The Canadian Journal of Psychiatry / La Revue Canadienne de Psychiatrie2023, Vol. 68(6) 461‐469© The Author(s) 2023Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/07067437221147420TheCJP.ca | LaRCP.ca
Objectives:To examine whether sexual and gender minority (SGM) emerging adults perceived their SGM status was linked to suicidal ideation, and to explore if their responses fell within tenets of the minority stress framework.
Method: Open text (survey) responses of Dutch and Flemish SGM emerging adults (n = 187) were thematically analysed using the constant comparative comparison method for qualitative analysis.
Results: We identified 8 themes in our qualitative analysis. Two themes fell within the scope of the minority stress framework that has received little attention: (1) concerns about relationships and family planning and (2) feeling different (internal stressor). Two additional themes emerged largely beyond the scope of existing minority stress framework studies on suicidality: (3) SGM-related questioning; (4) negativity in LGBT communities. Four established minority stress framework themes emerged: (5) gender identity stress; (6) victimization; (7) coming-out stress; (8) psychological difficulties linked to SGM status.
Conclusion: Suicide prevention needs to focus on supporting SGM emerging adults who worry about feeling “different”, or who have concerns over their romantic and family life, on reducing gender minority stress, as well as on caring for those who are victimized due to their sexual or gender identity.
Examiner si les adultes émergents de la minorité sexuelle et de genre (MSG) percevaient que leur état MSG était lié à l’idéation suicidaire, et explorer si leurs réponses s’inscrivaient dans les principes du cadre de stress minoritaire.
Méthode: Les réponses au texte ouvert (sondage) des adultes émergents hollandais et flamands de la minorité sexuelle et de genre (n = 187) étaient analysées par thème à l’aide de la Méthode comparative constante en analyse qualitative.
Résultats: Nous avons identifié 8 thèmes dans notre analyse qualitative. Deux thèmes relevaient du cadre de stress de la minorité qui ont reçu peu d‘attention: (1) inquiétudes au sujet des relations et de la planification familiale et (2) se sentir différent (stresseur interne). Deux thèmes additionnels ont émergé largement au-delà du champ des études MSG existantes sur la suicidabilité: (3) questionnement lié à la minorité sexuelle et de genre; (4) négativité dans les communautés LGBT. Quatre thèmes établis du cadre de stress de la minorité ont émergé: (5) stress de l’identité de genre; (6) victimisation; (7) stress du coming-out; (8) difficultés psychologiques liées au statut MSG.
Conclusion: La prévention du suicide doit être axée sur le soutien des adultes émergents de la minorité sexuelle et de genre qui s’inquiètent de se sentir “différents”, our qui s’inquiètent de leur vie romantique et familiale, sur la réduction du stress de la minorité de genre, et sur les soins à ceux qui sont victimisés en raison de leur identité sexuelle ou de genre.
Keywordssexual/gender minorities, suicidal ideation, minority stress, emerging adults
Sexual and gender minority (SGM) emerging adults in Canada and western Europe experience suicidal thoughts and behaviours at higher rates than their heterosexual or cisgender counterparts.1,2 Sexual minorities include people who self-identify as lesbian, gay, bisexual, queer, and people with nonheterosexual sexual behaviours or attractions. Gender minorities include persons who self-identify as transgender, genderqueer, nonbinary, or noncisgender. Together, sexual and gender minorities are referred to as “SGM” or “LGBTQ” in this paper. In Canada as well as elsewhere, SGM emerging adults3 (persons between the ages of 18 and 29) show a greater risk for mental health challenges than older cohorts.4 Mental health disparities among SGM individuals have been examined and understood through minority stress frameworks (MSFs),5,6 which posit that SGM individuals experience unique (distal and proximal) stressors since they grow up in a society where nonheterosexual or noncisgender orientations are stigmatized.
SGM people who experience biased-based victimization (a distal minority stressor) have an increased risk for suicide.2 SGM emerging adults also have lesser access to coping resources, such as family, peer, or school support.5,7 Proximal stressors such as internalized homophobia or transphobia8,9 and anxiety preceding disclosure to others10 are also associated with suicidal ideation and behaviours. Transgender people face unique minority stressors related to negative self and others’ evaluations of their bodies or gender expression as well as stigma from others for not fitting in within the traditional female/male gender binary, all of which influence suicidal behaviours.11,12
Moving beyond the MSF, social and/or medical transitions can influence the mental health of transgender individuals. Social transitions include name changes and adopting new pronouns, as well as changes in physical appearance or expression that may involve accessing hormone replacement therapy and/or gender-affirming surgery.13 Gender-affirming medical transitions can decrease suicidal ideation and attempts among transgender individuals.14 In young transgender people, access to pubertal suppression, or in a later stage to gender-affirming hormone therapy, decreases lifetime suicidal ideation.15
Researchers posit the need for a more granular examination of how SGM’s backgrounds of suicidal ideation and behaviours fit within or beyond the premise of the MSF.16 Qualitative research has explored whether and how SGM identities are linked to SGM peoples’ own narratives of suicidal thoughts. For example, qualitative research among SGM youth with histories of attempted suicide showed that their lived experiences in anti-SGM environments in the home and school were associated with fear of coming out and family rejection and this presented them with difficulties in self-acceptance.17,18 Moreover, homophobic and transphobic experiences were associated with negative cognitions, emotions, and behaviours that manifested through anger, shame, self-loathing, and self-blame—all of which influenced SGM’s desire to self-harm.18–20
The present qualitative study investigates whether and how SGM emerging adults link their sexual orientation and/or gender identity to past suicidal thoughts. Furthermore, we aimed to explore whether participants’ responses fit within or beyond the tenets of MSF.
Even though the Netherlands and Flanders are cultural contexts with progressive inclusive legislation towards SGM, SGM individuals in Flanders and the Netherlands have an estimated 3- to 7-fold increased risk of suicidal ideation and suicide attempts.21–24 Culturally, geographically, and linguistically, these two countries/regions and their populations are closely related.
SGM emerging adults (N = 1,410) from the Netherlands (n = 918) and Flanders (n = 492) between the ages of 18 and 28 (M = 21.80 years; SD = 2.97) participated in an online survey assessing associations among sexual orientation, gender identity, mental health, including suicidal ideation and attempts. Data collection in Flanders was carried out from September 2015 to March 2016, and in the Netherlands between October 2016 and February 2017.
Participants were recruited both online and offline through LGBT organizations, as well as through national online suicide prevention forums. The research team had expertise in qualitative and survey methodology, team members were both Flemish and Dutch and had diverse sexual and gender identities.
Participants gave informed online consent for this Institution Review Board-approved study before completing the survey in Dutch. Participants who completed the study were eligible to enter a raffle. Past suicidal ideation was not required for participating. Open text responses were translated into English and checked by bilingual experts.
Participants were asked how they defined their gender identity and expression with the following answering options: “my birth gender fully corresponds with my gender identity as man/woman”; “man who crossdresses”; “woman who crossdresses”; “transman (assigned female at birth)”; “transwoman (assigned male at birth)”; “genderqueer/nonbinary/gender fluid”; “other”).25 Participants indicating their birth gender fully corresponded to their gender identity were recoded as “cisgender,” other participants were recoded as “transgender.”
All emerging adult SGM respondents who reported a link between SGM status and (lifetime) suicidal thoughts in the survey were subsequently asked “How were your suicidal thoughts linked to your sexual orientation/gender identity?” Response options included: “My thoughts increased after coming-out,” “My thoughts decreased after coming-out,” “My thoughts increased after the access to transgender healthcare,”“My thoughts decreased after the access to transgender healthcare,” and “My thoughts were linked in another way.” Those participants who responded that their “suicidal thoughts were linked (to SGM) in another way,” were asked to “please explain how.” The responses to the last question were analysed in the qualitative part of the current study.
An inductive coding process was carried out by categorizing the data of the open-ended survey question into qualitative themes and subthemes,26 and analysing their meanings. Meanings were extracted from their expressed feelings, opinions, or knowledge of their suicidal feelings. Codes were reworked into themes following the constant comparative comparison approach,26 which is a systematic and comprehensive technique for identifying themes in qualitative data. Based on a close reading of the first 50 responses, 2 authors proposed a number of themes and subthemes that they derived directly from the data, and – after some adjustments and resolving discrepancies – these authors agreed on a coding system. Subsequently, 1 author continued with coding all data, which was checked by the second author. The third author also read all the coded segments for a final check. During and after theme development, the first coauthors recognized the relevance of the MSF and analysed and described to what extent data fitted the MSF frame.
From the full sample (N = 1,410), 65.6% (n = 925) of the participants reported a lifetime history of suicidal ideation, of whom 61.3% (n = 686) were LGB and 73.0% (n = 239) were transgender. In the Netherlands, this subsample of SGM with a history of suicidal ideation included 406 LGB and 166 transgender participants. In Flanders, this subsample consisted of 280 LGB and 73 transgender respondents.
Sixty-two percent (62%) of the participants (n = 573) who reported lifetime suicidal ideation stated their suicidal thoughts had been related to SGM status. Forty-four percent (44%) (n = 180) of sexual minorities indicated their suicidal ideation decreased after their coming out, and 26% (n = 107) reported an increase in suicidal thoughts after their disclosure. Access to transgender health care was followed by a decrease in suicidal thoughts in 25% (n = 42) of the transgender participants, while an increase was reported by 8% (n = 13). Table 1 and Figure 1 show descriptive information about the total sample and subsamples used for the study.
Based on 187 responses (n = 128 cisgender sexual minorities and n = 59 transgender individuals) to the open questions in the survey, 8 themes were identified (see Figure 2).
The first theme “relationship issues” was mentioned by mostly sexual minority participants (37%) and to a lesser extent by transgender participants (7%). This theme had two subthemes: “Concerns about future intimate relationships and family-planning” and “Relationship conflicts.” Although both subthemes were grounded in being SGM in society and thus fit MSF, they have received relatively little attention in existing studies about SGM emerging adults and suicidal ideation. In the subtheme “Concerns about future intimate relationships and family-planning,” cisgender sexual minority participants particularly mentioned they were longing for a romantic relationship, but they anticipated being alone in the future, which they linked to their suicidal thoughts: “I am afraid that I will never have a stable and monogamous relationship where I will live happily ever after.” These participants also expressed a fear of not being able to form a family with children in the future because of their minority status. As a cisgender sexual minority participant wrote: “You can never become a normal family with your own children. You will be different forever.”
The subtheme “relationship conflicts” was referred to by cisgender sexual minority participants (16%) and to a lesser extent, by transgender participants (7%). Participants described challenges they faced in their current relationships which they attributed to their SGM status. As a transgender participant illustrated: “I’ve had seven very happy years with my partner, but recently I introduced serious problems to our relationship because of my gender identity.” In line with this, some sexual minority participants mentioned that their same-sex relationship faced challenges when their partners came out as transgender, as they perceived themselves as gay or lesbian while their partner wanted a transition. In addition, being attracted to both genders was also explicitly described here as a factor, as a cisgender sexual minority participant reported: “My bisexuality made me doubt my heterosexual relationship, these doubts led me to feel worthless and bad.” When both subthemes are studied together, cisgender sexual minority individuals expressed more difficulties in finding a partner and transgender people expressed more problems in their current long-term relationships.
Another theme was “internal stressors” related to SGM identity. This was more often mentioned by cisgender sexual minority (38%) than transgender participants (25%). The first subtheme of “internal stressors,” which was less related to MSF, was the feeling of “being different,” “abnormal,” or falling outside “the norm,” all of which fell within a lack of belongingness. As a cisgender sexual minority respondent said: “I don’t feel at home in this world” or “I long to feel normal.” Or as a transgender respondent put it: “I thought I was weird as a gender-fluid person.” Many respondents who said they felt “different” or “not normal” used these statements in addition to expressions that fall under “internal stigma.” For example, some reported “being ashamed” of themselves for being SGM. Internal stigma was therefore the second subtheme of “internalized stressors.” A cisgender sexual minority participant phrased this internal stigma as follows: “I had an enormous self-hatred, not feeling like a full-fledged person, being less than others.”
Two other themes emerged that fell beyond the MSF in relation to suicidal ideation: “SGM-related questioning and confusion” and “negative experiences within LGBT communities.” Some cisgender sexual minorities (5%) and transgender participants (3%) described a narrative of having identity difficulties during adolescence, a period during which they had felt profoundly “confused.” Some SGM participants mentioned that it was only in hindsight that they could see the link between their SGM status and their confusion and anxiety, and realized that these suppressed experiences influenced their suicidal thinking: “I didn’t know I was suppressing my own feelings because of my religious family, but I was very confused about myself.”
Next, albeit reported relatively infrequently, both LGB and transgender emerging adults (3% and 2%, respectively), reported negative experiences within LGBT communities. They found these noninclusive practices in LGBT communities taxing their mental health. As a cisgender SGM respondent wrote: “The misery and drama that the gay community brings pushes me to deep agony.” Experiences of prejudice from other SGM people were reported by a transgender participant as relevant to their suicidal thoughts: “prejudice from and the way how LGBTQ-community interacted with one another were a bigger problem for me than discrimination from straight people.”
We found 4 themes that fit an existing body of work on MSF in relation to suicidal ideation. First, almost half (44%) of transgender participants mentioned experiences tied to gender identity stress. Access to health-care services for medical transitioning and its implications was characterized by gender identity stress, and these concerns were linked with suicidal thoughts: “I found it stressful that a medical [gender] transition would threaten my fertility.” Furthermore, a few transgender participants felt pressured to “prove themselves” to medical doctors, who were perceived as gatekeepers to hormone therapy. “The possibility of not being allowed to have a transition makes me so unhappy that suicide would be a real option.” One transgender respondent spoke about the high financial costs involving medical care for transgender health services. Issues related to social transitioning also contributed to suicidal thoughts. Several transgender participants mentioned that they feared or experienced a lack of validation and understanding of their gender identity by others: “not being able to be who you are,” which was “really unpleasant.” One transgender participant mentioned this caused “a sense of alienation from my body and its needs.”
The second theme consisted of SGM victimization, which was experienced by 24% of sexual minorities and 32% of transgender minorities. Two subthemes existed: personal experiences with victimization and perceived group-based stigma. As for personal experiences, approximately 12% of the participants reported verbal and physical bullying experiences perpetrated by school peers and strangers. A cisgender sexual minority respondent wrote: “I was stalked for a long time by a group of people in a car who shouted homophobic comments.” A transgender participant described being victimized by their school peers: “I was bullied, which together with a personal aversion of my body, and my fear of puberty led to a suicide attempt.” About 7% of the respondents reported that their family explicitly said they did not accept their sexual orientation and/or gender identity and therefore they felt excluded from their family.
Regarding group-based stigma, about 5% of sexual minority and 12% of transgender participants mentioned that SGM-based stigma was associated with their suicidal ideation or attempts. Participants referred to feeling misunderstood by society or the world at large because of their SGM status. As a cisgender sexual minority respondent illustrated: “Sometimes, I get tired of belonging to a separate group and being judged accordingly. Now I personally do not experience that in Dutch society, but I feel pain of how LGBT people are treated in more homophobic cultural contexts.” A transgender respondent said the following about SGM group-directed stigma, “Transgender identities are increasingly shown in the media and reactions to them are overwhelmingly negative (…) The hatred is not directed at me personally but it hurts me.”
A third theme was “coming out stress” or the anticipation of a negative response by family members after disclosing one’s SGM identity, which was expressed by 14% of sexual minority and 10% of transgender participants. For example, a cisgender female sexual minority participant indicated: “If I start a relationship with a woman, I will never be able to introduce her [partner] without losing my bond with my parents.” Some participants also found themselves to be a burden or a disappointment to their families due to their “otherness.” Furthermore, participants also described the challenge to keep their SGM status hidden from their families. The combination of being worried about rejection, while simultaneously concealing their SGM identities and desire for authenticity, was a precursor for suicidal thoughts. For example, a transgender respondent stated: “I did not dare to tell that I am genderqueer, but at the same time I was struggling that people did not see who I really was.”
The final theme included the experience of psychological difficulties. Here participants explained that the unique challenges they face as SGM people made it hard to cope with their feelings of guilt, fear, depressed mood, disordered eating, and low self-image, including experiences of childhood trauma and stressful life events. Such difficulties were more often reported by cisgender sexual minority (15%) than by transgender participants (6%). Respondents perceived these psychological difficulties were linked to their SGM status and suicidal thoughts. A cisgender sexual minority participant illustrates this theme as follows: “It [sexual minority status] causes my self-image to be even lower than it already is.” Similarly, a transgender participant noted, “the fear I have of how the world perceives me does not exactly help when you already feel low.” See Figure 3 for a visual summary of the findings.
This study furthers our understanding of the determinants of suicidal ideation in vulnerable populations of SGM emerging adults. First, feelings of being “different” corroborate the MSF in relation to suicide research among SGM populations, yet those emerging themes have received little empirical attention.27 While the theme of “feeling different” has some resemblance with internalized stigma, these feelings seem to be qualitatively distinct from “phobia” or negativity and thus deserve further attention.27 Other participants made explicit that feeling “abnormal” or “different” was associated with a lack of feeling connectedness to others, which fits the interpersonal–psychological theory of suicidal behaviour,28 which emphasizes unmet needs to belong with others are explanatory of suicidal ideation.12,29
Our study also revealed topics that may go beyond wellknown tenets of the MSF. A commonly mentioned factor among participants was relationship problems specific to their SGM status. While it is known that separation or poorquality relationships can trigger suicidal ideation and attempts,30 this has rarely been studied in-depth in SGM individuals in relation to suicidal ideation or behaviours.31 Moreover, the expressed anticipation of “being alone forever” among single respondents in our study was prevalent. Our data could not reveal whether this anticipation could be influenced by rejection sensitivity; if so, these feelings could be linked to MSF.32 Hence, relationships of SGM individuals should be a focus of future suicide research.
Other reported factors that fell beyond well-known aspects of MSF were “confusion” and “questioning” of one’s SGM identity, as well as broader mental health problems. Indeed, sexual identity exploration and formation are often challenging developmental processes experienced in adolescence.33 Participants said they could only tell in hindsight that the difficult time and confusion they experienced in adolescence were related to sexual orientation challenges that negatively affected their mental health, corroborating findings from Boyer and Lorentz.34
Many respondents endorsed themes that fell within the existing body of literature MSF. Transgender respondents noted the impact of gender identity stress on suicidal ideation, which included concerns about social transitioning and validation and access to medical health care. This aligns with studies showing that dissatisfaction with one’s appearance may be a risk for suicidal behaviour among transgender populations.12,35 Furthermore, our study showed that transgender individuals who had successfully accessed transgender health care reported a decrease in suicidal ideation, corroborating research by Motmans et al.23
Many participants reported victimization, stressful coming out experiences, and psychological difficulties due to SGM challenges linked to suicidal ideation, which corroborates existing findings of SGM populations.2,10 Furthermore, some participants discussed their awareness of how SGM people across the globe were victimized. This suggests that the mental health of SGM people can be affected by global violence against SGMs despite a liberal sexual climate in their own countries or regions (e.g., Flanders, the Netherlands or Canada).
In addition, although infrequent, some participants reported that negative experiences within SGM communities were linked to their suicidal thoughts, which to the best of our knowledge, has not received much attention in the literature as a risk factor for suicidal thoughts or behaviours among SGM populations. The finding that some SGM people do not experience (certain parts of) LGBQ communities as positive deserves further examination.
An important conclusion is that even in countries and regions such as Canada, the Netherlands, and Flanders, which have introduced supportive legal and social changes in the past few decades to diminish stigmatization and mental health challenges for SGM people,36 SGM people continue to experience mistreatment because of their SGM status.
There are a few limitations worth noting. We had a relatively small number of participants within various sexual or gender identity groups which prevented us from presenting an analysis for multiple subgroups of SGM individuals. Next, findings were established in Flanders and the Netherlands, which may not be generalizable to other socio-cultural contexts. In addition, although the Dutch and Flemish population (with only 10% of their inhabitants having a nonwestern background) is substantially less culturally diverse than the Canadian population, we did not collect data on race or ethnicity, which prevented possibilities for examining these aspects.
These results showed that clinical guidance for SGM young individuals is particularly needed when discussing feelings of being “different.” Applying affirmative treatment and reducing gender identity stress37 and teaching effective coping skills to manage experiences of feeling “different” are necessary to improve the mental health of SGM people.38,39 Moreover, helping SGM persons seek and maintain supportive social and possibly, romantic relationships can protect against suicidal thoughts, as research among Canadian transgender persons has indicated.35
Clinical interventions would preferably need to address same-sex relations challenges40 and occur in tandem with society-based SGM affirmative policy initiatives, as our work and other studies5,41 have shown that societal stigma and violence in communities is a strong influence on decreased mental health. Lastly, making affirmative medical health care more accessible for emerging adult transgender persons is highly promising for suicide prevention, as evidence from Canada shows.35 Finally, to support young SGM emerging adults, the field of suicide research would need to initiate more suicide prevention and intervention studies including rigorous assessments of their effectiveness.
Lesley C. Biedermann and Renske Gilissen, The University of Groningen, Groningen, the Netherlands.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Diana D. van Bergen http://orcid.org/0000-0002-0068-5228
1 Department of Pedagogics and Education, University of Groningen, Groningen, the Netherlands
2 Unit for Suicide Research, Flemish Centre of Expertise in Suicide Prevention, Ghent University, Ghent, Flanders, Belgium
3 Department of Systems, Populations, and Leadership, University of Michigan School of Nursing, Ann Arbor, Michigan, USA
4 Transgender Infopunt, Ghent University Hospital, and Centre for Research on Culture and Gender, Ghent University, Ghent, Belgium
5 Independent Researcher, Berlin, Germany
6 113 Suicide Prevention the Netherlands, Amsterdam, the Netherlands
* Diana van Bergen and Eva Dumon share first authorship.
Corresponding Author:Diana D. van Bergen, Department of Pedagogics and Education, University of Groningen, Grote Kruisstraat 2/1, 9733TG Groningen, the Netherlands.Email: d.d.van.bergen@rug.nl
