Keywords

Youth who are lesbian, gay, bisexual, queer, and questioning their sexual identities (LGBQ+) and/or who are a gender distinct from their birth-assigned sex (i.e., transgender and gender diverse), collectively LGBTQIA+, show nearly triple the risk for self-injurious thoughts and behaviors (SITBs), including nonsuicidal self-injury, suicide ideation, and suicide attempts (Marshal et al., 2011). Unfortunately, few studies to date have rigorously tested SITB treatments in LGBTQIA+ youth. In a recent meta-analysis of all randomized controlled trials of SITB interventions, only 60/642 treatment studies reported on the LGBTQIA+ composition of the sample, and no study specifically focused on treatment for LGBTQIA+ youth or adults (Fox et al., 2020). It remains unclear if treatments designed for cisgender, heterosexual youth are similarly efficacious for LGBTQIA+ youth and regardless whether they are sufficient to reduce this heightened risk.

In this chapter, we review the state of research on SITB treatment and prevention programs for LGBTQIA+ youth. Given the high prevalence and social and emotional burden of LGBTQIA+ youth, we leverage this incomplete literature to provide steps for researchers, clinicians, and public health officials to take action now while we continue to build stronger evidence. We describe existing research and argue that to successfully reduce SITBs among LGBTQIA+ youth, treatment and prevention efforts should target LGBTQIA+ minority stress across individual, interpersonal, and structural levels (Chaudoir et al., 2017). Although discussed separately, each level interacts; for example, individual-level stressors (e.g., internalized stigma) are born out of the structural and interpersonal stressors that LGBTQIA+ youth face.

Key Terms and Considerations

SITB rates differ across specific LGBTQIA+ identities and across intersections with birth-assigned sex, race/ethnicity, and disability. Despite these nuances, most studies on LGBTQIA+ SITBs ignore individual identities and intersections to increase sample size and power. When relevant, abbreviated acronyms will be used to represent who was included in a given study. We will state when findings support clear differences across LGBTQIA+ and intersectional identities.

Evidence for Individual Targets for Suicide Prevention

Intrapersonal attributes encompass how a person thinks, acts, and feels as they navigate their own experiences. For example, internalized stigma is the process by which some LGBTQIA+ people internally adopt the societal norm (i.e., heterosexism) and, in turn, absorb negative stereotypes and assumptions about themselves (termed internalized stigma; Meyer, 2003). A systematic review of 35 studies recently identified internalized stigma as a major risk factor for adverse mental health outcomes in LGBQ youth (Hall, 2018), providing preliminary evidence that internalized stigma likely relates to elevated SITB risk as well. Similar relationships have been observed in transgender and gender-diverse adults, with internalized transphobia associated with suicide attempts above and beyond other factors (Perez-Brumer et al., 2015).

Due to an often hostile culture, rejection sensitivity, or the tendency to readily perceive, anxiously anticipate, and avoid possible rejection, may be a risk factor for SITBs for LGBQ+ (Feinstein, 2019) and transgender and gender-diverse (Wells et al., 2020) youth. Indeed, research suggests that rejection sensitivity is associated with social anxiety, posttraumatic stress, and generalized anxiety in GB men (Cohen et al., 2016) and with suicide attempts among LGBQ+ adults (Mereish et al., 2019). LGBTQIA+ youth may also hide (“conceal”) their identity to protect themselves from potential discrimination, which may cause stress, anxiety, and internalized stigma (Gleason et al., 2016). However, research linking identity concealment to psychopathology is relatively weak (Pachankis et al., 2020), and more research is needed to examine the relationship between concealment and SITBs.

Evidence for Interpersonal Targets for Suicide Prevention

Heteronormativity and binary views of gender (i.e., classification of gender into two distinct categories of man/woman) often lead to interpersonal stress and rejection for LGBTQIA+ youth by family members, friends, and peers. LGBTQIA+ youth report lower levels of family connectedness and support from teachers and other adults compared to non-LGBTQIA+youth (Eisenberg & Resnick, 2006). Bisexual and pansexual youth may face additional rejection from others in the LGBTQIA+ community and romantic partners (Feinstein, 2019). Interpersonal conflicts and rejection are consistently associated with SITBs among LGBTQIA+ individuals. For example, LGBTQIA+ young adults who died by suicide were more likely to have experienced relationship difficulties prior to death (e.g., Lyons et al., 2019).

In contrast, support from family members, friends, and communities is protective for LGBTQIA+ individuals (Puckett et al., 2019) and may play a key role in reducing SITB risk. Family connectedness and adult caring are protective against suicidal ideation and attempts among LGB youth both cross-sectionally (Eisenberg & Resnick, 2006) and longitudinally (Mustanski & Liu, 2013). Support from friends and family is negatively associated with past-year suicide attempts and ideation in transgender and gender-diverse youth (Kuper et al., 2018).

General and bias-based bullying and victimization are major stressors for many LGBTQIA+ youth (Kosciw et al., 2018). A scoping review on this topic indicates that LGBQ+ youth experience more bullying compared to their heterosexual peers and that these experiences are associated with higher rates of suicide ideation and attempts (Gower et al., 2018). Importantly, compared to other LGBTQIA+ youth, bisexual and transgender and gender-diverse youth (Gower et al., 2018; Horwitz et al., 2021) may experience particularly elevated rates of bullying and victimization. Bias-based bullying (due to LGBTQIA+ identity) may be even more harmful. Across several studies, anti-LGBQ+ discrimination was associated with higher rates of suicide attempts among youth concurrently and longitudinally (e.g., Fish et al., 2019; Mustanski and Liu, 2013). Among transgender and gender-diverse youth, violence and discrimination are especially prevalent, even compared to their cisgender LGBQ+ peers (Price-Feeney et al., 2020). Experiences of victimization and discrimination partially explain elevated SITBs in transgender and gender-diverse youth.

Evidence for Structural Targets for Suicide Prevention

The nature of most structural-level factors (e.g., city- and statewide policies, underlying cultural factors) precludes randomized controlled trials assessing their impact on SITBs. However, several studies have used large, cross-sectional, and longitudinal samples to assess the effects of policies that support LGBTQIA+ youth on mental health and SITBs. Compared to their cisgender, heterosexual peers, LGBTQIA+ youth are more likely to be homeless, with rates of homelessness ranging from 8% to 37% among this population (McCann & Brown, 2019). In addition to increasing risk for mental health difficulties and SITBs, homelessness also impacts access to mental and physical healthcare services and increases potential exposure to violence, food insecurity, and a host of other negative outcomes, each of which is disproportionately experienced by LGBTQIA+ youth (Paley, 2021). Hostile sociopolitical climates are also associated with SITBs in LGBTQIA+ youth. For example, low LGB supportiveness across the school and county level is associated with higher suicide risk (Hatzenbuehler & Pachankis, 2016).

Evidence-Based Interventions

Individual-Level Interventions

There is good news despite the many barriers to mental health equity. Interventions leveraging LGBTQIA+-affirming principles can effectively reduce internalized stigma and psychopathology. For example, interventions based on cognitive behavioral therapy (CBT) principles targeting minority-related stressors reduce internalized stigma, depression, alcohol use, and anxiety in young GB men (Pachankis et al., 2015) and LGBQ+ women (Pachankis et al., 2020). Given the strong link between internalized stigma and SITBs, these interventions may also be effective for reducing SITBs in LGBTQIA+ youth. Briefly, given evidence that interventions targeting psychopathology and SITBs show similar efficacy (Fox et al., 2020), interventions targeting psychopathology may also reduce SITBs in LGBTQIA+ youth. In light of the unique stressors faced by LGBTQIA+ youth, these treatments should be modified to incorporate modules and frameworks that incorporate these unique experiences (see Smithee et al., 2019). At least one uncontrolled study provides preliminary efficacy for this approach (Lucassen et al., 2015).

Interpersonal-Level Interventions

Interventions designed to bolster familial support and acceptance of LGBTQIA+ children may help to reduce SITBs. In a small (n = 10), uncontrolled study, an adapted model of attachment-based family therapy for LGBQ+ youth significantly reduced suicidal ideation (Diamond et al., 2012). Other interventions targeting parents of LGBTQIA+ youth that have shown potential include an educational film (Huebner et al., 2013), interactive online modules (Goodman & Israel, 2020), and expressive writing (Abreu & Kenny, 2017). As reviewed by Chaudoir et al. (2017), other interpersonal-level interventions seek to (1) increase contact and empathy with LGBQ+ people, (2) teach caregivers, health providers, teachers, and peers to reduce LGBQ+-based discrimination, and (3) increase LGBQ+-affirming behaviors. Each of these intervention targets demonstrates preliminary support. Across both experimental and correlational studies, intergroup contact— across teachers, medical providers, and students—increases positive attitudes and empathy toward LGBTQIA+ youth (Smith et al., 2009), and interventions have increased LGB-affirming behaviors and decreased rejection (Chaudoir et al., 2017). Future research is needed to test whether these interventions can reduce LGBTQIA+ discrimination long term and whether they lead to decreases in SITBs among LGBTQIA+ youth.

Structural-Level Interventions

Improved school climates and supportive environments across city and state levels also reduce SITBs across LGBTQIA+ youth (Gleason et al., 2016). Two factors may be key: anti-bullying policies including LGBTQIA+ youth as a protected group and gay/gender-straight alliances (GSAs). At the school and district level, anti-bullying policies are associated with reduced risk of suicide attempts (Hatzenbuehler & Keyes, 2013). The benefits of GSAs are also widely documented; schools with GSAs have fewer suicide attempts (Poteat et al., 2013), and students experience less homophobic victimization, fear for their safety, and homophobic remarks (Marx & Kettrey, 2016). Of note, several confounding factors co-occur with the presence of a GSA (e.g., larger schools, more experienced teachers; Baams et al., 2018). Additionally, state-level policies banning insurance policies from gender-based discrimination were associated with decreased suicidality in transgender and gender-diverse people (McDowell et al., 2020). Finally, indicating the importance of federal, LGBTQIA+-affirming policies, same-sex marriage policies have been associated with an estimated 134,446 fewer suicide attempts per year among high school students, with this effect driven by LGBQ+ students (Raifman et al., 2017).

Conclusions and Recommendations

Interventions that reduce minority stressors and increase coping skills in the context of minority stress are most effective. Although large randomized controlled trials using diverse samples of LGBTQIA+ youth are needed, interventions across levels and targets will likely result in the largest reductions in SITBs. In addition to inter- and intrapersonal-level interventions, we argue that major structural changes are needed to meaningfully reduce elevated risk for SITBs.

Policy Makers and Community Leaders

LGBTQIA+ inclusive and protective policies decrease SITBs in LGBTQIA+ youth. Continued creation and enforcement of LGBTQIA+-affirming, supportive, and protective policies are needed to reduce SITB risk in LGBTQIA+ youth. For example, federal and state-level laws should explicitly include sexual orientation and gender identity in laws protecting against discrimination and harassment in schools, housing, and the workplace; healthcare policies should explicitly prohibit discrimination based on gender and sexual identities.

Clinicians

Education for clinicians should include LGBTQIA+-affirming language and practices to reduce stigma, harassment, and insufficient care. This will decrease barriers and increase use of lifesaving physical and mental healthcare for LGBTQIA+ youth. Moreover, access to gender-affirming, including medical transition, services for transgender and gender-diverse individuals seeking such services decreases risk for SITBs (Bauer et al., 2015). Training programs and licensure exams should ensure that clinicians are knowledgeable of these services (e.g., local providers, requirements, structural barriers) and should teach clinicians to direct transgender and gender-diverse clients to gender-affirming care as desired while recognizing that individuals’ needs and desires will differ.

Researchers

Increased emphasis must be placed on recruiting diverse and representative samples; for too long, majority-white samples have remained the norm. Innovative methods are needed to engage racially diverse LGBTQIA+ youth and families, and researchers should aim for sufficient sample size for disaggregation of intersectional identity subgroups. Randomized controlled trials including active control groups and SITB outcomes in studies testing LGBTQIA+ interventions are also needed. When studying structural-level impacts on SITBs, quasi-experimental designs during major policy changes (e.g., after legalization of same-sex marriage) may allow for a more thorough investigation of potential confounding factors, compared to the existing, largely cross-sectional literature.