A Systematic Review and Meta-Analysis of Disparities in the Prevalence of Suicide Ideation and Attempt Among Bisexual Populations
Sexual minorities are at increased risk of suicide; however, it is unclear whether there are within-sexual minority differences in risk across specific sexual identities—notably between bisexual and lesbian/gay subgroups. We therefore conducted a systematic review and meta-analysis to quantify associations between bisexual identity and self-reported suicide ideation and attempt and the moderation of these associations by gender/sex, age, sampling strategy, and measurement of sexuality. Abstracts and full texts were independently screened by two reviewers, resulting in a total of 46 studies that met inclusion criteria and reported 12-month or lifetime prevalence estimates for suicide ideation or attempt. A consistent gradient was observed across all four outcomes, whereby bisexual respondents reported the highest proportion of suicide ideation or attempt, lesbian/gay respondents the next highest proportion, and heterosexual respondents the lowest proportion. Random-effects meta-analysis comparing bisexual individuals with lesbian/gay individuals yielded odds ratios (ORs) ranging between 1.22–1.52 across the four outcomes examined. Between-study variability in ORs was large. Thirty-one percent of heterogeneity was explained by sample type (e.g., probability vs. non-probability) and 17% by gender/sex. ORs were consistently larger for women (range: 1.48–1.95, all statistically significant at p < .05) than for men (range: 1.00–1.48, all p > .05), suggesting that gender/sex moderates the association between bisexual identity and suicide risk. Within-sexual minority differences in suicide risk may be attributed to structural and interpersonal experiences of monosexism, bisexual erasure and invisibility, or lack of bisexual-affirming social support, each of which may be experienced differently across gender/sex identities.
KeywordsSuicide Bisexual Sexual orientation Mental health Meta-analysis
Compliance with Ethical Standards
Conflict of interest
The authors declare that they have no conflicts of interest.
This study used secondary data; as such, ethical approval was not required.
- American Psychological Association. (2016). Guidelines for psychological practice with lesbian, gay, and bisexual clients. http://www.apa.org/pi/lgbt/resources/guidelines.aspx. Accessed 17 July 2016.
- Borenstein, M., Hedges, L. V., Higgins, J. P. T., & Rothstein, H. R. (2009). Meta-regression. In Introduction to meta-analysis. https://doi.org/10.1002/9780470743386.ch20.
- Bostwick, W. B., Boyd, C. J., Hughes, T. L., & McCabe, S. E. (2010). Dimensions of sexual orientation and the prevalence of mood and anxiety disorders in the United States. American Journal of Public Health, 100(3), 468–475. https://doi.org/10.2105/AJPH.2008.152942.PubMedPubMedCentralCrossRefGoogle Scholar
- Brennan, D. J., Bauer, G. R., Bradley, K., & Tran, O. V. (2017). Methods used and topics addressed in quantitative health research on gay, bisexual and other men who have sex with men: A systematic review of the literature. Journal of Homosexuality, 64, 1519–1538. https://doi.org/10.1080/00918369.2016.1247537.PubMedCrossRefGoogle Scholar
- Denny, S., Lucassen, M. F. G., Stuart, J., Fleming, T., Bullen, P., Peiris-John, R., … Utter, J. (2016). The association between supportive high school environments and depressive symptoms and suicidality among sexual minority students. Journal of Clinical Child and Adolescent Psychology, 45(3), 248–261.PubMedCrossRefGoogle Scholar
- Dorais, M. (2004). Dead boys can’t dance: Sexual orientation, masculinity, and suicide. Montreal, QC: McGill-Queens University Press.Google Scholar
- Eliason, M., & Schope, R. (2007). Shifting sands or solid foundation?: Lesbian, gay, bisexual, and transgender identity formation. In I. H. Meyer & M. E. Northridge (Eds.), The health of sexual minorities (pp. 2–26). New York, NY: Springer.Google Scholar
- Ferlatte, O., Hottes, T. S., Trussler, T., & Marchand, R. (2013). Evidence of a syndemic among young Canadian gay and bisexual men: Uncovering the associations between anti-gay experiences, psychosocial issues, and HIV risk. AIDS and Behavior, 18, 1256–1263. https://doi.org/10.1007/s10461-013-0639-1.CrossRefGoogle Scholar
- Galupo, M. P., Davis, K. S., Grynkiewicz, A. L., & Mitchell, R. C. (2014). Conceptualization of sexual orientation identity among sexual minorities: Patterns across sexual and gender identity. Journal of Bisexuality, 14(3–4), 433–456. https://doi.org/10.1080/15299716.2014.933466.CrossRefGoogle Scholar
- Ghabrial, M., & Ross, L. E. (2018). Representation and erasure of bisexual people of color in mental health research. Manuscript submitted for publication.Google Scholar
- Haas, A. P., Eliason, M., Mays, V. M., Mathy, R. M., Cochran, S. D., D’Augelli, A. R., … Russell, T. (2011). Suicide and suicide risk in lesbian, gay, bisexual, and transgender populations: Review and recommendations. Journal of Homosexuality, 58, 10–51. https://doi.org/10.1080/00918369.2011.534038.PubMedPubMedCentralCrossRefGoogle Scholar
- Hatzenbuehler, M. L., Birkett, M., Van Wagenen, A., & Meyer, I. H. (2014). Protective school climates and reduced risk for suicide ideation in sexual minority youths. American Journal of Public Health, 104(2), 279–286. https://doi.org/10.2105/AJPH.2013.301508.PubMedPubMedCentralCrossRefGoogle Scholar
- Hatzenbuehler, M. L., McLaughlin, K. A., Keyes, K. M., & Hasin, D. S. (2010). The impact of institutional discrimination on psychiatric disorders in lesbian, gay, and bisexual populations: A prospective study. American Journal of Public Health, 100(3), 452–459. https://doi.org/10.2105/AJPH.2009.168815.PubMedPubMedCentralCrossRefGoogle Scholar
- Herek, G. M., Norton, A. T., Allen, T. J., & Sims, C. L. (2010). Demographic, psychological, and social characteristics of self-identified lesbian, gay, and bisexual adults in a US probability sample. Sexuality Research and Social Policy, 7, 176–200. https://doi.org/10.1007/s13178-010-0017-y.PubMedPubMedCentralCrossRefGoogle Scholar
- Hjelmeland, H. (2016). A critical look at the current suicide research. In J. H. White, I. Marsh, M. J. Kral, & J. Morris (Eds.), Critical suicidology: Transforming suicide research and prevention for the 21st century (pp. 31–55). Vancouver, BC: UBC Press.Google Scholar
- Hottes, T. S. (2016). Exploring pathways from sexual stigma to suicide attempts within the life course narratives of adult gay men. In 16th European symposium on suicide and suicidal behavior. Oviedo, Spain.Google Scholar
- Hottes, T. S., Bogaert, L., Rhodes, A. E., Brennan, D. J., & Gesink, D. (2016a). Lifetime prevalence of suicide attempts among sexual minority adults by study sampling strategies: A systematic review and meta-analysis. American Journal of Public Health, 106(5), e1–e12. https://doi.org/10.2105/AJPH.2016.303088a.PubMedPubMedCentralCrossRefGoogle Scholar
- Hottes, T. S., Gesink, D., Ferlatte, O., Brennan, D. J., Rhodes, A. E., Marchand, R., & Trussler, T. (2016b). Concealment of sexual minority identities in interviewer-administered government surveys and its impact on estimates of suicide ideation among bisexual and gay men. Journal of Bisexuality, 16(4), 427–453. https://doi.org/10.1080/15299716.2016.1225622.CrossRefGoogle Scholar
- Hughes, T. L., Szalacha, L. A., Johnson, T. P., Kinnison, K. E., Wilsnack, S. C., & Cho, Y. (2010). Sexual victimization and hazardous drinking among heterosexual and sexual minority women. Addictive Behaviors, 35(12), 1152–1156. https://doi.org/10.1016/j.addbeh.2010.07.004.PubMedPubMedCentralCrossRefGoogle Scholar
- Institute of Medicine. (2011). The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding. Washington, DC: National Academies Press.Google Scholar
- Joiner, T. (2007). Why people die by suicide (1st ed.). Cambridge, MA: Harvard University Press.Google Scholar
- Justice Québec. (2016). Québec policy against homophobia. http://www.justice.gouv.qc.ca/english/ministere/dossiers/homophobie/homophobie-a.htm. Accessed 17 Jan 2018.
- King, M., Semlyen, J., Tai, S. S., Killaspy, H., Osborn, D., Popelyuk, D., & Nazareth, I. (2008). A systematic review of mental disorder, suicide, and deliberate self harm in lesbian, gay and bisexual people. BMC Psychiatry, 8(1), 70. https://doi.org/10.1186/1471-244X-8-70.PubMedPubMedCentralCrossRefGoogle Scholar
- Klonsky, E. D., May, A. M., & Saffer, B. Y. (2016). Suicide, suicide attempts, and suicidal ideation. Annual Review of Clinical Psychology, 12(1), 307–330. https://doi.org/10.1146/annurev-clinpsy-021815-093204.PubMedCrossRefGoogle Scholar
- Liu, J., Gustafson, P., Cherry, N., & Burstyn, I. (2009). Bayesian analysis of a matched case-control study with expert prior information on both the misclassification of exposure and the exposure-disease association. Statistics in Medicine, 28(27), 3411–3423. https://doi.org/10.1002/sim.3694.PubMedCrossRefGoogle Scholar
- Marshal, M. P., Dietz, L. J., Friedman, M. S., Stall, R., Smith, H. A., McGinley, J., … Brent, D. A. (2011). Suicidality and depression disparities between sexual minority and heterosexual youth: A meta-analytic review. Journal of Adolescent Health, 49(2), 115–123. https://doi.org/10.1016/j.jadohealth.2011.02.005.PubMedPubMedCentralCrossRefGoogle Scholar
- Millar, B. M., Wang, K., & Pachankis, J. E. (2016). The moderating role of internalized homonegativity on the efficacy of LGB-affirmative psychotherapy: Results from a randomized controlled trial with young adult gay and bisexual men. Journal of Consulting and Clinical Psychology, 84(7), 565–570. https://doi.org/10.1037/ccp0000113.PubMedPubMedCentralCrossRefGoogle Scholar
- Molina, Y., Marquez, J. H., Logan, D. E., Leeson, C. J., Balsam, K. F., & Kaysen, D. L. (2015). Current intimate relationship status, depression, and alcohol use among bisexual women: The mediating roles of bisexual-specific minority stressors. Sex Roles, 73, 43–57.PubMedPubMedCentralCrossRefGoogle Scholar
- Pachankis, J. E., Hatzenbuehler, M. L., Rendina, H. J., Safren, S. A., & Parsons, J. T. (2015). LGB-affirmative cognitive-behavioral therapy for young adult gay and bisexual men: A randomized controlled trial of a transdiagnostic minority stress approach. Journal of Consulting and Clinical Psychology, 83, 875–889. https://doi.org/10.1037/ccp0000037.PubMedPubMedCentralCrossRefGoogle Scholar
- Prah, P., Hickson, F., Bonell, C., McDaid, L. M., Johnson, A. M., Wayal, S., … Copas, A. J. (2016). Men who have sex with men in Great Britain: Comparing methods and estimates from probability and convenience sample surveys. Sexually Transmitted Infections, 92(6), 455–463. https://doi.org/10.1136/sextrans-2015-052389.PubMedPubMedCentralCrossRefGoogle Scholar
- Ross, L. E., Salway, T., Tarasoff, L. A., Hawkins, B. W., MacKay, J. M., & Fehr, C. P. (2017). Prevalence of depression and anxiety among bisexual people compared to gay, lesbian, and heterosexual individuals: A systematic review and meta-analysis. Journal of Sex Research. https://doi.org/10.1080/00224499.2017.1387755.Google Scholar
- Saewyc, E. M., Konishi, C., Rose, H. A., & Homma, Y. (2014). School-based strategies to reduce suicidal ideation, suicide attempts, and discrimination among sexual minority and heterosexual adolescents in Western Canada. International Journal of Child, Youth and Family Studies, 1, 89–112.CrossRefGoogle Scholar
- Salway, T., Gesink, D., Ibrahim, S., Ferlatte, O., Rhodes, A. E., Brennan, D. J., … Trussler, T. (2017). Evidence of multiple mediating pathways in associations between constructs of stigma and self-reported suicide attempts in a cross-sectional study of adult gay and bisexual men. Archives of Sexual Behavior. https://doi.org/10.1007/s10508-017-1019-0.PubMedGoogle Scholar
- Silverman, M. M., Berman, A. L., Sanddal, N. D., O’Carroll, P. W., & Joiner, T. E. (2007). Rebuilding the tower of babel: A revised nomenclature for the study of suicide and suicidal behaviors part 1: Background, rationale, and methodology. Suicide and Life-Threatening Behavior, 37(3), 248–263.PubMedCrossRefGoogle Scholar
- Tjepkema, M. (2008). Health care use among gay, lesbian and bisexual Canadians. Health Reports, 19(1), 53–64. http://www.statcan.gc.ca/pub/82-003-x/2008001/article/10532-eng.htm.
- Walters, M., Chen, J., & Breiding, M. (2013). The national intimate partner and sexual violence survey: 2010 Findings on victimization by sexual orientation. https://www.ncjrs.gov/App/Publications/abstract.aspx?ID=263171.
- World Health Organization. (2008). Suicide and suicide prevention in Asia. http://www.who.int/mental_health/resources/suicide_prevention_asia.pdf. Accessed 17 Jan 2018.