Protective Factors Associated with Suicidality in Sexual Minority Youth
Noor Galesloot (10587063) Supervisor: Henny Bos Master Thesis
Youth at Risk, University of Amsterdam 5164 words
2 Abstract
Previous studies have shown that sexual minority youth are at a higher risk for suicidality than their heterosexual peers, however studies on protective factors are lacking. The current study assessed whether youth with same-sex attraction have a higher risk for suicidality than heterosexual youth, and whether parental acceptance and self-esteem protect against this risk. 1175 secondary school students (49.1% female) between 13 and 18 years old (M = 14.67, SD = 1.01) completed a questionnaire, measuring same-sex attraction, suicidality, parental acceptance and self-esteem. Same-sex attracted youth were almost three times as likely to report suicidality compared to heterosexual youth. Students with low self-esteem were also more likely to report suicidality. Same-sex attracted youth who reported high self-esteem and high parental acceptance were not less likely to report suicidality. Therefore, this study concluded that there was no protective effect of self-esteem and parental acceptance on suicidality in sexual minority youth.
3 Introduction
Compared to heterosexual youth, sexual minority youth are at greater risk for mental health problems (Russell & Fish, 2016). For instance, sexual minority youth are more likely to report substance abuse (Marshal et al., 2008), and depressive symptoms (Marshal et al., 2011). Mental health disparities are also found with respect to suicidality: sexual minority youth are more than three times as likely than their heterosexual peers to report suicide attempts (Marshal et al., 2011). Differences in suicidality between sexual minority and heterosexual youth emerge during early adolescence and persist into young adulthood (Marshal et al., 2013). This suggests a need for early prevention, aimed at reducing the risk for suicidality and increasing the resources that protect against suicidality in sexual minority youth. However, the majority of studies has focused on the factors that increase the risk for suicidality, and studies on protective factors are lacking (Hatchel, Polanin, & Espelage, 2019). According to Werner (2000, page 116), a protective factor is a mechanism that buffers against the effects of stress or improves a child’s reaction to stress, so the child can adapt more successfully than he or she would if the protective factor was not present. In order to prevent suicidality in sexual minority youth, it is necessary to identify protective factors associated with suicidality (Russell & Joiner, 2001). This study investigated suicidality in sexual minority youth in the Netherlands and focused on positive factors that could protect against suicidality.
In this study, same-sex attraction (SSA) was used as a measure of sexual orientation, instead of self-identification as lesbian, gay or bisexual (LGB). SSA, defined as having romantic or sexual feelings towards people of the same sex, is seen as the first stage of sexual orientation identity development. This generally starts during childhood or early adolescence (Troiden, 1989). Identifying as homo- or bisexual occurs at a later stage, after the onset of puberty (Floyd & Stein, 2002). For an adolescent sample, same-sex attraction is therefore a more age-appropriate measure than self-identification (Van Beusekom, Overbeek, & Sandfort, 2015).
According to the minority stress model, sexual minority youth experience more stress than their heterosexual peers due to stigmatization, such as discrimination or rejection, which in turn increases their risk for adverse mental health outcomes (Meyer, 1995). Indeed, studies have shown that stigma-related stress is associated with mental health problems in sexual minorities, including suicidality (Meyer, 2003). For instance, LGB young adults who experienced family rejection due to their sexual orientation during adolescence, were more likely to report suicidality than those who did not (Ryan, Huebner, Diaz, & Sanchez, 2009). The psychological mediation framework expanded on the minority stress theory, by
4 explaining the mechanisms through which stigma-related stress increases the risk for mental health problems. According to this framework, this relationship is mediated by intra- and interpersonal processes (Hatzenbuehler, 2009). Intrapersonal processes occur within the individual, whereas interpersonal processes occur between people. These intra- and interpersonal processes are thought to be general risk factors for mental health, instead of unique to sexual minorities. Research has shown that general risk factors are related to mental health problems in sexual minorities, and that sexual minorities have higher levels of these general risk factors than heterosexuals (Hatzenbuehler, 2009). However, there is a need for research examining which mechanisms buffer against the effects of stigma-related stress on suicidality (Miceli, Klibert, & Yancey, 2019). Following the psychological mediation
framework, it is conceivable that general intra- and interpersonal processes could also protect against suicidality.
According to the interpersonal theory of suicide, intra- and interpersonal factors that increase belongingness and decrease perceived burdensomeness could protect against suicidality (Van Orden, Witte, Cukrowicz, Braithwaite, Selby, & Joiner, 2010). Low
belongingness, defined as feelings of social isolation, and perceived burdensomeness, or the feeling that one is a burden to others, are strong predictors of suicidality (Joiner, 2009). Indeed, low belongingness and perceived burdensomeness are associated with suicidality in sexual minority youth (Hatchel et al., 2019). Belongingness and burdensomeness have been proposed as mediators of the relationship between stigma-related stress and suicidality (Baams, Grossman, & Russell, 2015). These two mechanisms are influenced by intra- and interpersonal factors, which could in turn protect against suicidality. An intrapersonal factor is self-esteem. Self-esteem is thought to counteract perceived burdensomeness, since individuals with high self-esteem tend not to view themselves as a burden to others (Brausch & Decker, 2014). An interpersonal protective factor is social support, which increases feelings of belongingness (Kleiman & Liu, 2013). Previous research has found that the relationship with the parents is an important form of social support for sexual minority youth (Watson,
Grossman, & Russell, 2019). These two factors will be elaborated below.
Self-esteem, the possibly protective intrapersonal factor in this study, is defined as an individual’s subjective evaluation of their own value and competence, and has been identified as a general protective factor for mental health (Brausch & Decker, 2014). People with high self-esteem tend to perceive reality in a direction that promotes their well-being. A positive self-evaluation can therefore buffer against the effect of stress on mental health (Mann, Hosman, Schaalma, & De Vries, 2004). Moreover, adolescents with high self-esteem tend to
5 have more active coping styles, allowing them to manage stress effectively (Dumont &
Provost, 1999). High self-esteem could serve as a general protective mechanism, buffering sexual minority youth from the effects of stigma-related stress on suicidality. Previous
research has found that adolescents with depressive symptoms are less likely to report suicidal ideation when they have high self-esteem (Brausch & Decker, 2014). Self-esteem is also associated with a decreased risk for suicidality in sexual minorities (Hatchel et al., 2019; Ybarra, Mitchell, Kosciw, & Korchmaros, 2015).
An interpersonal factor that could potentially act as a buffer against the stress faced by sexual minority youth is the quality of the relationship with the parent, characterized by high parental acceptance. Parental support is associated with less mental health problems in sexual minority youth, including suicidality (Bouris et al., 2010). For instance, sexual minority who report high levels of family support are less likely to report lifetime suicide attempts
(Mustanski & Liu, 2013). A form of parental support is parental acceptance, defined as the degree to which children perceive themselves to be accepted by their parents (Rohner, Khaleque, & Cournoyer, 2005). Consistent with the psychological mediation framework, parental acceptance has been identified as a general protective factor: children who feel accepted by their parents tend to universally report less mental health problems than those who feel rejected (Rohner et al., 2005). Perceived parental acceptance could be even more important for sexual minority youth, since it can buffer against the effects of stress on mental health and counteract feelings of being different from everyone else (Mustanski, Newcomb, & Garofalo, 2011). Previous research has found that parental acceptance indeed protects against mental health problems and suicidal ideation in LGB adolescents (Ryan, Russell, Huebner, Diaz, & Sanchez, 2010). However, most of the studies on parental support and acceptance rely on convenience samples of sexual minority youth, for instance when they are recruited through LGB organizations (Bouris et al., 2010). Youth who are associated with LGB organizations could be more open about their sexual orientation, or experience more mental health problems. Because of this, it is unclear whether these findings generalize to the population of sexual minority youth (Bouris et al., 2010). One study did use a school-based sample, and found that that mother’s acceptance did buffer against the risk for mental health problems in same-sex attracted girls, but fathers’ acceptance did not. For boys, no protective effect of parental acceptance on suicidality was found (Van Beusekom et al., 2015).
Suicidality was not assessed in this study. Therefore, this study examined the protective role of parental acceptance in the relationship between same-sex attraction and suicidality in a sample of high school students.
6 The current study
Because of the lack of studies on protective factors associated with suicidality in sexual minority youth, this study examined which positive intra- and interpersonal processes protected against the risk for suicidality for these youth. In this study, suicidality was
operationalized as engaging in self-harm or suicide attempts, instead of suicidal ideation. Suicidal ideation, defined as thinking about suicide, is far more common than suicide
attempts, and only a few people who engage in suicide ideation go on to attempt suicide (Van Orden et al., 2010). Moreover, the disparity between sexual minority and heterosexual youth is greater for suicide attempts than for suicidal ideation (Marshal et al., 2011). Self-harm was included since this is an important predictor for suicidality (Hatchel et al., 2019). According to the interpersonal theory of suicide, self-harm increases pain tolerance and lowers the fear of death, which makes it possible to move on towards lethal forms of self-harm (Van Orden et al., 2010).
For this study, an existing dataset was used, originating from a larger study on adolescent mental health in the school year of 2009-2010, conducted in the Netherlands. In contrast to most studies on sexual minority youth, no convenience sample was used: participants were recruited through secondary schools. The only positive factors that were assessed in this study were parental acceptance and self-esteem. Therefore, the current study aimed to answer the research question whether youth with same-sex attraction have a higher risk for suicidality than heterosexual youth, and whether parental acceptance and self-esteem protect against this risk. The following hypothesis was tested: same-sex attracted youth are more likely to report suicidality than heterosexual youth, and this relationship will be less strong for adolescents who score high on parental acceptance and self-esteem.
Method Participants
Of the 1175 included participants, 49.1% (n = 577) was female. 8.2% (n = 96) of the participants reported same-sex attraction, which was 5.4% (n = 32) for boys and 11.1% (n = 64) for girls. The adolescents’ age ranged from 13 to 18 years old (M = 14.67, SD = 1.01). 22.6% (n = 266) of the participants was a first-year student, 28.3% (n = 332) was a second-year student and 49.1% (n = 577) was a third-second-year student. As for educational level, 22.6% (n = 265) of the adolescents attended pre-vocational secondary education, 26.6% (n = 312) attended senior general education and 50.9% (n = 598) attended pre-university education.
7 70.8% (n = 832) of the participants was categorized as being of Western descent, with both parents being born in a Western country.
Procedure
For this study a pre-existing dataset was used, which originated from a study examining adolescent health, relationships and school experiences among 1630 secondary school students. The data were collected during the 2009-2010 school year. No ethical commission was obtained, since this was not required at the time, but the study was conducted according to the guidelines of the Belmont Report (1979). Participants who had missing data on social demographics, same-sex attraction, suicidality, self-esteem or parental acceptance were excluded from this study, which resulted in a sample size of 1175
participants.
First-, second-, and third-year students could participate in the study, from three types of secondary schools in Amsterdam. Of the 32 secondary schools that were invited to
participate, only six accepted this invitation. This low acceptance rate could be due in part to the increasing number of requests to participate in studies that secondary schools receive. Research assistants from the University of Amsterdam and an administrator from each school arranged the students’ involvement and administration of the questionnaire in that particular school. For this study, passive parental consent was used: parents were sent a letter with details about the study and were asked to return a form if they objected against their child participating. 38 parents did not give consent. All of the adolescents who had parental consent and were present at the administration of the questionnaire, participated in the study. The adolescents filled in a paper questionnaire during the school day, which lasted 40-60 minutes, depending on educational level. This was overseen by research assistants from the University of Amsterdam, regular teachers were not present. When they were finished, participants handed in the questionnaire. At the last page of the questionnaire, participants could write down comments, but none did. Adolescents did not receive compensation for participating in the study.
Instruments Same-sex attraction
Similar to previous research on Dutch sexual minority youth (Bos, Sandfort, De Bruyn, & Hakvoort, 2008), same-sex attraction was assessed by an item asking ‘Do you ever have romantic and/or sexual feelings towards someone of the same sex?’ Participants filled in
8 an answer on a 5-point scale (1 = not at all and 5 = very often). As can be seen in Table 1, the distribution of scores on same-sex attraction was highly skewed, with the majority of the adolescents reporting no same-sex attraction. Therefore, same-sex attraction was recoded into a variable with two categories. Participants who reported no romantic or sexual feelings towards someone of the same sex were categorized as youth without SSA. Participants were categorized as same-sex attracted if they reported that they occasionally, regularly, often or very often felt attracted to the same sex. This approach has been previously used in research on same-sex attraction among youth in this age range (Bos et al., 2008).
Suicidality
To assess suicidality, an item of the Youth Self Report (Achenbach, 1991) was used, which stated ‘I try to deliberately harm myself or attempt suicide’. Participants indicated whether this statement was applicable to them in the past 6 months, on a 3-point scale (0 = not at all, and 2 = often). Since most adolescents reported no suicidality or self-harm, the
distribution of the scores on this item was highly skewed, see Table 2. 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.
Table 1
Distribution of Scores on Same-Sex Attraction, Including Frequency (n) and Relative Frequency (%), Separate for Boys and Girls
Same-Sex Attraction
Not at all Sometimes Frequently Often Very often
Gender n % n % n % n % n %
Girls 513 88.9% 44 7.6% 3 0.5% 7 1.2% 10 1.7%
Boys 566 94.6% 20 3.3% 5 0.8% 4 0.7% 3 0.5%
9 Table 2
Distribution of Scores on Suicidality, Including Frequency (n) and Relative Frequency (%), Separate for Boys and Girls
Suicidality
Not at all Sometimes Often
Gender n % n % n %
Girls 531 92.0% 35 6.1% 11 1.9%
Boys 563 94.1% 25 4.2% 10 1.7%
Total 1094 93.1% 60 5.1% 21 1.8%
Parental acceptance
Parental acceptance was measured using three items from a subscale of the Inventory of the Parent and Peer Attachment (Armsden & Greenberg, 1987). An example item is ‘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. All
participants who answered one or more of these items were assigned a score on parental acceptance, and were thus included in the analysis. Cronbach’s alpha in this study was 0.58.
Self-esteem
Self-esteem was measured with the Rosenberg Self-Esteem Scale (Rosenberg, 1979). This scale consists of ten items. Participants were asked to indicate whether they agreed with the statements on a 4-point scale (1 = strongly disagree and 4 = strongly agree). An example item is ‘I am proud of myself’. A high score on this scale indicated high self-esteem. All participants who answered one or more of these items were assigned a score on self-esteem, and were thus included in the analysis. Cronbach’s alpha in this study was 0.84.
Data analysis
For each step of the data analysis, a Bonferroni correction was used to control the Family-Wise Error Rate (Curtin & Schulz, 1998). This was done by dividing the alpha-level of .05 by the number of tests conducted within that step of the data analysis, resulting in an adjusted alpha level.
10 First, the associations between each demographic variable (gender, age, ethnicity, educational level and class) and each variable of interest (same-sex attraction, suicidality, parental acceptance and self-esteem) were tested. If the association between a demographic variable and one or more of the studied variables was significant, this demographic variable was treated as a control variable in the following analyses. Next, the intercorrelations between suicidality, parental acceptance and self-esteem were tested. The associations between same-sex attraction and the other studied variables were also assessed.
To test whether students who reported same-sex attraction were more likely to report self-harm or suicidality than students who did not report same-sex attraction, and whether this relationship was moderated by parental acceptance and self-esteem, a multiple regression analysis was conducted. In this analysis, self-harm or suicidality was the outcome variable, same-sex attraction was the focal predictor and students’ score on parental acceptance and self-esteem were the possible moderators. The two interaction terms (SSA × parental acceptance, and SSA × self-esteem) were entered simultaneously. There was a moderating effect if the interaction between SSA and self-esteem or parental acceptance was significant. Significant interactions were interpreted by examining the simple slopes according to the methods described by Jose (2013), to test whether higher levels of self-esteem and parental acceptance were associated with a reduced likelihood of reporting suicidality.
Post hoc power analyses were conducted for the analyses testing the associations between SSA and the studied variables, and for the logistic regression analysis testing the moderating effect of self-esteem and parental acceptance. For these analyses, the 1-β error probability was computed, given the alpha level, sample size and effect size (Faul, Erdfelder, Lang, & Buchner, 2007).
Results Demographic characteristics
First, associations between each variable of interest and the demographic
characteristics were tested. These associations are displayed in Table 3 and 4. A Bonferroni correction was used, separately for each table. Each table presents ten statistical tests,
resulting in an adjusted alpha level of .05/10 = .005. Girls were significantly more likely than boys to report same-sex attraction and scored significantly lower on self-esteem. Ethnicity was significantly related to each variable of interest. Students of Western descent were significantly more likely to report same-sex attraction and suicidality than students of
non-11 Western descent. Also, participants of Western descent scored significantly higher on parental acceptance and lower on self-esteem than students of non-Western descent. Lastly,
educational level was significantly related to parental acceptance, with students who attended pre-academic education scoring higher on parental acceptance than students who attended prevocational or general education. Gender, ethnicity and educational level were therefore treated as control variables in the following analyses.
12 Table 3
Demographic Characteristics by SSA and Suicidality
Same-Sex Attraction Suicidality
Non-SSA SSA χ2/t p No Yes χ2/t p
Gender, % (n) 12.90 < .001 2.06 .152 Boys 52.5 (566) 33.3 (32) 51.5 (563) 43.2 (35) Girls 47.5 (513) 66.7 (64) 48.5 (531) 56.8 (46) Age 1.09 .278 -0.20 .842 M 14.68 14.56 14.67 14.69 SD 1.01 1.02 1.01 1.01 Ethnicity, % (n) 7.93 .005 8.70 .003 Western 69.7 (752) 83.3 (80) 69.7 (763) 85.2 (69) Non-Western 30.3 (327) 16.7 (16) 30.3 (331) 14.8 (12) Educational level, % (n) 3.33 .189 1.07 .586 Pre-vocational 22.0 (237) 29.2 (28) 22.3 (244) 25.9 (21) General 27.1 (292) 20.8 (20) 26.9 (294) 22.2 (18) Pre-academic 51.0 (550) 50.0 (48) 50.8 (556) 51.9 (42) Class, % (n) 7.43 .024 6.98 .030 First year 21.9 (236) 31.3 (30) 22.8 (249) 21.0 (17) Second year 27.9 (301) 32.3 (31) 27.3 (299) 40.7 (33) Third year 50.2 (542) 36.5 (35) 49.9 (546) 38.3 (31)
13 Table 4
Demographic Characteristics by Parental Acceptance and Self-Esteem
Parental Acceptance Self-Esteem
M SD t/F/r p M SD t/F/r p Gender, % (n) 0.81 .421 6.50 < .001 Boys 3.18 0.62 3.30 0.50 Girls 3.15 0.62 3.10 0.60 Age -0.04 .152 -.02 .430 Ethnicity, % (n) 2.93 .003 -3.12 .002 Western 3.20 0.60 3.17 0.57 Non-Western 3.08 0.65 3.28 0.52 Educational level, % (n) 7.53 .001 0.69 .504 Prevocational 3.10 0.65 3.17 0.57 General 3.10 0.64 3.19 0.53 Pre-academic 3.23 0.59 3.22 0.57 Class, % (n) 0.07 .930 2.16 .116 First year 3.16 0.64 3.20 0.59 Second year 3.15 0.62 3.15 0.55 Third year 3.17 0.61 3.23 0.55
14 Intercorrelations among the variables of interest
To test the associations between the variables of interest, partial correlation analyses were conducted while controlling for the effects of gender, ethnicity and educational level. As can be seen in Table 5, the intercorrelations among suicidality, parental acceptance and self-esteem were all significant.
Table 5
Intercorrelations among Suicidality, Parental Acceptance and Self-Esteem Suicidality Parental acceptance Self-esteem Suicidality - - 0.178* - 0.343* Parental acceptance - - 0.298* Self-esteem -
Note. Gender, ethnicity and educational level were treated as control variables. * p < .001
Associations between SSA and the studied variables
Next, it was tested whether students who reported same-sex attraction differed from students who did not report same-sex attraction in the likelihood of reporting suicidality and in their scores on self-esteem and parental acceptance. For these four tests, a Bonferroni adjusted alpha level was used of .05/4 = .013. As can be seen in Table 6, students who reported same-sex attraction were significantly more likely to report suicidality. To test whether this association remains significant after controlling for the effects of gender, ethnicity and educational level, a logistic regression analysis was conducted. Students who reported same-sex attraction were significantly more likely to report suicidality after controlling for the demographic variables, b = 1.18, SE = 0.30, p < .001. For the logistic regression analysis, the 1-β error probability = 0.966, odd’s ratio = 3.76 (N = 1175, p = .05).
In Table 6, ANCOVA analyses are presented for parental acceptance and self-esteem, with gender, ethnicity and educational level as control variables. Students who reported same-sex attraction did not differ in their scores on parental acceptance from students who did not report same-sex attraction. However, students who reported same-sex attraction did score significantly lower on self-esteem compared to students who did not report same-sex
15 between SSA and parental acceptance was 1.0, f2 = 0.204 (N = 1175, p = .05). For the relation
between SSA and self-esteem the 1-β error probability = 1.0, f2 = 0.314 (N = 1175, p = .05).
Table 6
Suicidality, Parental Acceptance and Self-Esteem by Same-Sex Attraction (No Same-Sex Attraction versus Same-Sex Attraction)
No same-sex Same-sex attraction attraction F/χ2 p Suicidality, % (n) Yes No Parental acceptance 5.8 (63) 94.2 (1016) 18.8 (18) 81.3 (78) 22.90 5.26 < .001 .022 M 3.18 3.03 SD 0.60 0.75 Self-esteem 10.97 .001 M 3.22 2.97 SD 0.56 0.55
Note. Gender, ethnicity and educational level were treated as control variables.
The effect of self-esteem and parental acceptance
In Table 7, the results of the multiple logistic regression analysis are displayed, testing whether students who reported same-sex attraction were more likely to report suicidality than students who did not report same-sex attraction, and whether this relation was moderated by parental acceptance and self-esteem. Gender, ethnicity and educational level were treated as control variables. Students who reported same-sex attraction were significantly more likely to report suicidality than students who did not report same-sex attraction. Moreover, students who scored low on self-esteem were significantly more likely to report suicidality than students who scored high on self-esteem. The effect of parental acceptance was not significant, meaning that students who reported low parental acceptance were equally likely to report suicidality as students who scored high on parental acceptance. The interaction effects between SSA and self-esteem and between SSA and parental acceptance were both not significant. Self-esteem and parental acceptance therefore did not moderate the relation between same-sex attraction and suicidality, meaning that same-sex attracted students were not less likely to report suicidality if they also reported high
self-16 esteem and high parental acceptance. The model explained R2 = 11% of the variance. A post hoc power analysis showed, the 1-β error probability = 0.958, odd’s ratio = 3.76 (N = 1175, p = .05).
Table 7
Suicidality, Parental Acceptance and Self-Esteem by Same-Sex Attraction (No Same-Sex Attraction versus Same-Sex Attraction)
Suicidality
b SE 95% CI Wald p Odd’s ratio
Ethnicity -0.82 0.36 -1.53, -0.11 5.26 .022 0.44 Gender -0.32 0.28 -0.87, 0.23 1.38 .240 0.72 Educational level 0.08 0.16 -0.23, 0.39 0.24 .621 1.08 Same-sex attraction 1.04 0.46 0.14, 1.94 5.10 .024 2.84 Self-esteem -1.89 0.22 -2.32, -1.46 74.47 < .001 0.15 Parental acceptance -0.36 0.21 -0.77, 0.05 3.14 .077 0.70 SSA × self-esteem 0.58 0.62 -0.64, 1.80) 0.86 .354 1.78 SSA × parental acceptance -0.77 0.47 -1.69, 0.15 2.72 .099 0.46
Note. Gender, ethnicity and education level were treated as control variables. R2 = .11 (Cox & Snell), .29 (Nagelkerke). Model χ2(8) = 142.75, p < .001.
Discussion
This study investigated whether same-sex attracted adolescents are at a higher risk for suicidality than heterosexual adolescents, and whether parental acceptance and self-esteem protect against this risk. Same-sex attracted youth were more likely to report suicidality than heterosexual youth. However, same-sex attracted youth were not less likely to report suicidality if they scored high on parental acceptance and self-esteem. This means that parental acceptance and self-esteem did not protect against the risk for suicidality among same-sex attracted youth. Self-esteem was related to suicidality: students with low self-esteem were more likely to report suicidality, but this effect was equally strong for same-sex attracted and heterosexual adolescents.
Same-sex attracted adolescents in this study were almost three times as likely to report suicidality, compared to heterosexual youth. This effect size is similar to results of a meta-analytic review on
suicidality in sexual minority youth (Marshal et al., 2011). The heightened risk for suicidality in same-sex attracted youth could be explained by the stigma-related stress these youth face, such as discrimination or
17 rejection (Meyer, 2005). Moreover, sexual minority youth were more likely to report low self-esteem, compared to heterosexual youth. This result is consistent with the psychological mediation framework, which states that sexual minorities have higher levels of general risk factors for mental problems than heterosexuals (Hatzenbuehler, 2009). Contrary to previous research however, self-esteem and parental acceptance did not protect against the heightened risk for suicidality in sexual minority youth. A possible explanation for this finding is that low self-esteem and low parental acceptance may act as risk factors for suicidality, and not as protective factors. Low self-esteem is associated with perceived burdensomeness (Brausch & Decker, 2014), and parental rejection due to sexual orientation can reduce feelings of belongingness (Kleiman & Liu, 2013). In turn, perceived burdensomeness and low belongingness can increase the risk for suicidality (Van Orden et al., 2010). For instance, previous research has shown that the relation between sexual orientation and mental health problems is mediated by perceived
burdensomeness (Baams et al., 2015). It is possible that self-esteem acted as a risk factor in the present study, since sexual minority youth were more likely to report low self-esteem and low self-esteem did predict suicidality.
Parental acceptance did not protect against the risk for suicidality in same-sex attracted students. This finding is surprising, since previous research did find a protective effect of parental acceptance against suicidality in sexual minority youth (Ryan et al., 2010). One explanation for the current finding is that during adolescence, peer relationships become increasingly more important (Brown & Larson, 2009). Another study on suicidality in sexual minority youth showed a similar result: victimization at school was a stronger predictor for suicidality than victimization by the parents (Van Bergen, Bos, van Lisdonk, Keuzenkamp, & Sandfort, 2013). Previous research has indeed showed that peer support is associated with greater well-being among sexual minority youth (Shilo & Savaya, 2011). Peer support could therefore act as a more important protective factor for suicidality in sexual minority adolescents than parental acceptance.
The current study has several strengths. Firstly, it investigated the protective factors associated with suicidality in sexual minority youth, whereas most previous studies focused on risk factors (Hatchel et al., 2019). Studies on the factors that protect against suicidality in sexual minority youth can contribute to prevention programs that focus on increasing these resources. A second strength is that this study recruited participants through secondary schools. Most studies among sexual minority youth have relied on convenience samples, such as by recruiting through LGB organizations. These youth could be more likely or willing to disclose mental problems than other sexual minority youth, which could lead to an inflated estimate of the prevalence of mental problems (Bouris et al., 2010). Therefore, the school-based sample that was used in the current study made it possible to generalize these findings to other sexual
18 minority youth. A third strength is that contrary to other research, suicidality was operationalized as engaging in self-harm or suicide attempts, and not as suicidal ideation. Previous research has shown that compared to heterosexual youth, sexual minority youth are especially at risk for suicide attempts, whereas the difference is smaller for suicidal ideation (Marshal et al., 2011). It is therefore particularly important to examine the protective factors associated with suicide attempts among same-sex attracted adolescents.
One limitation of this study is that since same-sex attraction was used as a measure of sexual orientation, it was not possible to know whether the adolescents in this study identified as lesbian, gay or bisexual. This posed as a limitation for two reasons. Firstly, it was not possible to compare the likelihood of reporting suicidality between bisexual students and gay or lesbian students. Previous studies have found that bisexual youth are at a higher risk for suicidality than gay or lesbian students, however other research has shown the opposite effect (Hatchel et al., 2019). Secondly, self-identifying as lesbian, gay or bisexual could be a more important risk factor for suicidality than same-sex attraction. In a previous study, reporting a sexual minority identity or an unsure identity was related to suicidality, whereas reporting same-sex attraction was not (Zhao, Montoro, Igartua, & Thombs, 2010). This could be due to the many stressors associated with having a sexual minority status (Meyer, 2005). However, previous research has reported that identification as homo- or bisexual occurs after the onset of puberty (Floyd & Stein, 2002). Same-sex attraction was therefore a more age-appropriate measure of sexual orientation for the current sample than self-identification (Van Beusekom, et al., 2015). On the other hand, it could be possible that parental acceptance is more important for adolescents who identify as lesbian, gay or bisexual. For instance, a previous study showed that sexual minority individuals who experienced rejection by their families during their adolescence after coming out are at a higher risk for suicidality (Ryan et al., 2009). Using same-sex attraction as a measure of sexual orientation could therefore have led to a smaller effect of parental acceptance.
A second limitation is the use of self-report as a measure of suicidality. Previous research has suggested that among adolescents self-reported suicide attempts are often false positives, or in other words not actual or serious attempts (O’Carroll, 1992). There seems to be no difference between sexual minority youth and heterosexual youth in the likelihood of reporting a false positive (Plöderl et al., 2013). However, it is possible that adolescents who are willing to disclose feelings of same-sex attraction are also more willing to disclose engaging in suicide attempts or self-harm (Plöderl et al., 2013). This could have inflated the estimate of suicide risk among sexual minority youth in this study.
A third limitation is that suicidality was assessed by asking participants whether they engage in suicide attempts or self-harm. It is therefore not possible in the current study to disentangle attempting suicide from engaging in self-harm. The interpersonal theory of suicide states that self-harm is a pathway
19 to suicidality, since it increases pain tolerance and lowers the fear of death (Van Orden et al., 2010). Previous research has indeed shown that self-harm predicts suicidality (Hatchel et al., 2019). On the other hand, longitudinal research among sexual minority youth concluded that there are risk factors that are associated with both self-harm and suicidality, but that these two phenomena also have distinctive predictors. The authors of this study concluded that suicidality and self-harm are related, but distinct phenomena and thus not variations of the same behavior (Liu & Mustanski, 2012). It follows that the protective factors assessed in the current study are also only associated with suicidality. In the beforementioned study, social support was associated with suicidality, but not with self-harm (Liu & Mustanski, 2012). Since it is impossible to disentangle suicidality from self-harm in the current study, the effect of parental acceptance on suicidality could therefore have been underestimated.
More research is needed on protective factors associated with suicidality in sexual minority youth. Antibullying laws that forbid victimization based on sexual orientation, a protective school environment and a LGBT-inclusive school curriculum are associated with positive mental health outcomes in sexual minority youth (Russell & Fish, 2016). Future studies could focus on the protective role of these factors in suicidality in sexual minority youth. Questionnaires used in these studies should increase the validity of self-reported suicide attempts, by asking multiple questions related to suicidality. For instance, research has suggested that asking whether participants suffered injury or had to seek out medical care as a result of a suicide attempt decreases the number of false positives reported (O’Carroll, 1992). Future studies could also assess the specific protective factors associated with suicidality, instead of those related to both self-harm and suicide attempts. And finally, longitudinal research could shed light on the relative
importance of parental acceptance and peer support for the mental health of sexual minority youth, during childhood and adolescence.
This study indicated that sexual minority youth are at a higher risk for suicidality than heterosexual youth, which illustrates the need for prevention programs targeted specifically to these youth. Moreover, low self-esteem was shown to be a strong predictor for suicidality, equally for sexual minority and heterosexual youth. Prevention programs could therefore focus on increasing self-esteem in adolescents, to prevent them from engaging in self-harm of suicide attempts.
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