Clinical Context

Does self-harm activity suggest a higher risk for suicide? This was the clinical question considered by Birtwistle and colleagues, who published their study in the August 15, 2017 issue of the Journal of Affective Disorders.^[1] Researchers examined case records from 2 large urban hospitals in Leeds, England to answer their study question. They were particularly interested in the effects of self-harm via poisoning vs injury as potential risk factors for subsequent suicide.

There were 6155 patients (58% female, 42% male; median age: 32 years) who committed a total of 10,829 episodes of self-harm. Self-poisoning was the most common form of self-harm (72.3% of cases), but nearly 28% of cases of self-harm featured self-injury; 6.9% of patients combined self-poisoning with other self-injury.

The average follow-up time was 53 months after the self-harm event, and there were 339 deaths in the study cohort during follow up. A total of 69 of these deaths were due to suicide. Researchers found that a repeat self-harm event within 30 days of the original event was associated with nearly a 4-fold increase in the risk for suicide. Rates of suicide after self-poisoning or self-injury were similar; however, compared with either form of self-harm alone, the combination of self-poisoning plus self-injury was associated with a 3-fold increase in suicide. These outcomes were similar regardless of age and gender.

Persons from sexual orientation minority groups have higher rates of mental health disorders and risk for suicide. The current study by Chum and colleagues compared suicide-related behavior (SRB) among heterosexual/straight, gay or lesbian, and bisexual adults in a large sample of adults in Canada.

Study Synopsis and Perspective

Members of sexual minorities, particularly bisexual women, are at greater risk for SRB compared with heterosexuals, a new study indicates.

In a population-based study that included approximately 124,000 participants, the overall prevalence of 1 or more SRB events was 2.2% among heterosexual participants, 5.2% among gay or lesbian participants, and 8% among bisexual participants. In addition, gay men and lesbians were about twice as likely to make fatal and nonfatal suicide attempts compared with heterosexual participants.

This study is, according to the researchers, the first to link population-based survey data with health records for more than 123,000 individuals. This technique is intended to overcome the problem of survival bias (ie, not including persons who have died from suicide or are too ill to be included in surveys).

Despite the novel methodology, the results aligned with previous survey-based research, study author Antony Chum, PhD, chair in population health data science at York University in Toronto, Canada, told Medscape Medical News.

"The surprising part was that the crude incidence rates for SRB among bisexuals was as high as it was: over 5900 events per 100,000 person-years vs around 200 events in heterosexuals," Chum said. 

The study was published online June 7 in the American Journal of Psychiatry.^[2]

Less Support

The investigators linked data from the population-based Canadian Community Health Survey to health administrative records from 2002 to 2019 to analyze differences in time to SRB events across sexual orientations using Cox proportional hazards regression.

Their models incorporated the following sociodemographic information: year of birth, gender, ethnic minority status, level of education attained, marital status, rural vs nonrural domicile, and comorbidity indicator.

The primary outcomes were nonfatal self-harm and fatal suicide events associated with an emergency department presentation or hospitalization.

The sample included 123,995 participants, and the unweighted data set included approximately 2.1 million person-years (PY). The average follow-up time was 11.4 years. Bisexual participants were younger than the rest of the sample (mean age, 33.9 years vs 42.3 years), and fewer of them had completed postsecondary education (42.8% vs 52.6%).

During the study period, 164 people died from suicide, and 3192 people had at least 1 nonfatal SRB event.

The approximate crude incidence rates of SRB events per 100,000 PY were 225 for heterosexuals, 665 for gay and lesbian participants, and 5912 for bisexual participants.

In fully adjusted, gender-combined models, bisexual participants were 3 times more likely to have an SRB event, and gay men and lesbians were 2.1 times more likely to have such an event compared with heterosexuals.

Further analyses showed that the hazard ratio for these events for bisexual men compared with gay men was 0.97. For bisexual women compared with lesbians, it was 1.56.

"Bisexual women may experience less support from the [lesbian, gay, bisexual, transgender, queer/questioning, plus (others) (LGBTQ+)] community, compared to gays or lesbians," said Chum. "This is probably because of bi-erasure or biphobia, where bisexuality is dismissed, denied, or stigmatized by both the heterosexual community and LGBTQ+ community.

"This lack of support may lead to stress, isolation, and increased mental health risks, including SRB events," he said. "In addition, bisexual women tend to be at a higher risk of experiencing trauma, particularly from intimate partner violence, compared to lesbian women."

The findings align with those of the authors' related study published in March in PLOS One,^[3] which found that sexual minority status and living in neighborhoods with poor access to health care were independent risk factors for SRB, Chum noted.

The team is now conducting a study that examines patterns of follow-up outpatient mental health care across sexual orientations, and they plan to evaluate the impact of gender-affirming care on mental health and SRB of transgender individuals, who were not included in the current study. 

Clinicians Can Help

Commenting on the findings for Medscape, Albina Veltman, MD, associate chair of equity, diversity, inclusion, and indigenous reconciliation and associate professor of psychiatry and behavioral neurosciences at McMaster University in Hamilton, Ontario, said they are consistent with those of previous studies.

"Running a small clinic that specializes in working with individuals who identify as two-spirit LGBTQ+, I am fully aware that the risk of suicidality in this population is higher than those who identify as cisgender and heterosexual," she said. "Suicide risk assessment is top of mind for me with every patient I see." 

Much of Veltman's work focuses on "supporting my patients through potentially challenging and difficult situations such as coming out to their friends, family, or coworkers and helping them cope with instances of homophobia, biphobia, or transphobia," she said. "We know from other studies that the minority stress that people experience ... accounts for the vast majority of the increased risk for suicidality in lesbian, gay, and bisexual people, rather than the risk being due to something inherent in having these identities."

Healthcare professionals should be aware of the increased risk and screen their patients for other risk factors, such as lower social supports, she said. 

Increased education is also important, advised Veltman, who explained, "Most healthcare providers feel unprepared to provide care to individuals who identify as [two-spirit, lesbian, gay, bisexual, transgender, queer or questioning (2SLGBTQ+)] because they have not had sufficient education and training about these topics."

Furthermore, healthcare professionals and clinicians can be allies to the 2SLGBTQ+ community, she said, "meaning that you are willing to learn and you are willing to listen."

Chum added that clinicians can provide LGBTQ+-affirming care that acknowledges and validates patients' identities: "Avoid making assumptions or imposing heteronormative or cisnormative expectations. Tailor treatment plans to their unique needs and experiences."

In addition, he said, "Advocate for LGBTQ+ rights and equality. Speak out against discrimination, stigmatization, and marginalization of LGBTQ+ individuals. Advocate for policies that protect their rights and improve their access to healthcare."

Resources for training on these issues include Rainbow Health Ontario in Canada and the Boston-based National LGBTQIA+ Health Education Center.

The study was funded by a Canadian Institutes of Health Research project grant. Chum is supported by the Canada Research Chair program. Chum and Veltman declared no relevant financial relationships.

Implications for the Healthcare Team

• In a previous study by Birtwistle and colleagues of SRB presenting to the healthcare system, nearly three-quarters of events were self-poisoning. Researchers found that a repeat self-harm event within 30 days of the original event was associated with nearly a 4-fold increase in the risk for suicide. Rates of suicide after self-poisoning or self-injury were similar; however, compared with either form of self-harm alone, the combination of self-poisoning plus self-injury was associated with a 3-fold increase in suicide. These outcomes were similar regardless of age and gender.
• In the current study by Chum and colleagues that compared the risks for SRB based on sexual orientation, gay or lesbian adults had approximately a 2-fold increase in the risk of these behaviors compared with heterosexual/straight adults, and bisexual adults had a respective 3-fold increase in the risk for SRB.
• The healthcare team should monitor adults from minority sexual orientation groups for mood disorders that might promote a higher risk for SRB.

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