Abstract
Suicide is a public health problem disproportionately associated with some demographic characteristics (e.g., sexual orientation, veteran status). Analyses of the Massachusetts Behavioral Risk Factor Surveillance Survey data revealed that more lesbian, gay, and bisexual (i.e., sexual minority) veterans reported suicidal ideation compared with heterosexual veterans. Decreased social and emotional support contributed to explaining the association between sexual minority status and suicidal ideation. More research is needed about suicide risk among sexual minority veterans; they might be a population for outreach and intervention by the Veterans Health Administration.
In 2008, over 400 000 people engaged in suicidal behavior, with suicide ranking as the tenth leading cause of death.1 Although the etiologies of suicide-related morbidity and mortality are complex, research documented that lesbian, gay, and bisexual (i.e., sexual minority) populations bore a disproportionate burden of suicidal ideation and behavior.2 Although excess risk for suicide was identified among veterans who received services from the Veterans Health Administration3 or experienced active duty in Iraq or Afghanistan,4 the literature was unclear about whether veteran status might be universally associated with elevated suicide risk.5 Gates6 estimated that there were nearly 1 million gay and lesbian veterans; however, currently, there is little—if any—literature about sexual minority veterans’ health. This report aimed (1) to document the prevalence of sexual minority status among veterans in a representative statewide sample and (2) to compare mental health indicators and suicidal ideation by sexual minority status.
METHODS
Data were combined from the 2005 to 2010 Massachusetts Behavioral Risk Factor Surveillance Survey (BRFSS), which used random samples of noninstitutionalized adults (> 18 years) within the state.7 The analytic sample was limited to respondents randomly selected for a state-added module that assessed suicidal ideation (“During the past 12 months, did you ever seriously consider attempting suicide?”). Sexual orientation was assessed with a state-added question: “Do you consider yourself to be: heterosexual or straight; homosexual or gay or lesbian; bisexual; or other?” Veteran status was ascertained with a standardized item (“Have you ever served on active duty in the United States Armed Forces, either in the regular military or in a National Guard or military reserve unit? Active duty does not include training for the Reserves or National Guard, but DOES include activation, for example, for the Persian Gulf War.”). Veterans were defined as indicating “Yes, on active duty during the last 12 months, but not now,” or “Yes, on active duty in the past, but not during the last 12 months.”
Group differences were examined with the χ2 test of independence and the Fisher exact test for small sample sizes, and outcomes were tested with logistic regression models adjusted for demographic characteristics, social and emotional support (“How often do you get the social and emotional support you need?”), poor mental health (“Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?”), and perceived health status (“Would you say that in general your health is…; see Table 1). Maximum likelihood estimation was used to replace missing data for measures other than sexual orientation and suicidal ideation. The Syracuse Veterans Affairs (VA) Medical Center Institutional Review Board approved this project. All analyses were conducted using SAS version 9.2 (SAS Institute, Cary, North Carolina).
TABLE 1—
Demographics and Mental Health Indicators and Odds of Past 12 Months Suicidal Ideation Among Veterans, by Sexual Orientation: Massachusetts Behavioral Risk Factor Surveillance Survey, 2005–2010
| Bivariate Comparisons |
|||
| Variables | Sexual Minority, No. (%) | Heterosexual,a No. (%) | Multivariate Analysis: Suicidal Ideation AOR (95% CI) |
| Demographics | |||
| Sexual orientation | 61 (3.59) | 1639 (96.41) | 2.40 (0.92, 6.28) |
| Sex | |||
| Males | 49* (80.33) | 1482 (90.42) | 0.59 (0.29, 1.25) |
| Femalesb | 12* (19.67) | 157 (9.58) | … |
| Age, y | |||
| 18–39b | 6 (9.84) | 177 (10.80) | … |
| 40–64 | 42 (68.85) | 977 (59.61) | 1.01 (0.36, 2.79) |
| > 64 | 13 (21.31) | 485 (29.59) | 0.73 (0.23, 2.30) |
| Racec | |||
| Non-Whiteb | 2 (3.38) | 173 (10.56) | … |
| White | 59 (96.72) | 1465 (89.44) | 1.18 (0.48, 2.89) |
| Partnership status | |||
| Married/cohabitating | 19* (31.15) | 952 (58.12) | 0.57 (0.32, 1.03) |
| Single/divorced/separated/widowedb | 41* (68.85) | 686 (41.88) | … |
| Mental health indicators | |||
| Poor mental health | |||
| > 15 d/30 d | 10 (16.39) | 180 (10.98) | … |
| < 15 d/30 db | 51 (83.61) | 1459 (89.02) | 5.66* (3.10, 10.35) |
| Perceived health status | |||
| Excellent/very good/good | 47 (77.05) | 1360 (82.98) | 0.48* (0.26, 0.88) |
| Fair/poorb | 14 (22.95) | 279 (17.02) | … |
| Availability of social/emotional support | |||
| Always/usually | 41* (67.21) | 1337 (81.57) | 0.34* (0.19, 0.62) |
| Rarely/neverb | 20* (32.79) | 302 (18.43) | … |
| Outcome: suicidal ideation | 7 (11.48)* | 57 (3.48) | … |
Note. AOR = adjusted odds ratios; CI = confidence interval.
Reference group for comparisons between sexual orientation groups (i.e., heterosexual vs. sexual minority).
Reference categories for multivariate analyses.
Dichotomized into White versus non-White (i.e., Black/African American, Asian, Native Hawaiian/Other Pacific Islander, American Indian or Alaska Native, other race).
*P < .05.
RESULTS
Concordant with previous findings, veteran status was proportionally higher among sexual minority women than heterosexual women.6 Sexual minority veterans had significantly less availability of social and emotional support and higher prevalence of suicidal ideation. Sexual minority status was significantly associated with suicidal ideation in a model adjusted only by demographic covariates (data not shown); however, the addition of poor mental health and availability of social and emotional support variables attenuated the association (Table 1).
DISCUSSION
Among the entire sample, veteran suicidal ideation (3.76%) did not differ significantly from findings in other studies of veterans8 or the US general population.9 However, our results suggested that sexual minority veterans had a higher burden of suicidal ideation, which was concordant with other studies comparing outcomes by sexual orientation.2 Moreover, although sexual minority veterans had higher odds of suicidal ideation, the difference was explained by poor mental health and lower social and emotional support. This finding lent evidence that sexual orientation, in itself, was not a risk factor for poor health outcomes or risk behaviors.10,11 It also demonstrated that, in explaining the excess burden of suicidal ideation among sexual minority veterans, a key factor might be perceived social isolation, of which 1 hypothesized source could be marginalization because of homophobia and heterosexism.
Several limitations must be noted. Although a probability-based sample, the number of sexual minority respondents reporting suicidal ideation was small, and estimates were unweighted, limiting generalizability. Causation could not be inferred from this cross-sectional data. Underreporting was a likely issue given the stigma surrounding both sexual orientation and suicidal behavior. Omitted variable bias might have resulted because potentially key variables explaining suicide risk among veteran populations—namely, substance use—were not included in the analyses. Lastly, the self-identified veteran status limited the abilities to verify history of military service and to discern characteristics germane to suicidal behavior among veterans (e.g., period of service).12
To our knowledge, this report was one of the first to document the prevalence of and mental health indicators among sexual minority veterans. Further research is needed to confirm elevated prevalence of suicidal ideation among sexual minority veterans and to clarify the underlying mechanisms of this disparity, which may be targeted to reduce the burden of suicide and related outcomes in this population.
Acknowledgments
The authors thank the Massachusetts State Department of Public Health for use of state BRFSS datasets. The authors also thank John Altieri and Eric Silver with the Center of Excellence for Suicide Prevention at the Veterans Administration Medical Center at Canandaigua for their assistance in procuring and coding the data.
Human Participant Protection
The Syracuse Veterans Administration Medical Center Institutional Review Board approved this study.
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