Intra- and Interpersonal Mediators: Same-Sex Attraction and
Suicidality Among Dutch Youths
Master Thesis
Pedagogical Sciences: Youth at Risk Sophie Lang, 12910074
Supervisor: Henny Bos
Second supervisor: Peter Hoffenaar Amsterdam, 10/07/2020
Abstract A study among 1175 Dutch adolescents investigated whether feelings of same-sex attraction (SSA) were related to suicidality, specifically demonstrating the effect of intra and interpersonal risk factors as mediators to this relationship. Four mediators were investigated: self-esteem, social anxiety (internal), peer role strain and parental acceptance (external). Data were collected during the school year of 2009-2010 in several schools in the Netherlands through the use of self-reported questionnaires and with parental consent. A bootstrapped mediation analysis for multiple mediations was conducted, using one of the macros (Model 4) developed by Hayes (Hayes 2013). Findings showed a significant relationship between SSA and suicidality, mediated by the intrapersonal factor self-esteem. Thus, feelings of same-sex attraction were found to lead to lower levels of self-esteem and consequently significantly associated to suicidality. These findings can be incorporated into the fields of education and counseling, as these results are in line with previous research demonstrating significant mental and physical health disparities between sexual minorities and heterosexuals. It is important to find appropriate coping mechanisms for same-sex attracted youths and ultimately increase self-esteem and aim to eliminate the significant association to suicidality for future generations. Keywords: same-sex attraction, suicidality, mediators, Netherlands
Same-Sex Attraction and Suicidality among Dutch Youths Research among lesbian, gay and bisexual (LGB) adults has shown large health disparities between this group and heterosexual identified adults. LGB people are, for example, at greater risks for mental disorders such as depression and anxiety disorders in comparison to heterosexual control groups. They also report more frequent alcohol and drug dependency (e.g., King, Semlyen, Tai, Killaspy, Osborn, Popelyuk & Nazareth, 2008). Studies also showed higher suicidal ideation (frequent thoughts of ending one’s own life) among LGB adults in comparison to heterosexual individuals. It is important to note that most of these studies were conducted in the United States, however similar results were found among investigations in, for example, the Netherlands, which has a worldwide reputation as a liberal and LGB accepting country (Keuzenkamp & Bos, 2007, Patterson & Leurs 2019). Furthermore, it should be mentioned that most studies regarding health disparities and suicidal ideation among the LGB population are conducted among adults. Recently, more studies have focused on adolescents, yet the scientific knowledge regarding sexual minority youth is still small, particularly less is known about the mechanisms behind suicidal ideation among this group. Lastly, studies focusing on adolescents are usually based on convenience samples (participants are recruited through the LGB community) and among youth who self identify as being LGB. However, specific health disparities might already exist at a younger age when self-identification has not yet occurred (Zhao, Montoro, Igartua & Thombs, 2010). Therefore, the focus of this paper is on younger sexual minority adolescents (in the age of the first three years of secondary education) who do have romantic or sexual feelings towards someone of the same sex but do not necessarily identify as LGB. Participants with same-sex attraction (SSA) will be compared on suicidal ideation with their counterparts who do not have these feelings of SSA. Furthermore the current study focused on intra and inter-psychological mediations on the association between SSA and suicidal ideation. There are two main approaches to researching suicidal ideation and mental and physical health issues among sexual minority youths. Researchers either use a between-differences approach focusing on sexual minority youths
versus heterosexual youths, or alternatively look solely at sexual minority youths and the mechanisms behind suicidal ideation, known as the within-differences approach (Sandfort, 2000). An example of a study that investigated suicidality from a between-differences approach is the investigation conducted by Russell and Joyner (2011), which was based on 6254 adolescent girls and 5686 adolescent boys (grade 7 to 12) from the national Adolescence Health Study (i.e., Add Health Study) carried out in the United States. Measurements included same-sex attraction (have you ever had a romantic attraction to a male/female) and suicidality (both suicidal thoughts and attempts). Findings showed youths reporting same-sex attraction are significantly more likely to report suicidality than their heterosexual peers. They are also two times more likely to attempt suicide and were found to suffer from significantly more depression, hopelessness, anxiety and alcohol abuse. After controlling for variables such as age and family background, the association between SSA and suicidality persisted (Russell & Joyner 2011). Similar results were found by Zhao et al. (2010), in a comparison of suicidal ideation and attempts among Canadian adolescents with LGB identity, unsure identities and heterosexual identities (heterosexual identities with and without same-sex attraction/fantasy). A total of 1856 youths between the ages of 14 and 18 were surveyed anonymously to determine the association between sexual minorities and suicidality, particularly focusing on same-sex attraction and identity. Findings demonstrated youths with LGB or unsure identities were at a significantly greater risk of suicidality compared to their heterosexual peers and reported higher levels of depression, alcohol and drug abuse as well as physical and sexual abuse. However, it is important to note that youth who reported same-sex attraction or behavior with a heterosexual identity were not at an elevated risk, demonstrating that sexual minority youths do not comprise of a homogenous population and suggesting that same-sex attraction or behavior per se is not likely the driving force behind the increased risk seen in youths with a same-sex and unsure identities (Zhao et al., 2010). Therefore, to further explore sexual minority youths as a whole, studies examine this population using a within-difference approach, for example the
study conducted in the Netherlands by Dutch researchers Van Bergen et al (2013). By examining external factors (such as school victimization and homophobic rejection) on 274 sexual minority youths in the Netherlands, findings showed a significant positive association between peer victimization and suicidality. This means, students experiencing higher rates of peer victimization were significantly associated with suicidality. Furthermore, homophobic rejection by parents was significantly positively associated with actual suicide attempts. (Van Bergen, Bos, Van Linsdonk, Keuzenkamp & Sandfort, 2013) Studies as such give insight into the various risk factors that influence the association between sexual minorities and suicidality. Similar can be concluded based on other studies, for example an investigation based on 876 self-identified youth carried out in the United States, examining risk factors including coming-out stress, victimization, perceived burdensomeness, thwarted belongingness and depression on suicidality (Baams, Grossman & Russell, 2015). Findings supported the association of sexual orientation victimization with depression and suicidality, mediated by perceived burdensomeness among all sexual identity groups. Furthermore, for those identifying as LGB, coming-out stress was found to be significantly related to depression and suicidality, mediated by perceived burdensomeness (Baams et al., 2015). Results as such demonstrate the elaborate risk factors as well as mediators apparent in the sexual minority population as a whole as well as within separate sexual identity groups. These results demonstrate the need for further international research as well as implications for both social support groups and interventions. In order to explain the findings regarding suicidality (and mental and physical health) among sexual minority individuals (adolescence and adults), the sexual minority stress theory and psychological mediation model can be addressed. According to the sexual minority stress theory, sexual minority individuals experience unique stressors related to their SSA or LGB identity. They are confronted with these unique stressors above general daily stressors that are not related to their sexual minority status. These specific minority stressors include experiences of victimization related to a minority status such as bullying, discrimination and rejection, disproportionally compromising the
wellbeing of sexual minorities (Frost, Lehavot, & Meyer 2015). There is empirical evidence that these sexual minority stressors are significantly associated with psychological problems such as depression and suicidal ideation among sexual minority adults and also among sexual minority youth (Teasdale & Bradley-Engen 2010). According to the psychological mediation framework, the stigma sexual minorities are confronted with causes increased stress, which in turn negatively affects general intra and interpersonal psychological processes inducing psychological problems (Meyer, 2003). Intrapersonal factors are defined as characteristics of an individual such as knowledge, attitudes, behavior, self-esteem, and self-concept or skills. Interpersonal factors are defined by forces within an individual’s life-space that exert conforming influences on them, such as peer role strain and parental acceptance (Tatnell, Kelada, Hasking & Martin, 2014). It is assumed that differences between sexual minorities and heterosexual people on these general intra (e.g., self-esteem and social anxiety) and interpersonal (e.g., parental acceptance and peer role strain) psychological processes led to differences between these two groups regarding to their mental and physical health (Hatzenbühler, 2009). This model has been applied in multiple studies; for example, one Dutch study found that having an open and warm relationship with a father would significantly mediate the association between same-sex attraction and psychological adjustment (Bos, Sandfort, De Bruyn & Hakvoort, 2008). In sum, these studies are assuming that sexual orientation or being attracted to someone of the same sex on it self is not a risk factor per se but leads to psychosocial factors acting as risk factors in the relationship to mental health disparities (Russell & Fish, 2016). Therefore, it is important to focus on factors that might mediate the association between same-sex attraction and suicidality. To further examine this mediation between same-sex attraction and suicidality, specific intra and interpersonal factors should be examined. Based on previous research using the between-differences approach, some intra and interpersonal psychosocial aspects were highlighted among the mental health disparities between SSA and heterosexual youths. For example, sexual minority
youths may experience high feelings of exclusion among their peers due to their sexual orientation, concealment of their identity or because they feel different from their peers, resulting in lower self-esteem and social anxiety (Blais et al., 2014). Furthermore, it is important to acknowledge the importance of peer and school environments along with family during the age of adolescence. SSA youths are therefore more likely to experience family stressors and less social support as they may feel pressure to conceal their identity and relationships to their parents and peers (Teasdale et al., 2010). Even though risk factors of suicidality may significantly vary across population groups, it has been proven that stress resulting from prejudice and discrimination such as family rejection, bullying, violence and lack of social support, are known risk factors for suicidal ideation among sexual minorities. Furthermore, self-esteem has been shown to have a clear association to suicidality among the general population (Suicide Prevention Resource Center, 2015). Therefore, the focus in the current study is on two intrapersonal factors, self-esteem and social anxiety, as well as interpersonal factors peer role strain and parental acceptance as interest for further research. By using the between-difference approach and the psychological mediation model, it is expected in the current study that self-esteem and social anxiety, as intrapersonal aspects, and peer role strain and parental acceptance, as interpersonal aspects, play a significantly mediation role in the relationship between same-sex attraction and suicidality. It is hypothesized that in comparison to heterosexual youth, SSA youth will have lower levels of self-esteem, higher levels of social anxiety, higher levels of peer role strain and lower levels of parental acceptance, and in turn these aspects are assumed to be related suicidality. By combining these two approaches and applying them to the sensitive and important stage of adolescence, this study will produce unique results regarding same-sex attracted Dutch youths in the Netherlands. In sum, the aim of the present study was to investigate whether feelings of SSA were related to suicidality through general intra- (self-esteem and social anxiety)- and interpersonal (peer role strain and parental acceptance) psychosocial aspects.
Method Participants Participants were 1,175 Dutch students (598 boys and 577 girls; Mage = 14,67 years, SD = 1.01, range = 13 to 18 years, median = 15 years) attending 12 different secondary schools in the Netherlands. Most participants attended a school at pre-university (50.9%, n = 598). The remaining participants attended a school at senior general secondary (26.6%, n = 312) or pre-vocational secondary (22.6%, n = 265) level. In terms of ethnicity 70.8% (n = 832) could be classified as having a Dutch or Western ethnic background, and 29.2% (n = 343) a non-western background. This classification was made based on the answers regarding where the parents were born: if one parent was born in the Netherlands or in another Western country we categorized the ethnicity of the participant as Dutch or Western. The sample consisted of 96 (8.2%) participants with a same-sex attraction (SSA) to someone of the same sex and 91.8% (n = 1079) reported exclusively to be attracted to someone of the other sex (No SSA). Table 1 shows the figures regarding differences between SSA and no SSA participants on the demographic variables that were included in the study. Significant differences between SSA and no SSA were found on gender and ethnicity. Girls reported more often than boys to be attracted to someone of the same sex. Same-sex attracted feelings were more often reported among participants with a Dutch/Western background compared to those with a non-Western ethnic background. Procedure Data were collected during the school year of 2009-2010 as part of a larger research study on adolescent’s health, relationships and school experiences. Research assistants from the University of Amsterdam (UvA) contacted several secondary schools with the question if they were willing to participate in the study. In case that a school administrator was willing to participate, parents of the potential participants did get a letter with information about the study. Parents who did not want their child to participate were able to
return a form enclosed with the letter. This was in line with the ethical guidelines in the Netherlands and the University of Amsterdam at the time of data collection. Thirty-eight parents opted out of this study; reasons for refusal were not collected. Data collection took place during a regular mentor hour at school, and lasted 40-60 minutes, depending on the education level of that school. All students, whose parents consented and were present in class during the survey administration, completed the survey. There was no compensation for participation. Teachers were not present during the self-administered questionnaire, only the research assistants from the University of Amsterdam. Once finished, participants returned the completed survey to the research assistant and were given the opportunity to submit further comments. None were received. Instruments Same sex attraction Same-sex attraction was assessed with the question “Do you feel sexually attracted to someone of your own sex?” (1 = never, 2 = rarely, 3 = sometimes, 4 = frequently, 5 = very often). This question has been used successfully in previous studies among youth in the Netherlands (e.g., Bos et al., 2008; Kersten & Sandfort, 1994; Sandfort et al., 2010). Table 2 shows the distribution and frequency of the scores on this variable for the total group and for boys and girls separately. Because the small numbers of adolescents who reported the answer categories “rarely”, “sometimes”, “frequently”, and “very often”, we recoded this variables in the same way as was done in previous studies. Those who reported any attraction (“rarely”, “sometimes”, “frequently”, and “very often) to someone of the same sex were grouped in the same-sex attraction category and only those reporting never to have these feelings were grouped as non-same sex attraction. Suicidality To assess suicidality, an item of the Youth Self Report (Achenbach, 1991) was used, namely “I try to deliberately harm myself or attempt suicide’. Adolescents indicated whether this statement was applicable to them in the past
6 months (0 = not at all, 1 = sometimes, and 2 = often). Preliminary analyses showed that 5.1% (n = 60) and 1.8% (n = 21) of the participants filled out that they sometimes or often had these feelings respectively. Therefore, the students who reported to sometimes or often deliberately try to harm themselves or attempt suicide, were compared to those who did not report self-harm or suicide attempts. Intrapersonal psychosocial factors Two interpersonal psychosocial factors were included in the current study, namely self-esteem and social anxiety. Self-esteem was assessed with the Rosenberg Self-Esteem scale (Rosenberg, 1965) and consists of 10 items in which students were asked how much they agree or disagree with the statements, for example “I take a positive attitude toward myself” (1 = strongly disagree, 4 = strongly agree). A high score on this scale indicated high levels of self-esteem. Cronbach alpha’s for this self-esteem scale was in the current study .84. Social Anxiety was assessed using the Social Interaction Anxiety Scale (SIAS; Heimberg, Müller, Holt, Hope & Liebowitz et al. 1992) and consists of 10 items including questions such as “I find it difficult to make eye contact with others”. Students rated how much each item relates to them on a 5-point scale (0 = Not at all characteristic of me, 5 = Extremely characteristic of me). A high score on this scale indicated high levels of social anxiety. Cronbach alpha’s for the social anxiety scale in the present study was .7 Interpersonal psychosocial factors The two interpersonal psychosocial factors that were included in the current study were peer role strain and parental acceptance. In order to measure peer role strain, students completed a subscale of the Early Adolescent Role Strain Inventory (Fenzel, 1989). This subscale included six items. Students were asked to indicate how frequently their peers expressed negative behavior towards them for each item. An example of this is “My classmates ignore me” (1= not at all, 5= a lot). A high score on this scale indicated high levels of peer role
strain. Cronbach alpha’s for the peer role strain scale in the present study was .88. Parental acceptance was measured with a subscale of the inventory of the parent and peer attachment (IPPA; Armsden & Greenberg, 1987). This parental acceptance subscale consists of 3 items (e.g., ‘My parents accept me as I am’). Participants could answer on a 4-point scale (1 = almost never and 4 = very often). A high score on this subscale indicated high parental acceptance. Cronbach’s alpha in this study was .58. Analyses All the analyses for the current study were conducted in SPSS version 23. To ensure that the effect of SSA on suicidality through the mediating variables could not be attributed to the statistically significant differences between SSA and non-SSA on gender and ethnicity, the two demographics were included in all the analyses as controlling variables. On the other demographics that were included in the current study there were no differences between SSA and non-SSA, so it was not necessary to include them as controlling variables in the analyses. First, analyses of covariance (ANCOVA’s) were conducted to assess whether there were differences between SSA and non-SSA adolescents on self-esteem and social anxiety (i.e., intra psychological variables) and parental acceptance and peer role strain (inter psychosocial variables). Second, to examine the bivariate difference between SSA and non-SSA adolescents on suicidality a logistic regression analysis test was conducted. Third, to assess the associations between the intra- and inter psychosocial variables, Pearson r correlations were conducted. Finally, to examine whether feelings of SSA were related to suicidality through self-esteem, social anxiety, peer role strain and parental acceptance, a bootstrapped mediation analysis for multiple mediations was conducted and for this analyses used one of the macro’s (model 4) that was developed by Hayes (Hayes, 2013). In a model with more than one possible mediator, this bootstrap method is recommended because it is suggested to be
more appropriate than traditional mediation approaches (Preacher & Hayes, 2008; Shrout & Bolger, 2002), and it requires no assumption regarding the shape of the sampling distribution on the mediating effect (Hayes, 2013). In bootstrapping, random samples are generated based on the original data. In the current analysis, the bootstrapped mediation was done with 10,000 resamples. For each random sample, the mediated effects were computed. The distribution of these effects was then used to obtain 95% confidence intervals (CI) for the size of indirect effects of self-esteem, social anxiety, peer role strain, and parental acceptance on the relation between SSA and suicidality. The indirect effect for a mediator is significant when the obtained CI does not contain the value 0 (Hayes, 2013). Results Same-sex attraction and suicidality A logistic regression was used to assess the relationship between same-sex attraction and suicidality whilst controlling for both gender and ethnicity. The variable SSA was found to be a significant predictor of suicidality among Dutch youths (B=1.18, Wald= 15.71, p<0.05). The estimated odds ratio showed an increase of approximately 32% (Table 3), demonstrating a significantly higher associated of suicidality among SSA participants compared to their heterosexual peers. Same-sex attraction and intra and interpersonal psychosocial factors ANCOVAs with self-esteem, social anxiety (intrapersonal), peer role strain and parental acceptance (interpersonal) as dependent variables and SSA (SSA versus non SSA) as independent variable, showed significant findings on all dependent variables (see Table 4). It has been revealed that regarding the intrapersonal psychosocial factors SSA participants reported lower scores on self-esteem and higher scores on social anxiety compared to the non-SSA participants. Looking at the interpersonal factors, it was found that SSA participants reported higher scores on peer role strain and lower scores on parental acceptance compared to the non-SSA participants.
Intra and interpersonal psychosocial factors as mediation variables The multiple mediation (Figure 1) showed a significant negative association between the independent variable SSA and the mediators self-esteem and parental acceptance. This means, students with same-sex attraction reported lower levels of self-esteem and parental acceptance than their heterosexual peers. Similarly, a significantly negative association was found between the variables parental acceptance, self-esteem and suicidality, meaning low parental acceptance and self-esteem were significantly associated to suicidality. On the other hand, a significant positive association was found between SSA and peer victimization and social anxiety. This means, students with SSA reported higher levels of social anxiety and peer victimization than their heterosexual peers. The two variables were also positively associated to suicidality meaning higher levels of social anxiety and peer victimization were significantly associated to suicidality. The bootstrapping analyses confirmed that self-esteem mediated the relationship between same-sex attraction and suicidality, as 0 was not within in the confidence intervals (95% CI= 0.165, 0.632). However, social anxiety was not found to be a mediator (95% CI= -0.216, 0.039), as were peer role strain (95% CI= -0.009, 0.198) and parental acceptance (95% CI= -0.008, 0.201) because 0 was in the 95% CI interval. Furthermore, the mediation effect of self-esteem was in the expected direction; persons with same-sex attraction suffered from lower rates of self-esteem as an outcome; therefore lower levels of self-esteem results in higher scores of suicidality. Discussion In line with previous research, this study demonstrated the general mental health disparities found among same-sex attracted and heterosexual youths. We found that SSA youths had a higher association to suicidality compared to their heterosexual peers. This association was found to be mediated by the intrapersonal risk factor; self-esteem, and thus demonstrated that feelings of same-sex attraction led to lower levels of self-esteem and increased suicidality. Results did not find significance in relation to our other intra and interpersonal
mediators; social anxiety, peer role strain and parental acceptance, as they did not mediate the relationship between SSA and suicidality. Self-esteem has been shown to have a clear association and act as an important risk factor to suicidality among the general population (Resource Center, 2015), therefore this study further emphasizes the need to study this intrapersonal factor as a mediator and not just a risk factor among sexual minority youths. Through the use of the psychological mediation model and the between-differences approach comparing sexual minority and heterosexual youths, this study provided unique insight regarding intra and interpersonal mediators. According to the psychological mediation model, the stigmatization that sexual minorities are confronted with causes increased stress affecting general intra and interpersonal psychological process, in turn, inducing psychological problems (Hatzenbuehler 2019) Therefore, by examining four of these intra and interpersonal factors, we have shown that sexual minority and heterosexual youths differ in regards to these psychological processes (self-esteem, social anxiety, parental acceptance and peer role strain) leading to differences between these two groups regarding their metal health. These results further demonstrate that sexual orientation or being attracted to someone of the same sex is not a risk factor per se but creates disparities among psychological internal and external processes, which are able to mediate mental health outcomes. Similar to previous research by Russell & Joyner (2011) and Zhao et al. (2010), using a between-differences approach, our results found significance between SSA and suicidality after controlling for variables such as gender and ethnicity. These studies particularly focused on same-sex attracted individuals in adolescence instead of those identifying as LGB, and further demonstrated that open sexual orientation (“coming out”) is not what explains the mental health disparities among sexual minorities. Therefore the current study examined the relationship between SSA and suicidality with the use of the Hatzenbuehler’s mediation model to further demonstrate mental health disparities, particularly mediators to this relationship, a unique method applied to Dutch youths. By using this framework, the mechanisms behind suicidality of SSA youths were
examined and results were able to draw accurate representations on psychosocial mediators associated to suicidality. Results showed the importance of self-esteem among SSA youths and how this intrapersonal variable can significantly mediate the association to suicidality. It is important to note particular strengths and limitations within this study. A noteworthy strength of this study is that it specifically focuses on a young age group (students between the ages of 14 and 18) to gain insight into SSA before sexual identities have fully developed. By doing so, it is unclear whether these findings speak to youth who identify as lesbian, gay or bisexual however SSA is a good predictor of identifying as LGB later in life (Russell et al. 2001). These findings therefore draw conclusions on suicidality particularly directed at same-sex attraction, not sexual orientation. Furthermore, the data were collected within a larger study regarding adolescent’s health, relationships and school experiences, which strengthen this study, as students were not aware of our aim and hypothesis regarding sexual minorities and suicidality. Researchers such as Plöderl have criticized previous studies, claiming that results might be biased as participants are often asked to participate in a study regarding SSA or suicidality, thus creating a predisposition to those aspects (Plöderl & Tremblay, 2015). This study however, did not emphasize questions regarding sexual attraction or suicidality and used a convenient sample by collecting data from various secondary students in the Netherlands. A few limitations must be addressed, particularly regarding the target population. Even though a school based sample was used instead of a convenient or community sample, the number of participants was relatively small and homogenous in terms of cultural backgrounds, therefore not allowing for generalizability across cultures. It is important for future research to include more participants of this age belonging to different ethnic backgrounds. Furthermore, the measurement of suicidality only addresses the participants themselves, which has been questioned by previous researchers. To increase the validity of this measurement studies should question important people surrounding the individual (family, friends, peers) to gain better insight into the reality of suicidal ideation. Nevertheless, this poses an ethical issue as it involves
non-participant individuals’ input and does not allow for complete anonymity, and must therefore be further addressed in future research. Furthermore, this study controlled for gender and ethnicity to view SSA as a separate mechanism, therefore it would be interesting to view this data through an intersectionality lens, to determine how the variables sexuality, gender and ethnicity overlap and cause disadvantages among sexual minorities. Lastly, few researchers have undertaken test-retest studies to evaluate whether individuals can provide reliable self-reports, particularly on sexual behavior. Researchers have questioned the ability of individuals, particularly youths, to provide reliable self-reports in regards to sensitive topics such as sexual behavior (Schrimshaw, Rosario, Meyer-Bahlburg & Scharf-Matlick, 2006). Therefore, the potential for misleading results regarding the same-sex attraction and suicidality measurements must be acknowledged, as students may not feel comfortable sharing such information even with the assurance of anonymity. As this study was conducted in the Netherlands, a culture known for its liberal and accepting attitude towards the LGBTQ community, one could have imagined different findings than among studies conducted in the United States. Nevertheless, the strong association between SSA and suicidality was found regardless of the surrounding context. Even though the intra and interpersonal risk factors social anxiety, peer role strain and parental acceptance were not found to mediate the relationship between SSA and suicidality, along with studies by Van Bergen et al. (2013) these three risk factors were significantly associated to same-sex attraction. Therefore we can conclude regardless of being mediators, these variables continuously act as risk factors and affect youths with same-sex attraction in the Netherlands. Furthermore, factors such as coming-out stress, perceived burdensomeness and thwarted belongingness have been found to be significantly associated to suicidality among youths in the United States. As we have concluded that Dutch and US studies produce similar findings, research as ours including the psychological median model must be expanded and further address new psychological processes, as potential mediators in the SSA and suicidality relationship.
Based on our findings, we recommend that this knowledge be incorporated into both education and counseling, to inform parents and teachers of the importance of self-esteem, not only in regards to those who have openly declared themselves to be lesbian, gay or bisexual but also unsure sexualities. In working with same-sex attracted youth, the focus should be on increasing self-esteem and exploring ways to openly discuss coping mechanisms and treatment options. A potential of such treatment options would be to incorporate these findings and the overarching need to increase self-esteem into cognitive behavioral therapy (CBT). CBT has been shown to be effective in reducing the symptoms of mental illnesses that are associated with an increased risk of suicide, including depression, anxiety and psychosis (Mewton & Andrews, 2016). Thus, it could be of significance to include CBT and increase self-esteem for those struggling in regards to their attraction to someone of the same gender and overall as a coping mechanisms for individuals openly identifying as a sexual minority. Previous research has shown successful treatments using CBT to improve depression, anxiety and co-occurring health risks such as alcohol use and sexual compulsivity, among young adult gay and bisexual men. By focusing on reducing minority stress processes, promising results have been made in determining underlying sexual orientation-related mental health disparities and the potential in helping clinicians use evidence-based practices as treatments (Pachankis, Hatzenbuehler, Rendina, Safren & Parsons, 2015). Our findings suggest that more research regarding same-sex attraction among Dutch youths is needed, in particular choosing a within-subject approach rather than a comparison between heterosexuals and SSA. With the addition of the minority stress theory and the psychological mediation model, such an approach would draw important conclusions regarding specific minority risk and mediation factors among SSA adolescents. Using this set of data, it would be interesting to further examine the variable of same-sex attraction and compare those that have openly declared themselves to be lesbian, gay or bi, to those ranking lower on the SSA scale reporting answer such as “rarely” or “sometimes” in response to “Do you feel sexually attracted to someone of the same sex?” As our results found a significant association in relation to gender and ethnicity on
SSA, choosing a within-subject design would allow for insight into the diversity of SSA participants and determine how these variables coexist and overlap through an intersectionality framework. Furthermore it would be interesting to determine whether factors such as “coming out stress” similarly mediate the relationship between SSA and suicidality, particularly in a Dutch context, as this variable significantly relies on the acceptance of the outside world. We have drawn unique conclusions providing insight into self-esteem as a mediator on the relationship of SSA and suicidality among Dutch youths. We believe this must be expanded and further researched to determine the ways in which psychosocial factors act as mediators or risk factors among SSA youths, in order to appropriately target interventions and treatments with the highest effectiveness in the Netherlands.
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Table 1 Sample Demographics Demonstrated in both SSA and Non-SSA Participants
No SSA SSA F p-value
Gender 12.9 < 0.001 Male n (%) 556 (52.5%) 32 (33.3%) Female n (%) 513 (47.5%) 64 (66.7%) Age M (SD) 14.7 (1.5) 14.6 (1.0) 1.18 0.28 Education 3.33 0.19 Pre-Vocational n (%) 237 (22%) 28 (29.2%) Senior General n (%) 292 (27%) 20 (20.8%) Pre University n (%) 550 (51%) 48 (50%) Ethnicity 7.93 0.005 Dutch/Western n (%) 752 (69.7%) 80 (83.3%) Non-Western n (%) 327 (30.3%) 16 (16.7%)
Table 2
Levels of Same-Sex Attraction in Participant Sample
Not at all Sometimes Frequently Often Very often
n (%) n (%) n (%) n (%) n (%) Boys 566 (94.6) 20 (3.3) 5 (0.8) 4 (0.7) 3 (0.5) Girls 513 (88.9) 44 (7.6) 3 (0.5) 7 (1.2) 10 (1.7) Total 1079(91.8%) 64 (5.4%) 8 (0.7%) 11 (0.9%) 13 (1.1%) Students indicated on a 3-point scale how applicable the statement “I try to deliberately harm myself or attempt suicide” was to them in the past three months. 2In Dutch secondary schools students are in the fourth 15-16 year old, and in the fifth and sixth year 16-17 and 17-18, respectively. 3Peer Role Strain was measured using a subscale of Early Adolescent Role Strain Inventory. 4Parental Acceptance was measured using a subscale of the inventory of the parent and peer
attachment (IPPA). 5 Self Esteem was assessed using the Rosenberg’s Self-Esteem scale. 5 Social Anxiety was assessed
using the Social Interaction Anxiety Scale (SIAS)
Table 3 Logistic Regression showing SSA on Suicidality
B S.E Wald X P value OR
SSA 1.183 0.298 15.714 < 0.001 3.26
Gender 0.231 0.231 0.944 0.331 1.26
Table 4 Differences of SSA and Non-SSA Participants on Intra and Interpersonal psychosocial factors No SSA SSA F p-value ηp2 Intra Self-Esteem M (SD) 3.22 (0.56) 2.97 (0.55) 11.48 < 0.001 0.1 Social Anxiety M (SD) 1.90 (0.59) 2.14 (0.62) 12.7 < 0.001 0.01 Inter Peer role strain M (SD) 1.52 (0.59) 1.68 (0.62) 7.61 0.006 0.006 Parental Acceptance M (SD) 3.18 (0.60) 3.03 (0.75) 5.87 0.016 0.005
Multiple Mediation Analysis Figure 1
Findings of the Multiple Mediation Analysis of Self Esteem, Social Anxiety, Peer Role Strain and Parental Acceptance as Mediators on the Association between Same-Sex Attraction and Suicidality
Same-Sex attraction Suicidality
Peer role strain Self-Esteem Social Anxiety Parental acceptance (B= -0.199, S,E= 0.057, p<0.05) B= 0.229, S.E= 0.067, p<0.05) (B= -0.16 S.E= 079, p<0.05) (B= 0.175, S.E= 068, p<0.05) (B= -1.85, S.E = 0.231, p<0.05) (B= -0.285, S.E= 0.234, p>0.05) (B= 0.411, S.E= 0.191, p>0.05) (B= -0.457, S.E = 0.193, p>0.05) (B= 1.041, S.E= 0.336, p<0.005)
