Suicide Prevention Strategies for LGBTQ Youth
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This document provides an overview of a workshop on suicide prevention among lesbian, gay, bisexual, and transgender (LGBT) youth. It begins with background on research showing higher rates of suicidal behavior among LGBT youth. The workshop objectives are then outlined, which include increasing understanding of terminology, research, risk and protective factors, and strategies for reducing suicidal behavior among LGBT youth. The document provides context on suicide as a public health issue and risk factors in general before focusing specifically on issues related to LGBT youth.
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Suicide Prevention Strategies for LGBTQ Youth
- 2. Suicide Prevention among Lesbian, Gay, Bisexual, and Transgender Youth: A Workshop for Professionals Who Serve Youth Developed by the Suicide Prevention Resource Center Insert Leader 1 name and Organization here & Insert Leader 2 name and Organization here This training is available at http://www.sprc.org/LGBTYouthWorkshopKit.asp.
- 3. History • National Strategy for Suicide Prevention listed LGBT youth as a special population at risk in 2001.1 • SPRC published Suicide Risk and Prevention for LGBT Youth in 2008. It is available online at www.sprc.org/library/SPRC_LGBT_Youth.pdf. 1. U.S. Department of Health and Human Services, 2001
- 4. Rationale for this Workshop • More suicidal behavior in LGBT youth • Opportunity to modify risk and protective factors • Opportunity to develop/adapt interventions to be culturally competent with LGBT youth
- 5. Workshop Objectives At the end of this training, you will be able to: 1. Use terminology for suicidal behavior and LGBT issues correctly 2. Describe research related to suicidal behavior among LGBT youth 3. Discuss risk and protective factors for LGBT youth and the implications 4. Assess your school’s or agency’s cultural competence with LGBT youth and plan next steps 5. Describe strategies to reduce suicidal behavior among LGBT youth
- 6. Suicide Suicide is a major public health issue, meaning: • Suicide affects large numbers of people. • Prevention is based on research that is mostly related to risk factors. Most importantly, suicide can often be prevented.
- 7. Suicide • Suicide is the 11th leading cause of death in the United States.1 • Close to 35,000 people die by suicide each year.1 • 678,000 adults received medical attention and 500,000 adults reported spending at least one night in the hospital for suicide attempts in 2008.2 • 1.1 million adults reported attempting suicide in the past year.2 1. Centers for Disease Control and Prevention, 2007 (retrieved 2010). 2. Substance Abuse and Mental Health Services Administration, Office of Applied Studies, 2009.
- 8. Youth and Young Adult Suicide • Suicide is the 3rd leading cause of death for youths and young adults in the United States.1 • Over 4,000 youths and young adults die by suicide each year.1 • About 1 out of every 15 high school students attempts suicide each year.2 1. Centers for Disease Control and Prevention, 2007 (retrieved 2010). 2. Centers for Disease Control and Prevention, 2010.
- 9. What causes suicide? • Suicide is a complex behavior, driven by multiple factors-- individual, family, and social--that are more prevalent in people who die by suicide. • Although risk factors related to suicide have been identified, there are no identified causes of suicide. • Most people who die by suicide have mental illness and/or a substance use disorder. • There are other risk factors associated with suicide, including: • Previous suicide attempt(s) • Firearm ownership • Isolation • Hopelessness • Impulsivity and recklessness • Family discord and dysfunction
- 11. Ground Rules
- 12. Icebreaker
- 13. Terms – LGBT Issues Important distinction – gender identity and sexual orientation See handout – “LGBT Glossary”
- 14. Terms – Suicidology • Suicide death • Attempted suicide • Suicide ideation • Suicidal behavior See handout – “Suicidology Glossary”
- 15. Research Challenges • Most hospital and vital records – no information on sexual orientation or gender identity • Sexual orientation or gender identity hard to know for psychological autopsies • Respondents do not identify with these terms • Convenience sampling and small samples • Few studies include racial/ethnic data • Lack of longitudinal studies
- 16. Suicide Data A moment to remember… Behind the data are individuals who thought about suicide, attempted suicide, or died by suicide, as well as survivors.
- 17. Suicide Ideation in LGB Youth LGB youth are 1½ to 3 times more likely to report suicide ideation than non-LGB youth. Suicide Prevention Resource Center, 2008
- 18. Suicide Ideation in LGB Youth • 31.2% of GB male high school students vs. 20.1% of heterosexual male high school students (past month)1 • 36.4% of LB female high school students vs. 34.3% of heterosexual female high school students (past month)1 • 47.3% of GB adolescent boys vs. 34.7% of non-GB adolescent boys (lifetime)2 • 72.9% of LB adolescent girls vs. 53% of non-LB adolescent girls (lifetime)2 1. Remafedi et al., 1998 2. Eisenberg & Resnick, 2006
- 19. Suicide Ideation in LGB Youth • 42% of LGB youths said they sometimes or often thought of killing themselves. • 48% of LGB youth said suicidal thoughts were clearly or at least somewhat related to their sexual orientation (lifetime). D’Augelli et al., 2001
- 20. Suicide Attempts in LGB Youth • LGB youth are 1½ to 7 times more likely to have attempted suicide than non-LGB youth.1 • LGB youth attempts may be more serious, based on some initial findings about: • Intent to end their lives2 • Lethality3 1. Suicide Prevention Resource Center, 2008 2. Safren & Heimberg, 1999 3. Remafedi et al., 1991
- 21. Suicide Attempts in LGB Youth • LGB youth were more than 2 times more likely to attempt suicide than their heterosexual peers (past year). 1 • Bisexual and homosexual male high school students were 7 times more likely to attempt suicide than heterosexual counterparts (lifetime).2 • 30% of LGB youth vs. 13% of heterosexual youth (median age of 18) had attempted suicide (lifetime).3 • 52.4% of LB females vs. 24.8% of non-LB females and 29.0% of GB males vs. 12.6% of non-GB males had attempted suicide (lifetime).4 1. Russell & Joyner, 2001 2. Remafedi et al., 1998 3. Safren & Heimberg, 1999 4. Eisenberg & Resnick, 2006
- 22. Suicide among LGB Individuals LGB youth and young adults: • Two psychological autopsy studies did not find a higher rate of suicide for LGB individuals.1,2 • Although these two studies are important, both have methodological issues that make their conclusions questionable.3 2003 analysis of Danish data:4 • Found “elevated suicide risk for homosexuals” • Does not apply specifically to youth 1. Rich et al., 1986 2. Shaffer et al., 1995 3. McDaniel et al., 2001 4. Qin et al., 2003
- 23. Suicide among LGB Youth • Compared to non-LGB youth: • LGB youth have higher rates of suicide attempts. • LGB youth suicide attempts may be more serious. The higher rate of suicide attempts, as well as the possibility that attempts among LGB youth are more serious, may mean that this group of youth has a higher rate of suicide. However, additional research is needed before we can draw that conclusion.
- 24. Suicidal Behavior and Transgender Youth Transgender youth: • Limited research exists. • Studies show higher rates of suicidal ideation and suicide attempts. • Risk factors: Which ones are in common with those for LGB youth?
- 25. Using the Research – Exercise A. You want to bring a gay-straight alliance to your school, but the principal maintains there is only one gay student at the school, and there is no problem. B. You want to add information about LGBT suicide risk to your training, but your funder says they don’t need special attention. C. A journalist calls you because he has just read that research has not shown LGBT youth die by suicide at a higher rate. He wants to know why LGBT youth are a focus of your suicide prevention program.
- 26. Break
- 27. LGB Developmental Models Stages of sexual identity development: • Awareness, recognition • Testing, exploration • Identity, definition, adoption of a label • Disclosure (“coming out”) • Acceptance • Same sex contact, romantic or emotional involvement • Identity within a group, integration
- 28. Transgender Developmental Models Devor describes stages of transgender identity formation including: • Anxiety • Acceptance • Confusion • Transition • Discovery of trans identity • Integration • Tolerance • Pride • Delay before acceptance Devor, 2004
- 29. Nonlinear Model – Themes for Identity Evolution • Differences • Degree of integration • Confusion • Internalized oppression • Exploration • Managing stigma • Disclosure (coming out) • Identity transformation • Labeling • Authenticity • Distrust of the oppressor • Cultural immersion Eliason & Schope in Meyer & Northridge, 2007
- 30. Stages and Average Ages – LGB First feeling different: 8 years old1 First aware of same-sex attractions: • Age steadily declining • Males age 10, females age 112 First disclosure: • Males and females age 172 1. D’Augelli & Grossman, 2001 2. D’Augelli, 2002
- 31. Stages and Average Ages – Transgender Feel different: 7 ½ years old Consider self to be transgender: • FTM – 15 years old • MTF – 13 years old First disclosure: • FTM – 17 years old • MTF – 14 years old FTM = female to male; MTF = male to female Grossman et al., 2005
- 32. LGB Prevalence Behavior, attraction, or identity • Same-sex behavior: 1% of students1 • Same-sex attraction (some degree of): 10% to 20% of young adults2 • Self-identification as gay/bisexual: fewer than 2% of adolescents3 • Possibly only 10% of youth who engage in same-sex behavior self-identify as gay1 1. Savin-Williams & Cohen in Meyer & Northridge, 2007 2. Savin-Williams, 2005 3. Garofalo et al., 1999
- 33. Transgender Prevalence There is no widely accepted estimate for the prevalence of people who are transgender.
- 34. Risk and Protective Factors Being LGBT is not itself a risk factor for suicidal behavior BUT social stigma and discrimination unsafe schools ineffective providers are associated with mood, anxiety, and substance use disorders, and suicidal behavior.
- 35. Risk and Protective Factors Risk factors – Make a disorder or behavior more likely Protective factors – Make a disorder or behavior less likely
- 36. Risk and Protective Factors • Synergistic • Dynamic • Complex • Modifiable and non-modifiable
- 37. Risk and Protective Factors Consider: • Number of factors • Severity or strength of factors Research basis in relation to: • Suicides, attempts, or ideation • Specific populations
- 38. Ecological Model Individual Family and peers Institutional Community Society
- 39. Protective Factors • Family connectedness1 • Family acceptance2 • Safe schools1 • Caring adult1 • High self-esteem3 • Positive role models3 1. Eisenberg & Resnick, 2006 2. Ryan et al., 2009 3. Fenaughty & Harre, 2003
- 40. Protective Factors Family connectedness plays an important role for LGB youth. Youth who are more protected say, My family… • “cares about my feelings” • “understands me” • “has lots of fun together” • “respects my privacy, and my parents care about me” Eisenberg & Resnick, 2006
- 41. Protective Factors Family acceptance – parent and caregiver behaviors that help: • Talk with your child about his/her LGBT identity • Express affection when you learn that your child is LGB and/or T • Advocate for child when he/she is mistreated because of his/her LGBT identity • Bring your child to LGBT events • Connect your child with an LGB and/or T adult role model • Welcome your child’s LGB and/or T friends and partners into your home • Believe that your LGB and/or T child can have a happy future Adapted from Ryan, 2009
- 42. Protective Factors School safety includes: • “I feel safe going to and coming from school.” • “I feel safe at school.” • “Bathrooms in this school are a safe place to be.” Eisenberg & Resnick, 2006
- 43. Protective Factors Other adult caring includes: • How much youth felt that other adults in their community, faith leaders, and other adult relatives cared about them. Eisenberg & Resnick, 2006
- 44. Risk Factors – Youth • Previous attempt(s) • Stress (rejection, feared • Mental illness punishment) • Substance use disorder • Isolation • Significant negative • Hopelessness personality traits • Method availability • Mentally ill parents Berman et al., Adolescent Suicide, 2006
- 45. Risk Factors – LGB Youth • Gender nonconformity1 • Lack of adult caring5 • Internal conflict about • Unsafe school5 sexual orientation2 • Family rejection6 • Time of coming out3 • Victimization7 • Early coming out4 • Stigma and discrimination8 • Low family connectedness5 1. Fitzpatrick et al. 2005; Remafedi et al. 1991 5. Eisenberg & Resnick, 2006 6. Ryan et al., 2009 2. Savin-Williams 1990 7. Bontempo & D’Augelli 2002; Russell & Joyner 3. D’Augelli et al. 2001 2001 4. Remafedi 1991 8. Meyer 1995
- 46. Risk factors – What’s different for LGBT youth? More risk factors or more severe ones: • Unsafe school • Rejection/abuse within family • Victimization • Previous attempt(s) • Exposure to suicide loss Specific to or mostly relevant to LGBT youth: • Gay-related stress and minority stress • Gender nonconformity • Internal conflict regarding sexual orientation
- 47. Discussion Small group discussions: Risk and protective factors
- 48. Break
- 49. Cultural Competence – LGBT Description: LGBT cultural competence applies to sexual and gender minorities. Behaviors, attitudes, and policies for a professional, agency, or system to work in cross- cultural situations “a tandem process of personal and professional transformation… the journey towards cultural competency… an ongoing process” Turner, Wilson, & Shirah in Shankle, 2006 (p. 62)
- 50. Cultural Competence – LGBT Key elements: • Defined set of values • Effective cross-cultural work • Involvement of consumers and community • Capacity to manage the dynamics of difference Incorporate these elements into policies, administration, practice, and service delivery. Dunne, C. et al., 2004
- 51. Cultural Competence – LGBT LGBT cultural competence standards for agencies: • Make accurate information easily available • Train staff, volunteers, and board • Have staff and board reflect diversity • Have job descriptions, supervision, and performance review all reinforce cultural competence • Include diverse clients in program decisions • Make sure agency environment and policies are inclusive • Conduct ongoing agency self-assessments
- 52. Small Group Exercise – Assessment and Next Steps See handout “Developing LGBT Cultural Competence: Agency Assessment and School Assessment” • Identify one or two steps you could take. • Identify one or two steps your agency or school could take.
- 53. GLSEN Video Available from www.thinkb4youspeak.com (click image to play)
- 54. Programs and Practice – A Start • Suggest that sexual and gender minority issues be added to diversity or cultural competence training • Post a rainbow on your office door • Check your school or agency anti-discrimination policies for both sexual orientation and gender identity • Review with LGBT youth your confidentiality safeguards and how staff are trained to implement them • Review availability of information on LGBT youth issues in local libraries (e.g., staff, school, or community libraries) and on the Internet • Distribute the SPRC white paper on LGBT youth suicide prevention and lead a discussion about it at a staff meeting
- 55. Programs and Practice – Doing More • Interrupt a student who says “that’s so gay” • Lead a revision of agency forms to use more inclusive terms • Organize a LGBT consumer group to give feedback on the service space, forms, policies and procedures, and outreach materials • Attend a gay-straight alliance meeting at the school or help get a group started • Expand services to younger teens and families • Develop resources and attend training for your profession related to serving LGBT youth
- 56. Youth Suicide Prevention What is youth suicide prevention? • Case-finding of at-risk youth with referral for assessment or services • Gatekeeper programs • Screening • Crisis lines • Reduction of risk factors, increase in protective factors Gould, M. S. et al., 2003
- 57. Suicide Prevention – Case-Finding with Referral • Promote LGBT cultural competence through staff training • Refer LGBT youth to mental health services that are culturally competent • Reach out to providers and organizations who serve LGBT youth, particularly those at greatest risk
- 58. Suicide Prevention – Addressing Risk and Protective Factors • Include the topic of LGBT youth risk in awareness materials, conferences, and state and local prevention plans • Provide training for all staff about LGBT issues • Include the topics of dealing with discrimination and victimization in life-skills training for youth • Institute protocols for when youth are identified at risk, youth have attempted suicide, or youth have died by suicide
- 59. Suicide Ideation – Resources LEARN THE WARNING SIGNS AND WHAT TO DO You can find the best practices warning signs at the American Association of Suicidology: http://www2.sprc.org/sites/sprc.org/files/AASWarningSigns_factsheet.pdf See handout – “Warning Signs for Suicide Prevention”
- 60. Suicide Ideation – Resources • Take gatekeeper training (e.g., QPR, ASIST, Connect) to learn how to identify youth who may be having suicidal thoughts http://www.sprc.org/featured_resources/bpr/standards.asp • Contact your state suicide prevention coalition to find gatekeeper training in your area http://www.sprc.org/stateinformation/index.asp • Encourage your local referral network to be trained in assessing and managing suicide risk http://www.sprc.org/traininginstitute/amsr/clincomp.asp
- 61. Suicide Attempts – Resources • National Suicide Prevention Lifeline brochure “After an Attempt: Guide to Taking Care of Your Family Member after Treatment in the Emergency Department” http://www.suicidepreventionlifeline.org/App_Files/Media/P DF/Lifeline_AfterAnAttempt_ForFamilyMembers.pdf • Feeling Blue Suicide Prevention Council booklet “After an Attempt: The Emotional Impact of a Suicide Attempt on Families” http://feelingblue.org/docs/AFTER_AN_ATTEMPT_BOOKLET_ rev.pdf
- 62. Suicide Attempts – Resources What you can do for a youth after an attempt: • Let him or her know you care. Try: • “I’m sorry you hurt that badly. I wish I could have helped you.” • “I want to help you. Tell me what I can do to help you now.” • Provide information on suicide and mental illness • Ask the family to remove guns from their home and reduce access to lethal means • Arrange a therapy session for the youth and family before the youth returns home from the hospital if possible • Help find support and services: consider mental health or faith-based services Adapted from “After an Attempt: The Emotional Impact of a Suicide Attempt on Families”
- 63. Suicide Attempts – Resources • To help his or her recovery after getting out of the hospital, an individual who attempted suicide needs to: • Identify triggers for suicidal thoughts and plan to minimize their effects • Build a support system • Try to follow a routine • You can be an important support for LGBT youth who attempted suicide. Adapted from “After an Attempt: A Guide for Taking Care of Yourself“
- 64. Suicide Postvention – Resources What You Can Do • Work with a community group to set up policies and procedures for postvention (interventions following a suicide) • Remember that the rationale for postvention is to both promote healthy grieving for survivors and limit contagion • Help to limit contagion by encouraging the media to follow recommended reporting practices, training those with public roles how to respond appropriately, and memorializing the deceased in a way that is safe • Review resources, including guidance on memorial services, talking to the media, caring for survivors, and data for your state
- 65. Suicide Postvention – Resources • At-a-Glance: Safe Reporting on Suicide: http://www.sprc.org/library/at_a_glance.pdf • Youth Suicide Prevention, Intervention, and Postvention Guidelines from Maine Youth Suicide Prevention Program: http://www.maine.gov/suicide/docs/Guidelines%2010-2009-- w%20discl.pdf • After a Suicide: Recommendations for Religious Services and Other Public Memorial Observances: http://www.sprc.org/library/aftersuicide.pdf • For data: http://www.cdc.gov/ncipc/wisqars/ and http://www.sprc.org/stateinformation/index.asp
- 66. LGBT Youth Programs • Can support suicide prevention by strengthening protective factors and decreasing risk factors • Can train program staff and board in LGBT youth suicide risk, and risk and protective factors • Can advocate for LGBT youth leadership in suicide prevention programs • Can provide accurate information about LGBT youth suicide risk on the Web and in materials
- 67. Evaluation of LGBT Youth Programs Special considerations: • Respect the sensitivity and confidentiality of data during collection, analysis, and reporting • Respect group and individual privacy • Define terms clearly • Make the limitations of the findings explicit
- 68. Discussion • How can we work to create supportive environments for all youth? • How can we begin to address the barriers facing LGBT youth who need help? • What can we do to raise awareness about the particular needs of transgender individuals? • What will you do to help prevent suicide among LGBT youth?
- 69. Workshop Summary • Now that you have completed this training module, you can: 1. Use terminology for suicide and LGBT issues correctly 2. Describe research related to suicidal behavior among LGBT youth 3. Discuss risk and protective factors for LGBT youth and the implications 4. Assess your school’s or agency’s cultural competence with LGBT youth and implement next steps 5. Describe strategies to reduce suicidal behavior among LGBT youth
- 70. Contact Information Leader 1 Job title Phone number E-mail Agency Website Leader 2 Job title Phone number E-mail Agency Website
Notes de l'éditeur
- NOTE to the trainers:Italicized text in the leader notes is for you to use as a script and to adapt in your own words. Notes to the leader that are NOT to be read aloud are NOT italicized.Ahead of time—please replace “Insert Leader 1 (and 2) name and Organization here” with your names and organizations on the opening slide.Welcome! We’re excited to be here today.Each leader introduces himself or herself:NameOrganizationPositionPersonal interest in topic. Leaders may include their sexual orientation and/or gender identity.
- TheNational Strategy for Suicide Prevention is the founding document for our suicide prevention work, yet LGBT youth were only mentioned in an appendix as a special population at risk. The National Strategy came out in 2001. Our knowledge has improved since then as more and stronger research has been done about LGBT youth. In 2008, the Suicide Prevention Resource Center published a paper called Suicide Risk and Prevention for Lesbian, Gay, Bisexual, and Transgender Youth to summarize the research and get that information out to the field. In addition to the research summary, the paper provides prevention-oriented recommendations, a resource appendix, and an extensive bibliography. During this workshop, we are going to build on what the paper set out and discuss not only what has been learned about suicidal behavior among lesbian, gay, bisexual, and/or transgender youth but also how we can apply the learning.
- SPRC developed this workshop because we now have enough information to take action to prevent suicidal behavior among lesbian, gay, bisexual, and transgender (LGBT) youth.We know that there is more suicidal behavior among LGBT youth than among youth who are not LGB and/or T.Thanks to the research, we know some of the risk and protective factors associated with suicidal behavior. These present opportunities to intervene and make a difference in the lives of LGBT youth. We also know the importance of cultural competence in affecting positive change in schools, youth serving organizations, and suicide prevention programs. A note: Usually when we talk about cultural competence we mean working effectively with different ethnic, racial, and linguistic minorities by understanding and taking into consideration their experiences, knowledge, values, beliefs, attitudes, meanings, roles, and practices. As a distinct group, the LGBT community also has a culture. In addition to the positive culture that the LGBT community has been developing, its culture is also affected by the discrimination that people who are LGBT experience. As a result, LGBT youth need our special attention.
- At the end of this training, you will be able to use the terminology and the research related to LGBT youth that we discuss.You will also be able to discuss the risk and protective factors that we’re going to review from the research.Then we’re going to take some time and bring it home, to assess individual as well as school or agency LGBT cultural competence and plan next steps.We’ll also talk about designing program and practice adaptations.For a small group:I just want to take a moment to poll the group. Since it’s a small group, we’re going to use a round robin and quickly go around the room and have participants make a brief statement about the objectives listed on this slide. Specifically, how well do these objectives fit with your original hopes and/or expectations for this workshop? Do you have any other objectives for this workshop? For a large group:Same approach as for a small group except you ask a sample of participants to share their thoughts. Trainer’s response:You will have to address whether additional, suggested objectives can/will be covered in the training. You may wish to point participants to additional resources outside the training.
- Before we get into suicide prevention, let’s talk about the problem of suicide, and what it looks like.Public health looks at data to identify which groups of people are at higher risk of suicide and uses research to develop interventions to address this risk.
- For all U.S. residents, suicide is the 11th leading cause of death, but for some ethnic, racial, and age groups, suicide is a much more prevalent cause of death. For example, for youth and young adults, suicide is the 3rd leading cause of death.Each year, 35,000 people die by suicide in the United States—that’s nearly twice the number of people who die by homicide in the U.S. each year.We don’t have complete data for suicide attempts. While many people who make suicide attempts may see a health care professional, many don’t see anyone. None of these attempts are captured with hospital data. Self-injury is the closest proxy measure that we have to estimate attempts.First two statistics: Centers for Disease Control and Prevention. (2007). Web-based Injury Statistics Query and Reporting System (WISQARS). Retrieved February 20, 2010 from http://www.cdc.gov/injury/wisqars/index.htmlSecond two statistics: Substance Abuse and Mental Health Services Administration, Office of Applied Studies. (2009). Results from the 2008 National Survey on Drug Use and Health. Retrieved from http://www.oas.samhsa.gov/2k9/165/SuicideHTML.pdf
- From these data, you see that the problem of suicide could be seen as having a greater relative impact on youth when compared to other causes of death—it is the 3rd leading cause of death rather than the 11th. The rate of suicide for youth and young adults is defined as the proportion of suicides compared to the number of people in that age group. For youth the actual death rate is lower than for other groups. For example, middle-aged and elderly people have higher suicide rates. But for suicide attempts, young people have the highest rates.First two statistics: Centers for Disease Control and Prevention. (2007). Web-based Injury Statistics Query and Reporting System (WISQARS). Retrieved June 7, 2010 from http://www.cdc.gov/injury/wisqars/index.htmlThird statistic: Centers for Disease Control and Prevention. (2010). Youth risk behavior surveillance - United States, 2009. Surveillance Summaries. MMWR, 59(SS-5). Retrieved June 11, 2010, from http://www.cdc.gov/mmwr/pdf/ss/ss5905.pdf
- OK. Earlier we [the trainers] introduced ourselves. Now that you’ve had a few minutes to settle in, let’s take some time for you to introduce yourselves.Smaller participant groupStarting here [gesture to someone], let’s go around the room. When it’s your turn, please share your name, the organization you represent, and what you want to gain from attending this workshop.Larger groupGiven the size of this group, we don’t have time to hear from each of you. So, let’s just see a show of hands to get a sense of who is in the room. Raise your hand if you...work in suicide prevention… work in a school…work in child protective services or child welfare… work as a counselor or mental health professional… work with an LGBT organization… work with youth in a setting I haven’t named yet…Ask for settings that weren’t named, and feel free to comment on how broad the interest is in LGBT youth.
- During the small group exercises and the large group discussions later in this workshop, we’ll be talking about two topics that can be quite difficult for some people:(1) Suicide and (2) Sex and genderSo let’s take a moment to agree upon ground rules, so we can all feel as comfortable as possible sharing and learning from each other.[You may wish to write ground rules on a flip chart.]Some basic rules, which you’ve probably heard in other workshops, are:Listen respectfully—respect others while they are talking.Speak from your own experience instead of generalizing (Use “I” instead of “they”, “we,” and “you”).Do not be afraid to respectfully challenge one another by asking questions, but refrain from personal attacks. Focus on ideas.Participate to the fullest of your ability. Community growth depends on the inclusion of every voice.Note: These ground rules came from Guide for Setting Ground Rules by Paul C. Gorski, available online at http://www.edchange.org/multicultural/activities/groundrules.html. I will add one other rule—no cell phones or texting in this room. Cell phones can be distracting for the trainers and the participants. If you have something urgent you need to attend to, please take your call outside the room. How about confidentiality? How would you like to handle that? [Invite suggestions.]Other ground rules? [Invite suggestions. If you’re using a flip chart, write them down.]
- Now we’re going to do a little icebreaker. First, I’ll tell a story:Some of you may have heard of Roy and Silo, two male penguins in New York’s Central Park Zoo who, for six years, formed a couple. They behaved like penguins do when they are devoted to each other—they entwined necks, vocalized to each other… At one point they even tried to hatch a rock that resembled an egg. When the zookeepers realized that they seemed to want to parent together, they gave Roy and Silo a fertile egg that needed care to hatch. The pair of males took care of the egg and a chick, named Tango, was born. The pair raised Tango, keeping her warm and feeding her food from their beaks until she could go out into the world on her own.(WAIT before relating to training:)This story has a lesson for us about how the majority deals with the differences the minority has. There is a whole range of responses that we will begin to explore today—from rejection and isolation to acceptance and tolerance to alliance, advocacy, and celebration of minorities.Stand Up/Sit Down ExerciseNow we’re going to do an exercise that may get you thinking about what it’s like to be in the minority or to be aware of being in a majority. We borrowed this exercise from the Maine Youth Action Network and the Maine Youth Suicide Prevention Program.As I read a statement, please stand up if you identify with it. Remain standing briefly, and then sit back down. During the exercise, look around the room and see who is standing. If the statement does not apply to you, remain seated. I’ll read a number of statements. [Trainer: Use the Stand Up/Sit Down resource sheet. Choose ahead which statements you plan to read aloud. Join in the exercise with the participants. ]
- During the Stand Up/Sit Down exercise, I used terms such as “sexual orientation” and “gender identity”. So, what’s the difference between sex and gender? Sex refers to biological differences that distinguish males from females, e.g., things like chromosomes and sex organs.Gender refers to socially constructed roles, behaviors, activities, and attributes that a given society considers appropriate for men and women.Think male/female (i.e., sex) versus masculine/feminine (i.e., gender)—even though, in common usage, this is not a uniform or clear-cut distinction.Sexual orientation is a person’s romantic, emotional, and/or sexual attraction towards males, females, or both. Gender identity is one’s sense of self as male or female, or somewhere between or outside traditional genders.“Transgender” is a term that refers to people who live differently than the gender presentation and roles expected of them by society. Transgender individuals can be straight, gay, lesbian, or bisexual. Gender identity is separate from sexual orientation. That’s why you’ll hear us say “LGB and/or T” when referring to individuals.Please take a look at your handout titled “LGBT Glossary.” I’m going to give you a minute or two to read through it quietly… Any comments or questions? Leader:Questions may come up at this point or later in the workshop about language used in the transgender community, such as MTF, FTM, transmen, transgirls, transsexuals, etc.For additional definitions, go to Transgender Terminology at http://www.umass.edu/stonewall/uploads/listWidget/8758/trans%20terms.pdf.Additional definitions/resources are available online. For example: Girl's Best Friend Foundation and Advocates for Youth. Creating Safe Space for GLBTQ Youth: A Toolkit. Washington, DC: Advocates for Youth, 2005. Retrieved June 24, 2010, at the Advocates for Youth website http://www.advocatesforyouth.org/index.php?option=com_content&task=view&id=608&Itemid=177.See page 63 and pages 76–77 for transgender and other terms and explanations.
- In order to communicate clearly about risk of suicidal behavior among LGBT youth, we need to develop definitions of terms. The basic terms are listed on this slide.A suicide is a death from injury, including poisoning or suffocation, where there is evidence that the injury was self‐inflicted and the person intended to kill himself or herself. A death such as a car accident or drug overdose is not considered a suicide if the person did not intend to kill himself or herself. However, it is often very difficult to determine intent.An attempted suicide is a potentially self‐injurious act with at least some wish to die as a result of the act. The intent does not have to be 100%. If there is any intent or desire to die associated with the act, then it may be considered an actual suicide attempt. Non-suicidal self-injury, which we see a lot of, is done to relieve powerful emotions and is not a suicide attempt because there is not an intent to die. Self-injury is, however, a strong risk factor for suicide attempts.Suicide ideation is a term that describes thoughts of suicide, including talking about suicide. Suicide ideation can range from fleeting thoughts and a vague “wish to be dead” to detailed planning and intent to act on the plan.Suicidal behaviorrefers to all of the terms above.Take a look at the “Suicidology Glossary” handout. Any questions or comments?
- Before we proceed with our discussion of the research, let’s take a moment to pause. In talking about statistics and research methodology, it’s easy to sound distant from the fact that…We’re talking about individuals—young people—who thought about suicide, attempted suicide, or died by suicide. Many people have lost a loved one to suicide—a son, a daughter, a brother, a sister, or a friend. Many more of us have cared about someone who attempted suicide.Some of the people in this room may have seriously considered or attempted suicide in the past, perhaps even the recent past. Let’s acknowledge that the discussions we’re having today may be difficult at times. If you find yourself having a hard time with our discussion at any point, feel free to speak up, ask for help, take a break, or whatever you need to do to take care of yourself. And let’s remember that we’re not talking about “them” but “us”… our community.(Note to trainers about the importance of acknowledging the individuals behind the data. An SPRC staff person used this slide in a presentation where she showed youth suicides for the state she was presenting in. On a break, one of the participants told the trainer, “That was my son you were talking about. Thank you for making him less anonymous and acknowledging my loss.”)
- The first thing that you may notice is the title of this slide. You might wonder, Where are the transgender youth? We will talk about transgender youth later, mostly because the majority of research focuses on LGB youth.This is a summary slide. It summarizes the research that is included in the white paper from SPRC and that is available on the SPRC website.The bottom line is that a number of studies point to the higher rate of ideation by lesbian, gay, and bisexual youth. The findings from the white paper showed that LGB youth ranged from 1 1/2 to 3 times more likely to report suicide ideation.That’s significant and troubling to me. That’s a real disparity. It really gives us a wake-up call that we need to focus on this group of youth. Not only is suicide ideation disruptive for youth, it can escalate to a suicide attempt for some.
- The first study we are going to talk about is from Gary Ramafedi and others in 1998. He found that close to 1 in 3 gay and bisexual male high school students reported suicide ideation. That’s compared to 1 in 5 heterosexual male students. For females, he found the rates were roughly comparable. But for the males, there was a big difference. You’ll notice with the data that we report on, we indicate in parentheses whether the youth were asked about suicidal behavior in the past year or ever (lifetime). So, for example, Remafedi asked about thinking about suicide in the past month.The next study we’ll look at is from Eisenberg and Resnick. In that study, they found that nearly 1 in 2 gay and bisexual adolescent boys thought about suicide, compared to about 1 in 3 adolescent boys who weren’t gay and bisexual. And for lesbian and bisexual girls, it was nearly 3 out of 4 compared to 2 out of 4 of the non-lesbian and non-bisexual girls. You might ask, Why is there a range in results? In this case, the difference may partly be due to asking about suicide ideation over different time periods. The Remafedi study asked about thoughts and wishes of suicide in the past month, while the Eisenberg study asked about thoughts of suicide over a lifetime, or ever.Results can also vary because researchers survey different populations or use databases that cover different populations. The populations studied might be from different regions, cultural groups, and ages of youth. Researchers may also ask the questions differently. For example, consider the questions asked by researchers about sexual orientation. Researchers can ask about behavior—Did youth ever have sex with a male? Or they can ask about attraction, whether youth are attracted to the same or opposite sex. Or researchers can ask about how youth identify themselves—as straight or heterosexual, as bisexual, or as gay or lesbian or homosexual. Different questions yield different results. Differences may also result from how researchers ask about suicide ideation. Remafedi et al., 1998. Cross-sectional analysis of Minnesota Adolescent Health Survey database, including grades 7 to 12 in public school. LGB males = 212 and LB females = 182, total LGB = 394. Heterosexual comparison group = 336. Eisenberg & Resnick, 2006. 2004 Minnesota Student Survey, 9th and 12th graders in public schools. 2,255 LGB out of 21,927 total.
- The last study about ideation that I want to refer to is from Anthony D’Augelli. He found that 42% of lesbian, gay, and bisexual youth said they sometimes or often thought of killing themselves. Nearly 50% of them said that it was clearly or at least somewhat related to their sexual orientation. For these youth, what kind of experiences do they have as lesbian, gay, and bisexual that lead them to think of killing themselves? On the other hand, what about the nearly 60% of LGB youth who don’t consider suicide? Are there experiences in their lives or personality traits or cultural attitudes that keep them for considering suicide? Or are their lives going better generally?We will be exploring these issues when we talk about risk and protective factors. D’Augelli et al., 2001. 350 LGB youth aged 14 through 21 years old who attended community-based programs in USA, Canada, New Zealand. (no heterosexual comparison group).
- Based on research reviewed in the SPRC white paper, we can summarize that LGB youth are 1 1/2 to 7 times more likely to have attempted suicide than non-LGB youth.Keep in mind that this is based on self-reports. In other words, it is based on students or youth answering survey questions about their own suicide attempts, which brings up a research question about whether LGB youth would be more or less likely to report suicide attempts. There are researchers that argue both sides of the question.Youth who attempt suicide need our attention. Aside from medical attention, a mental health professional should do a thorough assessment of risk, and key adults need to know about the attempt and the youth’s status and plan for safety. Prior suicide attempts are one of the strongest predictors of a completed suicide. Yet many youth who attempt suicide don’t receive any medical attention or mental health services and go unrecognized. We can also compare the seriousness of attempts made by LGB youth compared to non-LGB youth. By seriousness I mean, how strong was the intent to die when the person attempted? What was the potential lethality of the method they employed?Safren and Heimberg found a stronger intent to die among LGB youth who attempted suicide. Another study found higher lethality—measured three ways:More lethal means, such as firearms or jumping from a heightHigher rate of hospitalizationsOpportunity for rescues following attempts were less likelyFurther research is needed to establish that LGB attempts are more serious because both of these studies are based on small, non-representative samples.Safren & Heimberg, 1999. 56 LGB youth who participated in after-school programs for sexual minority youth and 48 heterosexual youth between ages 16 and 21. Remafedi et al., 1991. 137 gay and bisexual males age 14 through 21 years old recruited from upper Midwest and Pacific Northwest.
- This slide looks at a number of studies, so I’m going to give you a moment to read it.The greater difference in attempts between LGB youth and heterosexual (or non-LGB) youth was in males.Any thoughts or feelings you want to share after seeing these data?These studies show a range in results—but all are in the same direction—for the same reasons we discussed when we talked about the ideation research results: different populations, different wording for questions about attempting suicide, defining sexual orientation differently, etc.Russell & Joyner, 2001. National Longitudinal Study of Adolescent Health, representative sample of 6,254 female and 5,686 males for total of 11,940.Remafediet al., 1998. Cross-sectional analysis of Minnesota Adolescent Health Survey database, including grades 7 to 12 in public school. LGB males = 212 and LB females = 182, total LGB = 394. Heterosexual comparison group = 336. Safren& Heimberg, 1999. 56 LGB youth who participated in after-school programs for sexual minority youth and 48 heterosexual youth between ages 16 and 21. Eisenberg & Resnick, 2006. 2004 Minnesota Student Survey, 9th and 12th graders in public schools. 2,255 LGB youth out of 21,927 total youth.
- Now we are going to talk about suicides.Two early studies did not find a higher rate of suicides for LGB youth; however, both studies have been challenged as possibly inaccurate (McDaniel et al., 2001). For example, the studies were criticized for using family to determine the sexual orientation of people who died by suicide, or for choosing prevalence rates for homosexuality where this was unknown. The Qin study analyzed socio-demographic data for people who died by suicide and found homosexuals had a higher risk for dying by suicide. The Qin research did not apply specifically to youth.None of these studies included individuals who are transgender as part of their research.Rich et al. study was of 283 adult and adolescent suicides in San Diego.Shaffer et al. study was of 120 youth under age 20 who died by suicide in the New York City area.Qin et al. subjects were 21,169 persons who died by suicide.
- We can look at suicides another way.We established that lesbian, gay, and bisexual youth probably have a higher rate of suicide attempts based on a number of research studies. Based on the disproportionate attempt rate, can we draw a conclusion about the number of suicides? For a moment, let’s look at another population—women. There are many more suicide attempts by women than men. Specifically, there are three female suicide attempts for every two male suicide attempts. And yet men die by suicide at four times the rate of women. The point here: You cannot conclude that a group that attempts suicide more often has more deaths by suicide.Regarding gay, lesbian, and bisexual youth—they probably have a higher number of suicide attempts. But we just demonstrated that we cannot project a conclusion about the suicide rate based on the attempt rate alone. However, when we consider the seriousness of attempts—based on intent to die and lethality of means—it may be that this group actually does have a higher rate of suicide. However, recall that the finding about the seriousness of attempts was based on small, non-representative samples. So we need larger studies that replicate these findings before we can reach this conclusion with certainty.
- As I mentioned earlier, we don’t know much about suicidal behavior in transgender youth. There is limited research, and the studies that are published have small samples and don’t have comparison groups. The studies about transgender individuals that SPRC reviewed had between 24 and 182 participants. Doing research about transgender youth is challenging. For example, a researcher might go to a health clinic that has a program for transgender youth and interview the youth there. But the sample of youth from the health clinic is not likely to be representative of transgender youth in general. For one thing, they have access to health care, unlike other transgender youth, such as those who are homeless. These studies that use convenience samples still have findings worth noting and prepare the way for additional research; however, the findings cannot be generalized to transgender youth overall.Studies on transgender individuals do demonstrate high rates of suicidal ideation and suicide attempts. They also show a higher likelihood of victimization and family rejection, both risk factors for suicidal behavior. The good news is that the number of studies being done with transgender youth is increasing, and the quality is improving. One question that I want to put to you: How comparable is the experience of being a transgender youth to being a gay, lesbian, or bisexual youth? For example, do transgender youth face risk around disclosing their gender identity? Are there differences in how they are victimized, or how family rejection occurs? When we talk later about risk and protective factors, we will discuss the similarities and differences between lesbian, gay, and bisexual youth, and transgender youth.
- Leader: For a small group, break out into groups of 3 or 4. For a larger group, divide the room into 3 sections.Then assign one scenario to each group or section from the slide—choices A, B, and C. Give participants 5 minutes to discuss an appropriate response to their scenario. Then have a brief report back.Issues that may come up: Being able to use terminology and describe research results effectively Building alliancesPossible responses from report backs:A. LGBT youth are not easily identified, but it is unlikely there is only one student. We will be describing prevalence in a few minutes.B. LGBT youth are at higher risk for suicidal behavior.C. Explain the research challenges (no sexual orientation or gender identity on vital records, limited population-based data sets, etc.) Data regarding suicides is difficult, but it is theorized—based on research findings—that LGBT suicide deaths are higher. Suicide prevention tries to prevent suicide ideation and attempts as well deaths by suicide.
- We are going to take a break now for XX minutes. (Fill in the number of minutes you would like to allow for the break.)
- Developmental models give us a way of looking at adolescence generally. But it’s important for us to understand the developmental challenges of LGBT youth before we go on to talk about risk and protective factors. Sexual minority youth experience challenges that straight youth don’t, which can be referred to as “gay-related stressors.” On the other hand, they also experience some challenges in common with straight youth, such as victimization. But how they respond to victimization can relate to where they are in their development. For example, do they internalize homophobia? Do they delay coming out? Disclosure in particular is a key time that LGBT youth are at risk for suicide attempts and suicide.Traditional developmental models are linear, and they are based on research with males. Developmental models tend to assume that later stages are more advanced than earlier stages. Immaturity is expected to progress to maturity, integration, and authenticity. In fact, identity formation is a lifelong process.When we look at the stages on the slide now—awareness and recognition, testing, exploration, identity, definition, adopting a label, disclosure, acceptance, same-sex contact and involvement in a same-sex romantic or emotional relationship, and identity within a group—there are potential gender differences. The stages in this model are based on males. For females, the timing, sequence, duration, and context could be different. There could also be differences across culture, race, class, gender, and disability, and other factors could come into play.For additional resources see:Eliason, M. J., & Schope, R. (2007). Shifting sands of solid foundation? Lesbian, gay, bisexual, and transgender identity formation. In I. Meyer and M. Northridge (Eds.), The health of sexual minorities: Public health perspectives on lesbian, gay, bisexual, and transgender populations (pp. 3-26). New York: Springer.
- Developmental models give us a way of looking at issues for transgender youth as well. This slide describes a model proposed for stages of transgender identity development based on a long-standing model of gay and lesbian development by Vivienne Cass. The Devor model has not been empirically validated. Devor’s model describes two social processes underlying the 14 stages of transgender identity development—witnessing (of transgender identity by others) and mirroring (seeing oneself in the eyes of someone who is similar). The model includes a couple of delay stages that represent stalled development. As with most developmental models, not all transgender individuals progress through all the stages in order.In contrast to non-transgender youth, transgender youth have to confront cultural assumptions establishing two genders as distinct and separate.
- This slide presents a nonlinear model with themes for identity evolution. This depicts a lifelong process with no beginning, middle, and end, and one in which themes will come up multiple times and not in a given sequence. The themes can apply to sexual and gender identity formation.How much do these differences play a role in a youth’s life?Is there confusion, exploration? Does the youth decide to come out or not?How do they deal with labeling, by themselves and from other people?How does their culture deal with sexual and gender minorities?How do they deal with the person or the group that oppresses them?Authenticity represents the opposite of secrecy and denial, which may be necessary to youth concerned with their safety. These themes provide issues to review in terms of risk and protective factors that we will discuss shortly. For example, what protective factors would help LGBT youth deal with these challenges?[Invite comments and discussion.]
- This topic comes up a lot in training. Heterosexual people are curious about when LGB individuals first get an idea that they might be gay or start thinking about it.The ages shown on the slide are averages. The sample sizes are fairly large, over 400 people.The important thing about this slide is that feeling different can start as early as age 8. And these ages seem to be getting younger over time, with each new generation. The take-away message: People working in suicide prevention need to be aware of the stages and ages of LGB identity development and coming out in order to design effective interventions. Coming out is a time of suicide risk.How do these figures compare with your experience or that of the youth you work with?
- This slide talks about the stages and ages for people who are transgender. This study was done with a convenience sample of 55 youth and is not considered representative. The youth participated in recreational programs in New York City and referred more youth to the study.The ages for feeling different and first disclosure are younger than many people expect. Thus, providers need to not only consider these issue possibilities for younger clients, but also to include families in their programs.Leader:Questions may come up at this point about language used in the transgender community, such as MTF, FTM, transmen, transgirls, transsexuals, etc.For additional definitions, go to Transgender Terminology at http://www.umass.edu/stonewall/uploads/listWidget/8758/trans%20terms.pdf.
- This slide talks about prevalence—the proportion of the population who are gay, lesbian, or bisexual. This topic touches upon some of the same issues we discussed earlier related to terminology and research challenges. Depending on the questions that researchers ask and the people they sample, they may get very different estimates. For example, research related to sexual orientation can include survey questions about behavior (who youth have sex with), attraction, or identity. Notice on the fourth bullet that many youth—perhaps 90%—who identify in same-sex behavior do not identify as gay.This slide shows the wide variation in research findings. We can only assume that the “real” prevalence is somewhere in that range.
- There is no widely accepted estimate for the prevalence of people who are transgender. “Transgender” is an umbrella term for people whose gender identity, expression, or behavior is different from those typically associated with their assigned sex at birth, including but not limited to transsexuals, cross-dressers, and people who do not conform with common gender norms. The small number of studies conducted to establish the prevalence of transgender individuals have only studied individuals who are transsexual, which is only a minority of people who are transgender. In addition, these few studies have had some significant research limitations.Another issue relevant to transgender prevalence is that many transgender individuals do not share there identity publicly, so they might not be counted in studies.
- One of the objectives of this workshop is for you to correctly describe suicide risk for LGBT youth.Towards that end, we’re going to review a couple of key concepts. Perhaps you’ve heard people say that “being LGBT is a risk factor for suicide.” Has anyone heard that before? Beinglesbian, gay, bisexual, and/or transgender is not in and of itself a risk factor for suicidal behavior. Instead, it is the social stigma and discrimination that LGBT youth experience that results in feelings and behaviors which are, in turn, associated with suicidal behavior. An example: A gay youth is harassed at school, even threatened with violence. He feels unsafe and starts missing school. He becomes isolated. He internalizes the homophobia. He starts thinking about suicide.We’re here today to better understand how to prevent suicidal ideation among LGBT youth in the first place. And, when we fail in that regard, how to identify young people who are considering suicide so that we can help them find support and help.And we must remember not to focus exclusively on risk. The fact is that many LGBT youth do not engage in suicidal behavior. The training today will help identify risk and protective factors that are key to suicide prevention.
- We have already referred to risk and protective factors quite a few times in this presentation, and I am about to discuss them in more depth. But before I do, I want to make sure that we are clear about the meaning of these terms. A risk factor for suicidal behavior is a characteristic that has been demonstrated through research to be associated with—although not necessarily the direct cause of—suicidal behavior for a particular group of people. A risk factor indicates that an individual or population with a particular characteristic is more likely to think about suicide, or attempt or die by suicide, but it cannot predict any individual’s behavior. On the other hand, a protective factor indicates that an individual or population with a particular characteristic is less likely to engage in suicidal behavior.Identifying risk and protective factors helps us determine the best way to implement suicide prevention programs and policies to help individuals and populations of people who may be at risk for suicide otherwise.As we have already discussed, being lesbian, gay, bisexual, and/or transgender is not in itself a risk factor for suicide. Certainly, the research studies we just discussed demonstrate higher risk for LGBT youth, so there is a clear association between LGBT status and suicidal behavior. However, being lesbian, gay, bisexual, and/or transgender suicide has not been shown to be an independent risk factor for suicide. What is important is to explore that relationship and better understand it so that we can develop suicide prevention programs and policies to prevent suicide among LGBT youth. As we discussed earlier, stigma and discrimination are risk factors for mental illness and suicidal behavior. In a few moments, we will learn about other risk factors. We will also identify protective factors, such as safe schools, caring adults, and family connectedness.
- Risk and protective factors help explain suicidal behavior—including suicidal ideation, suicide attempts, and suicides. Risk and protective factors affect the likelihood of suicidal behavior in ways that are both synergistic and dynamic. For example, in the case of risk factors, synergistic means that the effect of a single factor is increased when an individual has additional risk factors and that risk factors are not simply additive. Dynamic refers to how a risk factor’s meaning to and effect on an individual changes over time. Risk and protective factors are also complex. Suicidal behavior is often related to a combination of factors. Adding to the complexity is the fact that two different youth can be exposed to the same kind of stressful event and respond to the event differently. This is a phenomenon that I’m sure many of you have observed. It appears that the meaningyouth give to the risk factors they experience is a crucial variable.In fact, modifying protective factors may be a very effective prevention approach. A study of suicide attempts among American Indian and Alaska Native youth found that increasing protective factors was more effective for reducing the likelihood of attempts than decreasing risk factors. Protective factors included the ability to discuss problems with family or friends, connectedness to family, and emotional health (Borowsky, I. W., Resnick, M. D., Ireland, M., & Blum, R. W. (1999). Suicide attempts among American Indian and Alaska Native youth: Risk and protective factors. Archives of Pediatrics & Adolescent Medicine, 153(6), 573-580).From a public health perspective, the most important factors are the ones that are modifiable. In many cases, protective factors may be more modifiable than risk factors.
- The risk factors that apply to youth overall also apply to LGB youth. Kitts’s review of the research literature (2005) confirms this. Kitts concludes that the elevated risk of suicide attempts among LGB adolescents is a consequence of the psychosocial stressors associated with being lesbian, gay, or bisexual, including gender nonconformity, victimization, lack of support, dropping out of school, family problems, suicide attempts by acquaintances, homelessness, substance abuse, and psychiatric disorders. While heterosexual adolescents also experience these stressors, LGBT adolescents often experience more risk factors. Also, LGBT youth have fewer protective factors: Providers may be non-inclusive, and parents, friends, and faith communities may be rejecting.LGB youth may experience these factors in greater strength. Think about victimization. The abuse an LGBT youth experiences is often repeated and severe.Research studies establish these risk factors by asking youth specifically about suicide ideation and attempts. We generalize when we call them risk factors for suicide. An academic journal article will usually describe how the researcher defined a factor, such as stigma or victimization, and will specify whether the survey question asked about ideation or attempts.
- No single factor explains why some individuals attempt suicide or die by suicide, or why suicidal behavior is more prevalent in some communities than others.Suicidal behavior is the result of a complex interplay of individual, relationship, social, cultural, and environmental factors. The model shown in this slide is called the socio-ecological model. It visually reminds us that there are multiple levels of influence on an individual’s behavior.Consider the role of peers and family. LGBT youth who are not supported by their families are at greater risk for suicide.Family conflict is also a contributing factor to homelessness of LGBT youth.Family connectedness, on the other hand, is a protective factor, as is support from other adults. In our social environment, there is widespread discrimination and stigma against LGBT youth, which are associated with isolation, mental disorders, and suicidal behavior.An important protective factor is access to effective health and mental health providers.
- This slide shows some protective factors for LGB youth. Take a moment to read this slide to yourself. These protective factors also apply to youth generally, not just to LGB youth. Eisenberg and Resnick concluded that sexual orientation on its own accounts for only a small portion of risk for suicidal behavior. They also found that lower levels of three factors—family connectedness, safe schools, and a caring adult— accounted for much of the increased risk of suicide ideation and attempts. Ryan’s research on family acceptance found that specific behaviors by parents and caretakers can reduce risk of suicidal behavior for their LGBT children. We’ll talk more about these parent behaviors in a moment. The Fenaughty and Harre study was based on interviews with LGB youth, some of whom had attempted suicide. They found that self-esteem and positive role models played an important function for LGB youth.Let’s look at some of these factors in more detail.
- Eisenberg and Resnick found that family connectedness—as defined in this slide—was especially powerful. The quotation marks show that these are the survey questions that youth responded to. These behaviors as a group are combined under the term “family connectedness,” that is, feeling cared about, understood, having fun, and having privacy.This study has a powerful result. Youth with strong family connectedness were half as likely to think about suicide as those with low family connectedness. For professionals who work with youth, this is a key factor to look at in reducing suicide among LGB youth.Youth responded to a number of questions about family connectedness, which are shown above.
- Caitlin Ryan’s research has demonstrated that family acceptance of their LGBT child reduces the risk for health and mental health problems and helps promote their well-being. Ryan studied families who were accepting, unsure, or conflicted about their child’s gay or transgender identity, and identified over 100 behaviors that families use to respond to their LGBT child, some of which are listed here. Ryan made important findings related to suicide prevention for LGBT youth. Gay and transgender teens who were highly rejected by their parents were at very high risk for mental health problems as young adults. Specifically, highly rejected LGBT young people were more than 8 times as likely to have attempted suicide.Ryan found that even small shifts by families and caregivers towards being accepting made youth less likely to attempt suicide and other negative outcomes. She has published a list of rejecting behaviors as well so that parents can connect what they do to what could be damaging to their children. For many parents and caregivers, just knowing which behaviors are harmful and which are supportive of their LGBT youth is not enough. Deeply held beliefs or emotions may present barriers hard to surmount without help. Professionals can play a role in the process of parents adopting supportive behaviors and focusing on keeping their family strong. Ryan recommends that parents find support groups and learn about their child’s sexual orientation or gender identity. She also suggests that parents listen to their LGBT youth without interrupting. PFLAG—Parents, Families, and Friends of Lesbians and Gays—is a national organization with local chapters that offer support and information.Let’s discuss the implications for suicide prevention program staff and youth services professionals. For a small group, leaders will lead a discussion or form break-out groups. For a large group, leaders will ask participants to volunteer how they can use this information in their work.Some ideas to get the discussion going: For suicide prevention program staff, how do you get this information to parents and caregivers? How do you reach out to and support parent and caregivers who are rejecting their LGBT sons or daughters? How can you support staff working with families with LGBT youth? For youth-serving professionals, how do you reach parents and caregivers? Do you work directly with parents and caregivers? What agencies could you partner with to further these messages and support parents (for example, GSA’s, PFLAG, schools)?Adapted from Ryan, C. (2009). Helping families support their lesbian, gay, bisexual, and transgender (LGBT) children. (Practice brief). Retrieved October 4, 2010 from http://www11.georgetown.edu/research/gucchd/nccc/documents/LGBT_Brief.pdf
- These were the survey questions about school safety—they include safety at school, especially in the bathrooms away from staff vigilance, and coming from and going to school. Other surveys, such as the Youth Risk Behavior Survey or the Gay Lesbian and Straight Education Network’s National School Climate Survey, use different questions but corroborate the finding that LGB youth feel unsafe at school.Eisenberg and Resnick found that LGB students were less likely than non-LGB students to feel safe in school. Here is a comparison of the proportion of non-LGB students to LGB students: While nearly 1 in 3 heterosexual males felt very safe in school, only 1 in 5 gay or bisexual males felt very safe in school. For females, 1 in 4 heterosexual females felt very safe in school, while only 1 in 7 lesbian or bisexual females felt very safe in school. School safety was found to be a significant protective factor against suicidal behavior. The researchers say that school programs, policies, and resources are needed to support LGB adolescents. School safely is amenable to change and may protect young people from self-harm.We will discuss safe schools shortly.
- In spite of lower levels of other protective factors, caring from an adult was a factor that provided significant protection against ideation and attempts. When we discuss cultural competence shortly, it will be important to keep these protective factors in mind.
- And here are risk factors. On this slide, you can see risk factors for youth overall. Many of these also apply to LGBT youth. Naturally, this list is not complete. Not all the research is summarized here, and there may be factors that have not been established by research.I’ll highlight a couple of risk factors: Previous attempts: Youth who have attempted suicide are among those at highest risk, and future attempts may increase in lethality.Mental illness: This includes depression and other mood disorders, conduct disorder, and other disorders. Negative personality traits: These include impulsivity, low frustration tolerance, and aggression.Method availability: This means having access to lethal means, especially firearms. Youth suicides are often impulsive, during a short-lived crisis. If means are unavailable, the youth might not kill himself or herself. Firearms are especially lethal.We talked earlier about the importance of modifiable risk factors, since those are things you can do something about. Which of these risk factors seem most modifiable to you and why?
- And here are risk factors established through research with LGB youth specifically. Unfortunately, the research on risk factors is more extensive than it is on protective factors.Let’s talk about some of them specifically:Gender nonconformity: This is a term for individuals whose gender expression is different from societal expectations. This term and the term “cross-gender roles and behaviors” are framed from a gender bias that assumes mainstream gender roles. A gender-nonconforming youth may or may not be LGBT. Heterosexual youth may also not conform to gender roles and behaviors thought by the mainstream to define genders. Fitzpatrick and others found that gender nonconformity is a significant contributor to suicidal risk, much greater than sexual orientation. They also found that gender-nonconforming youth had less support from their families and peers.Internal conflict about sexual orientation: This can also be referred to as internalized homophobia, where a youth directs social disapproval inward. Internalized homophobia has been linked to depression.Coming out: Disclosure is a developmental stage that is important to LGBT youth. On one hand, rejection and harassment are often related to coming out. Fear of rejection means that the risk is not just following disclosure, but it can precede it. Remafedi found that youth coming out at earlier ages meant heightened risk. On the other hand, carrying a secret that is central to a youth’s identity—or a youth pretending to be other than what he or she is—carries its own stress.Victimization is a risk factor for suicide attempts and ideation as well as substance abuse and low self-esteem. LGB youth are victimized at higher rates than other youth. Let’s put these risk factors into a context for LGB youth.
- The context of risk and protective factors for LGB youth is that they:Have more risk factors and often experience more severe risk factors. For more severe risk factors, an example is suicide loss. LGB youth know more youth who have attempted or died by suicide, or who think about victimization. Other youth get victimized, but LGB youth get victimized repeatedly in different settings, and sometimes severely. LGB youth generally have fewer protective factors, such as safe schools and supportive families.Some risk factors are specific to being LGBT and are called gay-related stress. They involve factors like those related to coming out. Others are related to the minority stress of social discrimination and stigma that sexual and gender minority individuals experience. Again, not much research includes transgender youth, but we could make assumptions that transgender youth share experiences of rejection, discrimination, isolation, and victimization and lack many protective factors.
- One of the trainers will lead a discussion about risk and protective factors. Instruct the group to break into small groups of 2 or 3 participants each.I’d like you to take 10 minutes to discuss these questions. Think about LGBT youth you know.What risk and protective factors can you identify? What factors could be modified?After 10 minutes, ask for feedback from the small-group discussions. It’s not necessary to hear from all the groups. Try to identify common themes. If necessary, use the group to help solve challenges if they arise.
- We are going to take a break now for XX minutes. (Fill in the number of minutes you would like to allow for the break.)
- Before the break you learned about risk and protective factors specific to LGBT youth suicidal behavior. We’ve seen how larger social and cultural forces play an important role as risk factors themselves—such as discrimination or victimization—or leading to other risk factors—such as isolation and substance abuse. LGBT cultural competence is an approach to addressing these broad social forces and acknowledges that those who work with LGBT youth are working cross-culturally. Later, we will talk about approaches that are more specifically related to suicide prevention. LGBT cultural competence does NOT refer to ethnic, racial, or linguistic minorities, but to LGBT minorities. To work across cultures, basic operating assumptions are questioned. For example, U.S. culture is hetero-dominant, and that can make it difficult for heterosexuals to identify operating assumptions and values.As with other cultures that cultural competence addresses, LGBT individuals are minorities. Like members of other minorities, LGBT individuals are subject to discrimination and stigma, and they experience disparities in health and health services.Cultural competence has to take place at the individual, agency, and systems level, and includes not just policies, but what staff believe and do when they work across cultures.Many of us have experienced one-time trainings in cultural competence or diversity that meet some requirement, but cultural competence is comprehensive—throughout all aspects of a program or practice—and an ongoing process rather than a one-time event. The third point emphasizes that cultural competence must be ongoing, dynamic, and oriented to change.
- The National Center for Cultural Competence has an excellent resource at the link shown below. Although it is not specifically written to LGBT youth cultures, it is a great resource to use in strategic planning, service design and delivery, and evaluation and quality assurance. So let’s go through the key ingredients. What kind of values do you think it would be important to define?See what participants volunteer, but you may want to cite social justice, human rights, importance of family or community, and access to health care; that community members are full partners in decision-making; and that non-discriminatory practice is a priority. We will be describing shortly what we mean by effective cross-cultural work.Involving consumers and community is vital to cultural competence, but it is not easy to reach people who have been marginalized or feel invisible. In what ways can you reach LGBT youth?You may get responses from participants such as: outreach to LGBT organizations or partnerships with organizations that have a positive track record with LGBT youth; building relationships with LGBT youth; community events; plus all the ways we’ll address later to let people know that the organization is safe and welcoming.Managing the dynamics of difference can mean that you have staff who are skilled at facilitation and conflict resolution. It also means that an organization has leaders—although perhaps not the official leaders—who identify needs as they arise and push for change.Dunne, C., Goode, T., & Sockalingam, S., (2004). Planning for cultural and linguistic competence in state Title V programs serving children & youth with special health care needs and their families. Washington, DC: National Center for Cultural Competence, Georgetown University Center for Child and Human Development. Retrieved June 24, 2010 from http://www11.georgetown.edu/research/gucchd/nccc/documents/NCCC%20Title%20V%20Checklist%20%28CSHCN%29.pdf
- You see that cultural competence is pervasive and comprehensive. It affects all aspects of an agency: outreach, staffing, policy, and supervision.What helps make cultural competence successful? Here are some ideas: Consumers and feedback are involved throughout. The leader of the organization lives it. Staff is prepared and given a context. Cultural competence is consistently reinforced and supported, and successes are acknowledged.I’ll address the first few bullets. Make accurate information available to consumers and staff. Keep abreast of what’s new in the field and make it available. Many national organizations provide information. Train your staff, volunteers, board, and consumers to submit information, and have channels for the agency to distribute it. Assure that it is not all needs- or problem-based but also includes strengths and accomplishments, such as LGBT individuals who receive awards or legislation that is passed. Use new technologies to reach youth audiences (e.g., Twitter, YouTube, Facebook).Training includes pre-service training, orientation, in-service training, and mentoring. Include consumers in development of the trainings. Address the fact that LGBT youth have a higher risk of suicidal behavior.Remember the ecological model that starts with an individual at the core and builds out. Not only is your staff and board going to reflect diversity to your community, they are also the individuals who have to be willing to examine their own beliefs and behavior. The policies, the forms, the welcoming waiting room, all mean little if your staff and board are not engaged in cultural competence.Let’s talk about how some agencies go about this in a systematic way.
- HANDOUT – “Developing LGBT Cultural Competence: Agency Assessment and School Assessment” We are going to work with the agency and school LGBT cultural competence assessments. While the assessments go through some key features, they should not be considered complete. There are sections describing attributes at the individual and organizational levels. As we have explained, commitments at the individual level will support changes at the organizational level and vice versa. For example, a staff member explaining confidentiality procedures to a patient might hear a criticism or request that he or she can bring to the organization for change. Conversely, say the organization makes their waiting area more welcoming to LGBT youth. As a result, an individual staff member brings some books on LGBT issues to the office and makes them available to other staff and displays LGBT brochures and symbols in their office.Ask the participants to break into small groups. Depending on group size, allow about 10 minutes. Instruct the group to discuss which attributes on the list their organization already has and which attributes they could commit to developing. Ask participants, using the form, to list one or two steps each of them could take, first, as an individual, and then, one or two steps that their school or agency could take.Tell them that at the end of 10 minutes you will ask the whole group for volunteers to describe the steps they listed. Ask for steps that the participants identified. The leader needs to acknowledge and support where participants are. Make sure you hear both individual steps and agency or school steps.Now let’s watch a short video created by the Gay, Lesbian and Straight Education Network, a national education organization focused on ensuring safe schools for all students.
- Show video clip of “That’s So Gay” by Wanda Sykes.You may wish to comment on the video. The following text is from the GLSEN web- site: Lesbian, gay, bisexual and transgender (LGBT) teens experience homophobic remarks and harassment throughout the school day, creating an atmosphere where they feel disrespected, unwanted and unsafe. Homophobic remarks such as “that’s so gay” are the most commonly heard; these slurs are often unintentional and a common part of teens’ vernacular. Most do not recognize the consequences, but the casual use of this language often carries over into more overt harassment.The Think Before You Speak campaign aims to raise awareness about the prevalence and consequences of anti-LGBT bias and behavior in America’s schools. Ultimately, the goal is to reduce and prevent the use of homophobic language in an effort to create a more positive environment for LGBT teens. The campaign also aims to reach adults, including school personnel and parents; their support of this message is crucial to the success of efforts to change behavior.
- What can you or your organization do to promote cultural competence?On this slide are steps chosen by participants in other trainings. I want to point out that what seems like a small step can make a big difference. For example: At one training, a gay adult said that as a high school student seeing a rainbow sticker on a teacher’s office door got her through high school. This helped her, even though she never disclosed to the teacher that she was gay.Different participants are at different stages of readiness to identify steps they could take. The point is, any move in the direction of inclusivity or acceptance could benefit an LGBT youth. The trainer could continue the discussion by asking how these steps compared to the steps that they chose.
- On this slide are steps chosen by participants who were ready to do more. To some extent, this can reflect local culture. For example, states that have been leaders in sexual and gender minority rights may be interested in developing outreach to LGBT youth or participatory evaluation, or expanding advocacy efforts. Even states that have made progress with gay and bisexual rights might not be far along with transgender rights. If participants are not ready to begin these types of steps, then the leader can refer to these steps as part of a longer time frame and break them down into smaller steps. Again, the leader can ask how these steps compare to the steps the participants chose.To learn more about existing resources, see the handout “Resources on LGBT Issues.”
- We’ve laid a lot of groundwork with the topics of risk and protective factors and LGBT cultural competence. Now let’s apply some of what we learned to youth suicide prevention.What do we mean by LGBT youth suicide prevention?First let’s consider what youth suicide prevention is. Mostly, youth suicide prevention follows one of two approaches:Case finding with referral, such as gatekeeper programs, screening, and crisis lines. In these programs, a youth at risk is identified and referred for assessment or services, perhaps emergency services.Risk factor reduction, protective factor enhancement. Many of you serve as a protective factor for LGBT youth, whether you represent a caring adult, an LGB and/or T role model, or provider of services, such as counseling or a safe residential placement. We talked about this approach earlier.Gould, M. S., Greenberg, T., Velting, D. M., & Shaffer, D. (2003). Youth suicide risk and preventive interventions: A review of the past 10 years. Journal of the American Academy of Child & Adolescent Psychiatry, 42(4), 386-405.
- This slide outlines some ways that suicide prevention program staff can become LGBT culturally competent. On the last point, LGBT youth at greatest risk for suicide include those who are homeless and runaway, living in foster care, and/or involved in the juvenile justice system.Going back to the first two points, let’s take a specific example: gatekeeper training. These trainings generally refer to programs that seek to develop individuals’ knowledge, attitudes, and skills to identify those at risk, determine levels of risk, and make referrals when necessary.Some ways to increase a training’s LGBT cultural competence include: Provide accurate information about LGBT risk Feature LGBT youth stories in role-plays in trainings Train LGBT youth and adults as gatekeepersDevelop a list of assessment, treatment, and support services that are inclusive of LGBT youth, and use these services for referralsEvaluate whether participants learn key information about LGBT youth suicidal behavior Are there other ways to increase the cultural competence of gatekeeper trainings? Are there any ideas from cultural competence that you could use?
- These interventions decrease risk factors and increase protective factors. If you implement any interventions, you need to evaluate whether you meet your program's goal. For example, did you reach LGBT youth? How do you measure whether your schools are safer? Are your providers more culturally competent? Are families who don’t agree with their son or daughter’s sexual orientation or gender identity able to talk about and get support for accepting their youth? Do LGBT youth know adults they can go to for help?
- Ask participants to refer to the handout “Warning Signs for Suicide Prevention.”The Warning Signs for Suicide Prevention was developed by an expert working group convened by the American Association of Suicidology. It is important to distinguish warning signs from risk factors. Warning signs are the earliest detectable signs that indicate heightened risk for suicide in the near-term (i.e., within minutes, hours, or days), as opposed to risk factors that suggest a longer term risk (i.e., a year to lifetime.)Be alert to the warning signs of suicide. The resource sheet called “Warning Signs for Suicide Prevention” is a great resource to start with.On the resource sheet, note that imminent warning signs include:Someone talking about or writing about death, dying, or suicide, particularly when these actions are out of the ordinary for the person. Someone looking for ways—guns, pills, or other ways—to kill themselves.Someone threatening to hurt or kill themselves.For any of these behaviors, it is important to call 911 or get mental health care immediately.With the second group of signs—including hopelessness and agitation—it is often a constellation of signs that raises concern, rather than one or two symptoms alone. Any questions about these warning signs? How often do you see youth who are suicidal?
- Given the data, it’s clear that all of us need to be equipped to identify youth—particularly lesbian, gay, and bisexual youth—who may be thinking about killing themselves so that we can keep them safe and connect them with services and support.You may wish to attend a gatekeeper training. The purpose of gatekeeper training is to develop the knowledge, attitudes, and skills to identify those at risk of suicide and connect them with services and support when necessary. Your state suicide prevention coalition may know of a gatekeeper training in your area.You may want to be sure that your mental health professionals are trained to assess suicide risk. The third link above is for the SPRC course “Assessing and Managing Suicide Risk.”
- There are resources available to help people take care of themselves and their loved ones following a suicide attempt. The National Suicide Prevention Lifeline publishes a series of “After an Attempt” brochures. The link here is for a brochure for family members, but brochures are also available for the people who attempt suicide themselves and for emergency department staff. The brochures are also available in Spanish. Feeling Blue is a suicide prevention coalition in Pennsylvania. Some suggestions adapted from their booklet are on the next slide.
- What to do after a suicide attempt is not specific to LGBT youth but applies to all youth.These suggestions are adapted from “After an Attempt: The Emotional Impact of a Suicide Attempt on Families,” produced by the Feeling Blue Suicide Prevention Council.I won’t read this entire slide to you, but I do want to highlight the third bullet point. It is very important to restrict access to lethal means following a suicide attempt. Youth can be especially impulsive, and impulsivity combined with lethal means—such as guns or medications—can mean death by suicide for youth. Research shows that if lethal means are available, a person is more likely to die by suicide.Recall that LGB youth tend to use more lethal means, so this is an important intervention. As for the fourth and fifth bullet points, it can be challenging to find services that are inclusive for LGBT youth.
- The recommendations above come from “After an Attempt: A Guide for Taking Care of Yourself after Your Treatment in the Emergency Department.” It is important for youth service professionals to understand these objectives for youth who have attempted suicide. What might be different for LGBT youth? Trainers can lead a discussion here and consider using the following examples: Identify triggers for suicidal thoughts and plan to minimize their effects:This difficult work often takes place with a therapist, support group, or clergy member and may be difficult if LGBT youth have not found LGBT-inclusive providers. Create a list with contact information for key supporters. It is important to ask about victimization and whether youth are safe where they live. Build a support system:A support system includes an ally that a youth can trust with suicidal feelings. LGBT youth who haven’t disclosed their sexual orientation or gender identity may not have this. Try to follow a routine:For LGBT youth, routines that other youth take for granted might be difficult. For example, if school feels unsafe, they might avoid it. Jobs might be difficult if employers discriminate against them.
- Following a suicide, there are a number of things you can do. You can: Promote healthy grieving by acknowledging the survivors’ loss. Survivors are those who have lost someone close by suicide. In addition to family and close friends, they can include therapists, teachers, and others who knew the youth who died. Take steps to prevent contagion. Some vulnerable people are influenced to engage in suicidal behavior when they become aware of another person’s suicidal acts. This is called contagion. You may be aware of a community that has experienced a cluster of youth suicides. One way to limit contagion is to influence the media to use safe reporting guidelines in the coverage of suicides. Before there is a suicide, it is important to set up community protocols. Protocols establish policies and procedures for postvention in your community, including the provision of crisis intervention, support, and assistance for those affected by a completed suicide.
- This slide lists some of the postvention resources available to you online.The effect of contagion appears to be strongest among adolescents. That’s why SPRC has produced, with the help of others, the following: At-a-Glance: Safe Reporting on Suicide, which is a guide for the media After a Suicide: Recommendations for Religious Services and Other Public Memorial Observances
- If you work with an organization that specifically serves LGBT youth, then you may already be engaged in suicide prevention, whether you call it that or not.As we mentioned earlier, increasing protective factors and reducing risk factors is one way to prevent suicide. Many LGBT youth programs help LGBT youth connect with caring adults, introduce them to positive role models, reduce isolation, etc. Having seen today’s presentation on risk and protective factors, you may recognize opportunities to train program staff and board of LGBT youth organizations on risk and protective factors as well as the risk of suicidal behavior.
- When analyzing data and reporting results related to sexual orientation and/or gender identity, take care to ensure that sensitive data are not misused or abused, and data collected and/or analyzed are not used to stigmatize populations.Respect for individual (as well as group) dignity and privacy should guide the collection and analysis of data on any identifying personal characteristic—including sexual orientation and gender identity.Keep in mind that sexual orientation or gender identity can be an identifying piece of information especially in smaller communities and schools. Clearly define the terms you use. For example, as we discussed earlier, be clear about whether sexual orientation is defined in terms of identity, behavior, or attraction. For more guidance on this topic, go to http://www.GayData.orgAlways discuss the limitations of your findings to assist people in interpreting and using your results.
- Trainer:Lead a group discussion of the questions on the slide.
- Replace this slide with your contact information.