1. Philip T. McCabe CSW, CAS, CDVC, DRCC Health Educator
A Model of Suicide Prevention Strategies for Vulnerable Populations: LGBTQ Community
Philip T. McCabe CSW, CAS, CDVC, DRCC
Health Educator

2. Understanding the Differences One size does not fit all…
♥ Gay
♥ Lesbian
♥ Bisexual
♥ Transgender
♥ Queer

3. Behavioral Health Concerns
Research suggests that LGBT individuals face health disparities linked to societal stigma, discrimination, and denial of their civil and human rights.
Discrimination against LGBT persons has been associated with high rates of psychiatric disorders, substance abuse, and suicide.
Experiences of violence and victimization are frequent for LGBT individuals, and have long-lasting effects on the individual and the community.

4. Behavioral Health Concerns
Personal, family, and social acceptance of sexual orientation and gender identity affects the mental health and personal safety of LGBT individuals.
Homosexuality is not a mental illness In 1973, the American Psychiatric Association declassified homosexuality as a mental disorder. The American Psychological Association Council of Representatives followed in 1975

5. Minority Stress
Minority stress describes chronically high levels of stress faced by members of stigmatized minority groups. It may be caused by a number of factors, including poor social support and low socioeconomic status, but the most well understood causes of minority stress are interpersonal prejudice and discrimination.
Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129, 
 Clark, R., Anderson, N. B., Clark, V. R., & Williams, D. R. (1999). Racism as a stressor for African Americans: A biopsychosocial model. American Psychologist, 54,

6. LGBT Minority Stress
The stress that comes from continued exposure with discrimination and stigma is a primary risk factor of higher rates of substance use, as lesbian, gay bisexual and transgender people turn to tobacco, alcohol, other drugs or problematic behaviors as a way to cope with these challenges.
Minority Stress increases depression, anxiety and suicide risk for LGBT individuals

7. Surveillance Summaries Vol. 65 / No. 9
August 12, 2016
U.S. Department of Health and Human Services Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report Sexual Identity, Sex of Sexual Contacts, and Health-Related Behaviors Among Students in Grades 9–12 — United States and Selected Sites, 2015

8. New Jersey, students who had sexual contact with their own gender were more likely than students who had sexual contact solely with the opposite gender to:
have considered suicide (41% vs 15%) attempted suicide (35% vs 9%), cut or hurt themselves without wanting to die (49% vs 20%), carried a weapon in the past 30 days (29% vs 11%) been bullied on school property (43% vs 21%) smoked cigarettes recently (39% vs 18%) used marijuana during their life (79% vs 56%) to have used other illicit drugs such as heroin (17% vs 2%) cocaine (25% vs 6%) ecstasy (28% vs 9%) prescription drugs without a prescription (39% vs 15%).

9. Interpretation:
The majority of sexual minority students cope with the transition from childhood through adolescence to adulthood successfully and become healthy and productive adults.
However, this report documents that sexual minority students have a higher prevalence of many health-risk behaviors compared with non-sexual minority students.

10. Because many health-related behaviors initiated during adolescence often extend into adulthood, they can potentially have a life-long negative effect on health outcomes, educational attainment, employment, housing, and overall quality of life.

11. Risk Factors – LGB Youth
Gender nonconformity1
Internal conflict about sexual orientation2
Early coming out3
Low family connectedness4
1. Fitzpatrick et al. 2005
2. Savin-Williams 1990
3. D’Augelli et al. 2005
4. Eisenberg & Resnick 2006
Lack of adult caring4
Unsafe school4
Family rejection5
Victimization6
Bullying7
Stigma and discrimination8
5. Ryan et al., 2009
6. Bontempo & D’Augelli 2002; Russell & Joyner
2001
7. Suicide Prevention Resource Center 2011
8. Haas, et al., 2011
And here are risk factors established through research with LGB youth specifically. Unfortunately, the research on risk factors is more extensive than it is on protective factors.
Let’s talk about some of them specifically:
Gender nonconformity: This is a term for individuals whose gender expression is different from societal expectations. This term and the term “cross-gender roles and behaviors” are framed from a gender bias that assumes mainstream gender roles. A gender-nonconforming youth may or may not be LGBT. Heterosexual youth may also not conform to gender roles and behaviors thought by the mainstream to define genders. Fitzpatrick and others found that gender nonconformity is a significant contributor to suicidal risk, much greater than sexual orientation. They also found that gender-nonconforming youth had less support from their families and peers.
Internal conflict about sexual orientation: This can also be referred to as internalized homophobia, where a youth directs social disapproval inward. Internalized homophobia has been linked to depression.
Coming out: Disclosure is a developmental stage that is important to LGBT youth. On one hand, rejection and harassment are often related to coming out. Fear of rejection means that the risk is not just following disclosure, but it can precede it. Youth coming out at earlier ages means heightened risk. On the other hand, carrying a secret that is central to a youth’s identity—or a youth pretending to be other than what he or she is—carries its own stress.
Victimization and bullying are risk factors for suicide attempts and ideation as well as substance abuse and low self-esteem. LGB youth are victimized and bullied at higher rates than other youth. However, bullying itself does not cause suicide.
Let’s put these risk factors into a context for LGB youth.

12. Protective Factors
Family acceptance – parent and caregiver behaviors that help:
Talk with your child about his/her LGBT identity
Express affection when you learn that your child is LGB and/or T
Advocate for child when he/she is mistreated because of his/her LGBT identity
Bring your child to LGBT events
Connect your child with an LGB and/or T adult role model
Welcome your child’s LGB and/or T friends and partners into your home
Believe that your LGB and/or T child can have a happy future
Adapted from Ryan, 2009
Caitlin Ryan’s research has demonstrated that family acceptance of their LGBT child reduces the risk for health and mental health problems and helps promote their well-being. Ryan studied families who were accepting, unsure, or conflicted about their child’s gay or transgender identity, and identified over 100 behaviors that families use to respond to their LGBT child, some of which are listed here.
Ryan made important findings related to suicide prevention for LGBT youth. Gay and transgender teens who were highly rejected by their parents were at very high risk for mental health problems as young adults. Specifically, highly rejected LGBT young people were more than 8 times as likely to have attempted suicide.
Ryan found that even small shifts by families and caregivers towards being accepting made youth less likely to attempt suicide and other negative outcomes. She has published a list of rejecting behaviors as well so that parents can connect what they do to what could be damaging to their children.
For many parents and caregivers, just knowing which behaviors are harmful and which are supportive of their LGBT youth is not enough. Deeply held beliefs or emotions may present barriers hard to surmount without help. Professionals can play a role in the process of parents adopting supportive behaviors and focusing on keeping their family strong. Ryan recommends that parents find support groups and learn about their child’s sexual orientation or gender identity. She also suggests that parents listen to their LGBT youth without interrupting. PFLAG—Parents, Families, and Friends of Lesbians and Gays—is a national organization with local chapters that offer support and information.
Let’s discuss the implications for suicide prevention program staff and youth services professionals.
For a small group, leaders will lead a discussion or form break-out groups. For a large group, leaders will ask participants to volunteer how they can use this information in their work.
Some ideas to get the discussion going:
For suicide prevention program staff, how do you get this information to parents and caregivers? How do you reach out to and support parent and caregivers who are rejecting their LGBT sons or daughters? How can you support staff working with families with LGBT youth?
For youth-serving professionals, how do you reach parents and caregivers? Do you work directly with parents and caregivers?
What agencies could you partner with to further these messages and support parents (for example, GSA’s, PFLAG, schools)?
Adapted from Ryan, C. (2009). Supportive families, healthy children: Helping families support their lesbian, gay, bisexual, transgender children. Retrieved from

13. 7 Vital Stats About Our LGBT Elders
There are at least 3 million LGBT People Over 55 in The US, and that number will double in 20 years.
51% of Older LGBT People Are Very or Extremely Concerned About Their Financial Futures
2/3 of Older Trans People Worry About Being Denied or Having Limited Access to Medical Treatment
 24% of LGBT Older People of Color Experience Housing Discrimination

14. 7 Vital Stats About Our LGBT Elders
34% of Older LGBT People Live Alone and 32% Fear Growing Old Alone
21% of Older LGBT People are Concerned About Losing Physical Attractiveness
Twice As Many LGBT Older People See Themselves As Mentors Than Non-LGBT Older People

15. LGBTQ Elders
As they enter their later years, lesbian, gay, bisexual, and transgender (LGBT) older adults and their families are forced to navigate unique, complex barriers, often without the traditional support systems many seniors take for granted.

16. LGBTQ Elders
Discrimination in housing, employment, and healthcare has made many LGBT older adults vulnerable to an increased risk for social isolation and higher poverty rates.
The lack of relationship recognition, continued harassment by peers and healthcare providers, and the impact of lifelong discrimination silences many LGBT older adults and their families.

17. Providing LGBT Affirmative Care
Clinical applications such as affirmative-based practice are effective when working with sexual minorities.
Affirmative-based practice focuses on defining coping strategies, affirming a positive self-identity and increasing the ability to assess the effect of homophobia and stigma on psychological functioning and health risk behavior.

18. Other Tips for Consideration
Remember the heightened need for confidentiality
Sensitive topics need to be addressed carefully and unapologetically in easy-to-understand language
Use more inclusive questions
You are likely only getting a small piece of the story; telling a young person they “should” come out can be dangerous emotionally and physically (let them be the judge)
Use more inclusive interview questions: To a young woman “Are you dating someone?” is more inclusive byt achieves the same end as asking “Do you have a boyfriend?”
Move away from heteronormative expectations

19. It is NOT our place to tell a person when, whether, where, or how to come out.
You are likely only getting a small piece of the story; telling a young person they “should” come out can be dangerous emotionally and physically (let them be the judge)
Use more inclusive interview questions: To a young woman “Are you dating someone?” is more inclusive byt achieves the same end as asking “Do you have a boyfriend?”
Move away from heteronormative expectations
We CAN review with them their options, choices potential risks and benefits . 19

20. Cultural Competence – LGBT
LGBT cultural competence standards for agencies:
Make accurate information easily available
Train staff, volunteers, and board
Have staff and board reflect diversity
Have job descriptions, supervision, and performance review all reinforce cultural competence
Include diverse clients in program decisions
Make sure agency environment and policies are inclusive
Conduct ongoing agency self-assessments
You see that cultural competence is pervasive and comprehensive. It affects all aspects of an agency: outreach, staffing, policy, and supervision.
What helps make cultural competence successful? Here are some ideas:
Consumers and feedback are involved throughout.
The leader of the organization lives it.
Staff is prepared and given a context.
Cultural competence is consistently reinforced and supported, and successes are acknowledged.
I’ll address the first few bullets. Make accurate information available to consumers and staff. Keep abreast of what’s new in the field and make it available. Many national organizations provide information. Train your staff, volunteers, board, and consumers to submit information, and have channels for the agency to distribute it. Assure that it is not all needs- or problem-based but also includes strengths and accomplishments, such as LGBT individuals who receive awards or legislation that is passed. Use new technologies to reach youth audiences (e.g., Twitter, YouTube, Facebook).
Training includes pre-service training, orientation, in-service training, and mentoring. Include consumers in development of the trainings. Address the fact that LGBT youth have a higher risk of suicidal behavior.
Remember the ecological model that starts with an individual at the core and builds out. Not only is your staff and board going to reflect diversity to your community, they are also the individuals who have to be willing to examine their own beliefs and behavior. The policies, the forms, the welcoming waiting room, all mean little if your staff and board are not engaged in cultural competence.
Let’s talk about how some agencies go about this in a systematic way.

21. Communication: Avoiding Assumptions
Don’t assume all patients use traditional labels
Don’t assume all patients are heterosexual
Don’t assume sexual orientation based on appearance
Don’t assume sexual behavior based on sexual identity
Don’t assume sexual behavior and identity have not changed since last visit
Don’t assume bisexual identity is only a phase
Don’t assume transgender patients are gay, bisexual, or lesbian

24. Philip T McCabe CSW CAS, CDVC, DRCC