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Being LGBTQ+ and at Risk of Suicide, Suicide Ideation, and Self-Harm: A Systematic Review


By Ruth Spencer-Lewis


 

Background: Almost 800,000 people a year die by suicide globally. LGBTQ people are more at risk of suicide ideation, suicide and self-harm. Historically suicide among homosexuals was seen as a response to being ‘outed’, but with increased acceptance and improvements in laws there should be a decrease in suicide within the LGBTQ community, but this is not the case.


Methods: The research questions which guided the review are: (1) What are the main risk factors for self-harm, suicide ideation and suicide among LGBTQ? And (2) What factors protect against the risk of self-harm, suicide ideation and suicide among LGBTQ?

A systematic search of the literature was conducted under PRISMA guidelines in PsycInfo, PsycArticles, Sage Journals, Wiley Online and Science Direct. Thematic analysis was the qualitative method used to analyse the 10 articles which met the eligibility criteria.


Results: Identified were three psychological stages; realisation of identity, concealment of identity and coming out. With homophobia/transphobia, a lack of social support, having a psychological diagnosis and religious beliefs as contributing risk factors to the main risk factor of isolation throughout the stages. Identified as protective factors were self-acceptance and pride, representation of LGBTQ and social support.


Conclusions: Feelings of shame and self-hatred from homophobia experienced from a discriminatory society cause feelings of alienation and isolation leading to a lack of belonging. The LGBTQ community is often life-saving by giving a sense of pride and a community to belong to, giving a reason to live. Even in more accepting societies with equal and protective rights, there is still a long way to go for equality in society for LGBTQ people.


Keywords: LGBTQ, Suicide, Suicide Ideation, Self-harm, Isolation, Homophobia, Transphobia


 

Introduction


Lesbian, gay, bisexual, transgender and queer or questioning (LGBTQ) individuals are at higher risk of psychological distress leading to suicide and self-harm than heterosexual and cisgender people. Previously, suicide among the gay community was documented particularly among gay men due to fear of being ‘outed’ which was amplified during the 1980s with the AIDS epidemic as AIDS was seen as the gay man’s disease (Stulberg & Smith, 1988) and the introduction of Section 28 which prohibited the teaching or promotion of homosexuality within schools, this meant social stigma was rife. Society and laws at least in countries such as the UK, Canada and USA have changed massively for LGBTQ people, with increased protections in the law and acceptance of same-sex relationships have been on an increase since the 1990s (British Social Attitudes Survey, 2018) within society but LGBTQ people remain at higher risk of suicide. This literature review aims to address what puts this group at a higher risk of suicide and what may protect them.


Suicide is intentionally causing one’s own death; suicide ideation refers to thoughts of taking one’s own life. The World Health Organisation (WHO) report that globally almost 800,000 people a year die by suicide (WHO, 2016). According to the Samaritans Suicide Statistics Report (2019) the group with the highest suicide rate in the UK is men aged 45-49. In the UK men are 3 times more likely to attempt suicide than women but the Samaritans also report that suicides have been increasing among young people and is now at a record high for young females (Simms, S., Scowcroft, E., Isaksen, M., Potter, J., Morrissey, J., 2019). Suicide is the biggest killer of young people (16-24) in the UK (Simms et al., 2019) and the third biggest killer globally of 15-29 year olds (WHO). A statistic that hasn’t changed much since the Report of the Secretary’s Task Force on Youth Suicide (1989), which states that suicide more than doubled from 1950s to 1980s in the 15-24 age group to become the second biggest killer within the USA (United States, Department of Health and Human Services, Feinleib, & States, 1989).


Linked to suicide and suicide ideation is self-harm, deliberately causing hurt or injuries to one’s own body without suicidal intentions. It is often a coping mechanism for psychological distress and is most common among young people, according to the UK Adult Morbidity Survey (2016) 25.7% of women aged 16-24 and 9.7% of men in the same age group reported this, the overall figure for all age groups (16-75+) was 7.3%. Most people who self-harm do not go on to attempt suicide according to the Samaritans charity (Simms et al., 2019), however around half of people who attempt suicide have self-harmed in the past making it an important risk factor for suicide (Hawton, Saunders, & O'Connor, 2012).


In regard to suicide and suicide ideation among LGBTQ, research by Stonewall (2018), found that 31% of LGB and 47% of transgender people had suicidal thoughts in the last year with 12% of transgender people having attempted suicide. Attempted suicide for LGB people was 2%, but for youth (aged 18-24) this was 13% (Stonewall, 2018). The stonewall report (2018), shows there is a difference between sexual minorities and gender minorities when it comes to suicide and suicide ideation suggesting that transgender people are at a higher risk of suicidal thoughts than LGB people. However, biphobia is often experienced within the LGBTQ community as well as the rest of society, leading to a lack of connectedness to the community (Kertzner, Meyer, Frost, & Stirratt, 2009) and therefore lack of support and are at higher risk of suicide and suicide ideation (Figueiredo & Abreu, 2015). This may partly explain why research has found bisexuals to be at higher risk of mental health disorders (Semlyen, King, Varney, Hagger-Johnson, & Semlyen, 2016), compared to gay and lesbian people.


According to the minority stress model (Meyer, 2003), sexual minorities experience unique psychosocial stressors which can lead to mental health problems and risky behaviour (Meyer & Frost, 2012). Meyer describes the difference between distal stressors which include prejudice and discrimination coming from the outside world, and proximal stressors such as fear of rejection and internalised homophobia caused by the repeated exposure to distal stressors (Meyer, 2003).


Over the last 10 years there have been improvements in the laws in the UK including the Equality Act 2010 which includes sexual orientation, meaning it is now illegal to discriminate based upon someone’s sexuality in the UK. Same sex marriage has been legal in the UK since 2014, giving equal rights to same sex couples and the Gender Recognition Act 2004, making it possible for transgender people to legally change their gender and be issued a new birth certificate. However, even with all the improvements in laws the LGBTQ population are still more at risk of poor mental health and have higher rates of suicidality (Meyer, 2016). Therefore, at least in the UK it is not simply an issue of policy changing and law equality. There are other factors as to why LGBTQ populations are at greater risk of suicide, models such as the minority stress theory contribute to this explanation. It should be noted that across the globe there are countries far behind in terms of laws and acceptance compared to the UK. Recently some areas in Poland declaring themselves “LGBT free zones” (Noack, 2019), this is an example of the lack of acceptance and how much prejudice still exits.


This systematic review will look at qualitative research journal articles published in the last 10 years in an attempt to understand the experiences of LGBTQ people. Studies using qualitative research methods have been chosen to gain a richer and deeper understanding of LGBTQ lived experiences.


The questions this review aims to answer are:


1. What are the main risk factors for self-harm, suicide ideation and suicide among LGBTQ?


2. What factors protect against the risk of self-harm, suicide ideation and self-harm among LGBTQ?


 

Methods


Search Strategies


Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Moher, Liberati, Tetzlaff, & Altman, 2009) a systematic review was performed to identify published papers on suicidality and/or self-harm among LGBTQ. The databases used in the search were PsycInfo, PsycArticles and Sage Journals, additional articles were searched for through other databases (Wiley Online and Science Direct). The search terms used were lesbian OR gay OR bisexual OR transgender OR queer OR genderqueer OR “sexual minority” OR LGB OR LGBTQ and suicide OR “suicidal behaviour” OR “suicide attempt” OR “completed suicide” OR “suicide ideation” OR “self-harm”.



Eligibility Criteria


For an article to be included it needed to be a peer reviewed article in English and published in the last 10 years between 1st January 2010 and 29th February 2020. This time frame has been used due to wanting to keep the research recent but not too limited. This will also enable a comparison of studies conducted in 2010 with more recent studies to see if findings are consistent. The method of investigation must have been qualitative and investigating the subject of suicidality and/or self-harm within at least one aspect of LGBTQ.


A systematic review includes various steps to prepare and achieve (Khan, Kunz, Kleijnen, & Antes, 2003). Thematic analysis was conducted on the research articles identified; each article was systematically analysed to identify and interpret key themes (Clarke & Braun, 2017), by identifying patterns. An inductive approach was taken to extract explicit and underlying meanings in the articles in order to create a picture of the narratives.

 

Results


Synthesis of the Studies


The initial literature search identified 195 articles as shown in the Prisma flow diagram (figure 1). Only 1 additional article was added from another source, duplicates were then removed (n=63) leaving a remaining 132 articles to be screened of which 109 were excluded for reasons including not researching an aspect of LGBTQ, being quantitative research methods only and not being relevant to suicidality or self-harm. Full text articles remaining to be assessed was 23 of which 13 were excluding leaving 10 to be included in the systematic review. The reasons for these articles being excluded were 1. Mixed methods of quantitative and qualitative were used (n=2), 2. No research designs were used (n=3), 3. Other perspectives for examples staff of psychological services (n=2), 4. Being general to mental health and not specific to suicidality or self-harm (n=6).


The articles that were included in this systematic review are listed in Table 1. All articles used qualitative investigative methods, however these differed and are listed in the table, most using interviews with some using online methods. Other data included in the table is the purpose of each study, sample size, age data, what country the participants were recruited from and the main themes identified. Total of 4 studies were conducted in the UK, 3 were in the USA, 2 in Canada and 1 in the Philippines. Half of the studies had an age of 25 or below for either the participants age at time of the study or the age at which they attempted suicide. The sample sizes are mostly small, one study has only 4 participants, but the studies using online data have an estimated 290 contributions.










 

Risk factors for self-harm, suicide ideation and suicide among LGBTQ


All the studies analysed identify risk factors of self-harm, suicide ideation and suicide among at least one aspect of LGBTQ. Two focusing solely on the experiences of transgender people (Moody, Fuks, Peláez, & Smith, 2015; Smith et al., 2018), one on LGB people (Diamond et al., 2011), two on gay men (McAndrew & Warne, 2010; Salway & Gesink, 2018) and the rest on all LGBTQ identities (Elizabeth McDermott, 2015; McDermott, Roen, & Piela, 2015; Rivers, Gonzalez, Nodin, Peel, & Tyler, 2018; Williams, Frey, Stage, & Cerel, 2018). Together these studies have been thematically analysed and the main risk factors for self-harm, suicide ideation and suicide among LGBTQ have been identified. Three psychological stages have been identified as putting LGBTQ people at greater risk; these are realisation of identity, concealment of identity and coming out. It is important to note that these stages are interlinked, and an individual can be experiencing more than one at a time. Prominent themes identified running through these stages are homophobia/transphobia, lack of social support, having a psychological diagnosis and religious beliefs. The main risk factor that these themes contribute to is isolation, this is referred to in all the articles and suggests that LGBTQ people experience this more than heterosexual and cisgender people.



Stage 1: Realisation of identity


This was identified as a difficult time for participants in the majority of the studies (Bautista, Pacayra, Sunico-Quesada, Reyes, & Davis, 2017; Diamond et al., 2011; Elizabeth McDermott, 2015; McAndrew & Warne, 2010; McDermott et al., 2015; Moody et al., 2015; Williams et al., 2018) due to the psychological distress it creates. This period is filled with confusion and a feeling of being different and can start as children without knowing why they feel different (McAndrew & Warne, 2010). Once understanding the norms of society and what is considered acceptable behaviour, it becomes apparent why they are feeling different and that their thoughts go against social norms (Bautista et al., 2017; Elizabeth McDermott, 2015; McAndrew & Warne, 2010; McDermott et al., 2015; Williams et al., 2018). Feelings towards the opposite sex are denied, as being gay is not wanted (Bautista et al., 2017; Diamond et al., 2011; Elizabeth McDermott, 2015; Williams et al., 2018), causing psychological distress, self-hatred and withdrawal from others (Bautista et al., 2017; Elizabeth McDermott, 2015).



Stage 2: Concealment of identity


Concealing one’s identity caused great psychological distress to participants (Bautista et al., 2017; Diamond et al., 2011; Elizabeth McDermott, 2015; McAndrew & Warne, 2010; McDermott et al., 2015; Rivers et al., 2018; Salway & Gesink, 2018; Williams et al., 2018) which starts during the realisation process (Bautista et al., 2017). Concealment is an ongoing process of hiding an identity that is not the norm by not disclosing it or just to certain people (Diamond et al., 2011; Rivers et al., 2018; Williams et al., 2018). There is a need to keep one’s identity from family and friends and to have control over when people find out (Diamond et al., 2011).


For gay men, leading a ‘double life’ was a common way of describing their experiences of keeping their homosexual relations separate from their family life and/or perceived heterosexual self (McAndrew & Warne, 2010; Salway & Gesink, 2018). Salway and Gesink (2018), identified that this double life was due to the participants concealing their identity during the beginning of the AIDS epidemic and when gay entrapment by law enforcement was common causing anxiety and fear of being caught and/or ‘outed’. They also identified that most suicide attempts within their sample came before the point of coming out while trying to conceal their identity but did not attempt suicide after coming out. This suggests there is a link between concealing identity and suicide.


Feeling a need to abide by societal gender norms was a common theme in the literature in order to successfully conceal identity (Rivers et al., 2018; Williams et al., 2018), not just for transgender individuals but sexual minorities also, suggesting a link between gender and at least perceived sexual orientation.



Stage 3: Coming Out


Coming out is a stage that can have positive or negative consequences dependant on the reactions of those whom an individual discloses their sexual or gender identity (Rivers et al., 2018; Salway & Gesink, 2018; Williams et al., 2018). Before coming out there is a fear of people finding out due to the perceived consequences, therefore before coming out LGBTQ are at increased risk and if coming out is received with negative reactions then this also increases the risk of suicide (Rivers et al., 2018; Salway & Gesink, 2018; Williams et al., 2018). The greater the rejection received once disclosing their identity the more at risk of suicide an individual becomes (Rivers et al., 2018).



Homophobia/Transphobia


The literature suggests this is a main risk factor for LGBTQ of self-harm, suicide ideation and suicide (Bautista et al., 2017; Diamond et al., 2011; Elizabeth McDermott, 2015; McAndrew & Warne, 2010; McDermott et al., 2015; Rivers et al., 2018; Salway & Gesink, 2018; Smith et al., 2018; Williams et al., 2018). Homophobia for many was constant and from a young age, particularly experienced at school from peers (Diamond et al., 2011; McDermott et al., 2015; Rivers et al., 2018), and from family (Bautista et al., 2017; Diamond et al., 2011; Elizabeth McDermott, 2015; Salway & Gesink, 2018; Smith et al., 2018; Williams et al., 2018). However, studies also had participants that had experienced homophobia/transphobia at work, in clinical settings and within the community (Bautista et al., 2017; Smith et al., 2018). Experiencing homophobia increased psychological distress, leading to isolation and often depression which is associated with suicide (Bautista et al., 2017).


Internalised homophobia was common in the literature as a contributing factor adding to psychological distress due to feelings of self-hatred and loathing (Bautista et al., 2017; Diamond et al., 2011; Elizabeth McDermott, 2015; McDermott et al., 2015; Rivers et al., 2018; Williams et al., 2018).



Lack of social support


A common theme within the literature that links to homophobia is social support, a lack of social support puts an LGBTQ person at increased risk of suicidality and self-harm (Bautista et al., 2017; Diamond et al., 2011; Elizabeth McDermott, 2015; McAndrew & Warne, 2010; McDermott et al., 2015; Rivers et al., 2018; Smith et al., 2018; Williams et al., 2018). A lack of social support from friends and family can be experienced in many ways, from something subtle as just being able to tell that parents do not approve and to being physically attacked (Diamond et al., 2011; Rivers et al., 2018; Salway & Gesink, 2018), or losing a job (Smith et al., 2018).



Psychological diagnosis


Having a psychological diagnosis was identified in the literature as a risk factors (Bautista et al., 2017; Elizabeth McDermott, 2015; Rivers et al., 2018; Salway & Gesink, 2018; Smith et al., 2018; Williams et al., 2018). Due to stigma attached to mental illness some participants would reframe from seeking help (Elizabeth McDermott, 2015). Mental illness is often associated with self-harm and suicide which puts this as a risk factor, however it could be that distress caused by risk factors mentioned due to being LGBTQ cause a mental health disorder to develop (Salway & Gesink, 2018; Smith et al., 2018).



Religious beliefs


Religious beliefs and traditional values were mentioned in various studies (Bautista et al., 2017; Diamond et al., 2011; McAndrew & Warne, 2010; Rivers et al., 2018; Smith et al., 2018), as adding to internalised homophobia and homophobia/transphobia experienced from others. Families having strong religious beliefs make it harder to come out to, as a negative reaction is more likely expected (Diamond et al., 2011). Smith et al. (2018) found that rural communities were more likely to hold traditional beliefs which led to transgender participants feeling unsafe in the community and experiencing transphobia.



Isolation


The main risk factor that all these themes lead to is isolation, isolating oneself seems to start from the beginning of the realisation process and becomes particularly apparent while actively concealing identity (Bautista et al., 2017; Elizabeth McDermott, 2015; McAndrew & Warne, 2010; Rivers et al., 2018; Salway & Gesink, 2018; Williams et al., 2018). If there is a lack of social support once coming out this isolation exacerbates causing major psychological distress which is dealt with alone leading to feelings of depression, suicide ideation and suicide attempts (Bautista et al., 2017; Diamond et al., 2011; Elizabeth McDermott, 2015; McAndrew & Warne, 2010; McDermott et al., 2015; Rivers et al., 2018; Smith et al., 2018; Williams et al., 2018). For some self-harm was seen as the only option for coping through this difficult time (Elizabeth McDermott, 2015; McDermott et al., 2015). Isolation only begins to relieve when protective factors come into play, which can be at different times for different people.


 

Protective factors against self-harm, suicide ideation and suicide among LGBTQ


The main protective factors identified are self-acceptance and pride, representation of LGBTQ people and social support. A smaller but important factor is resilience (Bautista et al., 2017; Diamond et al., 2011; Moody et al., 2015; Salway & Gesink, 2018) which is built up throughout an individual’s experience if they are to get through the risk factors that are damaging to mental wellbeing and to seek out possible protective factors. Some studies also identified the protective factor of counselling and therapy (Bautista et al., 2017; Diamond et al., 2011; Moody et al., 2015).



Self-acceptance and Pride


Feeling pride for being LGBTQ and belonging to a community was crucial as a protective factor within the literature (Diamond et al., 2011; McDermott et al., 2015; Moody et al., 2015; Rivers et al., 2018; Salway & Gesink, 2018; Smith et al., 2018). In the studies conducted online, advice was often given to individuals that pride and not shame should be felt as being LGBTQ should be celebrated and should be seen as a positive aspect of identity (Elizabeth McDermott, 2015; McDermott et al., 2015). Simply acknowledging one’s own identity and accepting this can be protective, Moody et al. (2015) found that once participants had accepted that they were transgender and knew they would be able to take steps to live as their ‘true’ gender their mental health improved, and suicide ideation decreased. Belonging to the LGBTQ community brings a sense of collective identity along with individual identity and a feelings of pride which strengthens mental health and gives more of a purpose to live (Moody et al., 2015).



Representation of LGBTQ


Representation of LGBTQ in the literature refers to seeing that other people exist like you, realising you are not the only one and therefore not alone, reduces the feelings of being isolated and acts as a protective factor (Moody et al., 2015; Rivers et al., 2018; Salway & Gesink, 2018; Smith et al., 2018; Williams et al., 2018). LGBTQ support groups often come first before acceptance and help in the acceptance process (Smith et al., 2018). Finding support networks within the LGBTQ community could be online (Elizabeth McDermott, 2015; McDermott et al., 2015; Moody et al., 2015), crisis helplines (Moody et al., 2015) or in person (Moody et al., 2015; Rivers et al., 2018; Salway & Gesink, 2018; Smith et al., 2018; Williams et al., 2018). Rivers et al. (2018) found that one participant believed having the connection to the LGBTQ community was lifesaving and becoming a role model gave him a reason more important to live which reduced his suicide ideation.


When reaching out even for self-harm or suicide ideation LGBTQ people seem to seek out LGBTQ specific services and websites (Elizabeth McDermott, 2015; McDermott et al., 2015; Williams et al., 2018). This suggests that LGBTQ people feel more comfortable with others that have had similar experiences of being LGBTQ and therefore able to understand them would be less likely to experience discrimination and homophobia from.



Social support


Social support also came out as a vital protective factor within the literature (Bautista et al., 2017; Diamond et al., 2011; Moody et al., 2015; Salway & Gesink, 2018; Smith et al., 2018; Williams et al., 2018), this can be seen within the LGBTQ community that was discussed above. However, social support of family and friends is also important; how the people close to an individual react when coming out can have massive positive effects if reactions are good (Bautista et al., 2017; Diamond et al., 2011; Moody et al., 2015; Rivers et al., 2018; Salway & Gesink, 2018; Smith et al., 2018; Williams et al., 2018). For transgender individuals social support was vital before, during and after transition (Moody et al., 2015; Smith et al., 2018). Just one positive reaction and support from a family member can build resilience in order to help improve self-acceptance in the face of hostility shown by others with homophobic and negative reactions (Salway & Gesink, 2018). If lacking social support from family a ‘chosen family’ becomes a main source of support (Moody et al., 2015; Smith et al., 2018; Williams et al., 2018).



Accessing mental health services


Counselling/therapy was identified as a protective factor, however, there was more negative experiences (Diamond et al., 2011; Elizabeth McDermott, 2015; Rivers et al., 2018; Smith et al., 2018) of this documented than positive (Diamond et al., 2011; Moody et al., 2015). But where positive this does show the potential this has to become a bigger protective factor if can be inclusive of LGBTQ. Diamond et al. (2011), identified that most participants had a positive experience of counselling/therapy, with half of participants feeling the need for the practitioner to be LGBTQ or at least LGBTQ sensitive. Most participants also believed they would have benefited from family therapy. This study shows that LGBTQ want to be able to talk about their identity and emotions surrounding this in a safe space.


 

Discussion


The aim of this review was to systematically analyse the literature on self-harm, suicide ideation and suicide among the LGBTQ population in order to identify the risk factors and the protective factors. There was a total of 10 studies which met the inclusion criteria for analysis and were used in this review. The risk factors identified included three psychological stages an LGBTQ person goes through which puts them at a higher risk, these are realisation of identity, concealment of identity and coming out. Factors contributing to the risk include homophobia/transphobia (from the outside world and within oneself), lack of social support, psychological diagnosis, religious beliefs and the main overarching risk factor of isolation.


Isolation was evident in the literature as an important factor leading to self-harm and suicidality, due to feelings of alienation and loneliness from dealing alone with acknowledging and accepting one’s identity, concealing that identity and the fear of coming out. The need for positive and long lasting relationships, is the essential motivator for humans (Baumeister & Leary, 1995). According to Baumeister and Leary (1995) there is a need to belong that outweighs all other human needs including the need for food, the emotional, cognitive and physical benefits are needed to function as a healthy human, which would explain why it is such an important risk factor. Relationships are lost first though LGBTQ peoples internal struggles with their identity and pulling away from people in order to conceal their identity. Once coming out, relationships can be lost or damaged forever if negative reactions are received, plunging the LGBTQ individual into feeling alone, isolated and without a sense of belonging.


The LGBTQ community is extremely important in giving a collective and individual identity which creates feelings of pride and belonging. For those that lose family relationships due to their identity it is important to find other social networks, within the community often referred to as ‘chosen family’, this shows the importance of LGBTQ spaces, charities and support groups in order for LGBTQ people to seek and find this support and sense of belonging that is clearly needed. Pride is an important protective factor due its link of belonging to the LGBTQ community, it gives a sense of something bigger than oneself to live for as evident in the narratives of the importance of being a role model and helping others within the community (Rivers et al., 2018). This suggests pride events around the world are still just as important as they were when first started as an activist protest in 1970 in New York, today these events are much different but the message of belonging and showing the world that being LGBTQ should be celebrated and not hated or shameful is a powerful message which shows increasing representation of the LGBTQ community (Bruce, 2016).


Findings support the minority stress theory as both distal (homophobia/transphobia, discrimination, stigma) and proximal stressors (fear of rejection, internalised homophobia) were identified in the studies having contributed to self-harm and/or suicide attempts among participants. Distal stressors are caused by the ignorance and hate of the outside world which are out of the control of an LGBTQ person, society being discriminatory has a profound effect on an LGBTQ persons mental health, yet the burden is on the LGBTQ person themselves to deal with these stressors and to build resilience in order to survive (Bautista et al., 2017; Diamond et al., 2011; Moody et al., 2015; Salway & Gesink, 2018). It is clear that more needs to change and not just laws that give equal protections and rights (although this is important), as studies from 2010 are showing the same findings as studies from 2018, showing that discrimination and prejudice shown by those whom hold homophobic/transphobic views may be more responsible for suicide among LGBTQ people. In the UK, from September 2020 LGBT relationships will become part of the school curriculum, which could help combat the psychological distress with inner turmoil and help to fight homophobic beliefs within the younger and future generations.


In the studies which focused on adult gay men (McAndrew & Warne, 2010; Salway & Gesink, 2018), their experiences of coming of age as gay men are very different to the generation of adolescents today which are able to find their identity in countries (UK, USA and Canada) with legal recognitions and increased societal acceptance. Some of the gay men in these studies experienced major psychological distress of concealment of their identity due to fear of entrapment and living through the AIDS epidemic, which will have had major consequences on how they saw themselves which will have stayed with them (King & Richardson, 2017). Today the older generation are more likely to be isolated, putting this age group at a much higher risk (Rogers, Rebbe, Gardella, Worlein, & Chamberlin, 2013) which may support Samaritans (2019) findings that in the UK the highest suicide rate is among men aged 45-49 and that men are more likely to attempt suicide than women. Due to this LGBTQ charities are increasing their services for older LGBTQ people (over 50s). Older LGBTQ people often feel they don’t belong in the current LGBTQ community, simply using the term queer is still offensive to some who have had this ‘thrown’ at them as a slur (Bunch, 2017).


A few studies assessed only adolescents (Bautista et al., 2017; Diamond et al., 2011; Elizabeth McDermott, 2015; McDermott et al., 2015) as this is considered a particularly turbulent time especially with the added stressors that being LGBTQ brings and with suicide being the biggest killer of young people aged 16-24 in the UK. Young people have a hard time expressing and understanding their emotions leading to an increase in psychological distress and leading to self-harm and/or suicide (Bautista et al., 2017; Elizabeth McDermott, 2015; McDermott et al., 2015). Homophobia and discrimination are experienced from an early age, with bulling at school and within the community, simply for breaking societal norms of gender which has a perceived link to sexuality as well as gender identity (Diamond et al., 2011; McDermott et al., 2015; Rivers et al., 2018). This is a perceived link as gender identity has nothing to do with sexual orientation.


Limitations and future research


Studies collectively have an age range of 13-74, giving an insight into the experiences of both younger and older LGBTQ. The majority of studies being conducted in the UK or USA means they are limited to western society experiences. All studies used qualitative methods of research, with small sample sizes, with the exception of the studies that used online methods (Elizabeth McDermott, 2015; McDermott et al., 2015), which both estimate around 290 different contributors and a study which conducted online interviews with 133 participants (Moody et al., 2015). These small sample sizes mean that data cannot be generalised to the whole population. However, the purpose of these studies was to explore personal experiences of being LGBTQ in order to find out why this group is more at risk of suicidality and self-harm, which these studies did successfully.

This research has shown the importance of LGBTQ specific services and there are many charities with aims of reducing psychological distress among LGBTQ people in order to prevent suicide such as Mind Out, Switchboard LGBTQ+ helpline and London friend in the UK and The Trevor Project in the USA. Due to the findings that participants whom had experienced counselling/therapy and having a preference for an LGBTQ practitioner and those that had negative experiences due to homophobia and transphobia (Diamond et al., 2011; Elizabeth McDermott, 2015; Rivers et al., 2018; Smith et al., 2018), every professional in a clinical or educational setting should have training on LGBTQ issues to enable them to be more aware of any possible issues when dealing with this group. This would allow LGBTQ people accessing mental health services to receive the right recognition of the psychological distress they experience and potentially prevent suicide. The BPS has published guidelines on how psychologist should approach working with sexuality and gender diversity (British Psychological Society, 2019) which is a step in the right direction.


Future research should look at the impact of LGBT relationship teaching in schools (UK) after its implementation in September 2020, although this may take some years to see its full affect. More research should focus on the older generation of LGBTQ people, with an increasing ageing population in the UK, issues around care for the elderly LGBT community have become a topic of debate, due to older people being more isolated (Brennan-Ing, Seidel, Larson, & Karpiak, 2014).


Up to date research on bisexuals and biphobia within the LGBTQ community and society as a whole in order to understand any differences in experiences from gay and lesbian individuals and the differences between bisexual men and bisexual women, to see how much gender plays a role in biphobia and psychological distress experienced. The studies analysed in this review did not find any differences of bisexuals however there is literature showing that bisexuals are at increased risk of suicide (Figueiredo & Abreu, 2015), therefore is there could be something missing in this literature or is bisexuals are no longer at increased risk in a more accepting society.


After the reform of the Gender Recognition Act 2004, research should investigate the mental health of transgender individuals an what if any affect this has. Issues surrounding gender and transgender people have become more mainstream and is less socially acceptable then homosexuality, research into why and what can be done to change this may be needed to inform social policy.


 

Conclusion


To conclude, findings show that homophobia, discrimination and prejudice are still profound within society causing feelings of shame, self-hatred and isolating LGBTQ people causing psychological distress leading to self-harm and suicidality. Accepting oneself and feeling a sense of pride and connectedness to the LGBTQ community can give a sense of belonging reducing isolation and psychological distress. Ignorance within society needs to be challenged and educated to reduce the homophobia within society. Some steps have been taken such as LGBT education in schools but only time will tell what impact this makes. For clinical practice, practitioners need to be informed about LGBTQ issues. Continued research is needed to explore the differences within the LGBTQ community regarding gender, age and race to increase understanding of suicide within a changing society. Until it is no longer the norm to struggle with identity regarding sexuality and gender and while it is the norm for LGBTQ to feel that suicide is the only way out, heteronormative society must continue to be challenged by those that have a voice.


 

References


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By Ruth Spencer-Lewis, University of Westminster, 2020.

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