Suicidal behaviour in gay, lesbian, and bisexual youth
BMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7250.1617 (Published 17 June 2000) Cite this as: BMJ 2000;320:1617
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Bagley and D'Augelli contended that suicidal behavior in bisexual,
gay, and lesbian (BGL) youth is "an international problem that is
associated with homophobic legislation."(p1617) Heretofore, no cross-
cultural research existed to empirically examine their assertion.
However, a recently published study found considerable cross-cultural
variation in suicidality by sexual orientation. The present study
reexamined these intercontinental data to determine whether variations in
suicide ideations or attempts are associated with national legislation
concerning homosexual (a) adoption, (b) military service, (c) employment,
and (d) marriage or domestic partnership.
A more detailed description of the Participants and Methods and the
survey instrument can be found elsewhere. Four English-speaking
countries were selected from the intercontinental study2: Australia (n =
185, 17.3% BGL), Canada (n = 1,178, 10.95% BGL), United Kingdom (n = 116,
12.9% BGL), and United States (n = 34,843, 13.41% BGL). Only countries
with n = 15 for each category were included, as needed to detect a
proportional difference of 0.10, assuming a population proportion of M =
0.50 (no difference), alpha = .05, and 70% power. An index was created
for national governments' positions regarding each of the aforementioned
issues (a-d). Scoring was 0 (no position), +1 (prohibited), and -1
(protected), with a range of +4 to -4.
The scoring was as follows. Australian = -1: Adoption (0), marriage
or domestic partnerships (0), employment discrimination (0), military
service (-1). Canada = -4: Cf. Canadian Charter of Rights and Freedoms
Section 15(1), 1982; Human Rights Act of 1996; judicial decisions.
Adoption (-1), domestic partnerships (-1), employment discrimination (-1),
and military service (-1). United Kingdom = -2: Adoption (0), marriage
or domestic partnerships (0), employment discrimination (-1), military
service (-1). United States = +2: Adoption (0), marriage or domestic
partnerships (+1, Public Law 104-199), employment discrimination (0),
military service (+ 1, cf. Department of Defense Directive 1332.14,
January 28, 1982).
Table 1 shows each countries' cumulative index for homosexual-related
legislation (index). It then shows suicide ideation (I) and suicide
attempts (II) by each sexual orientation and country, with the OR and 95%
CI for BGL/Heterosexual risks. The final 2 columns reflect the Pearson's
correlation and its p-value for the relation between homosexual-related
legislation and suicidality cross-culturally. Homosexual suicide attempt
percentages were strong and statistically significant, but inversely
related to the index, r = -0.952, p <.05. The index was not
significantly associated with other suicidality variables.
Bagley and D'Augelli1 postulated a top-down, public policy model that
contended legislation mediates a putative relation between suicidality and
sexual orientation internationally. Conversely, Mathy2 hypothesized a
bottom-up, social constructivist model that suggests cultural attitudes
toward human sexuality mediate the relation between suicidality and sexual
orientation. The present study provides empirical evidence discomfirming
the public policy model. Thus, direct challenges to homosexual-related
public policy would appear to be a less effective strategy for preventing
gay and lesbian suicide attempts than would effecting positive changes in
cultural attitudes toward human sexuality.
Table 1. Suicide Ideators and Attempters (% Yes) by Sexual Orientation and Country, with National Index Scores for Legislative Policies Concerning Homosexuality, Pearson Product Moment Correlation Across Countries, and Associated Probabilities. Australia Canada UK US r p Legislation Scores -1 - 4 - 2 +2 I. Suicide Ideations Homosexual 28.1 28.5 18.8 25.3 -.102 .898 Heterosexual 24.2 14.9 18.0 13.8 -.096 .904 OR (95% CI) 1.23 (0.52, 2.88) 1.05 (0.27, 4.08) 2.28 (1.50, 3.45) 2.13 (1.98, 2.29) .564 .436 II. Suicide Attempts Homosexual 12.5 13.1 12.5 10.3 -.952 .048* Heterosexual 7.2 4.8 7.0 4.8 -.105 .895 OR (95% CI) 1.84 (0.55, 6.21) 1.90 (0.36, 10.07) 3.00 (1.68, 5.38) 2.28 (2.05, 2.54) .099 .901 Note: *p <.05
Competing interests: Table 1. Suicide Ideators and Attempters (% Yes) by Sexual Orientation and Country, with National Index Scores for Legislative Policies Concerning Homosexuality, Pearson Product Moment Correlation Across Countries, and Associated Probabilities.Australia Canada UK US r pLegislation Scores -1 - 4 - 2 +2 I. Suicide IdeationsHomosexual 28.1 28.5 18.8 25.3 -.102 .898Heterosexual 24.2 14.9 18.0 13.8 -.096 .904OR (95% CI) 1.23 (0.52, 2.88) 1.05 (0.27, 4.08) 2.28 (1.50, 3.45)2.13 (1.98, 2.29) .564 .436II. Suicide AttemptsHomosexual 12.5 13.1 12.5 10.3 -.952 .048*Heterosexual 7.2 4.8 7.0 4.8 -.105 .895OR (95% CI) 1.84 (0.55, 6.21) 1.90 (0.36, 10.07) 3.00 (1.68, 5.38) 2.28 (2.05, 2.54) .099 .901Note: *p <.05
In their editorial on suicidal behaviour in gay, lesbian and bisexual
youth, Bagley and Augelli 1 refer to the effects of societal and
institutional homophobia on the mental health of these at risk young
people. I
agree that restrictive legislation allows intolerance in the community and
its institutions to rest unchallenged.
As an important social institution, the medical profession has a role
in
working against prejudice, and has a duty to do so, at least in part to
atone for its treatment of gay, lesbian and bisexual people in the past,
but
also because almost all people seek medical advice at some time. One way
or
another, the success of many clinical interventions is partly determined
by a
trusting relationship between doctor and patient.
A number of studies have shown that lesbians and gay men still have
adverse experiences when consulting health professionals, especially
mental health
professionals 2 3. Such experiences include the health professional
ignoring the effects of living as a stigmatised person, ascribing problems
to the
person’s sexuality, focussing on sexuality when it is not the
issue,
and failure to acknowledge the importance of the person's partner.
Legislation change is critical as part of a broader social process
leading
towards acceptance of all minority groups of difference in our society.
New
Zealand's Human Rights legislation has helped reduce prejudice by
making exclusionary employment, educational, housing and other policies
and
practices illegal.
However, as a profession we still have much to do. Many of the lesbians in
our study felt that ignorance was the cause of problems they had had with
clincians, a view supported by other researchers 4. Our undergraduate and
postgraduate training needs to include material on different sexual
orientations and the relevant developmental and life issues. We are not
especially good
at this in New Zealand, despite our legislation. Here in the UK, the
profession should take a lead by tackling these in house issues as a
demonstration that at least some sectors of the wider community are ready
for change.
1. Bagley C, D'Augelli AR. Suicidal behaviour in gay, lesbian and
bisexual
youth. BMJ 2000;320:1617-1618.
2. McFarlane E. Diagnosis Homophobic - the experiences of lesbians,
gay
men and bisexuals in mental health services. London: PACE, 1997.
3. Welch S, Collings S, Howden-Chapman P. Lesbians in New Zealand:
their
mental health and satisfaction with mental health services. Australian and
New Zealand Journal of Psychiatry 2000;34:256-263.
4. Lapsley H. Mental health issues for lesbians. In: Romans S,
editor.
Folding back the shadows: a perspective on women's mental health. Dunedin:
University of Otago Press, 1998:137-146.
Competing interests: No competing interests
Dear Sir - The editorial, 'Suicidal behaviour in gay, lesbian and
bisexual youth' by Bagley and D'Augelli (BMJ 2000;320:1617-1618.(17 June)) highlights the tragic problem of
suicide among this
group of people.
They maintain that this must be directly linked to homophobia and
persecution in some schools. I think they are probably right and everyone
must condemn such attitudes of hatred and exclusion.
What cannot be accepted though is how they automatically link such
homophobic behaviour with the retention of Section 28 on the statute
books.
While this may seem, on the surface, a natural linkage it does not
actually have any evidence behind it and is a highly unscientific
conclusion to make in an editorial.
Section 28 is not homophobic in itself and within the legislation there is
ample room for discussion with pupils in a sensitive and caring way about
every aspect of human sexuality without condemning minorities. All Section
28 prevents is the active promotion of the homosexual lifestyle. It is
perfectly possible to keep Section 28 while still supporting and helping
those adolescents who are still struggling with their sexual orientation
or who are homosexual.
Many of us (and certainly the majority of us in Scotland) believe that
retention of Section 28 prevents vulnerable adolescents from being steered
into a homosexual lifestyle which is not inevitable for them as their
sexuality emerges and changes. It is well known that many boys go through
a
temporary homosexual orientation which is not fixed. For many of them it
would be a tragedy if they were pushed by active promotion to experiment
in homosexual practice before they have completed their teenage years. We
need
to remember that Section 28 was introduced because some schools were
pushing very hard to do just that - along with literature with line
drawings showing homosexual intercourse. It is not homophobic to deter
such promotion. To increase such promotion might even increase the suicide
rate. I say 'might' because we do not know. Bagley and D'Augelli seem so
certain of the opposite view but without any evidence.
Our Scottish parliament is about to remove Section 28 against the wishes
of the electorate in a flurry of ill thought-out political correctness.
Sadly, Bagley and D'Augelli. while undoubtedly genuinely concerned are
falling into the same trap.
Dr. Antony Latham
Competing interests: No competing interests
It is clear from Drs Stammers and Ward's responses that they have no
inkling of the pressures of growing up gay in an atmosphere almost
universally hostile. Not enough is heard in this debate about the effects
of such legislation on lesbians and gay people growing up in this country,
and all too much from morallists arguing (often from a religious
standpoint) from a position of complete ignorance.
Of course repealing this act will not immediately have any effect,
but over time attitutdes may change and this is the way forward. There are
many things that maintained schools should not be promoting, but we do not
have legislation specifically preventing it.
Competing interests: No competing interests
Sir,
At the very time when the media are saturated with stories of medical
negligence, medical arrogance and medical indifference, much to the
chagrin of people here, a BMJ editorial clearly identifies a social group
with four times the suicide rate of many other people [1] and the only
responses to this fact from ‘caring medical men’ are:
"…such a blatant example of politically correct propaganda as Bagley
and D'Augelli's editorial should [not] have been accepted by the BMJ."
[2]; "Clearly if you are anti-Section 28 you can ride your hobby-horse all
over the BMJ with little restraint." [2]; and a ‘bad Samaritan’ would
rather cross the street and avoid it because “he cannot condone
homosexuality due to Christian conviction” [3]. A further correspondent
denounces this editorial as: "another biased contribution, adding little,
if anything to the debate. In addition, I find difficulty in seeing the
reason it was accepted and published in the BMJ." [4]
Are these people at all aware of the detrimental implications of
these antiquated attitudes for the medical profession at this sensitive
time? Clearly not. Do they not bring even further shame to a profession
they would otherwise be proud members of? I would think that any other
clearly defined social group, with such a high suicide rate, would warrant
more than a little medical attention, not to say compassion. Is this the
best they can do? One wonders with some trepidation what other
reprehensible social prejudices lurk in the minds of British medical
practitioners.
Thunderous hair-splitting on points of theology [3] is hardly suited
to this forum, and Dr Young might be better asked to place his beloved
Bible to one side and get back to the main issue. By his account, Jesus is
even more uncompassionate and judgemental than I ever imagined and even
more unworthy of being called ‘spiritual’. I thank Dr Young for giving me
such a good example of why I lament having been brought up as a child with
such a mish-mash of heartless gibberish that has the gall to call itself a
religion. What he calls the "vehemence of his response" was clearly not
vehement enough by half. I never used the word ‘impossible’ in my letter.
It was not religious dogma, but compassion that was the gist of my
letters. Tolerance, forgiveness, acceptance, compassion and love - without
these, as healing social forces at work in society, what type of society
would we be living in? Well, these onerous correspondents clearly tell us:
they do not believe that this social group warrants any type of medical
attention at all, and would not flinch in consigning them to lives of
further misery, marginalisation and suicide. Nor should such material even
be published in the hallowed pages of BMJ. That is their clear message. If
that is ‘Christian compassion’ then this term must rank as a monumental
contradiction in terms.
The blather of prejudice, yes, but not a single word of rational
argument has thusfar been presented which demonstrates why the
marginalised people in Bagley and D’Augelli’s editorial should continue to
suffer in the way they do. In their view, Section 28 condemns these people
to that miserable style of life and that it should be lifted. That much
seems self-evident. I have presented clear reasons why greater tolerance
might comprise a better path than continued hostility. Where is the
‘vehemence’ in that?
It is noteworthy that these correspondents, who would seem to claim
to be compassionate medical practitioners, would prefer to keep Section 28
and to let the youth suicide rates continue to soar. Where, I ask, is the
compassion - human, medical or Christian - in that? They appear to bring
further disgrace to this profession. And to claim ‘religious conviction’
is a blatant hypocrisy. Their heartless and inflexible attitude reminds
one of certain Salvation Army hostels who used to force tramps to sing a
hymn if they wanted a bowl of soup, or missionaries in Africa brainwashing
natives and making them wear clothes. Come back Ivan Pavlov and B F
Skinner all is forgiven.
One wonders how different, if any, their responses would be to the
medical needs of vagrants, the elderly, black people, the disabled, the
Third World poor - other clearly marginalised social groups with medical
problems of their own. Would they also comprise "hobbyhorses of political
correctness" worthy only of such disgraceful indifference? Their comments
beggar belief from so-called medical professionals. What century and what
country are they living in? They seem shamelessly eager to parade
themselves as appalling examples for the rest of their profession, at the
very time when it is facing such hostile media scrutiny. How to shoot
yourself in the foot without really trying.
Sources
[1] C Bagley and A R D’Augelli, BMJ 2000;320:1617-1618 (17 June)
Editorials, Suicidal behaviour in gay, lesbian, and bisexual youth
http://www.bmj.com/cgi/content/full/320/7250/1617
[2] BMJ letter 1 July 2000, Dr Trevor Stammers, Hobbyhorse or serious
editorial?
[3] BMJ letter, June 2000, Dr Alan Young, Tolerance, Intolerance and
Care - 2 letters
[4] BMJ letter, 30 June 2000, Dr Ian Ward, Hobbyhorse or serious
editorial?
Competing interests: No competing interests
Dear Sir,
Dr Morrell has posted a second response to the original editorial
which is in contrast to his first. I found the first (not available when I
wrote) a gently reasoned response .1 My letter seems to have provoked
something quite different.
I struggle with his second response as follows:
1. His presumptions
He writes
“It seems one can use ‘religious conviction’ as a fall-back
position from which to denounces just about anything you personally
despise..”
“I’m afraid many will see this type of remark as a thinly-
disguised example of homophobic gay-bashing.”
“I presume that Dr Young rejects homosexuals from the human
family on religious grounds? Or on personal grounds, which he justifies
with religious dogma. You could use the same argument to justify excluding
black people, Jews, the disabled, those who smell, the poor, old people,
even the diseased – in short, anyone you dislike.” 3
On the basis of my short response he ‘presumes’ too much.
2. His interpretation of Jesus’ actions
He writes
“True compassion is to love and accept all other human beings
wholly and unconditionally, in the fullness of their being, regardless of
who they are or what ‘bad’ they have done. As soon as any element of
judgement creeps in, then inevitably it is not true compassion, but a
disguised form of selfishness, devoid of charity and shot through with
strands of hatred.”
“True compassion, I would maintain, is blind to dogma, it is
a generous, unselfish and loving impulse to help others, to care for them,
which reaches out indiscriminately to all living beings, without thought
of reward or judgement.”
“I do believe that this was the same impulse of Jesus Christ
himself, when he asked a prostitute to wash his feet…”3
There is no instant where Jesus asked a prostitute to do this. They were
spontaneous actions by the women themselves. The prostitute showed her
love for Jesus by washing his feet and the grief at her sins by the tears
she shed. It was on this basis that Jesus said to her, “Your sins are
forgiven.” 4
Even clearer is the account of the woman accused of adultery where Jesus
says, “Well then, I do not condemn you either. Go, but do not sin again.”
5
Jesus clearly and consistently showed the very combination of
compassion for the sinner but rejection of the actions that Dr Morrell
says is impossible.
3. Intolerance
The vehemence of Dr Morrell’s response concerns me. It may have arisen
because of the presumptions he makes about my views. If however it is not
acceptable to hold to biblical teaching and seek, falteringly and often
inadequately, to emulate Jesus’ combination of compassion for the
individual and rejection of the action, then where is the tolerance.
1. C Bagley and A R D’Augelli, BMJ 2000;320:1617 – 17 June 2000.
2. Peter Morell - e-Response 20 June 2000.
3. Peter Morrell – e-Response 28 June 2000.
4. Luke 7:48
5. John 8:11
Yours sincerely,
Alan Young
Competing interests: No competing interests
I share Ian Ward's amazement that such a blatant example of
politically correct propaganda as Bagley and D'Augelli's editorial should
have been accepted by the BMJ.
They failed to demonstrate how Section 28 had any real bearing on the
higher incidence of suicide amongst gay, lesbian and bisexual youth. There
may be many explanations for this including fear of, or infection with
HIV, the excess drug misuse in the gay community or the relative
instability of gay partnerships. The editorial also failed to consider
that the suicide rate of sexually active heterosexual youth is also three
times higher than their virgin peers(1).
Half of Bagley and D'Augelli's references are to their own work or
that of close associates and some were from very obscure journal and in
one case only a website.
Clearly if you are anti-Section 28 you can ride your hobby-horse all
over the BMJ with little restraint.
1. Adcock AG, Nagy S, Simpson JA, Selected risk factors in adolescent
suicide attempts Adolescence 1991 26 817-28
Trevor Stammers
Competing interests: No competing interests
The 'Section 28' debate going on in Britian seems to be one featured
by proponents of each opposing stance arguing from their own biased
viewpoint. I am yet to hear a balanced debate looking at all aspects
& implications of repealing section 28.
Yes, there are issues of bias and discrimination that need to be
addressed, but I think that section 28 is in many ways a side issue. What
ever happens to this piece of legislation, I think that it is unlikely to
have any effect on the issues that Bagley and D'Augelli raise. The only
way to tackle these is through long term work to change cultural and
individual's perceptions and preduces - not something that legislation has
a very good track record in.
From what I have heard and read, Section 28 prohibits the "promotion"
of homosexuality. I am yet to hear a reason why this should be changed,
nor why this stops teachers dealing with and answering questions about the
subject. Bagley and D'Augelli refer to the names children get called
along with social exclusion and psychological and physical persecution if
they identify themsleves as homosexual- this aspect will never be touched
by legislation. In addition, how relevent is research and experience in
the US & Canada directly relatable to the British context?
This editorial appears to me to be yet another biased contribution,
adding little, if anything to the debate. In addition, I find difficulty
in seeing the reason it was accepted and published in the BMJ.
Ian Ward
Competing interests: No competing interests
Sir,
Two points seem to have moved to the surface in this exchange…
Dr Alan Young from Bath says:
“The tragedy of young people in such distress that they have a
suicide rate four times higher than their peers does present a major
challenge for anyone with compassion. There are however ideas in the
editorial which merit challenging.” [1]
But then:
“It is assumed that anyone who cannot endorse the validity of
homosexuality as a lifestyle is uncaring or worse.
“I am one who, through Christian conviction, cannot endorse
homosexuality. It would therefore be inconsistent for me not to resist the
promotion of homosexuality. It would also be inconsistent of me not to
care for and have compassion for people in distress such as these young
people.” [1]
If you refuse to promote or condone it [“cannot endorse the validity
of homosexuality”], then you clearly denounce it. Where is the compassion
in that? It seems that one can use ‘religious conviction’ as a fall-back
position from which to denounce just about anything you personally
despise, and down the ages, that has been a recurrent theme for many
things. Arguably, it is not, therefore, one’s religion at all that is
repelled but your own personal sense of the matter. If you choose to, you
can also use religion to support forgiveness, humanity and true
compassion.
I’m afraid many will just see this type of remark as a thinly-
disguised example of homophobic gay-bashing. Maybe Dr Young should reflect
on this:
‘History is made only in those periods in which the contradictions of
reality are being resolved by growth, as the hesitations and awkwardness
of youth pass into the ease and order of maturity. History is a
dialectical movement, almost a series of revolutions, in which people
after people, and genius after genius, become the instrument of the
Absolute. Great men are not so much begetters, as midwives of the future;
what they bring forth is mothered by the Zeitgeist, the Spirit of the
Age...[they have] ‘a consciousness of the general Idea they were
unfolding...an insight into the requirements of the time - what was ripe
for development...the very Truth for their age...which was already formed
in the womb of time.’[2]” [3]
These backward people do not see the ‘contradictions of reality’,
wish not to be ‘resolved by growth’, wish no dialectic and no movement.
They see no ‘revolutions of history’, they decline to be ‘instruments of
the Absolute’ and thus refuse to be ‘midwives of the future’. They see no
‘development’, no ‘ripening’, no ‘unfolding’ before them, and thus see not
the ‘Truth of their age’. Such are the blind who walk in darkness. Such
are they who would condemn these people to continue living lives of
misery, marginalisation and suicide. There is, I would contend, no
Christian compassion in that. And little medical compassion either.
Carrying further this religious thread, we might say that true
compassion is rooted in love, not in religious dogma. True compassion is
to love and accept all other human beings wholly and unconditionally, in
the fullness of their being, regardless of who they are or what ‘bad’ they
have done. As soon as any element of judgement creeps in, then inevitably
it is not true compassion, but a disguised form of selfishness, devoid of
charity and shot through with strands of hatred. True compassion, I would
maintain, is blind to dogma, it is a generous, unselfish and loving
impulse to help others, to care for them, which reaches out
indiscriminately to all living beings, without thought of reward or
judgement.
Seeing as Dr Young has dragged religion into this, I will say that I
do believe that was the same impulse of Jesus Christ himself, when he
asked a prostitute to wash his feet, when healing lepers and it is also an
impulse found in many ‘great spirits’ who have graced all world religions.
It is a simple, uncomplicated and wholly un-intellectualised impulse. Many
will also say that it is the healing rock upon which medicine itself is
partly based.
The second theme is more overtly sociological. Regardless of whether
homosexuality has a genetic base, or is acquired behaviour, the fact that
such people often become trapped in loveless lives, emotionally damaged
and seek solace in drugs and suicidal impulses, is not very surprising,
considering the appalling social milieu they find themselves in. This was
explored quite well in the article by Bagley and D’Augelli [4]. But
intolerance is not the good option it seems, when you think about it more
deeply.
Intolerance and social exclusion comprise the very opposite of social
cohesion. On this basis, it is clear that highly-prized social cohesion is
only vouchsafed through tolerance, social harmony and a practical form of
forgiveness that we [most of us] daily bestow on everyone in accepting
them as part of the human family. I presume that Dr Young rejects
homosexuals from the human family on religious grounds? Or on personal
grounds, which he justifies with religious dogma. You could use the same
argument to justify excluding black people, Jews, the disabled, those who
smell, the poor, old people, even the diseased - in short, anyone you
dislike. This is not a religious argument at all, it is about a wholly
dishonourable form of personal taste, wrapped up in, and justified by, a
religious garb to make it look slightly more honourable.
All social harmony depends upon a great deal of tolerance. Thus any
form of social exclusion, which inevitably generates frictions, is a
detrimental strategy to adopt. It might be justified as a Darwinian ‘law
of the jungle’, but even a Christian would accept that we are more than
apes - one hopes? If ‘evolutionary principles’ are used to justify
homophobia, then perhaps those principles should be examined more
critically, and measured against those of compassion, tolerance, and
natural justice. These would seem to be far more precious than religious
dogma or Darwinism, quite simply because they enhance social harmony. The
cohesiveness of any society is not enhanced by adherence to such motives.
It derives from love and acceptance.
Thus, on the basis of true compassion and on social harmony, I think
that greater tolerance of homosexuality would be justified. I think that
answers the valid point Dr Young raises.
Sources
[1] BMJ letter Dr Alan Young Bath, Tolerance, Intolerance and Care
http://www.bmj.com/cgi/eletters/320/7250/1617#EL5
[2] Hegel’s Philosophy of History, p.31
[3] Will Durant, 1953, The Story of Philosophy, Washington Square
Press, USA, writing of Hegel, p.297
[4] C Bagley and A R D’Augelli, BMJ 2000;320:1617-1618 (17 June)
Editorials, Suicidal behaviour in gay, lesbian, and bisexual youth
http://www.bmj.com/cgi/content/full/320/7250/1617
Competing interests: No competing interests
Therapy for young homosexuals
Competing interests:
None declared
Competing interests: No competing interests