Previous Mental Health Care and Help-Seeking Experiences: Perspectives from Sexual and Gender Minority Survivors of Near-Fatal Suicide Attempts

Abstract

Sexual and gender minority (SGM) populations face heightened risk of suicide compared to their heterosexual and cisgender counterparts, and a previous suicide attempt is among the strongest predictors of suicide mortality. Despite this increased risk, limited research has explored mental health help-seeking behavior and previous mental health care experiences of SGM individuals among the highest risk for suicide – individuals with a recent, near-fatal suicide attempt. This study presents thematic analysis results of interviews with 22 SGM individuals who reported at least one near-fatal suicide attempt in the past 18 months. Identified themes were (1) factors that affect help-seeking for SGM individuals with a recent, near-fatal suicide attempt, including previous mental health care experiences, support systems, and structural barriers and facilitators, (2) hospitalization is not a one-size fits all solution, and (3) recommendations for improving care for this population. Findings demonstrate that anti-SGM stigma may magnify existing barriers to mental health care across all socioecological levels. Notably, participants cited a fear of loss of autonomy from inpatient hospitalization and previous discriminatory experiences when seeking mental health care as hampering help-seeking. Given increased risk for suicide mortality, this patient population is a necessary stakeholder in suicide prevention and intervention development and policy discussions affecting mental health care.

Impact Statement

Sexual and gender minority individuals with recent, near-fatal suicide attempts described that previous mental health care experiences, their support systems, structural factors, and their attitudes towards inpatient hospitalization can affect their future help-seeking behavior, particularly during a mental health crisis. Participants shared recommendations for improving care for other SGM individuals at high risk for suicide. These findings can inform efforts to improve the availability and quality of mental health care and suicide prevention for sexual and gender minority populations.

Suicide prevention is a major health care need for sexual and gender minority (SGM) individuals (Haas et al., 2016). Approximately one in ten sexual minority individuals, and one in three transgender individuals, attempt suicide in their lifetime (Adams et al., 2017; Hottes et al., 2016)—prevalence statistics that are much higher than those of cisgender and heterosexual individuals (4%; Hottes et al., 2016). Reducing suicide mortality requires increasing utilization and effectiveness of mental health care services (Hom et al., 2015). Estimates of mental health service usage amongst individuals with high risk for suicide vary based on definition of risk, timeframe, and age (Hom et al., 2015), but utilization rates are often low. Better understanding factors that can impact SGM individuals’ engagement in suicide prevention and treatment efforts is vital given the disparities with cisgender and heterosexual counterparts (Marshall, 2016). The purpose of the present study is to explore previous mental health care experiences and help-seeking behavior of SGM individuals with recent near-fatal suicide attempts, in effort to inform effective suicide interventions among SGM individuals.

A substantial literature demonstrates that SGM individuals broadly encounter substantial barriers to mental health care that span socioecological levels (Romanelli & Hudson, 2017; Snow et al., 2019; White Hughto et al., 2015). At an individual level, these barriers can include lack of time, transportation, and fear of encountering discrimination (Romanelli & Hudson, 2017). Interpersonal barriers may include experiencing discrimination and microaggressions from providers, such as misgendering or pathologizing of SGM identity (Mizock & Lundquist, 2016; Rees et al., 2020). Structural barriers to adequate mental health care services for SGM individuals are plentiful, such as lack of visibility of affirming providers and care systems and a dearth of competent providers or appropriate training (Rees et al., 2020; Romanelli & Hudson, 2017).

Amidst these barriers, mental health care utilization rates of SGM individuals with suicidal ideation or suicide attempts are largely unknown. Large surveys with SGM populations can offer some insight and demonstrate that not all who desire mental health care receive it. In a sample of over 27,000 gender minority individuals, in which 40% reported a past suicide attempt, 77% of participants desired counseling or therapy related to their gender identity, but only 58% had received it (James et al., 2016). The Trevor Project, a leading suicide prevention hotline for SGM youth, found in a recent national survey that 48% of surveyed SGM youth wanted mental health care, but did not receive it (The Trevor Project, 2021). Another study from the Trevor Project showed that in a sample of SGM youth and young adults who reported suicidal ideation or an attempt in the previous year, nearly half of participants did not tell anyone or seek help with their suicidality (Lytle et al., 2018).

Limited research has examined mental health experiences for the subgroup of SGM individuals with recent suicide attempts. In studies conducted without regard for sexual orientation or gender identity, barriers to seeking care among survivors of suicide include fear of hospitalization, and preference for self-management of problems (Hom et al., 2015). Facilitators include knowledge about mental health, positive stance towards mental health services, and receiving encouragement from support systems to seek care (Hom et al., 2015). Some barriers to care identified by SGM individuals at high risk for suicide may be universal, such as financial and insurance issues, avoidance/discomfort, and shame (Ferlatte et al., 2019), but other barriers may be heightened or unique based on SGM identity.

When examining mental health experiences of SGM individuals at risk for suicide, it is important to attend to factors that may contribute to further disparities and barriers. For example, gender minority individuals report higher rates of suicide attempts, more than double, compared to sexual minority cisgender individuals (Su et al., 2016). Structural level factors and gender-minority-specific factors that create barriers to mental health care can also confer additional risk for suicide attempts in gender minority adults (Kaniuka & Bowling, 2021; Perez-Brumer et al., 2015). Living in an area with more structural stigma (e.g. state-level policies protecting SGM individuals) was associated with greater lifetime suicide attempts in a sample of gender minority adults (Perez-Brumer et al., 2015). Internalized transphobia was also related with increased number of lifetime suicide attempts in the same sample, demonstrating that stigma across socioecological levels may affect gender minority individuals’ suicidal behavior. These findings speak to protective factors that can be leveraged in suicide prevention and intervention efforts for gender minority populations, including community connectedness, support from friends, and passing SGM-affirming legislation (Kaniuka & Bowling, 2021). The impact of stigma both on contributing to suicide risk for SGM individuals and barriers to appropriate mental health care cannot be understated.

Much of limited literature regarding SGM individuals, suicidality, and help-seeking focuses on youth and young adults and examines the impact of stigma. For example, among SGM adolescents, experiences of general discrimination are associated with decreased likelihood of disclosure of suicidal thoughts and behaviors to health care providers (Burke et al., 2021). Additionally, one mixed methods study revealed that SGM youth may be reluctant to seek help from formal and informal supports due to expected stigma related to their SGM identity, age, or mental health, as well as challenges with discussing emotion and the need to manage their issues independently in the context of SGM stigma (McDermott et al., 2018). Evidence also shows that SGM adolescents who hold less positive beliefs about help-seeking, such as perceptions that a counselor at school will not help them if they were upset, are more likely to attempt suicide than SGM adolescents with more positive beliefs (Hatchel et al., 2020). Additionally, while some data suggest that sexual minority individuals may be more likely to seek mental health services than heterosexual individuals (Grella et al., 2011; McNair & Bush, 2016), such help-seeking does not always buffer suicide risk, and in cases of seeking religious or spiritual help, may even increase risk (Meyer et al., 2015). This suggests that even when SGM individuals do engage in mental health care, the care that they receive may not adequately meet their needs.

One mechanism in which to improve the utilization and effectiveness of mental health treatment of suicide risk among SGM individuals is to understand previous mental health care experiences and help-seeking behavior of SGM individuals at high risk for suicide. Literature examining the specific needs of SGM individuals with previous suicide attempts is scarce and even rarer amongst those with a near-lethal suicide attempt, the primary predictor of a subsequent suicide attempt or death by suicide (Ribeiro et al., 2016; Joiner et al., 2005). Frequent exclusion from clinical trials, low base-rates, and ethical considerations including researchers’ responsibilities and IRB limitations contribute to those at highest risk for suicide often excluded from necessary research (Saigle et al., 2017), meaning qualitative research is an appropriate next step to address research gaps with this population. Seeking understanding through qualitative methods also affords the benefits of a more nuanced identification of unique areas to improve upon when providing treatment to SGM individuals with suicide risk, honors the complexity of suicide risk and help-seeking, and prioritizes voices and lived experiences of this underserved population (White, 2016). Thus, the current study drew upon lived experiences of SGM individuals with recent near-fatal suicide attempts to explore their previous mental health care experiences and help-seeking behaviors in effort to identify modifiable intervention points to reduce suicide in a high risk-population.

Methods

Participants and Procedures

Eligibility criteria for this study included: 1) 18 years or older; 2) identify as a sexual or gender minority individual; 3) live in the United States; and 4) report a near-fatal suicide attempt in the previous 18 months (e.g., use of a high-fatality method, overdose requiring medical treatment in an intensive care unit). Recruitment occurred online via paid and unpaid advertisements on social media sites including Facebook, Instagram, and Reddit, and the study was advertised with the general statement “Have you experienced suicidal thoughts or attempted suicide?” in effort to reduce selection bias (e.g., by recruiting only SGM individuals who associated their SGM identities with their suicidal histories). Five-hundred and eighty-three individuals began the eligibility screening questions and 27 individuals were eligible for the study. Twenty-two individuals consented and participated in an interview.

Twenty-two SGM adults who reported at least one near-fatal suicide attempt in the previous 18 months participated in semi-structured interviews. The interviewer (KAC) utilized an interview guide that included open-ended questions regarding the recent suicide attempt (e.g., method, preparation, and intent) as well participants’ perceptions of how their SGM identity shaped their mental health and suicidality-related factors, such as belonging and perceived burdensomeness. The interview guide focused discussion on a recent near-fatal suicide attempt and factors that contributed to acquired capability for suicide, described in Clark et al. (2022). Most participants discussed their perspectives on mental health help-seeking and their previous mental health care experiences prior to and following their near-fatal suicide attempt during the interviews, but probing questions were not specifically written to elicit these conversations. Interviews were conducted via telephone between October and December 2020. Interview lengths ranged from 31 to 67 minutes with a mean length of 48 minutes. An on-call clinical psychologist was available during all interviews in case of emergency. This study was approved by the Yale Institutional Review Board (protocol #2000028648).

Most participants identified as cisgender women (50.0%), bisexual (59.1%), and White (63.6%). Participants lived in 15 different states and the majority (91.9%) reported an income less than $30,000 per year. On average, participants were 24.1 years old, and ages ranged from 19 to 45. Detailed demographics are available in Table 1.

Table 1.

Sample Demographics

Demographic Variable	N (%)
Gender Identity
Cisgender Woman	11 (50.0)
Cisgender Man	3 (13.6)
Transgender Man	5 (22.7)
Transgender Woman	1 (4.5)
Non-binary	1 (9.1)
Sexual Orientation
Gay or Lesbian	6 (27.3)
Bisexual	13 (59.1)
Queer	6 (27.3)
Demisexual	1 (4.5)
Pansexual	2 (9.1)
Asexual	2 (9.1)
Uncertain, Not Sure	1 (4.5)
Race/Ethnicity
White	14 (63.6)
Black/African American	3 (13.6)
Latinx, Hispanic	2 (9.1)
Asian	2 (9.1)
Another Race/Ethnicity	1 (4.5)
Employment Status
Full-time (40 hours per week)	5 (22.7)
Part-time (fewer than 40 hours per week	8 (36.4)
Unemployed	6 (27.3)
Permanently or temporarily disabled and not working	3 (13.6)
Annual Income
Less than $10,000	9 (40.9)
$10,000 - $19,999	6 (25.7)
$20,000 - $29,999	5 (22.7)
$30,000 or more	2 (9.1)

Note. Percentages may total more than 100% as participants could select multiple options within a demographic category.

Data Analysis

Audio recordings of the interviews were transcribed verbatim by a HIPAA-compliant transcription company and the transcripts were imported into Dedoose, a qualitative analysis software. Thematic analysis, a common flexible qualitative analysis approach, was used to abstract themes and codes from the data (Braun & Clarke, 2012, 2019). Two coders (NRH and EB) conducted the thematic analysis focusing on interview excerpts that related to previous mental health treatment experiences or seeking care and support for psychological distress. The coders included a clinical psychology fellow with expertise in SGM mental health and a clinical psychology doctoral student, both who have lived experiences as SGM-identified individuals. An inductive approach was used, allowing themes to emerge from the data in a bottom-up manner such that themes are most closely linked to the data from participants, rather than the predetermined questions on an interview guide or an existing theory. The coders first familiarized themselves with the dataset, reading each interview multiple times and making annotations. Coders then met to discuss initial annotations and common topics seen in the data. The next phase involved generating initial codes by assigning semantic labels that described portions of the transcripts. The coders met via tele-conferencing to jointly assign initial codes to three interviews, building the codebook and discussing application of initial codes until consensus was reached on each interview. Coders then separately applied initial codes to four interviews and met again to discuss additions to the codebook based on this subset of interviews. Each coder’s version of these four interviews were reviewed to resolve any discrepancies. A total of 7 (31.8%) interviews were double coded. After this phase, the coders reviewed the codebook and discussed how codes related to each other and potential groupings of similar codes (e.g., mode of mental health care; support system). When applicable, existing codes were grouped into parent codes to organize the codebook and aid thematic development. Each coder was then assigned a portion of the remaining 15 interviews to independently code. This was an iterative process as new codes were added throughout this process and coders had ongoing communication about the evolving codebook. Interviews coded early in the process were re-reviewed to ensure completeness based on the final codebook. Once all interviews were coded, the coders met to review and organize the full codebook into potential themes. Through discussions with the research team and use of Dedoose’s qualitative analysis features, such as generating Word clouds and code matrices, data within each potential theme were reviewed and themes were finalized. As a final step, themes were presented to and discussed with a group of B.A.-, M.A.-, and Ph.D.-level researchers with expertise in SGM research and mental health to confirm data labels, themes, and organization.

Results

We identified several themes related to how previous mental health care experiences shaped participants’ attitudes about and future self-efficacy of seeking mental health care. Themes are listed in Table 2. The primary theme was (1) factors that affect help-seeking for SGM individuals with a recent near-fatal suicide attempt. These factors fell into several subthemes: (a) previous negative mental health care experiences; (b) previous positive mental health experiences; (c) social support; and (d) structural barriers and facilitators. Additional themes we identified were (2) hospitalization is not a one-size-fits-all solution and (3) recommendations for improving care for SGM individuals with high risk for suicide. We also include a summary of psychiatric disorders and treatment described by participants in their interviews to further describe the sample.

Table 2.

Themes and Example Quotes

Themes and Sub Themes	Example quote
Factors Affecting Mental Health Help- Seeking
• Previous negative mental health experiences	“I feel like I’m being tortured and dismissed in a psychiatric institution. It also makes me very wary of psychiatrists and mental health professionals” [28-year-old, bisexual/queer/pansexual cisgender woman]
• Previous positive mental health experiences	“When they [suicidal thoughts] do come, I do call my therapist and we just have a conversation. With the conversations that we had, I just feel much better. I feel like it has had a positive impact on my life.” [25-year-old, bisexual cisgender woman]
• Social support	“The reason why I chose to just walk up to the hospital is because at that moment, I didn’t have family that could come be with me. I didn’t have friends here. I didn’t have anyone else that I could go to” [29-year-old, bisexual, non-binary woman]
• Structural barriers and facilitators	“I was on a waiting list for a therapy here after I moved, but the waiting list here really, really long. I definitely didn’t have anything after a month and a half.” [24-year-old, bisexual/queer/pansexual transgender woman]
Hospitalization is not a One-Size-Fits-All Solution	“I know that I didn’t want to go to the hospital. I specifically requested, let’s just wait out. Let’s see what happens. I didn’t want to go to the hospital. I didn’t want to be put on a forced, like, 72-hour hold” [20-year-old, bisexual cisgender woman]
Recommendations for Improving Care for SGM Individuals with High Risk for Suicide	“There is no way that I was going to be able to talk to a therapist without my parents knowing when I was living with them … free anonymous mental health for LGBT youth would have helped” [24-year-old, bisexual/queer/pansexual transgender woman]

Psychiatric Descriptors of Participants from Qualitative Analysis

In order to further characterize the sample, information about participants’ psychological diagnoses, psychiatric symptoms, and venues in which they had sought mental health care was extracted from interview transcripts and categorized. Participants reported a history of several diagnoses and symptoms including: adjustment disorder, anxiety, autism, bipolar disorder, borderline personality disorder, cognitive deficits, depression, mania, obsessive-compulsive disorder, panic attacks, psychotic symptoms, psychosomatic symptoms, post-traumatic stress disorder, and substance use. Many participants described substantial trauma and abuse histories and most participants had previous suicide attempts in addition to the attempt that was the focus of the interview. Several participants described that they had sought mental health care services at many different venues including: college counseling centers, intensive outpatient programs, crisis centers, and outpatient clinics, with many receiving previous care on inpatient hospital units. Further, participants described receiving care from physicians, mental health therapists, providers in training, school counselors, and religious leaders. Several participants also sought care through peer support groups for substance use, suicide hotlines, texting crisis lines, and other online mental health resources.

Factors Affecting Mental Health Help-Seeking

This theme included 4 subthemes of factors that impacted participants’ mental health help-seeking behaviors and attitudes, particularly during moments of crisis or following a suicide attempt. Previous interactions with mental health care systems, presence or absence of support systems, and various structural factors were influential in how SGM participants described help-seeking processes.

Previous negative mental health care experiences.

Several participants who reported having negative mental health care experiences or encountering perceived barriers described how these factors may dampen desire to seek care during a suicidal crisis. Barriers occurred across socioecological levels, such as on an individual level, interpersonally, or from structural factors in their local community or political sphere. Micro- and macroaggressions, for example, are experiences of interpersonal stigma or discrimination that participants described may occur in one care setting and then impact other and future care relationships. One participant described:

Another patient in the hospital … told me I shouldn’t tell anybody that I was queer or trans because the staff and other patients wouldn’t treat me the same, which didn’t matter because I already told them I was trans when I came in. … It was really the worst thing I think that’s ever happened to me. After that, I totally severed all of the relationships I had with my mental health care providers because I just didn’t trust any of them after that. [22-year-old, queer transgender man]

The stigmatization that this participant experienced during an inpatient hospitalization compromised their trust in other providers and led to termination of care. Some participants described having poor alliance with previous providers and mistrusting mental health care systems, particularly inpatient hospitalization, even without explicit marginalizing experiences. For example, one participant described:

The doctors and nurses couldn’t keep their stories straight. They’d say, ‘Yes, we can get you out of here in three days.’ Then, next time it’s like, ‘Yes, you can get out of here in a week.’ I couldn’t trust them. I didn’t feel like they were being honest or genuine. [24-year-old, gay/queer cisgender man]

These quotes captured how poor alliance, communication, and negative and traumatizing experiences in previous treatment could impact trust and be difficult to overcome if care is needed in the future.

Previous positive mental health care experiences.

Several participants, but a minority of the sample, described having previous mental health care experiences that were positive and helpful, such as having an affirming provider or being currently enrolled in care when experiencing a suicidal crisis. These experiences could increase mental health help-seeking behaviors and improve attitudes, such as facilitating trust that connecting with a mental health care provider following a suicidal crisis would be helpful. Participants described that having trust and being aligned with a provider made them feel comfortable discussing suicide risk, such as engaging in safety planning for potential crisis situations. For example, one participant stated:

I had a very frank discussion with [my therapist] and was like, “If I am really in danger of doing that, if I think I can’t keep myself safe, I need to be able to sometimes express what I’m thinking and that might be concerning.” If I can’t express it, it’s actually worse. I was like, “If I’m ever in danger of actually that I think I can’t be safe, I will tell you that.” He trusted me to do that, and that was really helpful. [29-year-old, bisexual, non-binary woman]

Here, a participant felt comfortable setting expectations with their therapist about how they could work together to manage suicidality, aided by mutual trust. Having a provider to whom participants felt secure disclosing their suicidal urges and with whom they could jointly develop a safety plan led to several participants seeking care or support immediately after a suicide attempt. As one salient example of the benefit of mutual trust with a mental health care provider during a suicidal crisis, one participant stated:

I called my therapist and she answered. I talked to her for a little bit. Then I told her what I did [attempted suicide]. She told me to go to the hospital, but I told her I didn’t want to. She just said as long as I could get someone to come over, then she was comfortable with me staying home. I had my friend come over. [20-year-old, gay transgender man]

For this individual, their established relationship and trust with a provider facilitated help-seeking after a suicide attempt and reflects shared-decision making where the participant’s treatment preferences were considered.

Support systems.

Nearly all participants referenced their support system. These supports were described as both affirming or unsupportive, and had complex effects, both on the likelihood that someone seeks care in a crisis and their attitudes about care options. Some aspects of support systems were barriers to help-seeking before or during a suicidal crisis, including participants’ knowledge of a family member or friend’s negative experiences with hospitalization as well as lacking a support system, Further, for participants who were still attached to their parents’ health care insurance coverage, many described being fearful that seeking health care would disclose their suicidality to their parents. This fear of disclosure during help-seeking also occurred related to participants’ fear of their SGM identities being disclosed – or being “outed” – to their families, showing the complexities of perceived unsupportive family environments, care seeking, and mental health concerns for SGM youth and young adults. However, several participants instead described supportive interactions with family members following their suicide attempt or when experiencing substantial suicidal ideation that led them to access care, such as “I called my dad, talked to my dad and decided on inpatient would be the best to keep myself safe” [20-year-old, asexual cisgender woman]. Seeking support from friends was also described as components of safety plans developed with care providers.

Structural barriers and facilitators.

Most participants described many structural factors that they had encountered in the past when trying to seek care or that they anticipated encountering in the future. For many participants, care-system factors such as availability of providers created delays when attempting to seek mental health care. One participant described feeling fortunate to have access to low-cost services through their university counseling center, but still noted that “even … the university, they limited the number of sessions” [29-year-old, bisexual non-binary woman]. Cost concerns were not isolated to previous outpatient treatment but also affected participants when they were hospitalized on inpatient psychiatric units. For example, one participant captured the complex affective impact related to financial burden of involuntary admissions:

It was a lot of anxiety not knowing what was going to happen. I knew I was on a three-day pink slip but with that they can extend that to however long they want. I was really nervous. I was supposed to be at work the next day and money is super tight. I was freaking out about that and rent was due in two weeks so I was freaking out about that. [20-year-old, bisexual cisgender woman]

As evidenced here, financial burdens extended to precarious employment and, for some, housing instability, reflective of common structural disadvantages SGM people face that can exacerbate mental health concerns.

Other structural barriers participants identified included lack of culturally-appropriate care, limited availability of resources in rural locations, and lack of alternative crisis care options aside from hospitalization. One participant stated:

In the town over, there is-- it’s like 40 minutes from here. There is a place with a 24-hour crisis center. You can come and go. You can go in there. The thing is it’s really rural here and I didn’t have a car. If you can’t get there, the only other option is to go to the hospital. [29-year-old, bisexual non-binary woman]

This individual described how living in a rural location restricted their options for seeking care during a mental health crisis and was magnified by other barriers, such as lack of transportation. The participant later described how they had heard of police on their college campus offering students rides to the crisis center in another town, but those students would then have no transportation back home. This demonstrates that even when one structural barrier is removed, mental health help-seeking still may not be possible due to other structural barriers.

Hospitalization is not a One-Size-Fits-All Solution

Most participants described their past experiences within inpatient hospitalization settings and offered their feelings and attitudes about inpatient hospitalization as a mental health care option. Participants’ descriptions indicated that hospitalization is not a one-size-fits-all solution when an SGM individual is experiencing substantial suicidal ideation or has a recent suicide attempt. For those who expressed negative attitudes about hospitalization, fear of involuntary admission was common as participants desired personal autonomy in decisions about their care following suicide attempts. Participants also expressed fears of involuntary admission stemming from negative discriminatory experiences on hospital units, concerns about engaging with new providers, and worries about police involvement. One participant who had previously interacted with police during a mental health crisis described how the experience was traumatizing and generated fear of police involvement in their future:

Because the cops that came were very aggressive towards me, which wasn’t helpful in that moment or really ever. The guy who talked to me was like, ‘Well, I don’t understand why you would try and do something like this [attempt suicide]. Why your parents not love you? Do you not live in a house? You have a house? You have food? I don’t understand what is going on.’ I was like, ‘Well, those are excellent points,’ [laughs] ‘but also, I feel depressed.’ That doesn’t necessarily make me feel better … For me even when I know that it would be helpful to reach out, to call a hotline and that they would probably make me feel better, I don’t ever want to be put in that situation again. I don’t want to say the wrong thing or do something wrong to get police call[ed] to my house. [23-year-old, gay/queer, cisgender man]

The police officers that escorted this participant to the hospital scared the participant and minimized their experience of distress, questioning why they could possibly be experiencing suicidal thoughts. While the participant noted that “a friend rightfully called 911” in this instance, the experience with police shaped how they plan to utilize crisis care services in the future to minimize the potential for further police involvement.

While many participants described difficulties and fears regarding hospitalization, several described positive attitudes about inpatient hospitalization or recognized that it was the appropriate level of care following their suicide attempt. Some participants described benefits of inpatient hospitalization such as linkage to outpatient treatment upon discharge and feeling a sense of camaraderie with other patients. For example, one participant noted, “I met two girls that were really, really helpful in my recovery process. Both of whom have bipolar disorder as well and I still talked to them today … It was very, I think cathartic [to] go through and be like, ‘Yes, I’ve been through a lot of trauma and I see how I ended up here’” [22-year-old, bisexual cisgender woman]. Other participants described that hospitalization was effective when they received specialized care and a correct diagnosis and encountered providers that facilitated a strong therapeutic alliance.

Contextual factors, such as geographic location, also impacted participants’ attitudes about hospitalization. Participants in rural areas with limited care options beyond inpatient hospitalization noted their desire for alternative care options such as drop-in crisis centers that are more common in more urban areas. For example, one participant stated:

“You can stay there [crisis center] up to 24 hours and you’re free to go…. I think those kinds of things are really good. I think it’s really hard to have access to those kind of things in rural areas, but I think a lot more people would get help if there was something like that. It also helps decrease the involvement of … the police.” [29-year-old, bisexual non-binary woman]

This participant highlighted the potential benefits of a more established stepped care model that offers alternatives to hospitalization. Another participant described additional geographic barriers to accessing their desired level of care: “There’s one psych hospital that’s pretty good and they’re really far away. My insurance won’t cover ambulance rides there anymore, because I don’t have private insurance anymore. I used to go there, but it’s like two hours away.” [21-year-old, bisexual transgender man] This participant’s experience demonstrates that even when hospitalization is the desired solution, there are contextual factors that can impact help-seeking behavior.

Recommendations for Improving Care

All participants were directly asked what resources they thought would be helpful for SGM individuals at high-risk for suicide and the vast majority offered recommendations. A frequent recommendation was adaptations to crisis lines or contact points during crises. Suggestions and considerations included improved training for crisis line workers, importance of anonymity and confidentiality, alternatives to phone calls such as texting options, and more options for connecting with a crisis line. Regarding the last suggestion, one participant who was driving in their car while contemplating crashing recommended an emergency button in their car:

“I think if I had that option of being able to press a button and talk to somebody right then and there of like, “Hey, I’m going 90 miles an hour. I’m going up to 100, 120. I can’t think straight.” I’m like, “I want to kill myself,” and I’m connected with a mental health professional, I think that would have been extremely beneficial.” [23-year-old, bisexual cisgender woman]

Several participants noted the benefits of existing SGM specific crisis lines and need for additional SGM specific resources, particularly for youth who do not have affirming family support networks. A few participants described less effective experiences with contacting suicide hotlines, such as “I called the prevention hotline, and a guy answered … and he was just in my opinion, kind of curt. It’s not necessarily that he didn’t care, but it was less open-ended, and more of just cookie-cutter, this, this, and this. It just didn’t feel genuine or personal to me.” [24-year-old, gay/queer cisgender man] This participant’s experience highlights the importance of a trusting and comfortable relationship with mental health providers or peer support, even when the interaction is brief.

Participants also highlighted the importance of adapting services and public health messaging about mental health to be responsive to intersecting identities. For example, one participant captured the need for more tailored mental health services and outreach within their Southeast Asian community and the importance of providers that match their clients’ demographic backgrounds:

“I think it would be nice to see someone like me be a mental health professional, someone like me in those NAMI [National Alliance on Mental Illness] ads or something. [laughs] I think it would be nice to have support groups … or … workshops, where people can tell us their stories and it would be a diverse group of people. I wish that there would be more outreach actually to the Southeast Asian community.” [28-year-old, bisexual/queer/pansexual cisgender woman]

When asked directly about resources that are needed for SGM individuals experiencing suicidality, participants cited operational changes to mental health systems, including decreasing financial barriers to psychiatric and psychological services and broader availability of care services on an expanded continuum of intensity, such as drop-in crisis centers as alternatives to inpatient hospitalization. Underlying the need for improving mental health care services, participants were particularly cognizant of how anti-SGM stigma in the broader culture has created mental health disparities and psychological distress for SGM people is unlikely to decrease without sociopolitical and cultural changes. One participant succinctly stated this notion when asked about resources that might have thwarted their suicide attempt: “The biggest thing would be a better community and parents … sadly, I don’t think community as a whole or society as a whole is going to change the way it should anytime soon, if ever.” [24-year-old, bisexual/queer/pansexual transgender woman]

Discussion

Findings from our interviews with 22 SGM-identified adults who experienced a near-fatal suicide attempt in the previous 18-months demonstrated the influence of previous mental health experiences, social support networks, and structural barriers and facilitators on mental health help-seeking beliefs and behaviors. Grounded in participants’ past experiences with inpatient psychiatric care, it was clear that there is no one-size-fits-all solution for SGM people when experiencing a mental health crisis and that substantial changes to mental health care systems are needed to adequately serve SGM adults with high suicide risk.

Previous literature demonstrates that most adults with suicidal thoughts have not recently accessed mental health services (Piscopo et al., 2016), and our sample similarly included several participants who were not connected to care, even following their near-fatal suicide attempt. Participants identified many structural and personal barriers to care – transportation, finances, fear of involuntary admission – that may be universal for adults at high risk for suicidality (Hom et al., 2015; Hom et al., 2021), but our participants described these barriers intersecting with anti-SGM stigma at every socioecological level. Figure 1 describes some barriers to mental health help-seeking captured in our interviews that are exacerbated or unique to SGM individuals in this high-risk cohort. At the societal level, participants identified cultural anti-SGM stigma as contributing to psychological distress and limited availability of mental health resources, as well as potentially diminishing their likelihood to utilize the resources or interventions that do exist. Community-level barriers such as few available providers or lack of acute intervention services (e.g., 24-hour walk-in crisis center) can impact any adult at high-risk for suicidality, but SGM communities are disproportionately impacted by some of these barriers. For example, an SGM individual living in a rural locale will be affected not only by the shortage of mental health providers in an area, but also potentially by a lack of providers who are SGM-affirming (Rosenkrantz et al., 2017). Similarly, while SGM individuals may also benefit from common facilitators of mental health help-seeking among adults with high suicide risk, stigma can also be at play in these processes. Encouragement to seek care from support systems is one such facilitator. While some participants in our sample noted that supportive people in their life helped them connect to services following a mental health crisis, others described how stigma within their support network hindered care, such as fear of disclosure of SGM-identity and suicidality to parents if family insurance is used to access care act as barriers at the interpersonal level. Stigmatization was also at play at the individual level as participants both anticipated and experienced previous discrimination based on their identities while seeking mental health care.

Figure 1. Barriers to mental health help-seeking for SGM adults with previous near-fatal suicide attempts.

Note. MHC = mental health care

In our interviews, it was nearly impossible to disentangle previous discriminatory or traumatic experiences in mental health care and anticipation of stigma from help-seeking beliefs and behaviors. Negative experiences in therapy or inpatient hospitalization units or having a poor therapeutic alliance with a provider were often generalized by participants to future care situations. These experiences may affect participants’ likelihood of seeking mental health services in the future or their beliefs in the efficacy of mental health care. Previous research has shown that health care avoidance due to fear of discrimination is common among SGM individuals (Kcomt et al., 2020) and rejection sensitivity (increased fear or attention to stigma due to previous personal or community negative experiences) may mediate the relationship between previous mistreatment and avoidance of care-seeking (Hughto et al., 2018). Future research needs to examine how negative experiences in mental health care, a common occurrence for our sample, may spur heightened fear of stigma and thus decrease future mental health help-seeking behaviors.

A key theme in our data related to perceptions of inpatient hospitalization as an appropriate intervention during a mental health crisis. Participants rarely desired hospitalization both due to potential loss of autonomy and police involvement. SGM people may be disproportionately affected by stigma when police to respond to mental health crises given the potential for mistreatment and perceived or real anti-SGM bias from law enforcement (Hodge & Sexton, 2020). Participants described traumatizing experiences stemming from hospitalization and sought alternatives to an admission when possible. Further research on the effectiveness of inpatient hospitalization and as an intervention for individuals at high-risk for suicidality as well as possible alternative interventions is greatly needed, but some scholarship is beginning to critique the current use of hospitalization. For example, hospital stays have become shorter and are primarily focused on crisis management with a lack of evidence-based interventions (Ward-Ciesielski & Rizvi, 2021). Exposure to traumatic events while hospitalized is also a concern, and based on our data, may particularly affect SGM individuals. SGM individuals’ experiences during inpatient hospitalizations are understudied (White & Fontenot, 2019), but there is strong potential for encountering stigma and discrimination on inpatient. For example, SGM-related stigma can occur when patient units or interactions are divided by sex assigned at birth and a gender minority (GM) individual is not treated based on their gender identity, potentially creating additional psychological distress (Lyons et al., 2015; Walton & Baker, 2019). Examples like these raise important considerations for how providers working with SGM patients should engage in safety planning or make referrals for patients at high-risk for suicidality (Hope et al., 2022). In the current study, when inpatient hospitalization was described as an effective intervention, participants noted feeling heard and supported by hospital providers or found camaraderie with other patients on their unit. This emphasizes the importance of SGM-affirming providers and environments for inpatient units. Recommendations supported by our data and previous literature include treating GM patients according to their self-identified gender identity in documentation, rooming assignments, and gender-based programming, providing SGM-affirming training for all inpatient providers and team members, and using a trauma-informed approach to treatment (Walton & Baker, 2019).

The multitude of recommendations participants gave for improving mental health care services for SGM adults at high-risk for suicide is a strength of our study. This patient population is a necessary stakeholder in suicide prevention and intervention development and policy discussions affecting mental health care. For example, our qualitative results elucidate how previous mental health care experiences and intersecting stigma affect SGM individuals’ desire and efforts to engage in mental health care, an important research target for suicide prevention research (Hom & Stanley, 2021). Future research should continue to engage SGM individuals with high suicide risk to explore help-seeking processes in more detail, particularly given how stigma can occur in early stages of help-seeking such as searching online for a provider (Holt et al., 2020). Mental health care systems can engage with patient stakeholders through Community Advisory Boards to ensure that policy or structural changes meant to increase access to care are effective and address concerns of the community. SGM adults with high suicide risk should also be consulted in efforts to reduce police involvement in mental health crises. These discussions can occur individually with clients and providers to find appropriate, alternative methods to welfare checks with police while safety planning (see Drustrup et al., 2021 for practical recommendations) or as community stakeholders in development of non-police models of crisis intervention (Marcus & Stergiopoulos, 2022).

Limitations

Results from this study should be considered in light of its limitations. One limitation is lack of member checking with the study participants. However, we presented our themes to a panel of SGM researchers, and the authors involved in coding have both professional and lived experience with SGM communities. The nature of qualitative studies limits generalizability to broad populations, meaning experiences described by our participants are not universal to all adults at high-risk for suicidality nor do they represent the experiences of SGM youth experiencing suicidality. For example, our sample is limited by survivor bias and these results may not represent the experiences of SGM people who die by suicide. However, our participants represent a varied sample of SGM adults including diversity in racial and ethnic identity, gender identity, sexual orientation, and geographic location. Future research should utilize qualitative methods to inquire specifically about how SGM adult survivors of suicide take steps towards engaging in mental health care to better inform suicide prevention efforts (Hom & Stanley, 2021).

In this study we sought to center the voices of SGM individuals with recent, near-fatal suicide attempts to understand participants’ previous experiences with mental health help-seeking. Our results capture the complex impact of stigma on individual, interpersonal, and societal factors that affect help-seeking and the quality and availability of mental health services for SGM individuals with high suicide risk. Continuing to engage with SGM suicide attempt survivors is critical to informing suicide prevention efforts and ensuring that appropriate mental health care is available to SGM individuals when needed.