Children and Youth Services Review 102 (2019) 79–90

Contents lists available at ScienceDirect

Children and Youth Services Review

journal homepage: www.elsevier.com/locate/childyouth

Suicide etiology in youth: Differences and similarities by sexual and gender T

minority status
Tasseli McKaya, , Marcus Berzofskyb, Justin Landwehrb, Patrick Hsiehb, Amanda Smithb
⁎

a
Victimization and Resilience Research Program, Center for Applied Justice Research, RTI International, 1512 Milton Road, Durham, North Carolina 27712, United States
b
RTI International, United States

ABSTRACT

Sexual and gender minority (SGM) individuals are at steeply elevated risk for suicide, particularly in adolescence and young adulthood. Evidence on suicide risk
factors specific to SGM youth is emerging, but an integrated understanding of the etiology of suicide that accounts for both commonalities and differences between
SGM and non-SMG youth is lacking. Using 2018 data from a social media-based sample of SGM (n = 175) and non-SGM (n = 310) youth ages 14–21, we assess the
role of constructs from the general-population-based interpersonal-psychological theory of suicide and the SGM-specific minority stress theory in suicide ideation and
attempt. Parental support was a strong protective factor shared across the SGM and non-SGM youth samples. The role of other factors, such as racial/ethnic identity,
differed by group. Implications for suicide prevention and intervention in schools and other settings that include both SGM- and non-SGM youth are discussed.

1. Introduction
Suicide is the second leading cause of death among American ado-
lescents (Heron, 2018). A substantial body of evidence suggests that
sexual and gender minority (SGM) youth—that is, youth who have a
non- heterosexual orientation or who are transgender, gender non-
conforming, or genderqueer—are at steeply elevated risk for suicide
ideation and attempt across multiple identity categories and varied
measures and definitions of SGM experience (Almazan, Roettger, &
Acosta, 2014; Button, O'Connell, & Gealt, 2012; Eisenberg et al., 2017;
M. P. Marshal et al., 2011; Raifman, Moscoe, Austin, & McConnell,
2017; D. M. Stone et al., 2014).1 Longitudinal research shows that risk
for suicidality among SGM Americans tends to be highest during
teenage and young adult years, reaching its peak around age 18 (Fish,
Rice, Lanza, & Russell, 2018; S. T. Russell & Toomey, 2012).
Although risk does diminish somewhat in the transition from youth
to young adulthood (Cardom, Rostosky, & Danner, 2013), the stark
suicide disparities that emerge between SGM and non-SGM individuals
during adolescence persist into adulthood (Marshal et al., 2013). Ado-
lescence represents a critical period for evidence-based suicide pre-
vention and intervention with this population—yet no such
intervention yet exists for SGM youth (Marshall, 2016). Joiner's inter-
personal-psychological theory of suicide and Meyer's minority stress
theory may each be relevant for understanding risk and protective
factors for suicidality among SGM youth and their non-SGM peers (T.
Joiner, 2005; Meyer, 2003). In the interest of informing responses to
SGM youth suicide that are also relevant for their non-SGM peers, this
paper summarizes prior theoretical and non-theory-based empirical
work on suicide risk and protective factors among SGM youth and
presents new data from a social media-based sample of SGM and non-
SGM youth surveyed in 2018. The integrated understanding of youth
suicide that it helps to refine can inform youth suicide prevention and
intervention in settings (such as schools) that include both SGM and
non-SGM youth.
2. Methods and materials
2.1. Data collection approach
2.1.1. Sampling and recruitment approach
Data for this study were collected from a community sample of
youth recruited using the Twitter social media platform. We used

Corresponding author.
⁎

E-mail address: tmckay@rti.org (T. McKay).

1
Representative cross-sectional research on SGM youth suicide almost exclusively uses data from the Youth Risk Behavior Survey (YRBS), various modules of
which are implemented at the national, tribal, state, and school district levels with support from the Centers for Disease Control and Prevention. Representative
longitudinal research on SGM youth suicide tends to use data from the National Longitudinal Survey of Adolescent to Adult Health [Add Health], which followed a
cohort of individuals who were adolescents in the mid-1990s. Add Health captured all three recognized dimensions of sexual orientation as specified by the Federal
Interagency Working Group on Sexual Orientation and Gender Identity Measurement (2016): sexual attraction, behavior, and identity. Within YRBS, some states
opted to include optional measures of sexual identity, sexual behavior, and/or transgender identity; efforts to understand SGM youth suicidality have as a result
focused on these states.

https://doi.org/10.1016/j.childyouth.2019.03.039
Received 17 August 2018; Received in revised form 21 March 2019; Accepted 21 March 2019
Available online 22 March 2019
0190-7409/ © 2019 Elsevier Ltd. All rights reserved.
T. McKay, et al. Children and Youth Services Review 102 (2019) 79–90

Twitter's advertising capability to deliver a study invitation message to Table 1

individuals who were likely to be in our study population, which was Characteristics of social media sample compared to 2017 YRBS sample.
defined as individuals with active (within the past week) Twitter ac- Social media sample SGM Social media sample non-
counts, ages 14–21,2 who were residents of the United States. Twitter youth (N = 175) SGM youth (N = 310)
identified the handles of an initial set of users based on its internal user
data, and then used its conversion pixel to identify subsequent cohorts Frequency N Frequency N

of users deemed more likely to complete the survey. This approach Age
yielded most of the study population (n = 417). 14 years old 8.0 14 6.8 21
As part of the same recruitment effort, we also piloted a probability- 15 years old 13.1 23 12.3 38
based sampling approach in which we used data from Twitter's appli- 16 years old 12.0 21 17.7 55
17 years old 20.6 36 17.7 55
cation programming interface (API) to construct a systematic sampling
18 years old 17.1 30 11.0 34
frame representative of all U.S. Twitter users and stratify this sample 19 years old 7.4 13 11.3 35
according to users' likelihood of being SGM (according to the content of 20 years old 8.6 15 9.7 30
their public tweets). We then randomly selected a sample from each 21 years old 13.1 23 13.6 42
stratum, oversampling from the strata that likely contained a higher Race/ethnicity
proportion of SGM individuals and uploaded this frame of user handles White 50.9 89 51.9 161
to the Twitter platform for distribution of the study invitation. This Black 6.9 12 9.7 30
Latino 24.0 42 20.3 63
approach contributed a small, additional sample (n = 72). Asian American 9.7 17 11.3 35
Other races 8.6 15 6.5 20
2.1.2. Consent and survey administration approach Bullying victimization
All prospective study participants were shown a study invitation Bullied in past 34.3 57 24.2 72
12 months
with a link to click if interested. Those interested were brought to a
study landing page within the web-based Voxco platform to view in- Suicidality
formation about the study and confirm their current Twitter handles. Any ideation or 36.2 63 14.2 44
attempt
They were then automatically routed to a one-page, web-based in- No attempts 87.4 153 95.2 295
formed consent screen, also within the Voxco platform. Those who wish 1 attempt 6.9 12 2.3 7
to provide informed consent to participate in the survey were invited to 2 or 3 attempts 4.6 8 2.3 7
click on an “I agree” button and then advanced to the first survey screen 4 or 5 attempts 0.6 1 0.3 1
6 or more attempts 0.6 1 0.0 0
to begin the self-administered survey using a desktop or laptop com-
puter, tablet, or mobile phone. The requirement for parent permission
was waived due to the additional risk a permission process would pose
Youth Risk Behavior Survey (YRBS) in terms of the prevalence of bul-
to youth, particularly those who are SGM, given the sensitive nature of
lying victimization, suicide ideation, and attempt. Compared to the
the study questions (Mustanski, 2011).
YRBS sample, the social media-based sample reported a different racial
Using these procedures, 489 individuals (including 175 SGM youth
composition (with a lower proportion of Black youth and higher pro-
and 310 non-SGM youth) completed a 5-min survey. The survey cov-
portions of Asian American youth and youth of other racial identities).
ered age, race and ethnicity, sexual orientation, gender, school enroll-
Due to the non-school-based recruitment approach, the social media-
ment and grade, social connectedness, truancy due to feeling unsafe,
based sample was able to include older youth (aged 19–21) in the
school-based and cyber bullying victimization,3 sadness, suicide idea-
sample who were not represented in the YRBS. Including individuals in
tion and attempt, social media use, and preferences regarding survey
this age range is important given evidence of high suicide risk among
mode and recontact. Those who completed it were given a gift card as a
older youth, peaking around age 18 (Fish et al., 2018; Russell &
token of appreciation. The study protocol and all study materials were
Toomey, 2013). Further, due to the inclusion of a three-dimensional
approved by the Research Triangle Institute Institutional Review Board.
measure of sexual orientation in the current study, we were able to
apply a more complete definition of SGM in the social media-based
2.1.3. Sample characteristics sample than that used in the YRBS, which focuses only on behavior and
Characteristics of the social media-based sample are shown below identity. Consistent with 2016 recommendations of the Federal Inter-
(Table 1). agency Working Group on Improving Measurement of Sexual Orienta-
Youth in the social media-based sample generally resembled youth tion and Gender Identity in Federal Surveys, youth in our sample were
surveyed as part of the nationally representative, school-based 2017 classified as sexual minority if they who indicated any same-sex sexual
behavior, any same-sex sexual attraction, or a sexual identity other than
2
heterosexual. Youth were classified as gender minority if they identified
The US Centers for Disease Control and Prevention (CDC) considers “youth”
as transgender or if they indicated that their gender differed from the
to be individuals aged 10–24 (https://www.cdc.gov/violenceprevention/
sex assigned on their birth certificate (Federal Interagency Working
youthviolence/definitions.html, accessed on 2/3/2019) and the United
Nations Educational, Scientific and Cultural Organization (UNESCO) defines Group on Improving Measurement of Sexual Orientation and Gender
“youth” as individuals ages 15–24 (http://www.unesco.org/new/en/social- Identity in Federal Surveys, 2016).
and-human-sciences/themes/youth/youth-definition/, accessed on 2/3/2019).
Our eligibility criteria were designed to align as well as possible with these 2.1.4. Analytic approach
differing ranges in order to generate insights on youth generally, rather than an First, we constructed multiple logistic regression models to under-
age-specific sub-group of youth (e.g., adolescents or young adults). stand what risk and protective factors shaped suicidality. The depen-
3
Although not all youth in our sample were enrolled in school, it was deemed dent variable was defined as having “seriously considered” or at-
important to ask school-related questions based on prior research on the focal tempted suicide during the prior 12 months. Based on prior research
importance of school settings, including post-secondary settings, in shaping
and the results of a series of preliminary analyses, we selected the
SGM youth well-being. According to US Census data on school enrollment by
following independent variables for inclusion in the model:
age (https://www.census.gov/data/tables/2017/demo/school-enrollment/

• School-based
2017-cps.html, accessed 2/3/2019), the majority of youth remain enrolled in
school through age 21. Youth of any age who were not enrolled in school at the or cyber bullying victimization (yes/no) included
time of the survey were skipped out of school-related questions. being bullied in the last 12 months on school grounds or through

80
T. McKay, et al.
texting, Instagram, Facebook, or other social media
• Skipping school due to feeling unsafe was captured by the item,
“During the past 30 days, on how many days did you not go to
school because you felt you would be unsafe at school or on your
way to or from school?” (0 = 0 days … 6 = 6 or more days)
• Feeling close to people at school was measured by the item, “You
feel close to people at your school” (1 = strongly disagree …
5 = strongly agree)
• Feeling that parents care was measured by the item, “How much do
you feel that your parents care about you?” (1 = not at all …
5 = very much)
• Involvement in a religious youth group was captured for the past
12 months (yes/no)
Age, race and ethnicity (including separate variables for Black,
Latino, Asian American, and other races; white was omitted) were in-
cluded as control variables.
Next, we ran a pair of separate logistic regression models for SGM
and non-SGM youth, given the possibility that the relationship between
the independent and dependent variables might differ by SGM status
(McLean, Maxwell, Platt, Harris, & Jepson, 2008). These models used
the same dependent variables as the full-sample model. The model run
with the SGM youth sub-sample included the following additional in-
dependent variables:
• Gay or lesbian (yes/no) was based on a report of some combination
of same-sex attraction or behavior or gay or lesbian identity
• Bisexual (yes/no) was based on a report of some combination of
same- and different-sex attraction or behavior or bisexual identity
• Unsure (yes/no) was based on a report of being unsure of sexual
attraction or identity
• Transgender (yes/no) was based on a two-item measure that cap-
tures assigned sex at birth and current gender self-description
• Outness was operationalized with three variables based on the item,
“It is important to you to be ‘out’ to straight people you know. The
variable “Important to be out” was coded as 1 for respondents who
strongly agreed or somewhat agreed and as 0 if the respondent
chose another option or if the variable was missing (including
planned missing data due to skip patterns). The variable “Not im-
portant to be out” was coded as 1 for respondents who strongly
disagreed, somewhat disagreed, or neither agreed nor disagreed and
as 0 in all other cases. The variable “Outness not relevant” was
coded as 1 for SGM youth who did not identify as heterosexual (who
were not asked about the importance of outness) and as 0 otherwise.
This third variable was treated as the contrast in the regression
model.
•
Involvement in an LGBTQ+-related group in the past 12 months
(yes/no) captured participation in a gay-straight alliance or a pro-
gram for LGBTQ+ youth
These models also controlled for age and race/ethnicity.
To better understand the role of outness and sexual orientation
congruence in shaping social connectedness in the SGM sub-sample, we
used two-sample t-tests to compare the social connectedness and ser-
vice engagement of youth to whom it was important to be broadly “out”
(that is, out to heterosexual individuals) with that of youth to whom
outness was not important. These analyses examined the following
variables related to formal and informal social connection and bullying
victimization:
• Having accessed school- or community-based mental health services
in the past 12 months captured whether youth had been to a school
counselor or a social worker or therapist at school or had seen a
counselor, case manager, therapist, psychologist, or psychiatrist
outside of school in the past 12 months (yes/no)
• Connectedness to other groups or teams captured involvement in
81
Children and Youth Services Review 102 (2019) 79–90
after-school program or clubs; non-religious youth groups (such as
the Girl or Boy Scouts); mentoring (such as Big Brothers / Big
Sisters); or a community sports league not associated with school
(yes/no)
• Composite connectedness incorporated responses to nine con-
nectedness to groups, teams, or services items (scale from 0 to 9,
with higher scores indicating greater connectedness)
In addition, we tested for differences in involvement in a religious
youth group, involvement in an LGBTQ+-related group, skipping
school due to feeling unsafe, feeling that parents care, and school-based
or cyber bullying (as previously defined).
We then ran the same set of comparisons to identify any differences
in formal or informal social connectedness or bullying between youth
whose experiences were congruent among the three dimensions of
sexual orientation (attraction, behavior, and identity) and those whose
experiences of those dimensions was incongruent. We looked separately
at congruence between attraction and identity (yes/no) and congruence
between behavior and identity (yes/no).
Finally, we used chi-squared tests to compare youth who had con-
sidered (but not attempted) suicide in the last 12 months with those
who had attempted suicide at least once during that period. Youth in
these two groups were compared with regard to SGM status, safety-
related truancy, feeling close to people at school, feeling that parents
care, having accessed school- or community-based mental health ser-
vices, involvement in LGBTQ+-related groups, and connectedness to
other groups or teams.
3. Theory
3.1. Suicide vulnerability among Sexual and Gender Minority (SGM) youth
Meta-analysis indicates that, across a variety of North American
study populations, sexual minority youth are between two and three
times as likely to be suicidal as non-sexual minorities. Estimated dis-
parities between sexual minority and non-sexual minority youth are
typically even steeper for the most severe suicidality outcomes (for
example, suicide attempts and suicide attempts resulting in injury or
requiring medical attention) than for outcomes such as suicidal ideation
or planning (Marshal et al., 2011; Marshal et al., 2013; Miranda-
Mendizábal et al., 2017). Although many representative studies com-
bine gender and sexual minority youth in examining suicidality (due to
small samples), several studies show that gender minority youth are
also two to three times more likely than non-gender minority youth to
become suicidal (Eisenberg et al., 2017; B. Mustanski & Liu, 2013;
Perez-Brumer, Day, Russell, & Hatzenbuehler, 2017). For example, the
prevalence of suicidal ideation among gender minority youth in one
recent, representative sample4 was over three times that of non-gender
minority youth, with a majority (61.3%) of gender minority young
people reporting suicidal ideation—one quarter of them in the past two
weeks (Eisenberg et al., 2017). Estimates of suicidality among sexual
and gender minorities differ substantially by sampling method; how-
ever, meta-analysis indicates that roughly 11% of SGMs in population-
based research and 20% of SGMs in community-based research have
reported at least one prior suicide attempt (Hottes, Bogaert, Rhodes,
Brennan, & Gesink, 2016).
Across racial and ethnic groups, sexual minorities are more likely
than their peers to report suicide ideation and attempt (Lytle, Luca, &
Blosnich, 2014). Some may be even more vulnerable than others,
however. In the general population, youth who are members of smaller
racial minority groups (e.g., Asian American and Native American) may
be particularly vulnerable (Fried, Williams, Cabral, & Hacker, 2013).
4
The authors used data from the 2016 Minnesota Youth Risk Behavior
Survey.
T. McKay, et al.
Other researchers suggest that racial discrimination increases vulner-
ability to suicide among gender minority youth (Wilson, Chen,
Arayasirikul, Raymond, & McFarland, 2016).
3.2. Perspectives on SGM youth suicide
Theory and research on suicide risk and protective factors among
SGM youth have rapidly expanded in response to the prevalence and
seriousness of the problem. This growing understanding is necessary to
meet the urgent need for suicide prevention and intervention ap-
proaches that work for this unique population of youth who face ele-
vated risk, even as they will likely be implemented in contexts (such as
schools) where relevance to the general population of youth is also
important (Marshall, 2016). Various studies have found that SGM youth
experience some distinct risk and protective factors for suicidality, as
well as some factors in common with non-SGM youth (DeCamp &
Bakken, 2016; S.T. Russell & Toomey, 2013). However, the field lacks
an integrated understanding of youth suicide that is relevant to non-
SGM youth while also accounting for the unique experiences and vul-
nerability of SGM youth.
One of the most widely-applied theoretical perspectives on the
etiology of suicide in the general population, Joiner's interpersonal-
psychological theory, suggests that “perceived burdensomeness” (op-
erationalized, for example, as feeling that one does not matter) and
“thwarted belongingness” (operationalized, for example, as low social
support) are critical risk factors for suicidality (T. Joiner, 2005). In the
general population, application of this model has been empirically
supported among adolescents (Horton et al., 2016) and young adults
(Joiner et al., 2009). Joiner's theory further posits that, to make a
suicide attempt, individuals must also be exposed to sufficiently painful
or fear-inducing life experiences that the otherwise dominant instinct
for self-preservation is overcome (Joiner et al., 2009, p. 3).
To better understand suicide among SGM youth, this aspect of
Joiner's general-population theory could be complemented by Meyer's
minority stress model, which has been widely applied to understand a
variety of behavioral health concerns specific to SGM youth and adults.
The minority stress model proposes that experiences of anti-sexual
minority discrimination and hostility can lead to poorer mental health
among sexual minority individuals (Meyer, 2003). Among SGM youth,
perceived burdensomeness and thwarted belongingness as proposed by
Joiner and anti-SGM stigma, discrimination, and victimization experi-
ences as proposed by Meyer may each contribute to suicidality.
The minority stress model and the interpersonal-psychological
theory of suicide have been examined together in studies with sexual
minority youth (Baams, Grossman, & Russell, 2015), gender minority
youth (Frank, 2017), and gender minority adults (Testa et al., 2017),
with findings offering support for factors from both models in shaping
suicidality. Examined separately, the interpersonal-psychological
theory has been supported among gender minority youth (Grossman,
Park, & Russell, 2016) and the factors suggested by the minority stress
model have been supported among sexual minority youth (Bouris,
Everett, Heath, Elsaesser, & Neilands, 2016; Michael P. Marshal et al.,
2015; Puckett et al., 2017; Rimes et al., 2018) and gender minority
youth (Wilson et al., 2016) as well as in suicidality among sexual
minority adults (Michaels, Parent, & Torrey, 2015). These work-
s—taken together with a body of evidence on the individual factors
suggested by each model–suggest the potential for an integrated general
model of youth suicide that includes risk factors specific to SGM youth.
3.3. Evidence for theorized youth suicide risk and protective factors
The Social Ecological Framework (Bronfenbrenner, 1977) provides
a helpful overarching framework for considering prior theory and evi-
dence regarding risk and protective factors for youth suicide. Applied to
suicide, the framework suggests that individual suicide ideation and
attempt arise in the context of a set of nested environmental influence
82
Children and Youth Services Review 102 (2019) 79–90
extending from the individual outward to the immediate social en-
vironment (for example, parents and other family members), the larger
social environment (for example, the extended social network), the
institutional and organizational context (for example, schools), and the
broader societal and policy environment (Stone et al., 2017). Prior
theoretical and empirical work on suicide etiology suggests that factors
at each of these levels might operate in both common and distinct ways
for SGM and non-SGM youth.
3.3.1. “Minority stress,” bullying, and supportive environments
Many cross-sectional and some longitudinal studies have demon-
strated a link between anti-SGM stigma, discrimination, and victimi-
zation exposure and SGM youth suicidality. Anti-SGM victimization
predicts suicide ideation and attempt among both sexual minority and
gender minority youth (Frank, 2017; Liu & Mustanski, 2012; Michael P.
Marshal et al., 2015; Rimes et al., 2018; Shields, Whitaker, Glassman,
Franks, & Howard, 2012). Luong, Rew, and Banner's (2018) review
found that bullying and victimization related to sexual orientation or
gender identity increased the risk of suicidality among young men who
had sex with men, while positive (non-stigmatizing) views of SGM
identities protected against it (Luong et al., 2018). Among gender
minority youth, bullying victimization predicted suicide attempt
(Taliaferro, McMorris, Rider, & Eisenberg, 2018), having more people
in one's life who used one's chosen name (a possible indicator of lower
stigmatization) was protective (Frank, 2017). Bullying (in general) is a
major risk factor for suicide ideation and attempt among both SGM and
non-SGM youth, but the relationship between bullying victimization
and suicidality is stronger among SGM youth (Fish et al., 2018;
Montoro, Igartua, & Thombs, 2016; Ybarra, Mitchell, Kosciw, &
Korchmaros, 2015). Struggles with stigmatizing gender and sexuality
norms may also make it more difficult for SGM youth to seek help for
suicidality and more likely to normalize their own emotional distress
(McDermott, Hughes, & Rawlings, 2018; Testa & Hendricks, 2015).
Supportive academic, social, political environments may be pro-
tective against suicidality among SGM youth—with particularly strong
evidence for the role of school environments in shaping exposure to
minority stress (Denny et al., 2016; Hatzenbuehler, 2011; Peter, Taylor,
& Campbell, 2016; Whitaker, Shapiro, & Shields, 2016). School-based
threats and bullying victimization play a major role in shaping suicid-
ality among sexual minority youth (Bouris et al., 2016). Youth who
experience both school-based and cyber bullying appear to be at highest
risk (Duong & Bradshaw, 2014).
In contrast, feeling safe at school can protect against suicidality
among sexual minority youth (Taliaferro & Muehlenkamp, 2017) and
gender minority youth (Taliaferro et al., 2018). One eight-state study
found that suicide disparities between SGM and non-SGM youth almost
disappeared in areas with very supportive school climates (as evidenced
by the presence of “safe space” initiatives and gay-straight alliances in
schools) (Hatzenbuehler, Birkett, Van Wagenen, & Meyer, 2014). Many
other aspects of school climate have also been shown to be protective
against SGM suicidality, including norms of teacher intervention in
SGM-related bullying (Ploderl, Faistauer, & Fartacek, 2010; Rimes
et al., 2018), the presence of openly sexual minority identified students
and teachers (Ploderl et al., 2010), and the implementation of SGM-
inclusive anti-bullying policies (Hatzenbuehler & Keyes, 2013). Studies
capable of testing the specific mechanisms by which these school-based
factors protected against suicidality have shown that gay-straight alli-
ance involvement at school and connectedness to an adult at school
each protected against suicidality by attenuating the relationship be-
tween anti-SGM bullying victimization and suicidality (Davis, Royne
Stafford, & Pullig, 2014; Duong & Bradshaw, 2014; Ioverno, Belser,
Baiocco, Grossman, & Russell, 2016).
3.3.2. “Thwarted belongingness” and formal and informal social
connections
Among adults, thwarted belongingness has been operationalized in
T. McKay, et al.
terms of living alone, loneliness, and low social support (Van Orden,
Cukrowicz, Witte, & Joiner, 2012). Based on life course and develop-
mental differences, it is most often operationalized among youth as
homelessness, (low) social support and (limited) subjective closeness to
others. Many studies have supported the role of these factors in shaping
SGM youth suicidality. Connections with peers, family, and non-family
adults all tend to protect against suicidality for SGM youth (Liu &
Mustanski, 2012; Stephen T. Russell & Toomey, 2013; Deborah M.
Stone, Luo, Lippy, & McIntosh, 2015; Teasdale & Bradley-Engen, 2010).
The effect of family support and connectedness is especially protective
against SGM suicidality (Needham & Austin, 2010; Reisner, Biello,
Perry, Gamarel, & Mimiaga, 2014; Stephen T. Russell & Toomey, 2013;
Taliaferro & Muehlenkamp, 2017; Wilson et al., 2016) and has a more
consistently protective effect for SGM youth than connectedness to non-
family adults, which are not always protective for SGM youth (D. M.
Stone et al., 2014; Taliaferro & Muehlenkamp, 2017). Conversely, fa-
mily rejection and losing relationships with family or friends predicts
suicide ideation and attempt in adolescence and young adulthood
(Puckett et al., 2017; Rimes et al., 2018; Rivers, Gonzalez, Nodin, Peel,
& Tyler, 2018; Ryan, Huebner, Diaz, & Sanchez, 2009). Religious in-
volvement (often a very important source of social support for other
populations) also confers increased risk of suicidality among SGM
adolescents (Gibbs & Goldbach, 2015).
Many of the risk and protective factors identified among sexual
minority and combined SGM study populations have also held among
sub-groups of SGM youth, including young men who have sex with men
(MSM) and gender minority youth. Among young MSM, homelessness
and negative parent relationships conferred risk for suicidality while
family acceptance and feeling accepted at school and by peers was
protective (Luong et al., 2018). Among gender minority youth, con-
nectedness to parents and social support from classmates, friends, and
teachers protected against suicidality, while running away from home
conferred elevated risk for suicidality (Frank, 2017; Taliaferro et al.,
2018).
3.3.3. “Perceived burdensomeness” as mediator or moderator
Several theory-testing studies have examined the contribution of
perceived burdensomeness to SGM youth suicide. Baams et al. (2015)
tested Joiner's interpersonal-psychological theory and Meyer's minority
stress theory with a sub-sample of 876 self-identified sexual minority
youth drawn from a three-region, community-based longitudinal study
of 1061 SGM individuals. They found that perceived burdensomeness
mediated the relationship between sexual orientation-related bullying
and suicidality for sexual minority youth (Baams et al., 2015). Focusing
on 127 gender minority youth from the same sample, Frank (2017) also
assessed the fit of Joiner's and Meyer's models, finding some support for
constructs from each theory in shaping gender minority suicidality
(with a better overall fit for minority stress theory) (Frank, 2017). In a
small, cross-sectional study of sexual minority and non-minority college
students, perceived burdensomeness influenced suicidal ideation
among sexual minority students. Its effects were particularly strong
among those who perceived or anticipated more rejection due to their
sexual orientation (often considered a form of minority stress) (Hill &
Pettit, 2012).
3.4. Gaps and current study contribution
Prior empirically-based theoretical work suggests that SGM youth
experience unique risk and protective factors for suicidality (such as
those proposed by minority stress theory), as well as pathways shared
with non-SGM individuals (such as those proposed by the interpersonal-
psychological theory of suicide). Perceived burdensomeness and
thwarted belongingness, both central to general-population theories of
suicide, are also supported among SGM youth. Some evidence indicates
that minority stress might contribute both to perceived burdensomeness
and to thwarted belongingness among SGM youth (Baams et al., 2015;
83
Children and Youth Services Review 102 (2019) 79–90
Hill & Pettit, 2012). For SGM youth, certain forms of minority stress
could also act as a unique source of the “painful or fear-inducing life
experiences” that the interpersonal-psychological model also proposes
(Joiner et al., 2009).
Prior work also suggests that suicide prevention and intervention
efforts for SGM youth should likely target settings that include their
non-SGM peers, since schools and family homes each appear to be key
sites for suicide-related risk and protection. Gaps persist in the kind of
integrated understanding of SGM- and non-SGM youth suicide that
could guide efforts in these settings. For example, while social con-
nectedness and bullying exposure play a clear role in suicidality for all
youth, SGM youth may also juggle decisions related to sexual orienta-
tion and gender-related self-identification and visibility—such as
“outness” and LGBQ self-identification (for sexual minority youth) and
being able to actualize one's chosen gender in multiple contexts (for
gender minority youth)—that could promote greater social con-
nectedness but also expose them to greater bullying victimization. Yet
major youth surveys, such as the Center for Disease Control and
Prevention's Youth Risk Behavior Survey (YRBS) (on which much prior
research on youth suicide is based) do not tend to include items that
would allow researchers to examine these relationships. In addition,
whether various forms of social connection and engagement may have
different effects for SGM and non-SGM youth (such as involvement in
SGM-related youth organizations and in religious youth groups) re-
mains unclear. The current study uses new data from a national, social
media-based study of youth and young adults, including an oversample
of SGM youth, to help address these gaps.
4. Results
4.1. Suicide risk and protective factors for SGM and non-SGM youth
We constructed a set of three multiple regression models (Tables 2-
4) to understand what risk and protective factors made youth more
likely to have seriously considered or attempted suicide in the last
12 months. We ran three models: one using the full sample and one
model each among SGM and non-SGM youth respectively.
The first multiple regression model was constructed to answer the
question, What risk and protective factors for suicidality were evident
among all youth? The dependent variable in this model was a composite
reflecting any suicidal ideation or attempt in the past 12 months. The
independent variables were SGM status, school-based or cyber bullying
victimization, skipping school due to feeling unsafe, feeling close to
people at school, feeling that parents care, and being part of a religious
youth group. Age, race, and ethnicity were included as controls.
Next, we carried out a multivariate regression to answer the ques-
tion, What risk and protective factors for suicidality were evident among
non-SGM youth? This model included the same independent variables
(except for SGM status), same demographic controls, and same de-
pendent variable as the full-sample model.
Each of the risk and protective factors identified as significant in the
full sample remained significant among non-SGM youth (who con-
tributed the majority of cases to the full sample). School-based or cyber
bullying victimization (p < .05) and skipping school due to feeling
unsafe (p < .01) were significant risk factors for suicidality. Feeling
close to people at school (p < .05) and feeling that parents care
(p < .05) were protective against suicidality. In addition, being Asian
American emerged as a risk factor specific to non-SGM youth
(p < .01).
Finally, we carried out a multiple regression to answer the question,
What risk and protective factors for suicidality were evident among SGM
youth? This model included the same independent variables, same de-
mographic controls, and same dependent variable as the non-SGM
model. Sexual identity, gender identity, outness, and involvement in
LGBTQ+-related groups were included as additional independent
variables.
T. McKay, et al. Children and Youth Services Review 102 (2019) 79–90

Table 2
Multiple regression model of influences on suicidality in full sample (N = 489)a.
Independent variables Odds ratio 95% Confidence interval lower bound 95% Confidence interval upper bound

SGM status 2.04 1.20 3.46

School-based or cyber bullying victimization 2.28 1.32 3.96
Skipping school due to feeling unsafe 1.49 1.17 1.90
Feeling close to people at school 0.822 0.670 1.01
Feeling that parents care 0.574 0.430 0.766
Involvement in a religious youth group 0.734 0.402 1.34
Age 0.979 0.860 1.1
Blackb 0.781 0.281 2.17
Latino 0.692 0.345 1.39
Asian American 1.73 0.782 3.84
Other race 0.828 0.287 2.39
Constant 4.50 0.308 65.6

In the full sample, SGM status (p < .01), school-based or cyber bullying victimization (p < .01) and skipping school due to feeling unsafe (p < .01) were sig-
nificant risk factors for suicidality. Feeling that parents care (p < .001) was protective against suicidality.
a
Of the 489 youth who form the sample for these analyses, there were 444 youth for whom data were available on the variables included in this logistic regression
model.
b
“White” was treated as the reference category for race/ethnicity.

Among SGM youth, feeling that parents care (p < .001) was the
only independent variable from the full-sample model that remained
significant, although the point and interval estimates were generally
similar when comparing the results among the SGM youth to results
among either the full sample or the non-SGM youth. Although non-
significant, the observed role of Asian American identity and mem-
bership in a religious youth group were reversed in the SGM sample
compared to the non-SGM sample. Participation in gay-straight alli-
ances or LGBTQ+ youth groups was weakly associated with increased
suicidality as well, though it was also a non-significant influence.
4.2. Outness, sexual orientation congruence, and “belongingness”
Next, we undertook a set of two-sample t-tests to better understand
the relationships between outness and sexual orientation congruence
(respectively) and various kinds of formal and informal social connec-
tion (conceived of as forms of “belongingness” in Joiner's theory) and
one form of possible minority stress (school-based or cyber bullying
victimization).
Our first set of t-tests was aimed at answering the question, How did
the formal and informal social connections of out SGM youth compare to
those of youth who were not out? This analysis was restricted to the SGM
youth sample. (Youth who did not indicate any sexual or gender min-
ority experience were not asked about outness.) Two-sample t-tests
were used to assess whether outness was correlated with bullying vic-
timization or the various kinds of formal and informal social connection
shown in Table 5.
As shown in the table, youth for whom it was important to be out
were more likely to connect with LGBTQ+-related groups (p < .01)
than those who indicated that being out was not important to them.
Outness did not make a statistically significant difference in bullying
victimization.
We then ran an additional set of t-tests to address the question, How
did the formal and informal social connections of youth with congruent
sexual orientation compare to those of youth with incongruent sexual or-
ientation? These analyses included the full sample of youth. Two-sample
t-tests assessed whether identifying with a sexual orientation that was
consistent with one's sexual behavior or with one's sexual attraction was
correlated with bullying victimization or having various kinds of formal
and informal social connections, as shown in Table 6.
As shown in the table, youth whose sexual self-identification was
consistent with their attraction were less likely to be victims of school-
based or cyber bullying (p < .01). Youth whose sexual identity was
consistent with their behavior were also more likely to feel close to
people at school (p < .05) and were more likely to be involved in an
LGBTQ+-related group (p < .01). Congruence between behavior and
sexual orientation did not make a statistically significant difference in
bullying victimization.
4.3. Suicidal ideation versus suicide attempt
Next, we applied chi-squared tests to answer the question, What
characteristics distinguished youth who attempted suicide from those who
considered but did not attempt? These tests compared youth who had
(only) considered suicide in the last 12 months with those who had
attempted suicide at least once during that period.

Table 3
Multiple regression model of influences on suicidality in non-SGM Sample (N = 310)a.
Independent variables Odds ratio| 95% Confidence interval lower bound 95% Confidence interval upper bound

School-based or cyber bullying victimization 2.42 1.09 5.34

Skipping school due to feeling unsafe 1.80 1.26 2.57
Feeling close to people at school 0.716 0.539 0.951
Feeling that parents care 0.554 0.348 0.880
Involvement in a religious youth group 0.399 0.156 1.02
Age 1.00 0.831 1.20
Blackb 5.23 1.06 2.59
Latino 0.661 0.234 1.87
Asian American 4.03 1.52 10.7
Other race 0.653 0.122 3.48
Constant 5.31 0.112 252.

a
Of the 310 youth who form the sample for these analyses, there were 289 youth for whom data were available on the variables included in this logistic regression
model.
b
“White” was treated as the reference category for race/ethnicity.

84
T. McKay, et al. Children and Youth Services Review 102 (2019) 79–90

Table 4 and non-SGM youth. Understanding suicidality at this stage is critical,

Multiple regression model of influences on suicidality in SGM sample as adolescence and young adulthood represents a developmental period
(N = 175)a. of acute risk for all youth, and youth who navigate SGM status at this
Independent variables Odds ratio 95% Confidence 95% Confidence juncture are especially vulnerable (Dirkes, Hughes, Ramirez-Valles,
interval lower interval upper Johnson, & Bostwick, 2016).
bound bound Although prior research has made very effective analytic use of data
from the YRBS and other school-based surveys, those data typically lack
School-based or cyber 2.08 0.828 5.21
bullying victimization information on sexual attraction, outness, and specific kinds of social
Skipping school due to 1.35 0.948 1.92 connection (such as involvement in religious youth groups or LGBTQ
feeling unsafe +-related organizations). Consistent with emerging best practices, the
Feeling close to people at 0.961 0.689 1.34
current study used a complete, three-dimensional measure of sexual
school
Feeling that parents care 0.407 0.254 0.652
orientation (including sexual attraction, behavior, and identity) and a
Involvement in a religious 1.45 0.520 4.06 two-item measure of gender identity (including assigned sex at birth
youth group and current gender self-description) (Federal Interagency Working
Age 0.931 0.750 1.16 Group on Improving Measurement of Sexual Orientation and Gender
Blackb 1.02 0.205 5.07
Identity in Federal Surveys, 2016; GeniUSS Group, 2014). This three-
Latino 0.769 0.278 1.16
Asian American 0.240 0.045 1.29 dimensional sexual orientation measure enabled the inclusion of six
Other race 1.12 0.247 5.13 sexual minority youth who would otherwise have been classified as
Gay or lesbianc 0.477 0.145 1.57 heterosexual based on YRBS measures. Similarly, using the two-di-
Bisexual 1.67 0.500 5.55
mensional measure of gender, five individuals were included in the
Unsure 0.645 0.176 2.36
Transgenderd 0.467 0.072 3.01
gender minority sample who would have been misclassified using a
“Important to be out”e 1.29 0.300 5.57 transgender-inclusive measure that only captured whether an in-
“Not important to be out” 1.04 0.295 3.65 dividual's current gender self-description was “transgender” (as op-
Involvement in an 1.67 0.652 4.30 posed to capturing a minority lived experience of gender, such as being
LGBTQ+-related group
assigned male at birth and coming to understand oneself as female).
Constant 44.5 0.445 4440.
A precise approach to capturing SGM status enabled this study to
*** p < .001, ** p < .01, * p < .05. explore differences and similarities in suicide etiology by SGM status
a
Of the 175 youth who form the sample for these analyses, there were 154 with better precision, a task that is central to the development of an
youth for whom data were available on the variables included in this logistic integrated theoretical understanding of SGM and non-SGM youth sui-
regression model. cidality. Applying this improved classification, this study confirmed the
b
“White” was treated as the reference category for race/ethnicity. finding from prior research with other study populations and mea-
c
“Heterosexual” was treated as the reference category for sexual identity. surement approaches that SGM status confers elevated risk of suicide
d
“Cisgender” was treated as the reference category for gender identity.
e (Almazan et al., 2014; Button et al., 2012; Eisenberg et al., 2017; M. P.
“Outness is irrelevant” was treated as the reference category for outness.
Marshal et al., 2011; Raifman et al., 2017; D. M. Stone et al., 2014).
More importantly, this study contributed a sharper understanding of
As shown in Table 7, youth who attempted suicide were sig-
commonalities and distinctions in suicide etiology between SGM and
nificantly more likely to skip school due to feeling unsafe than those
non-SGM youth in a social media-based sample. It upheld the key role
who only ideated (p < .01). None of the other characteristics ex-
of parental supportiveness in protecting against suicidality among both
amined, including sexual or gender minority status, significantly dif-
SGM and non-SGM youth and called preliminary attention to two fac-
ferentiated those who considered suicide from those who attempted it.
tors that appeared to confer protection for one group of youth and
elevated risk for the other (although not all correlations were not sta-
5. Discussion
tistically significant in our small sample). Among non-SGM youth, being
Asian American conferred elevated suicide risk, while it appeared
5.1. Study contributions
protective (though non-significant) among those who were SGM.
Findings of the risk or protectiveness conferred by Asian American
Building on theoretical and empirical work on the etiology of sui-
identification depending on SGM status also highlight the complex of
cide among SGM youth, this study advances a richer understanding of
protection and vulnerability that arises at the intersection of racial
factors that shape suicidal ideation and suicide attempt among SGM

Table 5
Two-sample T-tests of social connection by outness (N = 175 SGM Youth).
“Important to be out” (N = 43) “Not important to be out” (N = 80)

Variable Obs. Mean Std. Err. Std. Dev. Obs. Mean Std. Err. Std. Dev. P-value

School-based or cyber bullying victimization 42 0.31 0.07 0.47 75 0.31 0.05 0.46 0.975
Skipping school due to feeling unsafe 39 0.60 0.18 1.12 73 0.42 0.13 1.12 0.424
Feeling close to people at school 43 3.33 0.21 1.41 80 3.11 0.14 1.29 0.400
Feeling that parents care 43 3.95 0.15 1.00 77 4.16 0.12 1.03 0.298
Involvement in a religious youth group in the past 12 months 43 0.12 0.05 0.32 80 0.20 0.05 0.40 0.243
Involvement in an LGBTQ + -related group in the past 12 months 43 0.49 0.08 0.51 80 0.26 0.05 0.44 0.012*
Having accessed school- or community-based mental health services in the past 43 0.67 0.07 0.47 80 0.55 0.06 0.50 0.183
12 months
Connectedness to other groups or teams in the past 12 months 43 0.49 0.08 0.51 80 0.55 0.06 0.50 0.518
Composite connectedness 43 2.49 0.32 2.11 80 1.96 0.18 1.63 0.128

*** p < .001, ** p < .01, * p < .05.

Of the 175 youth who form the sample for these analyses, there were 123 youth for whom data were available on the ‘outness’ variable.
Bolded values indicate statistical significance at the p < .05 level.

85
T. McKay, et al. Children and Youth Services Review 102 (2019) 79–90

Table 6
Two-sample T-tests of social connection by sexual orientation congruence (N = 175 SGM Youth).
Not Congruent Congruent

Variable Obs. Mean Std. Err. Std. Dev. Obs. Mean Std. Err. Std. Dev. P-value Effect Size

Congruence between attraction and identity

School-based or cyber bullying victimization 22 0.59 0.11 0.50 144 0.31 0.04 0.46 0.009** 0.61
Skipping school due to feeling unsafe 23 0.54 0.32 1.53 137 0.47 0.09 1.07 0.789 0.06
Feeling close to people at school 24 2.88 0.27 1.33 151 3.14 0.10 1.29 0.354 0.20
Feeling that parents care 24 3.96 0.28 1.37 148 4.09 0.08 1.02 0.565 0.13
Involvement in a religious youth group in the past 12 months 24 0.33 0.10 0.48 151 0.18 0.03 0.38 0.080 0.39
Involvement in an LGBTQ+-related group in the past 12 months 24 0.17 0.08 0.38 151 0.33 0.04 0.47 0.106 0.36
Having accessed school- or community-based mental health services in the past 24 0.42 0.10 0.50 151 0.60 0.04 0.49 0.100 0.36
12 months
Connectedness to other groups or teams in the past 12 months 24 0.71 0.09 0.46 151 0.54 0.04 0.50 0.116 0.35
Composite connectedness 24 1.75 0.25 1.22 151 2.15 0.15 1.82 0.306 0.23

Congruence between behavior and identity

School-based or cyber bullying victimization 12 0.42 0.15 0.51 154 0.34 0.04 0.47 0.582 0.17
Skipping school due to feeling unsafe 12 0.54 0.38 1.30 148 0.48 0.09 1.13 0.857 0.05
Feeling close to people at school 13 2.38 0.35 1.26 162 3.16 0.10 1.28 0.037* 0.61
Feeling that parents care 13 3.92 0.47 1.71 159 4.09 0.08 1.01 0.595 0.15
Involvement in a religious youth group in the past 12 months 13 0.31 0.13 0.48 162 0.19 0.03 0.39 0.316 0.29
Involvement in an LGBTQ + -related group in the past 12 months 13 0.00 0.00 0.00 162 0.33 0.04 0.47 0.012* 0.73
Having accessed school- or community-based mental health services in the past 13 0.46 0.14 0.52 162 0.58 0.04 0.50 0.408 0.24
12 months
Connectedness to other groups or teams in the past 12 months 13 0.69 0.13 0.48 162 0.55 0.04 0.50 0.321 0.29
Composite connectedness 13 1.77 0.34 1.24 162 2.12 0.14 1.79 0.493 0.20

*** p < .001, ** p < .01, * p < .05.

All 175 SGM youth who form the sample for these analyses had data available on the congruence variables.
Bolded values indicate statistical significance at the p < .05 level.

Table 7
Chi-squared tests comparing suicide ideators (n = 70) and attemptors (n = 38).
Variable Difference in mean Lower CI Upper CI Pearson chi-squared P-value

SGM status −0.01 −0.21 0.19 0.01 0.929

Skipping school due to feeling unsafe −0.86 −1.34 −0.038 18.21 0.001**
Feeling close to people at school 0.17 −0.37 0.71 5.05 0.282
Feeling that parents care 0.36 −0.07 0.79 5.62 0.229
Involvement in an LGBTQ+-related group in the past 12 months 0.01 −0.17 0.19 0.01 0.926
Having accessed school- or community-based mental health services in the past 12 months −0.12 −0.31 0.07 1.65 0.199
Connectedness to other groups or teams in the past 12 months 0.10 −0.09 0.30 1.14 0.285

*** p < .001, ** p < .01, * p < .05.

Bolded values indicate statistical significance at the p < .05 level.

identity and SGM status. Prior research suggested that SGM youth and
young adults of color face the dual bind of negotiating racism within
sexual minority communities and homophobia within their racial and
ethnic communities (Lytle et al., 2014; L. Smith, Foley, & Chaney,
2008). Minority stress theory would suggest that dual minority status
could elevate suicide risk by increasing young people's minority stress
exposure (Bowleg, Huang, Brooks, Black, & Burkholder, 2003). Find-
ings from this study do not clearly confirm either hypothesis, suggesting
that the minority stress and interpersonal-psychological theoretical
perspectives as partially assessed in this and other studies are not
capturing important aspects of SGM and non-SGM racial and ethnic
minority experiences.
This study also suggested a more complex role for social connection
and “belongingness” than has been uncovered in prior research.
Religious youth group involvement appeared protective in both the
combined and non-SGM samples but evidenced quite the opposite re-
lationship to suicidality in the SGM sample (though these findings were
not statistically significant). Although most previously-explored aspects
of formal and informal social connection were protective against youth
suicidality among both SGM and non-SGM youth, religious youth group
involvement offers a special case in which a form of “belongingness” as
conceptualized by Joiner might actually exacerbate minority stress
(perhaps through exposure to negative attitudes or beliefs regarding
SGM status) and increase the risk of suicide. This possibility has been
little examined in prior research and merits further exploration in a
larger sample (with more power to detect its potential effect).
Our findings also contribute an enhanced understanding of the re-
lationships of outness and SGM self-identification to social belonging-
ness. In this sample, youth who felt it was important to be out were
more likely to access mental health services (in or outside of school)
and to be involved in LGBTQ+-related groups (in or outside of school)
compared to those to whom it was not. Youth who had congruent
sexual orientations (that is, a sexual identity that matched their sexual
behavior and/or attraction) were more likely to feel close to people at
school. These findings speak to concerns raised in prior research that
outness or self-identification as SGM (as opposed to experiencing same-
sex attraction or behavior without having an SGM identity) might
confer elevated risk (Montoro et al., 2016), perhaps by increasing
minority stress exposures such as bullying related to SGM status.
Findings from the current study are insufficient to put that concern fully
to rest; however, in this social media-based sample, both outness and
sexual orientation congruence were associated with greater social
connection or belongingness in our sample and did not appear to con-
tribute added risk of bullying victimization among SGM youth.
Finally, this study helped to answer the call from suicide researchers
to distinguish ideation and attempt in research on the etiology of

86
T. McKay, et al.
suicide (Nock et al., 2018). In our sample, skipping school due to feeling
unsafe distinguished youth who had seriously considered suicide from
those who had attempted it. This finding underscores the importance of
school-based suicide prevention and intervention and of restorative
justice approaches to school truancy that work with students to address
the root causes of truancy rather than further punishing them
(Hirschfield, 2018).
5.2. Study limitations
This study was subject to several limitations associated with its
cross-sectional design, non-representative sample, and short (social
media compatible) survey format. The cross-sectional structure of these
data did not allow us to examine pathways or mechanisms. We were
unable to make assumptions about time-ordering of the observed ex-
periences and characteristics, nor to assess relevant mediation or
moderation paths that have been proposed in prior theoretical work on
this topic (Baams et al., 2015).
The non-probability-based sampling approach and the use of a
single social media platform for recruitment prevent us from general-
izing our results to a wider youth population. Approximately 47% of
adolescents and 45% of young adults use Twitter, with Black young
people tending to be somewhat overrepresented among American
Twitter users (Associated Press-NORC Center for Public Affairs
Research, 2017; A. Smith & Anderson, 2018). Other differences be-
tween youth who are and are not on Twitter are likely but have not
been rigorously measured; therefore, analysis weights, which would
correct for any population differences and allow for inference to the
general population, have not yet been developed. However, we do
know that the non-representative population recruited for this study
generally resembled the representative sample of youth most commonly
used in other research on this topic (the YRBS), while including a much
higher proportion of SGM youth.
Further, although we recruited a relatively large number of SGM
respondents (N = 175) within a relatively small sample (N = 489), our
overall sample size and limitations in sub-sample sizes constrained our
statistical power for the analyses presented. Small sub-sample sizes
prevented us from pursuing important sub-group analyses that might
have shed light on the distinct experiences of sub-groups of SGM youth,
such as gender minority youth and SGM youth of color, whom prior
research suggests are likely to face distinct risks and risk factors with
regard to suicidality, and whose distinct experiences have been less well
examined in other quantitative research. In addition, sample size con-
straints prevented us from being able to rigorously test the potential
moderating effects of SGM status on suicidality that are suggested by
differences in the SGM and non-SGM model results.
Finally, the use of a social media platform (rather than in-person
interviewers) to collect survey data with youth necessitated a very short
and parsimonious survey. As such, data were not collected on a number
of risk and protective factors suggested by the psychological-inter-
personal model and the minority stress model (Baams et al., 2015;
Frank, 2017) for the SGM sub-population—for example, perceived
burdensomeness, coming-out stress, and bullying experiences specific
to sexual orientation or gender identity.
6. Conclusions
6.1. Directions for future research
This and other studies of suicide risk factors and disparities have
been hindered by persistent shortcomings in measurement and sam-
pling methodology that must be addressed in future work. The school-
based surveys that produce most data on youth suicide and related
experiences in the United States do not capture sexual or gender min-
ority status in a manner consistent with widely-recognized best prac-
tices (Federal Interagency Working Group on Improving Measurement
87
Children and Youth Services Review 102 (2019) 79–90
of Sexual Orientation and Gender Identity in Federal Surveys, 2016).
They use measures of sexual minority status that are inconsistent and
conceptually incomplete (such that the same case might be classified as
sexual minority in one study but treated as part of the majority popu-
lation in another) and typically measure gender minority status in-
completely or not at all. These measurement issues undermine the
precision with which researchers can distinguish experiences specific to
SGM individuals, as well as the ability of such studies to precisely define
the population of interest to which their reported findings pertain.
Sampling methodologies in this area of research also demand im-
provement. Studies like the current one, which employ a (primarily)
non-probability-based sampling design, cannot be generalized to a
wider population. Yet representative designs that overcome that lim-
itation are plagued by underreporting of SGM status (Hottes et al.,
2016) and extremely small sample sizes for analyses focused on SGM
(and particularly gender minority) experiences. Further, the school-
based or address-based sampling designs that are typically considered
“gold standards” for population-based research are subject to coverage
gaps that disproportionately exclude SGM communities and the most
vulnerable individuals within those communities. To date, most re-
presentative research on youth and young adult suicidality has used
data from various state and local YRBS studies or the National Long-
itudinal Survey of Adolescent to Adult Health (Add Health), both of
which use school-based samples (although Add Health did include
students on school rosters who did not participate in school-based data
collection in a smaller number of in-home interviews). The known
coverage limitations of these approaches—the exclusion of youth who
are not in school from school-based studies and the exclusion of
homeless and runaway youth from household-based studies—dispro-
portionately affect SGM youth. Numerous studies shown that SGM
youth are more likely not to be in school and to be homeless or runaway
than their non-SGM peers (Irvine & Canfield, 2015; Poteat, Berger, &
Dantas, 2017). These coverage gaps are generally tolerated because of
the important advantages these strategies otherwise confer in terms of
study generalizability. But with suicide now the second leading threat
to the lives of adolescents (Heron, 2018), clear evidence that SGM
youth are at elevated risk, and the knowledge that SGM youth who are
not in school or have run away from home are even more likely than
other SGM youth to attempt suicide (Taliaferro et al., 2018), addressing
these methodological issues is more urgent than ever.
Social media-based research offers the potential to reach youth who
are not living in a stable home or not consistently in school. Further,
this method may be able to capitalize on some of the known, social
desirability-minimizing advantages of other computer-based, self-ad-
ministered approaches (Gnambs & Kaspar, 2017) along with the added
assets of respondent familiarity and comfort with the platform. How-
ever, maintaining the integrity of a particular sampling design while
navigating relatively rigid commercial platforms to communicate with
prospective study respondents is challenging, as is reaching adequate
numbers of social media users when distributing a study recruitment
message to a predetermined sample rather than using the platform's
usual approaches for increasing responsiveness (such as conversion
pixels), which would compromise the probability-based design.5 Re-
cruiting adequate numbers of SGM respondents within representative
studies to be able to parse out the distinct experiences of SGM youth
sub-groups is important, as small sub-sample sizes have prevented
adequate exploration of distinct risks and risk factors in this and other
prior work. Interventions may need to be tailored to the different needs
of these sub-groups, including SGM youth of color and particularly
gender minority (including transgender and gender non-conforming)
youth (O'Brien, Putney, Hebert, Falk, & Aguinaldo, 2016). Studies well-
equipped to inform such tailoring, including those that can rigorously
5
Berzofsky, M.E., McKay, T., Hsieh, P., Smith, A. (under review). Probability-
based samples on Twitter: Methodology and application.
T. McKay, et al.
test the potential moderating role of sexual minority and gender min-
ority statuses, continue to be lacking. Sampling approaches that enable
recruitment of adequate overall and sub-sample sizes to address this
issue in future research with SGM youth represent a paramount meth-
odological issue for the field. Overcoming barriers that have prevented
the recruitment of large samples of SGM youth (and adequate sub-
samples of gender minority youth and SGM youth of color) in studies of
modest size and budget will require creative strategies to combine the
strengths of representative, population-based research with those of
community-based studies.
6.2. Directions for future practice
Despite mounting evidence that SGM youth face steeply increased
chances of suicide and distinct suicide etiologies relative to youth in the
general population, no evidence-based suicide prevention intervention
exists for SGM youth (Marshall, 2016). The results of this study offer
further empirical support for the idea that suicide risk and protective
factors for SGM youth are distinct—in fact, this study suggests that
aspects of “belongingness” that are protective against suicide for non-
SGM youth (e.g., religious youth group involvement) might have the
opposite effect among SGM youth due to associated minority stress
exposure. They urge caution when applying the results of general-po-
pulation research to suicide prevention and intervention efforts that
include SGM youth. Rather, they argue for the application of an in-
tegrated model of youth suicide risk and protective factors that takes
into account areas of commonality and difference between SGM and
non-SGM youth.
An integrated understanding will be particularly important for in-
forming inclusive programming for both SGM- and non-SGM youth in
settings such as schools and family homes. These initiatives must aim to
be inclusive of all youth regardless of SGM status, without losing sight
of the complex ways that minority stress may alter the relationship
between general-population risk and protective factors (such as the risk
associated with thwarted belongingness or the protection conferred by
formal and informal social connection) and suicidality. When preven-
tion and intervention efforts aim to target the more “universal” aspects
of these protective factors, such as parental caring, they might opt to
incorporate content addressing the cultural stigmatization of SGM ex-
periences (and associated minority stress) with which caring parents
will need to help their SGM children cope.
Finally, given their consistent associated with youth suicide, the fact
that victimization disparities between SGM and non-SGM youth have
persisted or even worsened in recent decades (Katz-Wise & Hyde, 2012;
Toomey & Russell, 2016) should be a call to action for every adult.
Although a focus on the role of other youth in perpetuating anti-SGM
bullying may be tempting (Quinn & Meiners, 2013), such approaches
can also represent a distraction from full adult accountability for the
mounting suicide death toll among SGM youth. When we create sup-
portive, affirming social and political climates, differences in suicide
rates between SGM and non-SGM youth all but disappear
(Hatzenbuehler, 2011; Rodgers, 2017). With such knowledge in hand,
we cannot let these disparities outlive another generation of children.
Declarations of interest
Declarations of interest: none.
Acknowledgements
The authors wish to thank Marissa Bloomfield, Mindy Herman
Stahl, Mark Howell, Marni Kan, and Natasha Latzman. This research did
not receive any specific grant from funding agencies in the public,
commercial, or not-for-profit sectors.
88
Children and Youth Services Review 102 (2019) 79–90
References
Almazan, E. P., Roettger, M. E., & Acosta, P. S. (2014). Measures of sexual minority status
and suicide risk among young adults in the United States. Archives of Suicide Research,
18(3), 274–281. https://doi.org/10.1080/13811118.2013.824832.
Associated Press-NORC Center for Public Affairs Research (2017). Instagram and snap-
chat are most popular social networks for teens; black teens are most active on social
media, messaging apps (Retrieved August 17, 2018, from) http://apnorc.org/
projects/Pages/HTML%20Reports/instagram-and-snapchat-are-most-popular-social-
networks-for-teens.aspx.
Baams, L., Grossman, A. H., & Russell, S. T. (2015). Minority stress and mechanisms of
risk for depression and suicidal ideation among lesbian, gay, and bisexual youth.
Developmental Psychology, 51(5), 688–696. https://doi.org/10.1037/a0038994.
Bouris, A., Everett, B. G., Heath, R. D., Elsaesser, C. E., & Neilands, T. B. (2016). Effects of
victimization and violence on suicidal ideation and behaviors among sexual minority
and heterosexual adolescents. LGBT Health, 3(2), 153–161. https://doi.org/10.1089/
lgbt.2015.0037.
Bowleg, L., Huang, J., Brooks, K., Black, A., & Burkholder, G. (2003). Triple jeopardy and
beyond: Multiple minority stress and resilience among Black lesbians. Journal of
Lesbian Studies, 7(4), 87–108. https://doi.org/10.1300/J155v07n04_06.
Bronfenbrenner, U. (1977). Toward an experimental ecology of human development.
American Psychologist, 32(7), 513–531. https://doi.org/10.1037/0003-066X.32.7.
513.
Button, D. M., O'Connell, D. J., & Gealt, R. (2012). Sexual minority youth victimization
and social support: The intersection of sexuality, gender, race, and victimization.
Journal of Homosexuality, 59(1), 18–43. https://doi.org/10.1080/00918369.2011.
614903.
Cardom, R., Rostosky, S., & Danner, F. (2013). Does “it get better” for depressed sexual
minority youth in young adulthood? The Journal of Adolescent Health, 53(5), 671–673.
https://doi.org/10.1016/j.jadohealth.2013.07.023.
Davis, B., Royne Stafford, M. B., & Pullig, C. (2014). How gay-straight alliance groups
mitigate the relationship between gay-bias victimization and adolescent suicide at-
tempts. Journal of the American Academy of Child and Adolescent Psychiatry, 53(12),
1271–1278.e1. https://doi.org/10.1016/j.jaac.2014.09.010.
DeCamp, W., & Bakken, N. W. (2016). Self-injury, suicide ideation, and sexual orienta-
tion: Differences in causes and correlates among high school. Journal of Injury and
Violence Research, 8(1), 1–10.
Denny, S., Lucassen, M. F., Stuart, J., Fleming, T., Bullen, P., Peiris-John, R., ... Utter, J.
(2016). The association between supportive high school environments and depressive
symptoms and suicidality among sexual minority students. Journal of Clinical Child
and Adolescent Psychology, 45(3), 248–261. https://doi.org/10.1080/15374416.
2014.958842.
Dirkes, J., Hughes, T., Ramirez-Valles, J., Johnson, T., & Bostwick, W. (2016). Sexual
identity development: Relationship with lifetime suicidal ideation in sexual minority
women. Journal of Clinical Nursing, 25(23–24), 3545–3556. https://doi.org/10.1111/
jocn.13313.
Duong, J., & Bradshaw, C. (2014). Associations between bullying and engaging in ag-
gressive and suicidal behaviors among sexual minority youth: The moderating role of
connectedness. The Journal of School Health, 84(10), 636–645. https://doi.org/10.
1111/josh.12196.
Eisenberg, M. E., Gower, A. L., McMorris, B. J., Rider, G. N., Shea, G., & Coleman, E.
(2017). Risk and protective factors in the lives of transgender/gender nonconforming
adolescents. The Journal of Adolescent Health, 61(4), 521–526. https://doi.org/10.
1016/j.jadohealth.2017.04.014.
Federal Interagency Working Group on Improving Measurement of Sexual Orientation
and Gender Identity in Federal Surveys (2016). Evaluations of sexual orientation and
gender identity survey measures: What have we learned? 61.
Fish, J. N., Rice, C. E., Lanza, S. T., & Russell, S. T. (2018). Is young adulthood a critical
period for suicidal behavior among sexual minorities? Results from a US National
Sample. Prevention Science. https://doi.org/10.1007/s11121-018-0878-5 Mar 29.
[Epub ahead of print].
Frank, J. A. (2017). Factors promoting risk and resilience for suicidal ideation among trans-
gender youth. US: ProQuest Information & Learning.
Fried, L. E., Williams, S., Cabral, H., & Hacker, K. (2013). Differences in risk factors for
suicide attempts among 9th and 11th grade youth: A longitudinal perspective. The
Journal of School Nursing, 29(2), 113–122. https://doi.org/10.1177/
1059840512461010.
GeniUSS Group (2014). Best practices for asking questions to identify transgender and
other gender minority respondents on population-based surveys. Retrieved August
17, 2018, from https://williamsinstitute.law.ucla.edu/research/census-lgbt-
demographics-studies/geniuss-report-sept-2014/.
Gibbs, J. J., & Goldbach, J. (2015). Religious conflict, sexual identity, and suicidal be-
haviors among LGBT young adults. Archives of Suicide Research, 19(4), 472–488.
https://doi.org/10.1080/13811118.2015.1004476.
Gnambs, T., & Kaspar, K. (2017). Socially desirable responding in web-based ques-
tionnaires: A meta-analytic review of the candor hypothesis. Assessment, 24(6),
746–762. https://doi.org/10.1177/1073191115624547.
Grossman, A. H., Park, J. Y., & Russell, S. T. (2016). Transgender youth and suicidal
behaviors: Applying the interpersonal psychological theory of suicide. Journal of Gay
& Lesbian Mental Health, 20(4), 329–349. https://doi.org/10.1080/19359705.2016.
1207581.
Hatzenbuehler, M. L. (2011). The social environment and suicide attempts in lesbian, gay,
and bisexual youth. Pediatrics, 127(5), 896–903. https://doi.org/10.1542/peds.2010-
3020.
Hatzenbuehler, M. L., Birkett, M., Van Wagenen, A., & Meyer, I. H. (2014). Protective
T. McKay, et al.
school climates and reduced risk for suicide ideation in sexual minority youths.
American Journal of Public Health, 104(2), 279–286. https://doi.org/10.2105/ajph.
2013.301508.
Hatzenbuehler, M. L., & Keyes, K. M. (2013). Inclusive anti-bullying policies and reduced
risk of suicide attempts in lesbian and gay youth. The Journal of Adolescent Health,
53(1 Suppl), S21–S26. https://doi.org/10.1016/j.jadohealth.2012.08.010.
Heron, M. (2018). Leading causes of death for 2016. Atlanta, GA: Centers for Disease
Control and Prevention. Retrieved from https://stacks.cdc.gov/view/cdc/57988.
Hill, R. M., & Pettit, J. W. (2012). Suicidal ideation and sexual orientation in college
students: The roles of perceived burdensomeness, thwarted belongingness, and per-
ceived rejection due to sexual orientation. Suicide and Life-threatening Behavior, 42(5),
567–579. https://doi.org/10.1111/j.1943-278X.2012.00113.x.
Hirschfield, P. J. (2018). The role of schools in sustaining juvenile justice system in-
equality. Future of Children, 28(1), 11–35.
Horton, S. E., Hughes, J. L., King, J. D., Kennard, B. D., Westers, N. J., Mayes, T. L., &
Stewart, S. M. (2016). Preliminary examination of the interpersonal psychological
theory of suicide in an adolescent clinical sample. Journal of Abnormal Child
Psychology; New York, 44(6), 1133–1144. https://doi.org/10.1007/s10802-015-
0109-5.
Hottes, T. S., Bogaert, L., Rhodes, A. E., Brennan, D. J., & Gesink, D. (2016). Lifetime
prevalence of suicide attempts among sexual minority adults by study sampling
strategies: A systematic review and meta-analysis. American Journal of Public Health,
106(5), e1–e12. https://doi.org/10.2105/AJPH.2016.303088.
Ioverno, S., Belser, A. B., Baiocco, R., Grossman, A. H., & Russell, S. T. (2016). The
protective role of gay-straight alliances for lesbian, gay, bisexual, and questioning
students: A prospective analysis. Psychology of Sexual Orientation and Gender Diversity,
3(4), 397–406. https://doi.org/10.1037/sgd0000193.
Irvine, A., & Canfield, A. (2015). The overrepresentation of lesbian, gay, bisexual, ques-
tioning, gender nonconforming and transgender youth within the child welfare to
juvenile justice crossover population. American University Journal of Gender, Social
Policy and the Law, 24, 243–262.
Joiner, T. (2005). Why people die by suicide. Cambridge, MA: Harvard University Press.
Retrieved from http://www.hup.harvard.edu/catalog.php?isbn=9780674025493.
Joiner, T. E., Van Orden, K. A., Witte, T. K., Selby, E. A., Ribeiro, J. D., Lewis, R., & Rudd,
M. D. (2009). Main predictions of the interpersonal-psychological theory of suicidal
behavior: Empirical tests in two samples of young adults. Journal of Abnormal
Psychology, 118(3), 634–646. https://doi.org/10.1037/a0016500.
Katz-Wise, S. L., & Hyde, J. S. (2012). Victimization experiences of lesbian, gay, and
bisexual individuals: A meta-analysis. The Journal of Sex Research, 49(2–3), 142–167.
https://doi.org/10.1080/00224499.2011.637247.
Liu, R. T., & Mustanski, B. (2012). Suicidal ideation and self-harm in lesbian, gay, bi-
sexual, and transgender youth. American Journal of Preventive Medicine, 42(3),
221–228. https://doi.org/10.1016/j.amepre.2011.10.023.
Luong, C. T., Rew, L., & Banner, M. (2018). Suicidality in young men who have sex with
men: A systematic review of the literature. Issues in Mental Health Nursing, 39(1),
37–45. https://doi.org/10.1080/01612840.2017.1390020.
Lytle, M. C., Luca, S. M. D., & Blosnich, J. R. (2014). The influence of intersecting
identities on self-harm, suicidal behaviors, and depression among lesbian, gay, and
bisexual individuals. Suicide and Life-threatening Behavior, 44(4), 384–391. https://
doi.org/10.1111/sltb.12083.
Marshal, M. P., Dermody, S. S., Cheong, J., Burton, C. M., Friedman, M. S., Aranda, F., &
Hughes, T. L. (2013). Trajectories of depressive symptoms and suicidality among
heterosexual and sexual minority youth. Journal of Youth and Adolescence, 42(8),
1243–1256. https://doi.org/10.1007/s10964-013-9970-0.
Marshal, M. P., Dietz, L. J., Friedman, M. S., Stall, R., Smith, H. A., McGinley, J., ... Brent,
D. A. (2011). Suicidality and depression disparities between sexual minority and
heterosexual youth: A meta-analytic review. The Journal of Adolescent Health, 49(2),
115–123. https://doi.org/10.1016/j.jadohealth.2011.02.005.
Marshal, M. P., Goldbach, J. T., McCauley, H. L., Shultz, M. L., Dietz, L. J., Montana, G. T.,
& D'Augelli, A. R. (2015). Gay-related stress and suicide risk: Articulating three
mediated pathways that increase risk for suicidality among sexual minority youth. In
D. A. Lamis, N. J. Kaslow, D. A. Lamis, & N. J. Kaslow (Eds.). Advancing the science of
suicidal behavior: Understanding and intervention (pp. 253–268). Hauppauge, NY, US:
Nova Science Publishers.
Marshall, A. (2016). Suicide prevention interventions for Sexual & Gender Minority
Youth: An unmet need. The Yale Journal of Biology and Medicine, 89(2), 205–213.
McDermott, E., Hughes, E., & Rawlings, V. (2018). Norms and normalisation:
Understanding lesbian, gay, bisexual, transgender and queer youth, suicidality and
help-seeking. Culture, Health & Sexuality, 20(2), 156–172. https://doi.org/10.1080/
13691058.2017.1335435.
McLean, J., Maxwell, M., Platt, S., Harris, F. M., & Jepson, R. (2008). Risk and protective
factors for suicide and suicidal behaviour: A literature review. Scottish Government.
Retrieved from http://dspace.stir.ac.uk/handle/1893/2206.
Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bi-
sexual populations: Conceptual issues and research evidence. Psychological Bulletin,
129(5), 674–697. https://doi.org/10.1037/0033-2909.129.5.674.
Michaels, M. S., Parent, M. C., & Torrey, C. L. (2015). A minority stress model for suicidal
ideation in gay men. Suicide and Life-threatening Behavior, 46(1), 23–34. https://doi.
org/10.1111/sltb.12169.
Miranda-Mendizábal, A., Castellvi, P., Pares-Badell, O., Almenara, J., Alonso, I., Blasco,
M. J., & Alonso, J. (2017). Sexual orientation and suicidal behaviour in adolescents
and young adults: Systematic review and meta-analysis. British Journal of Psychiatry,
211(2), 77–+. https://doi.org/10.1192/bjp.bp.116.196345.
Montoro, R., Igartua, K., & Thombs, B. D. (2016). The association of bullying with suicide
ideation and attempt among adolescents with different dimensions of sexual or-
ientation. European Psychiatry, 33, S71. https://doi.org/10.1016/j.eurpsy.2016.01.
89
Children and Youth Services Review 102 (2019) 79–90
984.
Mustanski, B., & Liu, R. T. (2013). A longitudinal study of predictors of suicide attempts
among lesbian, gay, bisexual, and transgender youth. Archives of Sexual Behavior,
42(3), 437–448. https://doi.org/10.1007/s10508-012-0013-9.
Mustanski, B. (2011). Ethical and regulatory issues with conducting sexuality research
with LGBT adolescents: A call to action for a scientifically informed approach.
Archives of Sexual Behavior, 40(4), 673–686. https://doi.org/10.1007/s10508-011-
9745-1.
Needham, B. L., & Austin, E. L. (2010). Sexual orientation, parental support, and health
during the transition to young adulthood. Journal of Youth and Adolescence, 39(10),
1189–1198. https://doi.org/10.1007/s10964-010-9533-6.
Nock, M. K., Millner, A. J., Joiner, T. E., Gutierrez, P. M., Han, G., Hwang, I., ... Kessler, R.
C. (2018). Risk factors for the transition from suicide ideation to suicide attempt:
Results from the army study to assess risk and resilience in Servicemembers (Army
STARRS). Journal of Abnormal Psychology, 127(2), 139–149. https://doi.org/10.
1037/abn0000317.
O'Brien, K. H., Putney, J. M., Hebert, N. W., Falk, A. M., & Aguinaldo, L. D. (2016). Sexual
and gender minority youth suicide: Understanding subgroup differences to inform
interventions. LGBT Health, 3(4), 248–251. https://doi.org/10.1089/lgbt.2016.0031.
Perez-Brumer, A., Day, J. K., Russell, S. T., & Hatzenbuehler, M. L. (2017). Prevalence and
correlates of suicidal ideation among transgender youth in California: Findings from a
representative, population-based sample of high school students. Journal of the
American Academy of Child and Adolescent Psychiatry, 56(9), 739–746. https://doi.
org/10.1016/j.jaac.2017.06.010.
Peter, T., Taylor, C., & Campbell, C. (2016). “You can't break…when you're already
broken”: The importance of school climate to suicidality among LGBTQ youth.
Journal of Gay & Lesbian Mental Health, 20(3), 195–213. https://doi.org/10.1080/
19359705.2016.1171188.
Ploderl, M., Faistauer, G., & Fartacek, R. (2010). The contribution of school to the feeling
of acceptance and the risk of suicide attempts among Austrian gay and bisexual
males. Journal of Homosexuality, 57(7), 819–841. https://doi.org/10.1080/
00918369.2010.493401.
Poteat, V. P., Berger, C., & Dantas, J. (2017). How victimization, climate, and safety
around sexual orientation and gender expression relate to truancy. Journal of LGBT
Youth, 14(4), 424–435. https://doi.org/10.1080/19361653.2017.1365037.
Puckett, J. A., Horne, S. G., Surace, F., Carter, A., Noffsinger-Frazier, N., Shulman, J., ...
Mosher, C. (2017). Predictors of sexual minority youth's reported suicide attempts
and mental health. Journal of Homosexuality, 64(6), 697–715. https://doi.org/10.
1080/00918369.2016.1196999.
Quinn, T., & Meiners, E. R. (2013). From anti-bullying Laws and gay marriages to queer
worlds and just futures. QED: A Journal in GLBTQ Worldmaking, 149–176. https://doi.
org/10.14321/qed.0149.
Raifman, J., Moscoe, E., Austin, S. B., & McConnell, M. (2017). Difference-in-differences
analysis of the association between state same-sex marriage policies and adolescent
suicide attempts. JAMA Pediatrics, 171(4), 350–356. https://doi.org/10.1001/
jamapediatrics.2016.4529.
Reisner, S. L., Biello, K., Perry, N. S., Gamarel, K. E., & Mimiaga, M. J. (2014). A com-
pensatory model of risk and resilience applied to adolescent sexual orientation dis-
parities in nonsuicidal self-injury and suicide attempts. American Journal of
Orthopsychiatry, 84(5), 545–556. https://doi.org/10.1037/ort0000008.
Rimes, K. A., Shivakumar, S., Ussher, G., Baker, D., Rahman, Q., & West, E. (2018).
Psychosocial factors associated with suicide attempts, ideation, and future risk in
lesbian, gay, and bisexual youth. Crisis. https://doi.org/10.1027/0227-5910/
a000527 Jun 21:1-10. [Epub ahead of print].
Rivers, I., Gonzalez, C., Nodin, N., Peel, E., & Tyler, A. (2018). LGBT people and sui-
cidality in youth: A qualitative study of perceptions of risk and protective circum-
stances. Social Science & Medicine, 212, 1–8. https://doi.org/10.1016/j.socscimed.
2018.06.040.
Rodgers, S. M. (2017). Transitional age lesbian, gay, bisexual, transgender, and ques-
tioning youth: Issues of diversity, integrated identities, and mental health. Child and
Adolescent Psychiatric Clinics of North America, 26(2), 297–309. https://doi.org/10.
1016/j.chc.2016.12.011.
Russell, S. T., & Toomey, R. B. (2012). Men's sexual orientation and suicide: Evidence for
U.S. adolescent-specific risk. Social Science & Medicine, 74(4), 523–529. https://doi.
org/10.1016/j.socscimed.2010.07.038.
Russell, S. T., & Toomey, R. B. (2013). Risk and protective factors for suicidal thoughts
among sexual minority youth: Evidence from the add health study. Journal of Gay &
Lesbian Mental Health, 17(2), 132–149. https://doi.org/10.1080/19359705.2012.
753398.
Ryan, C., Huebner, D., Diaz, R. M., & Sanchez, J. (2009). Family rejection as a predictor of
negative health outcomes in white and Latino lesbian, gay, and bisexual young
adults. Pediatrics, 123(1), 346–352. https://doi.org/10.1542/peds.2007-3524.
Shields, J. P., Whitaker, K., Glassman, J., Franks, H. M., & Howard, K. (2012). Impact of
victimization on risk of suicide among lesbian, gay, and bisexual high school students
in San Francisco. The Journal of Adolescent Health, 50(4), 418–420. https://doi.org/
10.1016/j.jadohealth.2011.07.009.
Smith, A., & Anderson, M. (2018). Social media use in 2018. Retrieved August 2, 2018,
from http://www.pewinternet.org/2018/03/01/social-media-use-in-2018/.
Smith, L., Foley, P. F., & Chaney, M. P. (2008). Addressing classism, ableism, and het-
erosexism in counselor education. Journal of Counseling & Development, 86(3),
303–309.
Stone, D. M., Holland, K., Bartholomew, B., Crosby, A., Davis, S., & Wilkins, N. (2017).
Preventing suicide: A technical package of policy, programs, and practices. Centers for
Disease Control and Prevention62.
Stone, D. M., Luo, F. J., Ouyang, L. J., Lippy, C., Hertz, M. F., & Crosby, A. E. (2014).
Sexual orientation and suicide ideation, plans, attempts, and medically serious
T. McKay, et al.
attempts: Evidence from local youth risk behavior surveys, 2001-2009. American
Journal of Public Health, 104(2), 262–271. https://doi.org/10.2105/ajph.2013.
301383.
Stone, D. M., Luo, F., Lippy, C., & McIntosh, W. L. (2015). The role of social connectedness
and sexual orientation in the prevention of youth suicide ideation and attempts
among sexually active adolescents. Suicide and Life-threatening Behavior, 45(4),
415–430. https://doi.org/10.1111/sltb.12139.
Taliaferro, L. A., McMorris, B. J., Rider, G. N., & Eisenberg, M. E. (2018). Risk and pro-
tective factors for self-harm in a population-based sample of transgender youth.
Archives of Suicide Research. https://doi.org/10.1080/13811118.2018.1430639 2018
Feb 20:1–19. [Epub ahead of print].
Taliaferro, L. A., & Muehlenkamp, J. J. (2017). Nonsuicidal self-injury and suicidality
among sexual minority youth: Risk factors and protective connectedness factors.
Academic Pediatrics, 17(7), 715–722. https://doi.org/10.1016/j.acap.2016.11.002.
Teasdale, B., & Bradley-Engen, M. S. (2010). Adolescent same-sex attraction and mental
health: The role of stress and support. Journal of Homosexuality, 57(2), 287–309.
https://doi.org/10.1080/00918360903489127.
Testa, R. J., & Hendricks, M. L. (2015). Suicide risk among transgender and gender-
nonconforming youth. In P. Goldblum, D. L. Espelage, J. Chu, B. Bongar, & P.
Goldblum (Eds.). Youth suicide and bullying: Challenges and strategies for prevention and
intervention (pp. 121–133). New York, NY, US: Oxford University Press.
Testa, R. J., Michaels, M. S., Bliss, W., Rogers, M. L., Balsam, K. F., & Joiner, T. (2017).
90
Children and Youth Services Review 102 (2019) 79–90
Suicidal ideation in transgender people: Gender minority stress and interpersonal
theory factors. Journal of Abnormal Psychology, 126(1), 125–136. https://doi.org/10.
1037/abn0000234.
Toomey, R. B., & Russell, S. T. (2016). The role of sexual orientation in school-based
victimization: A meta-analysis. Youth & Society. https://doi.org/10.1177/
0044118X13483778 Retrieved from.
Van Orden, K. A., Cukrowicz, K. C., Witte, T. K., & Joiner, T. E. (2012). Thwarted be-
longingness and perceived burdensomeness: Construct validity and psychometric
properties of the interpersonal needs questionnaire. Psychological Assessment, 24(1),
197–215. https://doi.org/10.1037/a0025358.
Whitaker, K., Shapiro, V. B., & Shields, J. P. (2016). School-based protective factors re-
lated to suicide for lesbian, gay, and bisexual adolescents. The Journal of Adolescent
Health, 58(1), 63–68. https://doi.org/10.1016/j.jadohealth.2015.09.008.
Wilson, E. C., Chen, Y. H., Arayasirikul, S., Raymond, H. F., & McFarland, W. (2016). The
impact of discrimination on the mental health of trans*female youth and the pro-
tective effect of parental support. AIDS and Behavior, 20(10), 2203–2211. https://doi.
org/10.1007/s10461-016-1409-7.
Ybarra, M. L., Mitchell, K. J., Kosciw, J. G., & Korchmaros, J. D. (2015). Understanding
linkages between bullying and suicidal ideation in a national sample of LGB and
heterosexual youth in the United States. Prevention Science, 16(3), 451–462. https://
doi.org/10.1007/s11121-014-0510-2.