Journal of Adolescent Health xx (2011) xxx

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Adolescent health brief

Impact of Victimization on Risk of Suicide Among Lesbian, Gay, and Bisexual High School Students in San Francisco
John P. Shields, Ph.D., M.S.W.*, Kelly Whitaker, M.P.A., Jill Glassman, Ph.D., M.S.W., Heather M. Franks, M.A., and Kelli Howard, M.A.
ETR Associates, San Francisco, California

Article history: Received February 27, 2011; Accepted July 19, 2011 Keywords: Lesbian, gay, and bisexual youth; Suicide risk; Logistic regression; Youth Risk Behavior Survey (YRBS); Victimization

A B S T R A C T

Purpose: This study investigated the association between sexual orientation, victimization, and suicide risk-related outcomes among youth attending public high schools in San Francisco. Methods: Data from the 2009 Youth Risk Behavior Survey were analyzed using bivariate and logistic regression methods for complex samples to examine the relationship between sexual orientation, victimization, and three suicide risk-related outcomes (sadness/depression, suicide planning, and attempting suicide) while controlling for demographics and substance use. Results: Lesbian, gay, or bisexual (LGB) youth reported signicantly higher rates of substance use, victimization, and suicide risk-related outcomes than heterosexual youth. However, in the controlled regression models, victimization was a signicant predictor of sadness/depression and suicide attempts, regardless of sexual orientation. There was a signicant interaction effect between sexual orientation and victimization on suicide planning, with heterosexual youth more affected than LGB youth. Conclusions: Results underscore the deleterious effect of victimization on suicide risk-related outcomes, regardless of sexual orientation. As LGB youth continue to report higher rates of victimization, effective violence prevention approaches must focus on reducing violence among youth, specically LGB youth. Additional research should focus on identication of other factors that may help further explain elevated suicide risk among LGB youth. 2011 Society for Adolescent Health and Medicine. All rights reserved.

Adolescents who self-identify as lesbian, gay, or bisexual (LGB) are two to three times more likely to report suicidal ideation and attempts than heterosexual (H) youth [1,2]. LGB youth have also reported higher rates of mental health and substance use problems than H youth [2,3], and higher rates of these problems have been associated with higher rates of suicidal ideation and attempts in adolescents [4,5]. Research also suggests that exposure to harassment and violence may be another risk factor explaining elevated suicide risk among LGB youth [4,6]. This is of particular concern because LGB youth have consistently reported harassment, bullying, and other forms of victimization at signicantly higher rates than H youth

[2,7,8]. In one school-based survey, 84.6% of lesbian, gay, bisexual, and transgender (LGBT) middle and high school students reported verbal harassment, 40.1% reported physical harassment, and 18.8% reported being assaulted at school because of their sexual orientation [9]. The goal of this study was to investigate the association between sexual orientation, victimization, and suicide risk-related outcomes for youth attending high school in the San Francisco Unied School District (SFUSD) while controlling for substance use and demographics. Methods Sampling The current study used data from SFUSDs 2009 Youth Risk Behavior Survey (YRBS), a population-based survey developed

* Address correspondence to: John P. Shields, Ph.D., M.S.W., Senior Research Associate II, ETR Associates, 251 Rhode Island St., Suite 204, San Francisco, CA 94103. E-mail address: johns@etr.org (J.P. Shields).

1054-139X/$ - see front matter 2011 Society for Adolescent Health and Medicine. All rights reserved. doi:10.1016/j.jadohealth.2011.07.009

J.P. Shields et al. / Journal of Adolescent Health xx (2011) xxx

by the CDC (84% response rate, n across 15 SFUSD high schools). Measures

2,154 students in grades 9 12

Table 1 Bivariate association between sexual orientation and substance use, victimization, and suicide risk-related outcomes Indicator Unweighted n (weighted %) LGB Ever used alcohol or marijuana Ever used cocaine, heroin, and other drugs Past 12 months, skipped school due to lack of safety Past 12 months, threatened or injured with a weapon at school Past 12 months, bullied at school Past 12 months, in a physical ght that resulted in an injury Past 12 months, in a physical ght Past 12 months, victimization indicator (one or more of above) Past 12 months, sad/depressed for at least 2 weeks Past 12 months, made a suicide plan Past 12 months, attempted suicide
a

Odds ratiosa

Three suicide risk-related outcomes from the YRBS were analyzed as dichotomous dependent variables: sadness/depression (i.e., during the past 12 months, did you ever feel so sad or hopeless almost every day for 2 weeks or more in a row that you stopped doing some usual activities?), suicide plan (i.e., during the past 12 months, did you make a plan about how you would attempt suicide?), and suicide attempt (i.e., during the past 12 months, how many times did you actually attempt suicide?). Independent variables included age, race, gender, sexual orientation, and three scales derived using factor analysis: (1) a veitem scale measuring alcohol and marijuana use ( .846) (i.e., current alcohol use, binge drinking, drinking at school, marijuana use, marijuana use at school), (2) a ve-item scale measuring other drug use ( .878) (i.e., lifetime use of cocaine, inhalants, heroin, methamphetamines, ecstasy), and (3) a ve-item scale measuring victimization ( .580) (i.e., in past 12 months bullied at school, skipped school for safety concerns, got in a physical ght, injured in a ght, threatened or injured with a weapon at school). These scales were dichotomized for the logistic regression analyses. Sexual orientation was measured by the item Which of the following best describes you? which included a four-item response set (Heterosexual [straight]; Gay or lesbian; Bisexual; not sure). For this study, the variable was dichotomized into H and LGB, and the not sure option was removed from analysis, following the approach of previous research [4,7]. Analysis Bivariate associations were analyzed to assess differences in characteristics by sexual orientation. Separate binary logistic regression models for complex samples were used to assess the relationship between sexual orientation, victimization, and the three dependent variables while controlling for demographics and substance use. Odds ratios (ORs) and adjusted odds ratios (AORs) were used to describe effect sizes. Statistical signicance was set at p .05. Results LGB youth reported signicantly higher rates of substance use, victimization, and suicide risk-related outcomes than H youth (Table 1). Statistically signicant ORs ranged from 3.3 to 6.2 across measured indicators. No signicant interaction effect between sexual orientation and victimization was found in the logistic regression models examining sadness/depression or suicide attempt. In both models, sexual orientation and victimization showed statistically signicant main effects after controlling for demographics and substance use (Table 2). A signicant interaction effect between sexual orientation and victimization was found in the model examining suicide plan. Therefore, we calculated the following conditional AORs: the AOR for making a suicide plan for victimized versus nonvictimized LGB youth was 1.08 (95% CI: .4 2.8), whereas the AOR for victimized versus nonvictimized H youth was 3.0 (95% CI: 2.0 5.0). The conditional AOR for making a suicide plan for LGB

H 465 (28%) 216 (13%) 103 (6%) 109 (6%) 214 (11%) 37 (2%) 347 (20%) 555 (31%) 419 (22%) 195 (10%) 116 (8%) 4.9b 5.1b 3.7b 4.1b 3.3b 6.2b 5.1b 3.6b 3.3b 3.9b 3.6b

71 (66%) 50 (43%) 21 (18%) 26 (21%) 34 (29%) 14 (12%) 49 (46%) 70 (62%) 56 (49%) 36 (31%) 23 (23%)

Odds ratios represent the ratio of the odds of indicator variable being yes for LGB versus H students. Associations are statistically signicant at p .05.

versus H victimized youth was 1.6 (95% CI: .8 3.3), whereas for LGB versus H nonvictimized youth it was 4.4 (95% CI: 2.3 8.6). Discussion No differential effect of victimization was found on the reports of sadness/depression or suicide attempts for LGB versus H youth. Controlling for demographics and substance use, victimization and sexual orientation were found to be signicant risk factors for these two suicide risk-related outcomes. By contrast, there was a differential effect of victimization on reported suicide planning, with H youth reporting more severe consequencesa threefold increase in the odds of suicide planning for H youth reporting victimization versus a negligible increase for LGB youth reporting victimization. Yet, among nonvictimized youth, those who reported being LGB were four times more likely to make a suicide plan than those who reported being H. Together, these results suggest there are factors beyond those included in our models that further explain the higher overall rates of suicide risk-related outcomes among LGB youth [10]. Conclusions Despite the sample size limitations of this study and its focus on relatively low prevalence outcomes, which can undermine statistical power because of low cell counts, the results do underscore the deleterious effect of victimization on suicide-related outcomes among both LGB and H youth in our school-based sample. Our results also conrm that more research is needed on other contextual factors and experiences beyond those measured by our models (e.g., family support, community characteristics), which might also be affecting the higher rates of suicide attempts among LGB youth [10]. Only the suicide planning model showed a statistically significant differential effect of victimization across LGB versus H youth, with H youth being more severely affected. Although it does not appear that victimization disproportionately affected

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Table 2 Logistic regression analysis results by suicide risk-related outcome Parameter B Standard error Hypothesis test tb Sadness/depression Gender Raced Sexual orientation Alcohol/marijuana use Other drug use Victimization Gender Raced Sexual orientation Alcohol/marijuana use Other drug use Victimization Sexual orientation by victimization Gender Raced Sexual orientation Alcohol/marijuana use Other drug use Victimization .438 .845 .502 .446 .956 .291 1.491 .237 .680 1.093 1.007 .260 .808 .120 .814 1.242 .126 .222 .166 .201 .140 .146 .331 .214 .209 .205 .503 .218 .313 .255 .243 .229 3.472 3.807 3.024 2.221 6.822 1.993 4.500 1.103 3.264 5.331 2.00 1.191 2.58 .471 3.347 5.426 dfc 89 89 89 89 89 89 89 89 89 89 89 89 89 89 89 89 89 89 89 Signicance .001 .019 .000 .003 .029 .000 .049 .460 .000 .273 .002 .000 .049 .237 .376 .012 .638 .001 .000 .645 2.327 1.652 1.563 2.602 .747 4.440 1.267 1.975 2.983 .365 .771 2.243 .887 2.257 3.461 AORa Exp(B) 95% Condence interval for Exp(B) Lower .502 1.497 1.188 1.048 1.969 .559 2.299 .827 1.305 1.985 .134 .500 1.204 .534 1.392 2.197 Upper .829 3.617 2.299 2.330 3.437 .999 8.575 1.940 2.989 4.483 .993 1.190 4.177 1.472 3.661 5.454

Suicide plan

Suicide attempt

a b c

AOR adjusted odds ratio, adjusted for all other variables in model. The t test shown here is equivalent to the Wald F test which is appropriate for hypothesis tests involving complex samples (Morel [11]). The degrees of freedom for the test of signicance for the coefcient is based on the sampling design (the difference between the number of primary sampling units and the number of strata in the rst stage of sampling). Race included six categories, and their associated Bs are not included to reduce table size given this is a control variable only.

the suicide risk of LGB youth relative to H youth in this sample, more rened measures incorporating the type, severity, and intent of victimization experienced by LGB youth are needed. Currently, the YRBS does not routinely include such items, nor indeed any items on sexual orientation in many communities. As LGB youth continue to report higher rates of victimization, there remains a need for additional investment in the development and implementation of effective prevention approaches that reduce victimization for all youth and among LGB youth specically. Acknowledgments This research was funded by the San Francisco Unied School District under cooperative agreement with the CDCs Division of Adolescent and School Health, National Center for Chronic Disease Prevention and Health Promotion (5U87DP001177-03). References
[1] DuRant RH, Krowchuck DP, Sinal SH. Victimization, use of violence and drug use at school among male adolescents who engage in same-sex sexual behavior. J Pediatr 1998;133:113 8.

[2] Garofalo R, Wolf RC, Kessel S, et al. Association between health risk behaviors, sexual orientation among a school-based sample of adolescents. Pediatrics 1998;101:895902. [3] Russell ST. LGBTQ youth are at risk in U.S. school environment. SIECUS Report 2001; 29:19 22. [4] Russell ST, Joyner K. Adolescent sexual orientation and suicide risk: Evidence from a national study. Am J Public Health 2001;91:1276 81. [5] Robin L, Brener ND, Donahue SF, et al. Association between health risk behaviors and opposite, same and both sex sexual partners in representative samples of Vermont and Massachusetts high school students. Arch Pediatr Adolesc Med 2002;156:349 55. [6] Hershberger SL, DAugelli AR. The impact of victimization on the mental health and sucidality of lesbian, gay, and bisexual youths. Dev Psychol 1995;31:6574. [7] Bontempo DE, DAugelli AR. Effects of at school victimization and sexual orientation on lesbian, gay, or bisexual youths health risk behavior. J Adolesc Health 2002;30:364 74. [8] Goodenow C, Szalzcha L, Westheimer K. School support groups, other school factors and the safety of sexual minority adolescents. Psychol Schools 2006;43:573 89. [9] GLSEN, The 2009 National School Climate Survey. New York, NY: Gay, Lesbian and Straight Education Network, 2009. [10] Silenzio VM, Pena JB, Duberstein PR, et al. Sexual orientation and risk factors for suicidal ideation and suicide attempts among adolescents and young adults. Am J Public Health 2007;97:20179. [11] Morel JG, Logistic regression under complex survey designs. Survey Methodology 1988;15(2):20323.