated questionnaire

Evaluate the rate of suicide attempts and its association with distress and bullying in Japanese gay and bisexual Cross-sectional study

1,025 No

Self-administered questionnaires

Evaluate the factors associated with suicidal feelings including sexual orientation Observational study

1,300 No

Self-complete questionnaire

Recruit self-identified LGB individuals and their siblings and compare LGBs with heterosexuals within this sample on mental health variables and the use of mental health services, controlling for siblings variance Observational study Find possible predictors of mental illness in gay lesbian and bisexual Cross-sectional study

533 No

J Sex Med 2014;11:1903–1913

2,430 No

- Questionnaire “Sisters and Brothers Project” - Brief Symptom Inventory (BSI) - Global Severity Index (GSI)

Computer-based questionnaire

Results

Conclusion

Bisexual adolescents reported Sexual orientation is highest percentage of recent significantly associated with suicide ideation (bisexual suicidal behaviors (P < 0.01). 17%, gay 3%, and Bisexual youth resulted to heterosexual 6%). Bisexual have higher risk than gay also reported higher rate of and lesbian youth suicide attempts (bisexual 23%, gay 19%, and heterosexual 7%) Lesbian, gay, and bisexual There’s a need to reduce youth have an increased risk depression, emotional stress of suicidal ideation and and suicidal tendencies attempts when compared among sexual minority youth with their heterosexual to try to stem a major cause peers. of death among young people. The 56.7% of lesbian and Psychiatric disorders or 53.2% of bisexual women symptoms seems to be have been treated for associated to the depression (P < 0.01). The stigmatization that sexual 21.3% of bisexual and minorities experience and 16.7% of lesbian have inversely related to the attempted suicide (P < 0.01). comfort they feel with their sexual orientation 15% of homosexual and 17% Social distress increased of bisexual attempted suicidal risk among gay and suicide, 83% experienced bisexual youth school bullying, and 60%) were verbally harassed because of their sexuality

Suicidal thoughts are Bisexual and gay men had significantly associated with almost the same levels of sexual orientation suicide thoughts with a (P < 0.001) heterosexual mean twice than the 0.31 homosexual 0.61 and heterosexual men. bisexual 0.62. Being gay and bisexual is associated with other suicide risk factors (feeling bad, living alone, illicit drug use, sexual risk taking, and contact with the HIV/AIDS epidemic) Sexual minorities scored LGB reported greater higher than did psychological distress, heterosexuals in predicting suicidal ideation and self-injurious behavior, attempts, and use of mental histories of psychotherapy, health services than would and psychiatric medications their heterosexual as well as both suicidal counterparts. ideation and attempts.

Gay, lesbian and bisexual 47% of gay man, 55% of Men and women have high bisexual man, 56% of levels of mental disorder, lesbian, and 57% of bisexual possibly due to women considered suicide. discrimination. 25% of gay, 27% of bisexual men 31% of lesbian, and 33% of bisexual woman had attempted suicide. Variables associated with suicide attempt were having been attacked in the past 5 years (OR1⁄41.4, 95% CI 1.1–1.9) and having been insulted at school (OR1⁄41.4, 95% CI 1.1–2.0).

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Bisexuality and Suicide Table 1

Continued FollowSample up Method

Study

Quality score*

Aim and study design

Huebner et al. [31]

I=1 II = 1 III = 1 IV = 1 V=1 VI = 2 VII = 1 Total score = 8

Investigate incidence of 1,248 discrimination verbal harassment and physical violence in gay and bisexual youth and association with lower self-esteem and suicidal ideation Cross-sectional study

No

Self-administered questionnaires

Paul et al. [32]

I=1 II = 1 III = 1 IV = 1 V=1 VI = 2 VII = 2 Total score = 9

Examine lifetime prevalence of suicide attempts and suicidal ideation in a population of gay and bisexual man Cross-sectional study

2,881

No

A telephone probability sample of U.S. urban gay and bisexual men were interviewed between November 1996 and February 1998

Rutter et al. [33]

I=0 II = 1 III = 0 IV = 1 V=1 VI = 0 VII = 1 Total score = 4

Examine the relationship between youth suicide risk and sexual orientation. Observational study

100

No

Data obtained from clinical interviews.

Results

Conclusion

37% experienced verbal This study shows the harassment because of their importance of preventing sexual orientation (95% anti-gay mistreatment in confidence interval order to create safe social [CI] = 34.3%, 39.7%); 11.2% settings and avoid the reported discrimination (95% psychological effects of CI = 9.4%, 13.0%), and these events 4.8% reported physical violence (95% CI = 3.6%, 6.0%). Discrimination (P < 0.001) and physical violence (P < 0.05) associated with increased suicidal ideation. 11% of gay 12% of Gay and bisexual man have heterosexual and 16% of an increased risk of suicidal bisexual attempted suicide behaviours (P < 0.01) most of them made the first attempt before age 25. 20% of gay 17% of heterosexual 30% of bisexual had suicide plan Bisexual and questioning Suicide risk influenced by youth did not show a greater several factors and can vary suicide risk than the significantly in relation to heterosexual. Wilks’s many psychosocial variables lambda was 0.87; such as support. F(2, 94) = 0.12 (not significant at the 0.05 level). Individuals with support from school, friends, and family showed less suicide risk and suicidal ideation.

*Studies were rated for the quality assessment using the following criteria as specified below: I) Representativeness of the sample than the general population (0 or 1 point): 0 not representative; 1 representative II) Presence of a control group (1 or 2 points): 1 point without control group, 2 point with control group III) n subjects /treatment group (1 or 2 points). 1 point if 500 IV) Duration (year) follow up group (1 or 2 points). 1 point 1 years V) Evidence based measures of assessment (1 or 2 points) ): 0 absence of evidence-based measures of assessment; 1 presence of evidence-based measures of assessment VI) Data presentation (1 or 2 points). 1 point, not clear data presentation in the text; 1 point clear data presentation in the text VII) Evidence-based measures assessing suicide or suicide attempts (1 or 2 points): 1 absence of evidence-based measures assessing suicide or suicide attempts; 2 presence of evidence-based measures assessing suicide or suicide attempts Quality ratings reported 13 as maximum score

assessing suicide or suicide attempts (1 or 2 points). Quality ratings have 13 as the maximum score for each study. Results

Male Samples Abelson et al. [28] obtained a sample of 1,300 Australian urban men recruited from nightclubs, social and political organizations, and other groups and asked them how often they felt suicidal with answers ranging from never (0) to often (3). The bisexual and homosexual men had similar mean scores on this item (0.62 and 0.61, respectively), but both of those groups had significantly higher scores than the heterosexual men (0.31). In a multiple regression analysis, feeling suicidal was predicted by experience of harassment, taking sexual risks, seeking professional help, living alone, social

interactions, and feeling bad, in addition to sexual orientation. Paul et al. [32] examined the lifetime prevalence of suicide attempts and suicidal ideation in 2,881 American men using a telephone-based survey, obtaining a sample that was disproportionately homosexual (84%). Homosexual, bisexual, and heterosexual men did not differ significantly in ever having attempted suicide or the age when they attempted suicide, but more of the bisexual men had formulated a plan for suicide (30%) than the homosexual or heterosexual men (20% and 17%, respectively). In a multiple regression, sexual orientation did not predict a history of attempted suicide. Using an Internet-based survey, Hidaka and Operario [27] studied 1,025 homosexual and bisexual Japanese men and asked whether they had ever attempted suicide (15.0% reported that they J Sex Med 2014;11:1903–1913

1908 had done so). The incidence was similar in homosexual men (15.4%) and bisexual men (17.4%). Brennan et al. [22] used a survey of 49,901 Canadian men to assess lifetime suicidality, a term that was not explicitly defined. Bisexual men reported a higher incidence of lifetime suicidality (34.8%) than homosexual men (25.2%) and heterosexual men (7.4%). In a study of 1,248 young (aged 18–27) American gay and bisexual men, Huebner et al. [31] found no differences in their experience of harassment, discrimination, and violence (although the bisexual men reported a nonsignificant tendency to greater frequencies). Huebner et al. did not report on differences in suicidal ideation in the prior 2 months, but they found that experience of discrimination and physical violence predicted recent suicidal ideation in the sample overall.

Female Samples Koh and Ross [26] surveyed 1,304 American women seeking primary healthcare and asked about their lifetime number of suicide attempts. The bisexual women were more likely to report prior suicide attempts (21.3%) than the lesbians (16.7%) and the heterosexual women (10.2%), and the same order was found for frequent thinking about suicide in the past year (5.6%, 1.9%, and 0.6% for the answer very often). The frequency of suicidal ideation in the past year was predicted by age, education, a history of an eating disorder, being in a committed relationship, experience of stress in adolescent and adult years, and some aspects of sexual identity. Lesbians who were not “out” and bisexuals who were “out” had more suicidal ideation. Bisexuals and lesbians had similar levels of suicidal ideation and similar lifetime histories of attempted suicide. Mixed Samples The largest sample studied is by Kann et al. [12] of 9 years of the Youth Risk Behavior Surveillance Surveys, which included 156,145 American high school students from 2001 to 2009. The bisexual students more often reported seriously considering attempting suicide in the prior year (40.3%) compared with homosexual students (29.6%) and heterosexual students (11.7%). For attempted suicide in the prior year, the bisexual and homosexual students were more similar (28.0% and 25.8%) but different from the heterosexual students (6.4%). For attempts requiring medical treatment, the same differences were found (11.3%, 12.6% and 2.2%, respectively). J Sex Med 2014;11:1903–1913

Pompili et al. Hatzenbuehler [21] studied 31,852 11th grade American high school students. Both homosexual and bisexual students significantly more often reported attempting suicide in the past year (19.6% and 22.0%, respectively) than heterosexual students (4.2%). Attempting suicide was predicted by sex, being homosexual, being bisexual, race/ ethnicity, depressive symptoms, binge drinking, peer victimization, and physical abuse from adults. Langhinrichsen-Rohling et al. [34] surveyed a mixed sample of 1,412 adolescents in an American urban high school and a truancy program and classified as juvenile delinquents, of whom 48% were female and 50% African American, using a 24-item suicide proneness scale and questions about recent suicidal ideation and whether they had ever thought about or attempted suicide. The adolescents were asked whether they experienced same sex or opposite sex attractions. Those reporting attraction to both sexes had significantly higher scores on all measures of suicidal behavior than those reporting opposite sex attractions. Those reporting same-sex attractions were intermediate in scores and did not differ significantly from either of the other two groups. For example, 23% of the bisexual adolescents, 19% of the heterosexual adolescents, and 7% of the homosexual adolescents reported lifetime suicidal attempts, bearing in mind that the measure was attraction and not actual sexual contact. However, 12% of the homosexual adolescents who had homosexual experience reported prior suicide attempts vs. only 6% of homosexual adolescents who had not had homosexual experience. Path analyses showed that the link between sexual orientation and suicidal behavior was mediated by hopelessness and depression scores. Langhinrichsen-Rohling et al. did not analyze the data separately for boys and girls. Needham and Austin [25] used a national survey of 11,153 American adolescents (the Ad Health Survey) who were asked about suicidal ideation in the prior year. Homosexual and bisexual females more often reported suicidal ideation than heterosexual females (20.8% and 17.7%, respectively, vs. 6.3%), and the same result was found for men (16.5% and 12.5%, respectively, vs. 5.7%). The homosexual and bisexual females also had higher levels of drug and alcohol use, but this difference was not found for the males. Mustanski et al. [24] studied 246 American adolescents who identified as homosexual or bisexual. Bisexual adolescents less often reported a prior lifetime suicide attempt and tended to less often report suicidal ideation and attempts in the past

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Bisexuality and Suicide year. The sex or ethnicity of the adolescents were not associated with suicidal behavior. This is a smaller sample than in the study of Langhinrichsen-Rohling et al. reviewed above, but the results of Mustanski et al. are in the opposite direction to those of Langhinrichsen-Rohling et al. The sample of Mustanski et al. was a community sample, whereas the sample of LanghinrichsenRohling et al. was of both troubled and regular adolescents, which may account for this difference in results. Rutter and Soucar [33] studied 100 American youths aged 17–19 from the community and found that bisexual, homosexual, and heterosexual youths did not differ in current suicidal ideation or hopelessness. There appeared to be no sex differences in this result. Ryan et al. [23] studied suicidal ideation and attempts in the past 6 months in 245 LGBT youths in California. Although family acceptance was associated with a lower frequency of suicidal behavior in the prior 6 months, bisexuality vs. homosexuality was not. Saewyc et al. [1] analyzed the data from nine large school-based surveys of students in Canada and the United States that were carried out over a 17-year period. They summarized their findings as indicating that homosexual and bisexual students more often reported prior suicidal ideation and suicide attempts than heterosexual students, both for boys and for girls. Saewyc et al. concluded that differences between bisexual and homosexual students were small and varied across the nine studies. Blosnich, Bossarte and Silenzio [20] used a data set collected from 113,790 American college students to create a sample of 11,046 students aged 18–24 to study suicidal ideation and attempts in the prior year. Suicidal ideation was more common in the bisexual students (21.0%) than in the homosexual students (15.0%) and heterosexual students (5.5%), and a similarly significant difference was found for attempted suicide (4.6%, 3.3% and 0.9%, respectively). For all three groups, intimate partner violence and family problems predicted suicidal ideation. Conron et al. [16] used a Behavioral Risk Factor Surveillance System data set from Massachusetts comprised of 67,359 adults. Bisexual men and women more often reported serious suicidal ideation in the prior year (18.5%) than homosexual and heterosexuals (4.2% and 3.0%, respectively), and these differences were found on other measures of adjustment (such as general mental health and illicit drug use).

Balsam et al. [29] obtained a sample of 1,254 American adults and some of their siblings and asked them about suicidal ideation and attempts prior to age 18 and after age 18. Overall, the heterosexuals reported a lower incidence of suicidal ideation and attempts. Homosexual and bisexual respondents, however, did not differ from each other in their history of suicidal behavior. Lester [35] studied a sample of 4,700 individuals responding to a questionnaire on a bodymodification website. Bisexuals and homosexuals more often reported lifetime suicidal ideation and suicide attempts than did heterosexuals. The differences between bisexuals and homosexuals were inconsistent. For women reporting current depression, bisexuals more often reported prior suicide attempts, but this difference was not found for nondepressed women. However, for nondepressed men, the homosexuals more often reported prior suicide attempts than the bisexuals. This data set differed from others in breaking the bisexuals into those with heterosexual “leanings” and those with homosexual “leanings,” a distinction not made in other data sets. Warner et al. [30] surveyed adults in England and Wales using a snowballing technique and a computer-based questionnaire and reported data on 741 men and 544 women who reported being homosexual or bisexual. For both sexes, homosexual and bisexual individuals did not differ in lifetime suicidal ideation or attempts or, incidentally, in scores on the General Health Questionnaire or the Clinical Interview Schedule. Jessup and Dibble [19] asked 371 elderly Americans (over the age of 54) whether they had had suicidal thoughts in the previous year. Those identifying as bisexual reported significantly more often having ever thought about suicide (35.7%) than the homosexuals (13.6%) and heterosexuals (10.4%). The bisexual elders also reported more depression symptoms, anxiety symptoms, substance abuse, and other mental health problems. No sex differences were reported. The results of these 19 studies are summarized in Table 1. Discussion

In this review of current literature, summarized in Table 1, bisexuals were more likely than heterosexuals to report prior suicidal behavior (suicidal ideation or attempted suicide) in 13 of the 15 studies, with two studies reporting no significant differences. The results were less clear when J Sex Med 2014;11:1903–1913

1910 bisexuals were compared with homosexuals. For this comparison, eleven studies found no differences in suicidal behavior between bisexuals and homosexuals, five studies found that bisexuals reported more suicidal behavior, one study found that they reported less suicidal behavior, and two studies reported inconsistent results. It was not possible to find reasons for the inconsistent results in the comparison of bisexuals and homosexuals (e.g., size of sample or the sources of subjects for the study). The association between suicide and sexual orientation is typically viewed as resulting from discrimination, victimization, and experience of homophobia and violence [6,21,36,37]. Some studies have found that LGB individuals reported high rates of bullying and physical and verbal harassment [38,39]. Meyer et al. [40] proposed a minority stress model in which he suggested that homophobic victimization has a stronger association with adverse outcomes on mental health, school belonging, and concerns than general victimization for other groups. Individuals reporting a bisexual orientation may experience more psychological distress and mental health problems than their homosexual and heterosexual peers because of their belief that they do not belong to a particular group, which makes them more isolated and more vulnerable to bullying and harassment [26,31,32]. LGB youth may experience a variety of psychological problems related to stigmatization about their sexual orientation, including harassment and discrimination by family, peers, and authority figures. This chronic stress may lead to an increased risk of depression, suicidal behavior, social anxiety, substance use, and body image disturbance [41,42]. Hatzenbuehler [21] examined the link between social environment of communities and the higher the risk of suicide attempts occurring in LGB youth. The risk of attempting suicide was 20% greater in those living in bad communities (e.g., communities with school that have implemented anti-bullying policies) compared with not more positive communities. Several studies have demonstrated that a healthy parent–child relationship marked by acceptance and support is generally associated with positive mental health outcomes. Parents can be a source of stress but also a source of support. Family acceptance is a protective factor for LGB adolescents and young adults, resulting in greater self-esteem, social support, and general positive health outcomes. Family acceptance is also a protective factor for depression, substance abuse, and suicidal ideJ Sex Med 2014;11:1903–1913

Pompili et al. ation and behaviors [23]. Not disclosing one’s sexual orientation friends was one of the major risks for suicide into bisexual men [27]. In women, however, these differences were less pronounced. Surprisingly, there were no studies evaluating the efficacy of psychotherapy for suicidal LGB youth. However, there are clinical trials of treatment for suicidal adolescents in general, with conflicting results [13,43]. Harrington et al. [44] suggest that a brief family-based intervention for young adolescents who had poisoned themselves was more effective in decreasing suicidal ideation than routine care alone. Huey et al. [45] observed a greater effectiveness for multisystemic family therapy in reducing rates of suicide attempts (but not suicidal ideation, depressive affect, or hopelessness) when compared with hospitalization. Diamond et al. [46] attempted to adapt attachment-based family therapy (ABTF) [47,48] for use with suicidal LGB adolescents. ABTF is a brief family-based treatment (12–16 weeks) that was developed initially for suicidal and depressed adolescents and may be considered a valid approach to support LGB adolescents.

Limitation The present review should be considered in the light of some limitations. First, we did not carry out a meta-analysis because the data from most of the studies on the topic did not permit this. All of the articles included in this review were cross-sectional, and so it was not possible to draw conclusions regarding causation between the risk factors and suicidal behavior. Longitudinal studies are needed to understand the relation between sexual orientation and suicide. The relatively small number of bisexual studies (compared with the number of studies on gay and lesbian individuals) suggests that this population is difficult to recruit and that bisexual individuals may be less willing to disclose their true sexual identity. The data set used by Lester [35] was unique in allowing bisexual participants to indicate a preference for the same or opposite sex. Conclusions

Bisexuality appears to be associated with a history of prior suicidal behavior, but it is less clear whether bisexual individuals are at greater risk for suicidal behavior than gay and lesbian individuals. The higher rate of suicidal behavior in LGB individuals is related to several risk factors, including stigmatization, victimization, and discrimination.

Bisexuality and Suicide Moreover, sexual minorities in general have high rates of depression, anxiety, emotional distress, and substance abuse in addition to increased suicidal behavior. The risk of suicide may vary significantly in relation to many protective factors such as social support, family acceptance, and parental support. These protective factors have a positive effect on the state of mental and physical health of LGB youth. Future research should study bisexual individuals separately from homosexuals and lesbians in order to better understand unique risk factors and to evaluate a more specific approach to preventing suicidal behavior in this group. Corresponding Author: Maurizio Pompili, MD, PhD, Department of Neuroscience, Mental Health and Sensory Organs—Suicide Prevention Center, Sant’Andrea Hospital, “Sapienza” University of Rome, 1035-1039, Via di Grottarossa, 00189 Rome, Italy. Tel: (39) 0633775675; Fax: (39) 0633775342; E-mail: [email protected] Conflict of Interest: The author(s) report no conflicts of interest. Statement of Authorship

Category 1 (a) Conception and Design Maurizio Pompili (b) Acquisition of Data Alberto Forte; Maria Elena Seretti; Denise Erbuto (c) Analysis and Interpretation of Data David Lester; Mario Amore

Category 2 (a) Drafting the Article Dorian A. Lamis (b) Revising It for Intellectual Content Paolo Girardi; Maurizio Pompili

Category 3 (a) Final Approval of the Completed Article Paolo Girardi References 1 Saewyc EM, Skay CL, Hynds P, Pettingell S, Bearinger LH, Resnick MD, Reis E. Suicidal ideation and attempts in North American school-based surveys: Are bisexual youth at increasing risk? J LGBT Health Res 2007;3:25–36. 2 Sell RL. Defining and measuring sexual orientation: A review. Arch Sex Behav 1997;26:643–57. 3 Cochran SD, Mays VM. Relation between psychiatric syndromes and behaviorally defined sexual orientation in a sample of the US population. Am J Epidemiol 2000;151:516– 23.

1911 4 Skegg K, Nada-Raja S, Dickson N, Paul C, Williams S. Sexual orientation and self-harm in men and women. Am J Psychiatry 2003;160:541–6. 5 Martin AD, Hetrick ES. The stigmatization of the gay and lesbian adolescent. J Homosex 1988;15:163–83. 6 Russell ST, Joyner K. Adolescent sexual orientation and suicide risk: Evidence from a national study. Am J Public Health 2001;91:1276–81. 7 Rosario M, Schrimshaw EW, Hunter J, Gwadz M. Gayrelated stress and emotional distress among gay, lesbian, and bisexual youths: A longitudinal examination. J Consult Clin Psychol 2002;70:967–75. 8 D’Augelli AR, Grossman AH, Salter NP, Vasey JJ, Starks MT, Sinclair KO. Predicting the suicide attempts of lesbian, gay, and bisexual youth. Suicide Life Threat Behav 2005;35:646– 60. 9 Rivers I, D’Augelli AR. The victimization of lesbian, gay and bisexual youths: Implication for intervention. In: D’Augelli AR, Patterson CJ, eds. Lesbian, gay, and bisexual identities and youths: Psychological perspectives. New York, NY: Oxford University Press; 2001:199–223. 10 Steensma TD, van der Ende J, Verhulst FC, Cohen-Kettenis PT. Gender variance in childhood and sexual orientation in adulthood: A prospective study. J Sex Med 2013;10:2723– 33. 11 Faulkner AH, Cranston K. Correlates of same-sex sexual behavior in a random sample of Massachusetts high school students. Am J Public Health 1998;88:262–6. 12 Kann L, Olsen EO, McManus T, Kinchen S, Chyen D, Harris WA, Wechsler H; Centers for Disease Control and Prevention (CDC). Sexual identity, sex of sexual contacts, and health-risk behaviors among students in grades 9–12—youth risk behavior surveillance, selected sites, United States, 2001–2009. MMWR Surveill Summ 2011;60:1–133. 13 King CA, Kramer A, Preuss L, Kerr DC, Weisse L, Venkataraman S. Youth-nominated support team for suicidal adolescents (version 1): A randomized controlled trial. J Consult Clin Psychol 2006;74:199–206. 14 Jorm AF, Korten AE, Rodgers B, Jacomb PA, Christensen H. Sexual orientation and mental health: Results from a community survey of young and middle-aged adults. Br J Psychiatry 2002;180:423–7. 15 Langhinrichsen-Rohling J, Lamis DA, Malone PS. Sexual attraction status and adolescent suicide proneness: The roles of hopelessness, depression, and social support. J Homosex 2010;58:52–82. 16 Conron KJ, Mimiaga MJ, Landers SJ. A population-based study of sexual orientation identity and gender differences in adult health. Am J Public Health 2010;100:1953–60. 17 Marshal M, Dietz L, Friedman M, Stall R, Smith H, McGinley J, Thoma B, Murray P, D’Augelli A, Brent D. Suicidality and depression disparities between sexual minority and heterosexual youth: A meta-analytic review. J Adolesc Health 2011;49:115–23. 18 Marshal MP, Friedman MS, Stall R, King KM, Miles J, Gold MA, Bukstein OG, Morse JQ. Sexual orientation and adolescent substance use: A meta-analysis and methodological review. Addiction 2008;103:546–56. 19 Jessup MA, Dibble SL. Unmet mental health and substance abuse treatment needs of sexual minority elders. J Homosex 2012;59:656–74. 20 Blosnich JR, Bossarte RM, Silenzio VM. Suicidal ideation among sexual minority veterans: Results from the 2005–2010 Massachusetts Behavioral Risk Factor Surveillance Survey. Am J Public Health 2012 ;102(1 suppl):44–7. 21 Hatzenbuehler ML. The social environment and suicide attempts in lesbian, gay, and bisexual youth. Pediatrics 2011;127:896–903.

J Sex Med 2014;11:1903–1913

1912 22 Brennan DJ, Ross LE, Dobinson C, Veldhuizen S, Steele LS. Men’s sexual orientation and health in Canada. Can J Public Health 2010;101:255–8. 23 Ryan C, Russell ST, Huebner D, Diaz R, Sanchez J. Family acceptance in adolescence and the health of LGBT young adults. J Child Adolesc Psychiatr Nurs 2010;23:205–13. 24 Mustanski BS, Garofalo R, Emerson EM. Mental health disorders, psychological distress, and suicidality in a diverse sample of lesbian, gay, bisexual, and transgender youths. Am J Public Health 2010;100:2426–32. 25 Needham BL, Austin EL. Sexual orientation, parental support, and health during the transition to young adulthood. J Youth Adolesc 2010;39:1189–98. 26 Koh AS, Ross LK. Mental health issues: A comparison of lesbian, bisexual and heterosexual women. J Homosex 2006;51:33–57. 27 Hidaka Y, Operario D. Attempted suicide, psychological health and exposure to harassment among Japanese homosexual, bisexual or other men questioning their sexual orientation recruited via the internet. J Epidemiol Community Health 2006;60:962–7. 28 Abelson J, Lambevski S, Crawford J, Bartos M, Kippax S. Factors associated with “feeling suicidal”: The role of sexual identity. J Homosex 2006;51:59–80. 29 Balsam KF, Beauchaine TP, Mickey RM, Rothblum ED. Mental health of lesbian, gay, bisexual, and heterosexual siblings: Effects of gender, sexual orientation, and family. J Abnorm Psychol 2005;114:471–6. 30 Warner J, McKeown E, Griffin M, Johnson K, Ramsay A, Cort C, King M. Rates and predictors of mental illness in gay men, lesbians and bisexual men and women: Results from a survey based in England and Wales. Br J Psychiatry 2004;185:479–85. 31 Huebner DM, Rebchook GM, Kegeles SM. Experiences of harassment, discrimination, and physical violence among young gay and bisexual men. Am J Public Health 2004;94:1200–3. 32 Paul JP, Catania J, Pollack L, Moskowitz J, Canchola J, Mills T, Binson D, Stall R. Suicide attempts among gay and bisexual men: Lifetime prevalence and antecedents. Am J Public Health 2002;92:1338–45. 33 Rutter PA, Soucar E. Youth suicide risk and sexual orientation. Adolescence 2002;37:289–99. 34 Langhinrichsen-Rohling J, Lamis DA, Malone PS. Sexual attraction status and adolescent suicide proneness: The roles of hopelessness, depression, and social support. J Homosex 2011;58:52–82. 35 Lester D. Sexual orientation and suicidal behavior. Psychol Rep 2006;99:923–4. 36 Robin L, Brener ND, Donahue SF, Hack T, Hale K, Goodenow C. Associations between health risk behaviors and opposite-, same-, and both-sex sexual partners in representative samples of Vermont and Massachusetts high school students. Arch Pediatr Adolesc Med 2002;156:349–55.

J Sex Med 2014;11:1903–1913

Pompili et al. 37 McDaniel JS, Purcell D, D’Augelli AR. The relationship between sexual orientation and risk for suicide: Research findings and future directions for research and prevention. Suicide Life Threat Behav 2001;31:84–105. 38 Garofalo R, Wolf RC, Kessel S, Palfrey SJ, DuRant RH. Association between health risk behaviors, sexual orientation among a school-based sample of adolescents. Pediatrics 1998;101:895–902. 39 Bontempo DE, D’Augelli AR. Effects of at-school victimization and sexual orientation on lesbian, gay, or bisexual youths’ health risk behavior. J Adolesc Health 2002;30:364–74. 40 Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychol Bull 2003;129:674–97. 41 Hart TA, Heimberg RG. Presenting problems among treatment-seeking gay, lesbian, and bisexual youth. J Clin Psychol 2001;57:615–27. 42 Safren SA, Heimberg RG. Depression, hopelessness, suicidality, and related factors in sexual minority and heterosexual adolescents. J Consult Clin Psychol 1999;67:859– 66. 43 Brent D, Greenhill LL, Compton S, Emslie G, Wells K, Walkup J, Vitiello B, Bukstein O, Stanley B, Posner K, Kennard BD, Cwik M, Wagner A, Coffey B, March J, Riddle M, Goldstein T, Curry J, Barnett S, Capasso L, Zelazny J, Hughes J, Shen S, Gugga S, Turner JB. The treatment of adolescent suicide attempters study (TASA): Predictors of suicidal events in an open treatment trial. J Am Acad Child Adolesc Psychiatry 2009;48:987–96. 44 Harrington R, Kerfoot M, Dyer E, McNiven F, Gill J, Harrington V, Woodham A, Byford S. Randomized trial of a home-based family intervention for children who have deliberately poisoned themselves. J Am Acad Child Adolesc Psychiatry 1998;37:512–8. 45 Huey SJJ, Henggeler SW, Rowland MD, Halliday-Boykins CA, Cunningham PB, Pickrel SG, Edwards J. Multisystemic therapy effects on attempted suicide by youths presenting psychiatric emergencies. J Am Acad Child Adolesc Psychiatry 2004;43:183–90. 46 Diamond GM, Diamond GS, Levy S, Closs C, Ladipo T, Siqueland L. Attachment-based family therapy for suicidal lesbian, gay, and bisexual adolescents: A treatment development study and open trial with preliminary findings. Psychotherapy 2012;49:62–71. 47 Diamond GS, Reis BF, Diamond GM, Siqueland L, Isaacs L. Attachment-based family therapy for depressed adolescents: A treatment development study. J Am Acad Child Adolesc Psychiatry 2002;41:1190–6. 48 Diamond GS, Wintersteen MB, Brown GK, Diamond GM, Gallop R, Shelef K, Levy S. Attachment-based family therapy for adolescents with suicidal ideation: A randomized controlled trial. J Am Acad Child Adolesc Psychiatry 2010;49:122– 31.

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Bisexuality and Suicide Appendix

Study

Sample

Suicidality

Abelson et al. (2006) [28] Balsam et al. (2005) [29]

Australian men American adults

Blosnich & Boasarte (2012) [20]

American students

Brennan et al. (2010) [22] Conron et al. (2010) [16] Hidaka & Operario (2006) Kann et al. (2011) [27]

Canadian men American adults Japanese men American students

Koh & Ross (2006) [26]

American women

Hatzenbuehler (2011) [21] Jessup & Dibble (2012) [19] Langhinrichsen-Rohling et al. (2011) [34]

American youths American elderly American youths

Lester (2006) [35]

American adults

Mustanski et al. (2010) [24]

American youths

Needham & Austin (2010) [25] Paul et al. (2002) [32]

American youths American men

Rutter & Soucar (2002) [33] Ryan et al. (2010) [23]

American youths American youths

Saewyc et al. (2007) [1]

Canada/USA youths

Warner et al. (2004) [30]

English adults

ideation ideation attempts ideation attempts suicidality ideation attempt ideation attempts attempts ideation attempts ideation ideation attempts ideation attempts ideation attempt ideation attempts plan ideation ideation attempts ideation attempts ideation attempts

Bisexual vs. Heterosexuals

Bisexuals vs. Homosexuals

bisexuals bisexuals bisexuals bisexuals bisexuals bisexuals bisexuals

more more more more more more more

bisexuals bisexuals bisexuals bisexuals bisexuals bisexuals bisexuals bisexuals bisexuals bisexuals

more more more more more more more more more more

ns ns ns ns ns bisexuals more bisexuals more ns bisexuals more bisexuals more bisexuals more bisexuals more ns bisexuals more ns ns inconsistent results inconsistent results bisexuals less bisexuals less ns ns bisexuals more ns ns ns ns ns ns ns

bisexuals more ns bisexuals more ns

bisexuals more bisexuals more

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