Journal of Adolescent Health 50 (2012) 418 – 420

www.jahonline.org

Adolescent health brief

Impact of Victimization on Risk of Suicide Among Lesbian, Gay, and Bisexual

High School Students in San Francisco
John P. Shields, Ph.D., M.S.W.*, Kelly Whitaker, M.P.A., Jill Glassman, Ph.D., M.S.W.,
Heather M. Franks, M.A., and Kelli Howard, M.A.
ETR Associates, San Francisco, California

Article history: Received February 27, 2011; Accepted July 19, 2011
Keywords: Lesbian, gay, and bisexual youth; Suicide risk; Logistic regression; Youth Risk Behavior Survey (YRBS); Victimization

A B S T R A C T

Purpose: This study investigated the association between sexual orientation, victimization, and suicide
risk-related outcomes among youth attending public high schools in San Francisco.
Methods: Data from the 2009 Youth Risk Behavior Survey were analyzed using bivariate and logistic
regression methods for complex samples to examine the relationship between sexual orientation, victimiza-
tion, and three suicide risk-related outcomes (sadness/depression, suicide planning, and attempting suicide)
while controlling for demographics and substance use.
Results: Lesbian, gay, or bisexual (LGB) youth reported significantly higher rates of substance use, victimization,
and suicide risk-related outcomes than heterosexual youth. However, in the controlled regression models,
victimization was a significant predictor of sadness/depression and suicide attempts, regardless of sexual orien-
tation. There was a significant interaction effect between sexual orientation and victimization on suicide planning,
with heterosexual youth more affected than LGB youth.
Conclusions: Results underscore the deleterious effect of victimization on suicide risk-related outcomes, regardless of
sexual orientation. As LGB youth continue to report higher rates of victimization, effective violence prevention ap-
proaches must focus on reducing violence among youth, specifically LGB youth. Additional research should focus on
identification of other factors that may help further explain elevated suicide risk among LGB youth.
䉷 2012 Society for Adolescent Health and Medicine. All rights reserved.

Adolescents who self-identify as lesbian, gay, or bisexual
(LGB) are two to three times more likely to report suicidal ide-
ation and attempts than heterosexual (H) youth [1,2]. LGB youth
have also reported higher rates of mental health and substance
use problems than H youth [2,3], and higher rates of these prob-
lems have been associated with higher rates of suicidal ideation
and attempts in adolescents [4,5].
Research also suggests that exposure to harassment and vio-
lence may be another risk factor explaining elevated suicide risk
among LGB youth [4,6]. This is of particular concern because LGB
youth have consistently reported harassment, bullying, and other
forms of victimization at significantly higher rates than H youth
[2,7,8]. In one school-based survey, 84.6% of lesbian, gay, bisexual,
and transgender (LGBT) middle and high school students reported
verbal harassment, 40.1% reported physical harassment, and 18.8%
reported being assaulted at school because of their sexual orienta-
tion [9].
The goal of this study was to investigate the association be-
tween sexual orientation, victimization, and suicide risk-related
outcomes for youth attending high school in the San Francisco
Unified School District (SFUSD) while controlling for substance
use and demographics.
Methods

* Address correspondence to: John P. Shields, Ph.D., M.S.W., Senior Research
Associate II, ETR Associates, 251 Rhode Island St., Suite 204, San Francisco, CA
94103.
E-mail address: johns@etr.org (J.P. Shields).
Sampling
The current study used data from SFUSD’s 2009 Youth Risk
Behavior Survey (YRBS), a population-based survey developed

1054-139X/$ - see front matter 䉷 2012 Society for Adolescent Health and Medicine. All rights reserved.
doi:10.1016/j.jadohealth.2011.07.009
 J.P. Shields et al. / Journal of Adolescent Health 50 (2012) 418 – 420 419

by the CDC (84% response rate, n ⫽ 2,154 students in grades 9 –12 Table 1
across 15 SFUSD high schools). Bivariate association between sexual orientation and substance use,
victimization, and suicide risk-related outcomes

Measures Indicator Unweighted n Odds

(weighted %) ratiosa

Three suicide risk-related outcomes from the YRBS were an- LGB H
alyzed as dichotomous dependent variables: sadness/depression
Ever used alcohol or marijuana 71 (66%) 465 (28%) 4.9b
(i.e., during the past 12 months, did you ever feel so sad or Ever used cocaine, heroin, and other 50 (43%) 216 (13%) 5.1b
hopeless almost every day for 2 weeks or more in a row that you drugs
stopped doing some usual activities?), suicide plan (i.e., during Past 12 months, skipped school due to 21 (18%) 103 (6%) 3.7b
lack of safety
the past 12 months, did you make a plan about how you would
Past 12 months, threatened or injured 26 (21%) 109 (6%) 4.1b
attempt suicide?), and suicide attempt (i.e., during the past 12 with a weapon at school
months, how many times did you actually attempt suicide?). Past 12 months, bullied at school 34 (29%) 214 (11%) 3.3b
Independent variables included age, race, gender, sexual orien- Past 12 months, in a physical fight 14 (12%) 37 (2%) 6.2b
tation, and three scales derived using factor analysis: (1) a five- that resulted in an injury
Past 12 months, in a physical fight 49 (46%) 347 (20%) 5.1b
item scale measuring alcohol and marijuana use (␣ ⫽ .846) (i.e.,
Past 12 months, victimization 70 (62%) 555 (31%) 3.6b
current alcohol use, binge drinking, drinking at school, marijuana indicator (one or more of above)
use, marijuana use at school), (2) a five-item scale measuring Past 12 months, sad/depressed for at 56 (49%) 419 (22%) 3.3b
other drug use (␣ ⫽ .878) (i.e., lifetime use of cocaine, inhalants, least 2 weeks
Past 12 months, made a suicide plan 36 (31%) 195 (10%) 3.9b
heroin, methamphetamines, ecstasy), and (3) a five-item scale
Past 12 months, attempted suicide 23 (23%) 116 (8%) 3.6b
measuring victimization (␣ ⫽ .580) (i.e., in past 12 months––
a
bullied at school, skipped school for safety concerns, got in a Odds ratios represent the ratio of the odds of indicator variable being yes for
LGB versus H students.
physical fight, injured in a fight, threatened or injured with a b
Associations are statistically significant at p ⬍ .05.
weapon at school). These scales were dichotomized for the logis-
tic regression analyses. Sexual orientation was measured by the
item “Which of the following best describes you?” which in- versus H victimized youth was 1.6 (95% CI: .8 –3.3), whereas for
cluded a four-item response set (Heterosexual [straight]; Gay or LGB versus H nonvictimized youth it was 4.4 (95% CI: 2.3– 8.6).
lesbian; Bisexual; not sure). For this study, the variable was
dichotomized into H and LGB, and the “not sure” option was Discussion
removed from analysis, following the approach of previous re-
search [4,7]. No differential effect of victimization was found on the reports of
sadness/depression or suicide attempts for LGB versus H youth.
Analysis Controlling for demographics and substance use, victimization and
sexual orientation were found to be significant risk factors for these
Bivariate associations were analyzed to assess differences in two suicide risk-related outcomes. By contrast, there was a differ-
characteristics by sexual orientation. Separate binary logistic ential effect of victimization on reported suicide planning, with H
regression models for complex samples were used to assess the youth reporting more severe consequences–a threefold increase in
relationship between sexual orientation, victimization, and the the odds of suicide planning for H youth reporting victimization
three dependent variables while controlling for demographics versus a negligible increase for LGB youth reporting victimiza-
and substance use. Odds ratios (ORs) and adjusted odds ratios tion. Yet, among nonvictimized youth, those who reported being
(AORs) were used to describe effect sizes. Statistical significance LGB were four times more likely to make a suicide plan than
was set at p ⫽ .05. those who reported being H. Together, these results suggest
there are factors beyond those included in our models that fur-
Results ther explain the higher overall rates of suicide risk-related out-
comes among LGB youth [10].
LGB youth reported significantly higher rates of substance
use, victimization, and suicide risk-related outcomes than H Conclusions
youth (Table 1). Statistically significant ORs ranged from 3.3 to
6.2 across measured indicators. Despite the sample size limitations of this study and its focus
No significant interaction effect between sexual orientation on relatively low prevalence outcomes, which can undermine
and victimization was found in the logistic regression models statistical power because of low cell counts, the results do under-
examining sadness/depression or suicide attempt. In both mod- score the deleterious effect of victimization on suicide-related
els, sexual orientation and victimization showed statistically sig- outcomes among both LGB and H youth in our school-based
nificant main effects after controlling for demographics and sub- sample. Our results also confirm that more research is needed on
stance use (Table 2). other contextual factors and experiences beyond those mea-
A significant interaction effect between sexual orientation sured by our models (e.g., family support, community character-
and victimization was found in the model examining suicide istics), which might also be affecting the higher rates of suicide
plan. Therefore, we calculated the following conditional AORs: attempts among LGB youth [10].
the AOR for making a suicide plan for victimized versus nonvic- Only the suicide planning model showed a statistically signif-
timized LGB youth was 1.08 (95% CI: .4 –2.8), whereas the AOR for icant differential effect of victimization across LGB versus H
victimized versus nonvictimized H youth was 3.0 (95% CI: 2.0 – youth, with H youth being more severely affected. Although it
5.0). The conditional AOR for making a suicide plan for LGB does not appear that victimization disproportionately affected
420 J.P. Shields et al. / Journal of Adolescent Health 50 (2012) 418 – 420

Table 2
Logistic regression analysis results by suicide risk-related outcome

Parameter B Standard Hypothesis test AORa ⫽ 95% Confidence

error Exp(B) interval for Exp(B)
tb dfc Significance Lower Upper

Sadness/depression Gender ⫺.438 .126 ⫺3.472 89 .001 .645 .502 .829

Raced 89 .019
Sexual orientation .845 .222 3.807 89 .000 2.327 1.497 3.617
Alcohol/marijuana use .502 .166 3.024 89 .003 1.652 1.188 2.299
Other drug use .446 .201 2.221 89 .029 1.563 1.048 2.330
Victimization .956 .140 6.822 89 .000 2.602 1.969 3.437
Suicide plan Gender ⫺.291 .146 ⫺1.993 89 .049 .747 .559 .999
Raced 89 .460
Sexual orientation 1.491 .331 4.500 89 .000 4.440 2.299 8.575
Alcohol/marijuana use .237 .214 1.103 89 .273 1.267 .827 1.940
Other drug use .680 .209 3.264 89 .002 1.975 1.305 2.989
Victimization 1.093 .205 5.331 89 .000 2.983 1.985 4.483
Sexual orientation by ⫺1.007 .503 ⫺2.00 89 .049 .365 .134 .993
victimization
Suicide attempt Gender ⫺.260 .218 ⫺1.191 89 .237 .771 .500 1.190
Raced 89 .376
Sexual orientation .808 .313 2.58 89 .012 2.243 1.204 4.177
Alcohol/marijuana use ⫺.120 .255 ⫺.471 89 .638 .887 .534 1.472
Other drug use .814 .243 3.347 89 .001 2.257 1.392 3.661
Victimization 1.242 .229 5.426 89 .000 3.461 2.197 5.454
a
AOR ⫽ adjusted odds ratio, adjusted for all other variables in model.
b
The t test shown here is equivalent to the Wald F test which is appropriate for hypothesis tests involving complex samples (Morel [11]).
c
The degrees of freedom for the test of significance for the coefficient is based on the sampling design (the difference between the number of primary sampling units
and the number of strata in the first stage of sampling).
d
Race included six categories, and their associated Bs are not included to reduce table size given this is a control variable only.

the suicide risk of LGB youth relative to H youth in this sample, more
refined measures incorporating the type, severity, and intent of
victimization experienced by LGB youth are needed. Currently, the
YRBS does not routinely include such items, nor indeed any items
on sexual orientation in many communities. As LGB youth continue
to report higher rates of victimization, there remains a need for
additional investment in the development and implementation of
effective prevention approaches that reduce victimization for all
youth and among LGB youth specifically.
Acknowledgments
This research was funded by the San Francisco Unified School
District under cooperative agreement with the CDC’s Division of
Adolescent and School Health, National Center for Chronic Dis-
ease Prevention and Health Promotion (5U87DP001177-03).
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