Accepted Manuscript

Suicide Risk For Sexual Minorities in Middle and Older Age:

Evidence from the National Study of Drug Use and Health

Benjamin D. Capistrant ScD , Ora Nakash PhD

PII: S1064-7481(18)30614-6
DOI: https://doi.org/10.1016/j.jagp.2018.12.023
Reference: AMGP 1161

To appear in: The American Journal of Geriatric Psychiatry

Received date: 11 September 2018

Revised date: 13 December 2018
Accepted date: 14 December 2018

Please cite this article as: Benjamin D. Capistrant ScD , Ora Nakash PhD , Suicide Risk For Sexual
Minorities in Middle and Older Age: Evidence from the National Study of Drug Use and Health, The
American Journal of Geriatric Psychiatry (2018), doi: https://doi.org/10.1016/j.jagp.2018.12.023

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Highlights

• This study primarily addresses: to what extent do sexual minorities (lesbian, gay, and

bisexual (LGB)) middle- and older-age (50+) adults have higher suicidial behaviors than

heterosexual counterparts?

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• Sexual minority adults in middle- and older-age had significantly higher prevalence of

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suicidial ideation in the preceding 12 months. We estimate that there were roughly 185,000

LGB adults aged 50+ with suicidial ideation in the preceding year. Among adults aged 50+

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with suicidal ideation, sexual minorities had significantly higher prevalence of suicide plans

in the preceding 12 months.

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• These findings suggest that sexual minority adults in middle- and older-age are at elevated

risk for suicide than their heterosexual counterparts.

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Suicide Risk For Sexual Minorities in Middle and Older Age: Evidence from the National
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Study of Drug Use and Health

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Benjamin D. Capistrant, ScD; Ora Nakash, PhD

Affiliations of all authors

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Smith College, School of Social Work, Northampton, MA, USA

Corresponding Author

Benjamin D. Capistrant, Smith College School of Social Work, 23 West St,

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Northampton, MA 01063, Tel: +1-413-585-4634, Email: bcapistrant@smith.edu

Acknoweldgments, Conflicts of Interest and Source of Funding

There are no conflicts to declare. The Substance Use and Mental Health Services

Administration, part of the U.S. Department of Health and Human Services, funded and made

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data publically available for the National Survey on Drug Use and Health. The authors had no

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additional, specific funding to support this work. The authors thank three anonymous reviewers

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for their helpful comments on previous drafts of this work.

Manuscript text word count: 1489

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MeSH Keywords: aged, middle aged, sexual and gender minorities, suicide, suicidal
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ideation
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Abstract

Objectives No studies have estimated the difference in suicide ideation, plans and

attempts for lesbian, gay, or bisexual (LGB) adults aged 50+ compared to heterosexuals using

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nationally representative data. Methods We used 2015-2017 National Survey on Drug Use and

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Health data to estimate the prevalence of self-reported suicide ideation, plans and attempts for

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LGB adults 50+ compared to heterosexuals in the preceding 12 months. Results Over 185,000

LGB adults aged 50+ in the U.S. were estimatated to have had suicidal ideation in the preceding

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year. After adjusting for sex and race/ethnicity, LGB individuals aged 50+ had 4.5-percentage

points higher prevalence of suicidal ideation compared to heterosexuals (PD: 0.045, 95% CI:
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0.022,0.067). Of those with suicidal ideation, LGB individuals aged 50+ had 17.2-percentage

points higher prevalence of suicidal plans compared to heterosexuals (PD: 0.172, 95% CI:
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0.011,0.332). Conclusions LGB adults in middle- and older-age had higher suicidal ideation and
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plans than heterosexual peers.

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Objectives

Suicide rates peak in midlife (age 45-64: 19.2 per 100,000) and attenuate only slightly

through later life (age 65+: 16.7 per 100,000). These rates are especially high for white men.1

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Suicidal ideation, plans, and attemtps are critical, modifiable risk factors for suicide mortality.

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Indeed, as predacessors to suicide mortality, suicidal ideation is even more prevalent still than

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suicide mortality. Identifying risk factors and populations of older adults who are at particular

risk for suicide can facilitate and prioritize prevention interventions.

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Sexual minorities - lesbian, gay, and bisexual (LGB) individuals - are at higher risk of
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suicide compared to their heterosexual counterparts, largely due to minority stress and associated

exposure to discrimination and social stigma related to their sexual identity. These patterns have
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been studied primarily in LGB youth and younger adults.2 In a recent meta-analysis of sexual

minority differences in suicide attempts Hottes et al. found that most studies were community
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rather than population based samples, and that overwhelming majority of studies focused on
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younger samples (mean age of population studies was 43; community studies was 32).3

Psychosocial processes related to suicidality, including social stigma and perceived

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belongingness that are attributed as risk factors for LGB youth, manifest differently in later life.

Despite the high rates of suicide in middle- and older-age and different mechanisms from the
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evidence about LGB youth suicide risk, no studies to our knowledge have examined LGB

suicidal behaviors in LGB middle- and older-age adults with population representative data.

We used data from the only federally coordinated, national survey that assesses suicide

behaviors and sexual identity to compare the prevalence of suicidal ideation, plans and attempts
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among LGB and heterosexual adults in middle- and older-age (50+).

Methods

The National Survey on Drug Use and Health (NSDUH)4 is an annual, cross-sectional

survey in all 50 states. NSDUH began asking respondents about sexual identity in 2015. We

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pooled data from 2015 and 2016 among adults aged 50+ with complete data on suicidal thoughts

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and sexual identity (n=26,175). NSDUH used a complex, multi-stage sampling strategy, and

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calculated sampling weights that generate estimates that represents the U.S. civilian, non-

institutionalized population aged 12 or older. For estimates of 2 years of pooled data, we

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adjusted the survey weights by dividing them by 2 to reflect estimates of an average U.S. civilial,
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non-institutionalized population between 2015 and 2016.

All adult NSDUH respondents self-reported if they had thought seriously about trying to
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kill themselves in the preceding 12 months. Those who reported serious thoughts of suicide were
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also asked both whether they had made a plan to kill themselves and whether tried to kill

themselves in the preceding 12 months. Repsondents reported either yes or no answers to each
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question.
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NSDUH includes questions about sexual attraction and sexual identity; we used the latter

in this study. Respondents self-reported whether they considered themselves to be “heterosexual,

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that is, straight”, “lesbian or gay” or “bisexual”. We combined lesbian, gay, and bisexual (LGB)

answer responses due to small sample sizes, and used a binary indicator variable of LGB identity

(reference: heterosexual/straight).

Gender, and race/ethnicity were also self-reported. We used a binary variable of

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respondent sex (female vs. male [reference]) and a categorical variable of race/ethnicity (non-

Hispanic White [reference]; non-Hispanic Black; non-Hispanic Native American; non-Hispanic

Native Hawaiian or Pacific Islander; non-Hispanic Asian; non-Hispanic multiple race; Hispanic).

Other suicide risk factors may mediate the relationship between sexual identity and suicidality;

consistent with previous studies,1 we included only demographic potential confounding

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variables.

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We graphed the survey weighted prevalence (and 95% Confidence Intervals (CI)) of

estimated suicidal ideation and plans, respectively, in the previous 12 months by sexual identity

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(lesbian, gay, or bisexual (LGB) vs. heterosexual) in bar charts. We also modeled the difference

in prevalence on the additive/absolute scale between LGB and heterosexual adults in unadjusted
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and sex-and-race/ethnicity adjusted generalized linear regression models with an identity link.

We report this prevalence difference (PD) on a scale from 0.00-1.00, which correspond to
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percents from 0-100%; for example, PD estimates of 0.03 can be conceptualized as a 3

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percentage point difference between two groups’ prevalence. We used the survey package in R to

account for NSDUH clustered and stratified sampling design adjusted standard errors. We used
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the package’s default Taylor series linearization for variance estimation5. We also used the

survey package to apply the NSDUH sampling weights to make population estimates. All
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statistical tests reflect survey adjusted standard errors and two-tailed tests / 95% CIs. Statistical
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code for replication of these results is available at [website redacted for blinded peer-review].

Results

The weighted total population estimates suggest that there were 2,709,534 LGB adults

aged 50+ (95% CI: 2,465,475, 2,953,594) in the U.S. In relative percentage, we estimated (2.5%;
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95% CI: 2.2, 2.7) of the adults aged 50+ identified as LGB.

Among those LGB adults aged 50+, 185,190 (95% CI: 120,805, 249,575) had suicidal

ideation in the prior year (6.8%). Of the LGB adults aged 50+ with suicidal ideation, 73,399

(95% CI: 33,807, 112,991), or 39.6%, had suicidal plans and 34,977 (95% CI: 6,651, 63,304), or

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18.9%, had suicidal attempts in the 12 months prior to the survey. We present additional details

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on population size and percent prevalence of suicide ideation and behaviors in Supplemental

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Table 1.

Suicidal ideation and behaviors in the previous 12 months were more prevalent among

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LGB adults than heterosexual populations (Figure). After adjusting for sex and race/ethnicity,
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LGB individuals aged 50+ had 4.5-percentage points higher prevalence of suicidal thoughts in

the preceding 12 months compared to heterosexual individuals (PD: 0.045, 95% CI: 0.022,0.067,
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z:3.891, p=0 ). Of those adults aged 50+ with suicidal ideation in the previous 12 months, LGB

adults had 17.2-percentage points higher prevalence of suicidal plans in the preceding 12 months
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compared to heterosexual individuals (PD: 0.172, 95% CI: 0.011,0.332, z:2.098, p=0.042 ).

Among those with suicidal ideation, LGB adults aged 50+ also had higher adjusted prevalence of
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suicide attempts in the preceding 12 months than heterosexuals; however, these confidence
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intervals were wide and included the null, and the tests of these differences were not statistically

signficant (PD: 0.102, 95% CI: -0.03,0.234, z:1.509, p=0.139). Complete unadjusted and
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adjusted results are presented in Supplemental Table 2.

Conclusion

To our knowledge, this is the first study to estimate the prevalence of suicidal thoughts

and behaviors among sexual minority older-adults in a nationally representative sample. Building
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off a strong body of research that has well documented the higher prevalence of suicidal ideation

among LGB youth, our results illustrate that middle- and older-age LGB adults also have higher

prevalence of suicidal ideation and plans than heterosexual counterparts. Indeed, we estimated

185,190 LGB adults aged 50+ in the U.S. had a prevalence of suicidal ideation the preceding 12

months.

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LGB older adults may face many of the previously posited mechanisms of suicidal

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ideation in later life, particularly social disconnectedness, prevalence of depression,6 persistent

adverse childhood experiences (ACEs),7 chronic and/or new experiences of discrimination.8

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LGB older adults are less likely to be married or have children than heterosexuals,9 which may

leave more LGB older adults socially isolated. The prevalence of ideation among LGB adults
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aged 50+ was nearly double that of heterosexuals (6.8% vs. 2.4%), or other estimates of the

overall prevalence of suicide ideation using these data.10 Thus, LGB-specific suicide risk factors
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may merit additional consideration.

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Despite pooling three years of survey data, there were too few LGB adults aged 50+ to

power more robust statistical tests appropriately, particularly for suicidal attempts, or to
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disaggregate further by age (50-64, 65+). Future work of larger samples of middle- and older-age
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LGB adults is needed to address these limitations. Sexual minority identities and suicidal

thoughts are both stigmatized and may be underreported in this sample. These results also have a
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survivor bias of the HIV/AIDS crisis that killed many men who have sex with men from this age

cohort, though it is unclear in which direction this bias may affect the estimates. We adjusted for

basic demographics – gender and race/ethnicity – which was consistent with prior research.

Additional suicide risk factors may be mediators and would bias the estimates if they were
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controlled for as though they were confounding variables. Although we speculate about potential

mediating mechanisms, future research with larger samples of LGB older adults should indentify

specific social, interpersonal, and individual factors that are differentially associaited with

suicidality in older LGB individuals to inform strategies for prevention and intervention to

reduce suicidal risk.

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These results offer novel evidence of LGB middle- and older-adults’ higher prevalence of

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suicidal ideation compared to heterosexual adults. Clinicians should consider screening LGB

patients for suicide ideation and prioritize managing suicide risk factors in LGB adults in middle

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and later life. Higher prevalence of suicide plans may stem from higher prevalence of ideation

though this has not been demonstrated empirically; future research and clinical work should
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consider whether the path between ideation and plans may also be stronger for LGB adults in

middle and older-age compared to heterosexual counterparts. Evidenced based suicide

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prevention interventions for LGB populations should be built for and implemented across the
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lifecourse. Our findings suggests that suicide risk reduction interventions are needed not just for

LGB youth, but LGB adults in middle- and later-life as well. These findings’ clinical, practice
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and research implications should motivate additional responses to understand and reduce LGB

elevated suicide risk, particularly for LGB adults in middle- and older-age.
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Figure Proportion of Suicidal Ideation and Behaviors in Preceding 12 Months among

Adults Aged 50+ by Sexual Identity

Footnote: Prevalence of suicidal thoughts and behaviors are in the preceding 12 months,

and prevalence of plans is of those with suicidal ideation. Proportions on the 0.00-1.00 scale

corespond to percent (0-100%) prevalence. Vertical grey bars reflect the 95% Confidence

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Interval (CI) around the estimated prevalence. Estimates are from survey weighted prevalence

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and standard errors. Data are from the National Survey of Drug Use and Health (NSDUH): 2015-

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2017

Supplemental Digital Content

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