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. Author manuscript; available in PMC: 2014 Jan 1.
Published in final edited form as: J Gay Lesbian Ment Health. 2013 Jul 11;17(3):278–293. doi: 10.1080/19359705.2012.763081

Differential reports of suicidal ideation and attempts of questioning adults compared to heterosexual, lesbian, gay, and bisexual individuals

Eva N Woodward 1, David W Pantalone 2, Judith Bradford 3
PMCID: PMC3775355  NIHMSID: NIHMS509706  PMID: 24058715

Abstract

Many sexual minority individuals attempt suicide each year, but little is known about the suicidality of individuals who are questioning their sexual orientation. This study assessed suicidal ideation and attempts of questioning individuals compared to lesbian/gay, bisexual, and heterosexual individuals. This cross-sectional study enrolled participants (N = 2,841) from a community health center. Questioning (OR = 4.286, 95% CI [2.119–8.671]), lesbian/gay (OR = 3.024, 95% CI [2.351–3.890]), and bisexual (OR = 4.389, 95% CI [2.942–6.575]) individuals had significantly greater odds of considering suicide compared to heterosexuals. However, questioning individuals had non-significant odds of attempting suicide compared to heterosexuals. We discuss possible explanations for these findings.

Keywords: LGB, questioning, sexual minority individuals, suicide attempts, suicidal ideation

Introduction

Tragically, many sexual minority individuals (those who identify as lesbian, gay, or bisexual [LGB]) lose their lives each year to suicide (e.g., King et al., 2008). Indeed, there has been increased attention to this issue after a rash of well-publicized suicides of young sexual minority men in the fall of 2010 (e.g., Hubbard, 2010). A meta-analysis of 25 studies from 11 databases reported that LGB individuals are 2.47 times more likely to have attempted suicide than heterosexually-identified individuals (King et al., 2008). Meyer, Dietrich, and Schwartz (2008) report that, in a community sample of 338 New York City adults—a metropolitan area with significantly more gay-affirmative resources available than in other parts of the United States—7.9% of lesbians/gays and 10% of bisexual individuals reported serious suicide attempts. Another study documented that men and women from the National Comorbidity Survey (NCS) who reported any same-sex partner in their lifetime were at significantly greater risk of suicidal thoughts and plans than individuals with only opposite-sex partners (Gilman et al., 2001). These and other studies have concluded that LGB individuals report higher rates of suicidal ideation and attempts than their heterosexual peers (e.g., Cochran & Mays, 2006).

However, little information has been published about individuals who are questioning their sexual orientation. Questioning individuals include those who, unlike self-identified LGBs, feel unsure of their sexual orientation. They may be either actively questioning or passively undecided about whether they will eventually identify their sexual orientation as heterosexual, gay/lesbian, bisexual, or none of those. Fluidity of sexual orientation has been well-documented in young people (Ott, Corliss, Wypij, Rosario, & Austin, 2011; Russell, Clarke, & Clary, 2009) as well as adults, via findings that sexual orientation identification may change over the lifespan, especially for women (e.g., Diamond, 2000). This fluidity of sexual orientation has also been established in men (Savin-Williams & Diamond, 2000). Individuals who do not identify as either heterosexual or LGB endorse greater uncertainty and more exploration regarding their sexual identities than heterosexual individuals (Thompson & Morgan, 2008). In this report, we will refer to the state of being undecided about or questioning one’s sexual orientation as “questioning.”

The lack of suicide research on questioning individuals is surprising given that, when this group is included in research on sexual orientation and suicide, these such individuals appear to be at especially high risk for considering ending their own lives. In one of the few published studies on suicide in questioning individuals, Zhao, Montoro, Igartua, and Thombs (2010) found that, in a sample of adolescents living in Montreal, Quebec, self-identified LGBs and questioning individuals (whom the authors termed a “forgotten group”) were more likely to report having considered suicide compared to heterosexual individuals without same sex fantasies or behavior (pp. 104). Another interesting finding was that, although more questioning youth reported considering suicide than heterosexual youth, the questioning youth were not more likely to attempt suicide than heterosexual youth. The authors hypothesized that questioning individuals internalize negative social messages about LGBs, which may make them more likely to consider suicide (Zhao, Montoro, Igartua, & Thombs, 2010). Another study found that, compared to LGB and heterosexual peers, questioning youth in a large Midwestern county reported more suicidal ideation, mental health problems (e.g., depressive symptoms), and discriminatory experiences (e.g., bullying & homophobic victimization), even though they did not publicly identify as being LGB (Birkett, Espelage, & Koenig, 2009). These findings indicate a critical need for suicide research and intervention development for questioning individuals. Indeed, the federal government listed reducing suicide rates in sexual minorities as a primary objective in its Healthy People 2020 document (U.S. Department of Health and Human Services, 2010), underscoring the widespread agreement about the importance of this topic to the health of all Americans. Moreover, it seems essential for behavioral scientists to focus not just on identified LGB individuals, but also those who are questioning their sexual orientation.

In this study, our primary aim is to replicate and extend the findings of Zhao and colleagues (2010), by assessing reports of suicidal ideation and attempts of questioning individuals, and comparing them to those of heterosexual and LGB individuals. Most research on questioning individuals has focused on youth (e.g., Birkett, Espelage, & Koenig, 2009; Zhao et al., 2010), although evidence strongly suggests that adults can either enter, or remain in, a phase of questioning or indecision about their sexual orientation (e.g., Diamond, 2000). We alsol extend upon previous research by conducting a secondary data analysis of a sample of adults who are unsure about their sexual orientation to better understand suicidal ideation and attempts in questioning adults. Our main research inquiry is to determine if there are differences in sexual orientation groups between individuals who consider suicide, but do not attempt it, and individuals who both consider and attempt suicide. Based on previously reported findings on this topic from the only other study of suicide in questioning individuals (Zhao, Montoro, Igartua, & Thombs, 2010), we propose the following hypotheses:

Hypothesis 1

Questioning individuals will be more likely to report only considering (but not attempting) suicide than lesbian/gay, bisexual, and heterosexual individuals.

Hypothesis 2

However, questioning individuals will be no more likely to report considering suicide and also attempting suicide (as opposed to considering & never attempting) compared to lesbian/gay, bisexual, and heterosexual individuals.

Methods

Participants

Participants (N = 2,841) were enrolled patients receiving their healthcare from a large, community-based health clinic in the northeastern United States focused on (but not exclusively) serving sexual minorities. The demographic characteristics of patients are shown in Table 1.

Table 1.

Demographic Characteristics of the Sample by Sexual Orientation Identity (N = 2,841)

Homosexual
(Lesbian/Gay)
N = 1373 (48.3%)		 Bisexual

N = 147 (5.2%)		 Questioning

N = 38 (1.3%)		 Heterosexual/
Straight
N = 1283 (45.2%)
Age (years)
M = 35.86 M = 32.97 M = 30.81 M = 26.36
SD = 9.17 SD = 11.54 SD = 11.86 SD = 8.76
Gender
  Female 254 (18.5) 77 (52.4) 24 (63.2) 623 (48.6)
  Male 1113 (81.1) 69 (46.9) 13 (34.2) 646 (50.4)
Race/Ethnicity
  Asian/Pacific Islander 34(2.5) 5 (3.4) 1 (2.6) 142 (11.1)
  Black (non-Hispanic) 67 (4.9) 14 (9.5) 2 (5.3) 82 (6.4)
  Hispanic/Latino(a) 68 (5.0) 7 (4.8) 3 (7.9) 104 (8.1)
  Native American 6 (0.4) 1 (0.7) 0 (0.0) 4 (0.3)
  Biracial 4 (0.3) 2 (1.4) 1 (2.6) 3 (0.2)
  White (non-Hispanic) 1176 (85.7) 111 (75.5) 30 (78.9) 909 (70.8)
  Other 13 (0.9) 6 (4.1) 1 (2.6) 33 (2.6)
Employment
    Full-time 947 (69.0) 84 (57.1) 17 (44.7) 376 (29.3)
    Part-time 106 (7.7) 10 (6.8) 1 (2.6) 96 (7.5)
    Unemployed 150 (10.9) 14 (9.5) 5 (13.2) 112 (8.7)
    Retired 13 (0.9) 0 (0.0) 1 (2.6) 7 (0.5)
    Student 85 (6.2) 30 (20.4) 11 (28.9) 642 (50.0)
    Homemaker 5 (0.4) 0 (0.0) 1 (2.6) 11 (0.9)
    Other 59 (4.3) 9 (6.1) 2 (5.3) 29 (2.3)
Housing Status
    Home/Apartment 1338 (97.5) 134 (91.2) 36 (94.7) 1127 (87.8)
    Transitional 4 (0.3) 6 (4.1) 0 (0.0) 52 (4.1)
    Mission/Shelter 3 (0.2) 0 (0.0) 1 (2.6) 4 (0.3)
    Streets 1 (0.1) 0 (0.0) 0 (0.0) 1 (0.1)
    Other 23 (1.7) 6 (4.1) 1 (2.6) 84 (6.5)
Family Income
  < $20,000 234 (17.0) 26 (17.7) 15 (39.5) 304 (23.7)
  $20,000 – $34,999 274 (20.0) 44 (29.9) 10 (26.3) 253 (19.7)
  $35,000–$49,999 283 (20.6) 25 (17.0) 6 (15.8) 180 (14.0)
  >$50,000 542 (39.5) 48 (32.7) 4 (10.5) 413 (32.2)
Lifetime Suicide Experience
    No ideation or attempt 1014 (73.9) 96 (65.3) 24 (63.2) 1149 (89.6)
    Only ideation 211 (15.4) 25 (17.0) 8 (21.1) 97 (7.6)
    Ideation and attempt(s) 148 (10.8) 26 (17.7) 6 (15.8) 37 (2.9)
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Note: Column percentages do not equal 100 because of participants who declined to answer each question.

Procedures

This research project (called “The CORE Data Project”) was approved by the health center’s institutional review board. For a one year period, all new and existing patients at the health center were offered the opportunity to complete a one-time, one-page, pencil and paper questionnaire along with whatever other paperwork they were given when checking-in for an appointment. The questionnaire included 25 investigator-designed questions developed at the health center with input from medical and mental health providers. The measure was considered a screening measure only and, as such, brevity was crucial to maximizing participation. Thus, longer and full standardized instruments were not used.

Patients were informed that participation was voluntary and that they could opt not to complete the questionnaire. Instructions were placed at the top of the form, to explain to clients the purpose of the project: “The following information is needed from each client so that we can continue to fulfill our mission of providing quality services. This information allows us to provide the best care possible and gives us vital information about the communities we serve to help our advocacy and research efforts.” The form did not include a place to enter one’s name. Participants filled out the survey confidentially. The collected information was not entered into the participants’ medical records or reported to their providers, and the physical survey instrument was identified only by a code number. Because of the recruitment format, there are no data available on the rates of, or reasons for, refusal to participate.

Measures

Demographics

Basic demographic information about the sample was collected through questions about age, race, income, socioeconomic status (employment status, housing status, family income), and gender identity.

Sexual Orientation

Although there are many ways to assess sexual orientation (i.e., attractions, behavior, or identity), a common measurement method in the literature has been to categorize individuals based on a single item self-reporting their identity (e.g., Cochran, Mays, & Sullivan, 2003; Lehavot & Simoni, 2011; Ott, Corliss, Wypij, Rosario, & Austin, 2011; Russell & Richards, 2003). Thus, in our study, one item assessed the self-identity of participants’ sexual orientation. Participants could endorse any one of the following options: Homosexual (Lesbian/Gay), Bisexual, Heterosexual (Straight), Not Sure/Undecided, or Prefer Not to Say.

Suicide

The following item assessed lifetime suicidal ideation: “In your lifetime, have you ever thought seriously about killing yourself?” Response choices were yes/no. A similar item assessed the presence of any suicide attempt in a participant’s lifetime: “In your lifetime, have you ever made a suicide attempt?” Response choices were also yes/no. One item assessments for both suicidal ideation and attempts are common screening methods used in suicide research (e.g., Hatzenbuehler, 2011; House, Van Horn, Coppeans, & Stepleman, 2011) and in large studies, such as population-based surveys (e.g., Remafedi, French, Story, Resnick, & Blum, 1998; Russell & Joyner, 2001).

Analytic Plan

We utilized logistic regression analyses to investigate whether sexual orientation was a significant predictor of both suicidal ideation and suicide attempts, and to analyze odds ratios to discern whether questioning individuals were more likely to consider or attempt suicide than lesbian/gay, bisexual, and heterosexual individuals. Descriptive statistics indicated that the data met the assumptions of logistic regression.

Results

Participants

For our analyses, we reviewed the data collected on 3,103 of the participants enrolled in the CORE Data Project. We excluded 262 total participants for several reasons, including missing data on key variables of interest related to suicide (64) or sexual orientation (160), and seemingly inconsistent findings such as reporting no lifetime suicidal ideation and at least one suicide attempt (15), which may have either indicated spontaneous suicide attempts or an improbable pattern of responding. We also excluded 23 gender minority participants who identified as transgender. A chi-square analysis revealed that transgender participants were significantly more likely to consider suicide (55.9%), compared to male (20.5%) and female (17.7%) participants, which would have skewed results for all non-gender minority participants. An additional chi-square analysis indicated that within transgender participants, there were no significant differences on suicidal ideation or attempts between self-identified sexual minorities and heterosexual individuals. Thus, this exclusion is unlikely to bias results toward one particular sexual orientation group and prevents an inaccurate elevation of levels of suicidal ideation for the non-gender minority participants. The aforementioned exclusions resulted in our final analytic sample (N = 2,841), of whom 48.3% identified as homosexual/lesbian/gay, 45.2% identified as heterosexual/straight, 5.2% identified as bisexual, and 1.3% identified as not sure/undecided, or questioning (see Table 1). Although our predictor variable, sexual orientation, is characterized by unequal sample sizes in the primary group comparisons (i.e., not sure/undecided & heterosexual/straight), logistic regression analyses used in this study are robust to such violations of normal distribution and equal variance within each group (Tabachnick & Fidell, 1996).

Hypothesis 1

To assess Hypothesis 1, we conducted three sets of logistic regressions. In the first regression model—that compared all sexual minority groups to heterosexual individuals—we entered sexual orientation as the independent variable (with heterosexual individuals as the referent group), suicidal ideation as the dependent variable, and controlled for race/ethnicity, employment status, housing status, and family income (see Table 2). An omnibus chi-square test indicated that the model had good fit (χ² = 227.282, df = 26, p < .001) and the Hosmer and Lemeshow omnibus test was non-significant, which indicated low error in the model (p > .05).

Table 2.

Odds Ratios [and 95% Confidence Intervals] for Lifetime Suicidal Ideation and Attempts by Sexual Orientation Identity, Controlling for Race/ethnicity, Employment, Housing, and Family Income

Ideation vs. No Ideation
OR, CI (95%)		 p Only Ideation vs. Ideation and Attempt(s)
OR, CI (95%)		 p
Heterosexual Referent Group -- Referent Group --
Lesbian/Gay 3.024, 2.351–3.890 .000 2.008, 1.226–3.289 .006
Bisexual 4.389, 2.942–6.575 .000 2.980, 1.459–6.083 .003
Questioning 4.286, 2.119–8.671 .000 1.908, 0.585–6.222 .284
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Note: OR = odds ratio; CI = confidence interval.

The model suggested that sexual orientation was a significant predictor of lifetime suicidal ideation (p < .001), such that the groups of lesbian/gay individuals, as well as the bisexual individuals, had significantly greater odds of considering suicide compared to heterosexual individuals (Wald = 74.290, OR = 3.024, 95% CI [2.351–3.890], and Wald = 52.099, OR = 4.389, 95% CI [2.942–6.575], respectively). Questioning individuals had significantly greater odds of reporting having considered suicide, compared to heterosexual people (Wald = 16.388, OR = 4.286, 95% CI [2.119–8.671]). Our results suggested that sexual minority people consider suicide more than heterosexual people irrespective of demographic factors (see Table 2). We also conducted the same logistic regression, controlling for gender. The results remained significant (p < .05), suggesting that differences in suicidal ideation did not vary by gender for sexual minority individuals.

We utilized the same variables that were utilized in the first regression to run the second and third sets of logistic regression analyses with the lesbian/gay group and bisexual group as the referent groups, respectively, to test our hypothesis that questioning individuals would be more likely to report suicidal ideation than lesbian/gay and bisexual individuals. Results from both regressions suggested that questioning individuals do not appear to be at significantly greater risk of considering suicide (p > .05) than lesbian/gay (Wald = 1.391, OR = 1.490, 95% CI [0.798–2.891]) or bisexual individuals (Wald = 0.013, OR = 0.959, 95% CI [0.463–1.985]). However, results indicated that bisexually-identified individuals were significantly more likely to report suicidal ideation than lesbian/gay individuals, even after controlling for race/ethnicity and socioeconomic factors listed above (Wald = 3.862, OR = 1.454, 95% CI [1.001, 2.113].

Hypothesis 2

For analyses for Hypothesis 2, we created a dichotomous dependent variable that indicated endorsement of either suicidal ideation only, or both suicidal ideation and at least one suicide attempt. We created the variable to ensure a comparison between individuals who considered suicide but did not attempt and individuals who considered suicide and then went on to attempt it. By creating the variable in this way, we ensured that in our large sample, we were not collecting results for any individuals who endorsed a suicide attempt with no previous suicidal ideation—as this may have represented a spontaneous suicide attempt or an error in data reporting. We utilized this dependent variable in three sets of logistic regression analyses to investigate whether sexual orientation (IV) was a significant predictor of both suicidal ideation and suicide attempts versus suicidal ideation only (DV). In the first model, we also controlled for race/ethnicity, employment status, housing status, and family income. We compared sexual minorities, including questioning individuals, to heterosexual individuals. An omnibus chi-square test indicated the model had good fit (χ ² = 50.570, df = 26, p = .003) and the Hosmer and Lemeshow omnibus test was non-significant, which indicated a low amount of error in the model (p > .05).

Results showed a significant effect (p < .05) for self-identified sexual minority groups for considering and attempting suicide, versus only considering suicide, compared to heterosexual individuals. Specifically, compared to heterosexual people, both lesbian/gay (Wald = 7.675, OR = 2.008, 95% CI [1.226–3.289]) and bisexual individuals (Wald = 8.989, OR = 2.980, 95% CI [1.459–6.083]) had greater odds of considering and attempting suicide versus only considering suicide. Self-identified sexual minority individuals were significantly more likely (p < .05) to report suicide attempts than their heterosexual peers (44.3% vs. 2.9%). However, there was no significant effect for considering and attempting suicide, versus only considering suicide, for questioning individuals compared to heterosexual individuals—suggesting that questioning individuals were no more likely than heterosexual people to actually attempt suicide (see Table 2).

Further, the Wald statistics in this regression (note that a larger Wald value indicates a greater statistical contribution of the predictor to the overall model) for race/ethnicity (Wald = 1.569) and employment (Wald = 3.714) were small, and indicated that family income (Wald = 12.199) and housing status (Wald = 7.719) were better predictors of suicide attempts in this model. These analyses suggest that participants in this sample who identify as either lesbian/gay or bisexual have considered and attempted suicide more than heterosexual people, irrespective of socioeconomic factors, such as family income and housing status. We also repeated the original logistic regression testing Hypothesis 2, this time controlling for gender. All results remained significant, suggesting that differences in considering and attempting suicide did not vary by gender for sexual minority individuals.

In the second and third models, we conducted the same logistic regression used to test hypothesis 2 (including covariates) to discern whether questioning individuals were more likely to report considering and attempting suicide than lesbian/gay and bisexual individuals, respectively. All results were not significant (p > .05), such that questioning individuals were no more likely to have both considered and attempted suicide compared to lesbian/gay (Wald = 0.024, OR = 0.919, 95% CI [0.319–2.645]) or bisexual individuals (Wald = 0.621, OR = 0.626, 95% CI [0.195–2.007]). Although analyses for hypothesis 1 suggested that bisexually identified individuals were more likely to consider suicide than lesbian/gay individuals, these analyses suggested bisexually identified individuals were not more likely to report suicide attempts than any other sexual minority group (p>.05).

Discussion

We compared patterns of suicidal ideation and suicide attempts in adults questioning their sexual orientation to self-identified sexual minority groups (lesbian/gays & bisexuals) and heterosexually identified individuals, in a sample of 2,841 enrolled participants recruited from a community health clinic. Our results provided partial support for our hypotheses regarding questioning individuals. We also found significant results for self-identified sexual minorities for both hypotheses.

The most interesting finding is that, although questioning individuals were significantly more likely to report having considered suicide compared to heterosexual individuals, they were not more likely to report a past suicide attempt than their heterosexual peers. Contrary to our hypotheses, questioning individuals were not more likely to report considering suicide or attempting suicide compared to lesbian/gay or bisexual individuals. These results suggest that individuals who are questioning their sexual orientation appear to be at significantly greater risk for considering suicide, compared to heterosexually identified individuals, but are not at greater risk for attempting suicide. This finding in our sample of adults is consistent with some previous research conducted with questioning and unsure youth (Birkett, Espelage, & Koenig, 2009; Zhao et al., 2010). One possible explanation for this finding is that the experiences of a person, based on their sexual orientation, are associated with other risk factors that make it more likely that they would consider suicide. Thus, a sexual orientation label may serve as a kind of proxy for a constellation of experiences that, taken together, collectively increase the risk of suicidal thinking. Empirical research has identified some such risk factors for greater likelihood of considering suicide, such as negative reactions from peers or family (Scourfield, Roen, & McDermott, 2008), peer victimization (Hatzenbuehler, 2011), gender noncomformity, and more generally, discrimination and homophobia (e.g., McDaniel, Purcell, & D'Augelli, 2001; Russell & Richards, 2003).

An additional way that we might understand these findings comes from the general suicidality literature. Joiner (2005) proposed an interpersonal theory to explain suicides that has received empirical support in various populations, including both college (Van Orden, Witte, Gordon, Bender, & Joiner, 2008) and military samples (Bryan, Morrow, Anestis, & Joiner 2010). Joiner’s three-part model proposes that suicidal ideation and attempts are more likely if a person (a) perceives that they are a burden on others (i.e., high burdensomeness), (b) has acquired the capability for suicide (e.g., they are not bothered by blood), and (c) believes they do not belong to a community (i.e., thwarted belongingness). Although Joiner’s theory has not been empirically tested in a sexual minority sample, it lends some theoretical support for our findings. We can expect that questioning individuals may experience thwarted belongingness to either heterosexual or lesbian, gay, or bisexual communities and, thus, meet one criterion for greater suicide risk. We cannot know, in this sample, whether the individuals meet Joiner’s other criteria—although a more thorough investigation of his model in questioning individuals seems like a worthwhile future endeavor.

The reasons why questioning individuals are no more likely to report suicide attempts than heterosexual individuals are less clear. Further data testing for our second hypothesis suggested that questioning individuals were no more likely to consider and attempt suicide than either lesbian/gay or bisexual individuals as well. The reasons for these findings are largely unknown, as little research has been conducted on questioning individuals (Zhao et al., 2010). Although questioning individuals may experience thwarted belongingness (Joiner, 2005), they may be less likely than self-identified sexual minorities to experience high burdensomeness on others because they may be less likely to disclose a sexual minority status to others. The absence of a significant mental health problem (i.e., suicide attempt) in our questioning sample does not infer resilience (e.g., Stall & Herrick, 2011); however, questioning individuals may engage in a unique social or interpersonal process (e.g., relying on social support) that may account for their lack of risk for suicide attempts. Further identification and explication of these strengths and resilient processes could strengthen suicide prevention interventions for sexual minority individuals. However, it is possible that, because questioning people are at greater risk of considering suicide than heterosexual individuals, they may be completing suicides more than heterosexual individuals, and thus, are absent from this research—an unfortunate possibility that would explain our findings.

The results for our first hypothesis regarding other self-identified sexual minority groups indicated that individuals in each of these groups (lesbian/gay & bisexual) had significantly greater odds of considering suicide compared to the heterosexual individuals, which is consistent with much previous literature (e.g., Gilman et al., 2001). For our second hypothesis regarding self-identified sexual minority groups, we assessed for differences between these groups and heterosexuals on either only considering suicide, or both considering and attempting suicide. Compared to heterosexual individuals, both lesbian/gay and bisexual individuals had significantly greater odds of considering and attempting suicide. This finding has also been established in previous literature (e.g., King et al., 2008).

There were interesting results for bisexually-identified individuals, specifically. Similar to questioning individuals, bisexual adults may also experience low levels of belongingess to either sexual minority or heterosexual communities. Thus, this is one possible explanation for the finding of increased risk for suicidal ideation and attempts for bisexual individuals, compared to heterosexual individuals, and also increased risk for suicidal ideation compared to lesbian/gay individuals. Bisexual individuals’ increased risk of both suicidal ideation and attempts has been documented in other studies as well (e.g., Koh & Ross, 2006). Although there has been controversy about the existence of physiological sexual arousal of self-identified bisexual individuals to both men and women (Rieger, Chivers & Bailey, 2005), more recent research suggests that there is evidence of both physiological and subjective reports of such sexual arousal patterns in bisexual samples (Rosenthal, Sylva, Safron, & Bailey, 2011). With such disagreement on the existence of bisexuality within the scientific community, self-identified bisexuals individuals are likely subject to debates about their “existence” and authenticity among peers as well. Such experiences could contribute to invalidation and lack of social support, and essentially, low levels of belongingness, and thus lead to more suicidal ideation or attempts. In addition, many studies of sexual minority samples do not differentiate between bisexual individuals and lesbian/gay individuals in analyses (Birkett, Espelage, & Koenig, 2009; Cochran & Mays, 2006), which makes it difficult to understand the processes of suicide for bisexual people, specifically.

Our sexual orientation groups also significantly differed on some variables, such that the heterosexual group was younger and had a higher percentage of students than the sexual minority groups combined (lesbian/gay, bisexual, & questioning). The significant age difference between the heterosexual and sexual minority groups may have introduced more Type I error in our results, such that heterosexual individuals reported less suicidal ideation and attempts because they have had fewer life experiences (i.e., less time alive to gather them) than the older sexual minority individuals. However, in our sample, heterosexual and questioning individuals, specifically, did not differ significantly by age, and thus, results between these two groups are not likely to be impacted by age.

There are limitations to any individual study. Because our study consisted of secondary data analysis of a screening instrument delivered in the context of clinical care at a large community health center, our results may potentially be limited by sampling bias. Our study is also limited by restricted measurement in general, and especially of sexual orientation, suicidal ideation, and suicide attempts. Despite the norm of one-item assessment of suicidal ideation and attempts in research, one previous study suggests that using only a single item measurement of suicide attempts (like the item used in this study), results in inflated reports of suicide attempts from sexual minority individuals (Savin-Williams, 2001). Measurement could be improved by using established measures of suicidal ideation, attempts, and risk more generally. More thorough assessment of recent and lifetime suicide experiences, as well as severity of such experiences, would improve both validity and reliability. Another measurement issue was the incongruent or unknown temporal sequence of the key variables. Specifically, our study assessed both current sexual orientation and past suicidal ideation or attempts at one time point, such that our results can only be interpreted as significant associations between suicide and sexual orientation in the present, and should not be interpreted as a causal relation.

Research Implications

A key question for future researchers to address is the reasons why questioning individuals are at significant risk of considering, but not attempting, suicide, compared to individuals who identify as heterosexual. An important suggestion for future researchers is to oversample for people who identify as questioning, unsure, undecided, “mostly” heterosexual, or “mostly” gay or lesbian in order to ensure a large enough number of questioning individuals for adequate statistical power. To help meet research goals outlined in the Healthy People 2020 document (U.S. Department of Health and Human Services, 2010), questions about sexual orientation and suicide should be added to large, federally-funded surveys—including response choices that allow data analysts to separate questioning individuals from either heterosexual- or sexual minority-identified participants. Researchers may also consider assessing individual and community-level social support, as well as homophobic victimization, for questioning individuals as well as identified sexual minorities, to assess whether such variables account for differences in reports of suicidal ideation and attempts. Finally, it may be helpful to frame research on questioning individuals through the lens of positive psychology to help explain this finding, that is, to assess resilience factors in addition to risk factors.

The limited research on questioning individuals is generally quantitative; thus, qualitative research may be helpful to understand more about the development of their questioning identity, and any relevant social interactions related to their perceived or actual sexual identity or behaviors. While the CORE data project only assessed sexual orientation/identity through one question, it may be helpful for future studies to assess this construct using broad measures of sexual orientation, such as multiple identity questions (see Sell, 1996) and questions about recent and lifetime sex behavior. By doing so, researchers would be able to group sexual minority individuals for analyses according to their research question, rather than arbitrarily analyzing groups that many not accurately capture individuals with similar experiences. For example, if a research question involves variables related to sexual behavior, such as HIV risk, researchers glean more accurate results if they grouped individuals by sexual behavior (e.g., the category of ‘men who have sex with men’) rather than identity (e.g., heterosexual men), because results would reflect participants’ sexual experiences and, thus, sex-related HIV risk.

Clinical Implications

One strength of this project is that the researchers recruited individuals at a community health care setting, which is one of the settings in which many mental health interventions occur (e.g., Wells, Morrissey, Lee, & Radford, 2010). Therefore, our findings may be more representative of other sexual minority samples in the northeastern U.S., or other areas with similar political and social climates. The recruitment methods of this study also indicate that, using minimal questioning to screen for suicide risk is possible and, thus, primary health care settings could utilize a few items on their intake forms as screeners for suicide risk. Providers should discuss any suicide risk further with the patient, and mental health referrals should be made when necessary.

Conclusion

The empirical literature on suicide in unsure, undecided, and questioning individuals is nascent. Results from the research presented here indicate that while questioning individuals may be at significant risk for suicidal ideation compared to heterosexual individuals, they are not reporting increased odds of actually attempting suicide. Because the results from this study are similar to findings from a previous study of adolescents and young adults (Zhao et al., 2010), there may be some unique process about questioning one’s sexual orientation that is related to increased suicidal ideation, but notto attempting suicide. There is likely more than one process, and they could be either at the ecological or individual level. While some factors hypothesized in this paper are belongingness to a sexual identity group and age, more research on this sexual minority group and suicidal thoughts and behaviors is necessary to create a more accurate, coherent picture to explain these findings.

Acknowledgments

The project described was supported by the Summer Institute in LGBT Population Health, supported by NICHD (R25 HD064426), the Center for Population Research in LGBT Health at The Fenway Institute, and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) under Award Number R21HD051178. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NICHD or the National Institutes of Health. We would like to thank Sari Reisner for his statistical consultation, and Dr. Aimee Van Wagenen who provided invaluable administrative support to this research.

Footnotes

The authors report no conflicts of interest.

Contributor Information

Eva N. Woodward, Suffolk University

David W. Pantalone, University of Massachusetts--Boston

Judith Bradford, The Fenway Institute.

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