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. Author manuscript; available in PMC: 2021 Sep 1.
Published in final edited form as: Am J Prev Med. 2020 May 21;59(3):394–403. doi: 10.1016/j.amepre.2020.03.024

Alcohol Use and Suicidality by Sexual Orientation Among U.S. Youth, 2009–2017

Gregory Phillips II 1, Blair Turner 1, Dylan Felt 1, Rachel Marro 1, Xinzi Wang 1, Megan Ruprecht 1, Jacob Broschart 1, Lauren B Beach 1
PMCID: PMC7483808  NIHMSID: NIHMS1591894  PMID: 32446749

Abstract

Introduction:

Alcohol use and suicidality remain serious risks for U.S. youth. Research has established that disparities exist in these outcomes between heterosexual and sexual minority youth. However, research into the associations between alcohol use and suicidality has yet to consider the differential role of sexual orientation.

Methods:

Using a pooled, diverse sample from the 2009–2017 Youth Risk Behavior Survey, associations of alcohol use and suicidality by sex and sexual orientation, and changes in these outcomes over time, were investigated. Analyses were conducted in 2019.

Results:

Suicidality was highest among non-heterosexuals, who ranged from twofold to sevenfold higher odds to report suicidality across all time points, with the most striking disparities among male sexual minority youth. Rates among all students remained stable or increased over time; notable exceptions included a decrease in suicide attempts among bisexual students. Among all students, current alcohol use was associated with elevated levels of suicidality. For female students, the association between drinking and suicidality did not significantly differ by sexual identity; for male students, it was significant regardless of sexual identity, and most pronounced among not sure youth.

Conclusions:

These results emphasize the need for additional research into the relationship between contemporaneous alcohol use and suicidality, with attention to differences based on sex, sexual orientation, and other factors that may impact these relationships. There is a particular need for research to examine the temporal nature of the association such that evidence-informed, high-impact interventions can be developed to improve suicidality outcomes among sexual minority youth.

INTRODUCTION

Compared with heterosexual peers, sexual minority youth (SMY) experience higher rates of suicidality.1–6 National data from the 2015 Youth Risk Behavior Survey (YRBS) show that 42.8% of all lesbian, gay, or bisexual respondents have seriously considered suicide—nearly three times higher than the rate observed among heterosexual youth.7 In the same report, 36.2% of lesbian, gay, and bisexual respondents had made a suicide plan, and 29.4% had made an attempt.7 This high prevalence of suicide in SMY has been conceptualized using a minority stress framework,8,9 recognizing the complex influence of contextual factors on these disparities,10 including familial rejection,11,12 victimization,13–18 discrimination, and violence.19–21 Minority stress theory posits that stigma-induced and discriminatory forms of stress contribute to maladaptive coping mechanisms and chronic stress, ultimately affecting long-term health disparities in populations that experience discrimination.

The high prevalence of alcohol use among adolescents suggests exploring how alcohol could contribute to suicide risk in this population.22 Multiple studies support the role of alcohol use in suicidality among adolescents generally.2,23–29 YRBS data show that 60.4% of students had ever drank alcohol and 19.8% reported alcohol use in the past 30 days.30 National data sets consistently demonstrate elevated alcohol use in SMY compared with heterosexual peers,7,30–33 though no study of the relationship between alcohol use and suicidality has addressed the role of sexual identity. Still, research focused on the role of alcohol in suicidality among SMY suggests that anti–lesbian, gay, and bisexual discrimination may impact the association between alcohol use and suicidality among SMY.34 Preliminary data have revealed that elevated alcohol use in SMY populations is associated with experiences of victimization,35 a known independent factor in suicidality.15,36 Therefore, these data suggest a potential differential relationship between alcohol use and suicidality among SMY. Exploring the potential role of minority stress in both inciting alcohol use, as well as moderating the relationship between alcohol use and suicide in SMY, is thus an important area of research. Prior work has also noted that disparities in both alcohol use and victimization are not equal across subpopulations, varying by age, sex, and sexual minority identity.35,37–39 For instance, the association between alcohol use and suicidality is significantly more robust in male versus female adolescents.40–42

Finally, research points to the importance of considering changes in both alcohol use and suicidality in populations over time; existing literature suggests that suicide trends in adolescents can fluctuate greatly.43 Given recent advances in sexual minority civil rights44 and the ongoing volatility of sexual minorities’ social and legal position in the U.S.,45 one may observe greater changes in alcohol use and suicidality in SMY by survey year. Moreover, recent studies have noted a decrease in alcohol use over time among SMY, although still elevated relative to heterosexual peers,46 warranting further research into these trends.

To address these gaps, this study investigates the association between alcohol use and suicidality by sexual identity within a large pooled data set of U.S. high school youth collected between 2009 and 2017. It tests three important questions: (1) Are rates of suicidality changing over time, particularly among SMY? (2) Are alcohol use and suicidality associated within this sample? And (3) Does the association between alcohol use and suicidality differ by reported sexual identity?

METHODS

The study received full review by the Northwestern University’s IRB and was granted exempt status.

The YRBS is a biennial national survey conducted by the Centers for Disease Control and Prevention to collect health data on students in Grades 9–12.47,48 This analysis used data from local versions of the YRBS, which are administered at a state, large urban school district, or country level by departments of education or health. In this implementation, jurisdictions use a two-stage cluster sample design to identify a representative sample of students.47

Study Sample

Local YRBS data were pooled across multiple jurisdictions and years (biennially from 2009 to 2017). The entire data set consists of 524,573 youth from 56 jurisdictions across five time points. A total of 143 jurisdiction-years assessed sexual identity (494,334 students). For the present analysis, students were excluded if they were missing primary demographic variables of interest and all suicidality outcomes (sexual identity: 4.7%, grade: 1.5%, race/ethnicity: 3.5%, sex: 0.9%, all suicidality outcomes: 0.3%; not mutually exclusive), resulting in a final sample of 448,212 students (85.4 % of the entire data set).

Measures

To assess sexual identity, participants were asked, Which of the following best describes you? Response options included: heterosexual (straight), gay or lesbian, bisexual, and not sure.

To assess sex, participants were asked, What is your sex? Response choices were male or female.

To assess race/ethnicity, participants were asked if they identified as Hispanic or Latino. Participants were asked to select all of the races that applied from the following list: American Indian or Alaska Native, Asian, black or African American, Native Hawaiian or other Pacific Islander, and white. These variables were combined to form four racial/ethnic groups: white, black or African American, Hispanic/Latino, and other.

To assess grade, participants were asked, In what grade are you? Reponses options were 9th, 10th, 11th, 12th, and ungraded or other grade. Participants that selected ungraded or other grade were removed from analysis (n=426, 0.09%).

To assess alcohol use, participants were asked, During the past 30 days, on how many days did you have at least one drink of alcohol? Responses options were from 0 days to all 30 days. Options were dichotomized as “0 days” and “≥1 days.”

Suicidality was assessed on three levels. Suicide ideation: Participants were asked, During the past 12 months, did you ever seriously consider attempting suicide? Suicide plan: Participants were asked, During the past 12 months, did you make a plan about how you would attempt suicide? Response options for both questions were yes and no. Suicide attempts: Participants were asked, During the past 12 months, how many times did you actually attempt suicide? Response options ranged from zero times to six or more times. Responses were collapsed and dichotomized to “zero times” and “one or more times.”

Statistical Analysis

All data cleaning and recoding was conducted in SAS, version 9.4 in 2019. Analyses were carried out using SUDAAN, version 11.0.1 to appropriately weight estimates and account for the complex sampling design of the YRBS, in accordance with Centers for Disease Control and Prevention guidelines.47

Descriptive analyses were conducted to determine prevalence of suicidality, alcohol use, and demographics by sex and sexual identity at each time point. Then, trends in suicidality and alcohol use by sex and sexual identity from 2009 to 2017 were assessed using the Centers for Disease Control and Prevention’s recommended approach to trend analysis. Time was modeled as a continuous variable using orthogonal coefficients to reflect the biennial spacing of the surveys.49 The linear time component was significant at p<0.05. These analyses were stratified by sex; controlled for grade and race/ethnicity; and assessed for linear, quadratic, and cubic trends. There were no significant cubic trends.

Next, it was tested whether SMY differed from their heterosexual peers in the prevalence of alcohol use and each suicidality outcome within each data collection year, adjusted for grade and race/ethnicity. Given the known differences in the associations between suicide and alcohol use in male and female individuals, sex differences were tested (data not shown) and held true for all models. Therefore, all models were stratified by sex.40–42 Finally, stepwise multivariable logistic regression was conducted to estimate the odds of alcohol use and each suicidality outcome. The first model included demographics and sexual identity, and the following two models sequentially added alcohol use, followed by the interaction between alcohol use and sexual identity. EFFECTS statements were used within PROC RLOGIST models to calculate stratified ORs and 95% CIs for all significant interactions. All logistic regression models controlled for survey year.

RESULTS

The pooled sample was split between male (50.4%) and female (49.6%) students, with approximately one quarter in each grade (Table 1). Nearly one half of the sample was white (45.5%), followed by Hispanic/Latino (29.8%) and black (14.8%). The majority identified as heterosexual (87.1%), with smaller proportions reporting bisexual (6.7%), gay/lesbian (2.4%), or not sure (3.9%) identities.

Table 1.

Participant Demographics and Suicidality, YRBS, 2009–2017

Variable Total n (%) Male n (%) Female n (%)
Demographics
 Sexual identity
  Heterosexual 389,261 (87.06) 197,839 (91.44) 191,422 (82.61)
  Gay/Lesbian 10,627 (2.42) 5,315 (2.61) 5,312 (2.22)
  Bisexual 29,348 (6.67) 6,124 (3.02) 23,554 (10.38)
  Not sure 18,528 (3.85) 7,536 (2.93) 10,992 (4.79)
 Race/Ethnicity
  White 190,798 (45.49) 93,542 (45.49) 97,256 (45.49)
  Black 66,947 (14.78) 31,580 (14.55) 35,367 (15.00)
  Hispanic/Latino 119,027 (29.84) 56,642 (29.67) 62,385 (30.00)
  Asian 310,803 (4.98) 15,432 (5.24) 15,651 (4.72)
  Other 39,909 (4.92) 19,618 (5.05) 20,291 (4.78)
 Grade
  9th 122,076 (26.94) 59,038 (27.25) 63,038 (26.63)
  10th 119,085 (25.9) 57,180 (25.97) 61,905 (25.84)
  11th 110,722 (24.03) 53,755 (23.84) 56,967 (24.22)
  12th 95,881 (23.13) 46,841 (22.94) 49,040 (23.31)
Current alcohol use
 Yes 118,797 (29.6) 53,836 (27.51) 64,961 (31.7)
 No 288,468 (70.4) 141,318 (72.49) 147,150 (68.3)
Suicidality (last year)
 Suicide ideation
  Yes 60,372 (16.26) 21,035 (11.63) 39,337 (20.95)
  No 338,135 (83.74) 170,821 (88.37) 167,314 (79.05)
 Suicide plan
  Yes 44,378 (13.72) 16,472 (10.14) 27,906 (17.36)
  No 301,183 (86.28) 151,169 (89.86) 150,014 (82.64)
 Suicide attempt
  Yes 32,942 (8.94) 12,952 (7.2) 19,990 (10.66)
  No 350,390 (91.06) 170,006 (92.8) 180,384 (89.34)
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YRBS, Youth Risk Behavior Survey.

More than one quarter of students reported current alcohol use (29.6%), with greater prevalence among female than male students (31.7% vs 27.5%, respectively). Prior year suicidality was also high—16.3% of students had contemplated suicide, 13.7% had made a plan to die by suicide, and 8.9% had attempted suicide. Prevalence of all suicidality measures was higher among female students (Table 1).

Among all male youth, ideation was the only suicidality outcome that significantly increased between 2009 and 2017 (Table 2, Appendix Figure 1). This increase was likely driven by an increase within gay male youth, from a prevalence of 24.0% in 2009 to 36.5% in 2017. The only other significant change by sexual identity was for attempts among bisexual male youth—this significantly decreased from 28.0% in 2009 to 17.5% in 2017.

Table 2.

Trends in Suicidality by Sexual Identity, Males, YRBS 2009–2017

2009 2011 2013 2015 2017 Change 2009–2017a
Suicide outcome n/N (%) n/N (%) n/N (%) n/N (%) n/N (%) Β p-value
Total
  Suicide ideation 1,734/16,824 (11.04) 2,633/25,731 (10.16) 4,025/38,135 (10.67) 5,574/51,040 (11.55) 7,069/60,126 (12.04) 0.15 0.0103
  Suicide plan 1,462/15,991 (9.59) 2,280/24,479 (9.97) 3,238/32,645 (10.02) 4,139/40,509 (10.13) 5,353/54,017 (10.21) 0.02 0.6155
  Suicide attempt 1,291/18,370 (8.10) 1,845/26,373 (6.41) 2,399/33,161 (6.82) 3,205/42,655 (6.34) 4,212/62,399 (7.73) 0.01 0.9119
Heterosexual
  Suicide ideation 1,433/15,791 (9.74) 2,170/23,910 (9.22) 3,245/35,359 (9.29) 4,284/46,691 (9.76) 5,258/53,705 (9.82) 0.03 0.4219
  Suicide plan 1,230/15,094 (8.62) 1,888/22,876 (9.11) 2,633/30,322 (8.65) 3,201/37,007 (8.72) 4,059/49,010 (8.66) −0.02 0.6663
  Suicide attempt 1,039/17,275 (7.11) 1,420/24,581 (5.41) 1,815/30,774 (5.26) 2,368/39,079 (5.05) 2,963/56,063 (6.33) −0.03 0.6956
Gay
  Suicide ideation 81/326 (23.95) 153/561 (19.88) 203/776 (30.56) 380/1,262 (32.70) 479/1,663 (36.45) 0.46 0.0089
  Suicide plan 62/267 (17.42) 95/427 (17.35) 161/639 (30.43) 265/1,019 (32.33) 384/1,475 (30.14) 0.33 0.095
  Suicide attempt 70/327 (28.19) 119/518 (18.20) 164/679 (25.09) 244/1,014 (25.75) 379/1,654 (30.47) 0.24 0.2559
Bisexual
  Suicide ideation 131/347 (43.83) 171/585 (20.08) 303/883 (33.15) 533/1,448 (40.38) 763/1,970 (38.32) 0.10 0.4925
  Suicide plan 102/306 (34.98) 151/518 (27.41) 223/724 (32.76) 392/1,177 (30.31) 558/1,738 (28.20) −0.18 0.2622
  Suicide attempt 103/390 (28.00) 155/602 (24.17) 209/799 (31.92) 328/1,232 (19.46) 449/2,133 (17.49) −0.61 0.0002
Not sure
  Suicide ideation 89/360 (27.74) 139/675 (23.46) 274/1,117 (24.70) 377/1,639 (22.27) 569/2,788 (27.29) −0.12 0.4612
  Suicide plan 68/324 (26.54) 146/658 (24.53) 221/960 (23.60) 281/1,306 (17.97) 352/1,794 (21.79) −0.28 0.1842
  Suicide attempt 79/378 (17.67) 151/672 (20.75) 211/909 (25.33) 265/1,330 (19.15) 421/2,549 (18.7) −0.24 0.1639
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Notes: Boldface indicates statistical significance (p<0.05).

a

Linear trend based on trend analyses using logistic regression model controlling for race/ethnicity and grade p<0.05.

YRBS, Youth Risk Behavior Survey.

More substantial changes in past year suicidality were seen among female youth, with significant increases in ideation, planning, and attempts between 2009 and 2017 among all female youth (Table 3, Appendix Figure 2). Although rates of ideation remained remarkably high between 2009 and 2017 among lesbian (33.2% in 2009 to 42.5% in 2017) and bisexual youth (40.1% in 2009 to 46.7% in 2017), only the increase for bisexual youth was significant. For heterosexual female youth, there were significant increases in both ideation (13.5% in 2009 to 16.8% in 2017) and planning (10.3% in 2009 to 14.2% in 2017), but no changes in attempts. Encouragingly, there were significant decreases in suicide planning among bisexual and not sure female youth between 2015 and 2017, and a significant decrease in attempts in not sure female youth.

Table 3.

Trends in Suicidality by Sexual Identity, Females, YRBS 2009–2017.

2009 2011 2013 2015 2017 Change 2009–2017a Quadratic changeb,c
Suicide outcome n/N (%) n/N (%) n/N (%) n/N (%) n/N (%) Β p-value Β p-value
Total
 Suicide ideation 2,969/18,854 (15.97) 4,418/27,627 (16.91) 7,861/41,354 (19.65) 10,928/54,455 (21.33) 13,161/64,361 (21.66) 0.25 <0.0001
 Suicide plan 1,990/17,150 (11.91) 3,340/25,248 (14.61) 5,645/35,168 (15.9) 7,593/43,190 (18.79) 9,338/57,174 (17.50) 0.25 <0.0001
 Suicide attempt 1,766/20,838 (8.19) 2,486/28,806 (9.06) 3,747/36,839 (10.23) 5,318/46,538 (10.65) 6,673/67,353 (11.03) 0.16 0.0031
Heterosexual
 Suicide ideation 2,144/16,559 (13.45) 3,166/23,882 (14.07) 5,559/35,599 (16.29) 6,995/44,739 (16.79) 7,830/50,532 (16.76) 0.14 0.0001
 Suicide plan 1,453/15,306 (10.29) 2,441/22,183 (12.57) 3,994/30,487 (12.88) 4,906/35,823 (14.51) 5,564/45,746 (14.19) 0.15 0.0008
 Suicide attempt 1,176/18,407 (6.45) 1,682/25,135 (6.81) 2,447/31,814 (7.57) 3,219/38,323 (7.79) 3,759/53,102 (8.24) 0.10 0.0842
Lesbian
 Suicide ideation 98/310 (33.21) 133/443 (32.34) 299/839 (37.17) 482/1,342 (42.65) 653/1,811 (42.53) 0.27 0.0977
 Suicide plan 59/230 (23.21) 89/332 (26.22) 211/721 (32.15) 356/1,062 (34.93) 494/1,594 (29.81) 0.18 0.3565
 Suicide attempt 84/307 (28.48) 91/385 (29.02) 179/717 (26.42) 288/1,105 (26.29) 395/1,838 (26.69) −0.14 0.4478
Bisexual
 Suicide ideation 554/1,416 (40.06) 836/2,280 (39.94) 1,494/3,442 (45.29) 2,556/5,698 (47.47) 3,491/7,880 (46.68) 0.2 0.0172
 Suicide plan 363/1,156 (28.40) 607/1,853 (30.93) 1,075/2,768 (45.44) 1,750/4,311 (45.44) 2,559/6,966 (35.85) 0.47 0.0005 −1.15 0.0004
 Suicide attempt 381/1,534 (24.19) 534/2,288 (25.77) 869/3,024 (31.35) 1,385/4,839 (28.57) 1,947/8,359 (24.79) −0.16 0.1045
Not sure
 Suicide ideation 173/569 (35.67) 283/1,022 (29.32) 509/1,474 (36.82) 895/2,676 (38.64) 1,187/4,138 (31.28) −0.18 0.1054
 Suicide plan 115/458 (25.56) 203/880 (26.47) 365/1,192 (31.69) 581/1,994 (34.51) 721/2,858 (23.09) 0.12 0.5107 −1.05 0.0100
 Suicide attempt 125/590 (19.16) 179/998 (21.53) 252/1,284 (19.21) 406/2,271 (19.19) 495/4,054 (15.81) −0.32 0.0160
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Notes: Boldface indicates statistical significance (p<0.05).

a

Linear trend based on trend analyses using logistic regression model controlling for race/ethnicity and grade p<0.05.

b

In bisexual females, there was significant increase during 2009–2015 (β=0.51, p=0.0001), followed by a significant linear decrease during 2015–2017 (β= –0.20, p=0.0166).

c

In not sure females, there was no significant change during 2009–2015 (β=0.32, p=0.0746), followed by a significant linear decrease during 2015–2017 (β=0.38, p=0.0018).

YRBS, Youth Risk Behavior Survey.

When odds of suicidal ideation, planning, and attempts in the prior 12 months were investigated within sex and by sexual identity, disparities between heterosexual and non-heterosexual youth were especially striking. Bisexuals had the greatest odds of ideation, with ORs ranging from 3.84 to 7.20. Similar patterns were seen for planning, in that bisexual individuals tended to have the greatest odds (OR=3.06–5.61). However, in 2015 and 2017, gay male youth had the highest odds of developing a plan (OR=5.06 and 4.57, respectively). For attempts, lesbian and bisexual female youth tended to have similarly high odds across the years. In male youth, both gay and bisexual students had similar odds of attempting suicide in 2009, but by 2017, gay male youth had nearly double the odds of attempt compared with bisexual male youth (OR=6.16 vs 3.18, respectively).

Overall, the rate of alcohol use significantly decreased between 2009 and 2017, from a prevalence of 38.7% in 2009 to 30.6% in 2017. The greatest drop was seen in gay/lesbian and not sure youth across years with the smallest decrease in heterosexual and bisexual youth.46

Current use of alcohol was significantly associated with higher odds of all three suicidality outcomes among male students, even after controlling for sexual identity (Table 4). Current drinkers had 2.24 times the odds of ideation, 1.90 times the odds of planning, and 2.36 times the odds of attempt compared with non-drinking peers.

Table 4.

Multivariable Logistic Regression Models: Suicidality by Alcohol Use and Sexual Identity, Males, YRBS 2009–2017

Suicide ideation Suicide plan Suicide attempt
Model A1 Model A2 Model B1 Model B2 Model C1 Model C2
Variables p-value OR (95% CI) p-value OR (95% CI) p-value OR (95% CI) p-value OR (95% CI) p-value OR (95% CI) p-value OR (95% CI)
Current alcohol use
 Yes <0.0001 2.24 (1.99, 2.53) <0.0001 2.28 (2.00, 2.60) <0.0001 1.90 (1.64, 2.19) <0.0001 1.93 (1.65, 2.25) <0.0001 2.36 (1.91, 2.91) <0.0001 2.18 (1.74, 2.73)
 No 1.00 1.00 1.00 V 1.00 1.00
Sexual identity Heterosexual 1.00 1.00 1.00 1.00 1.00 1.00
 Gay <0.0001 4.66 (3.57, 6.08) <0.0001 5.22 (3.71, 7.35) <0.0001 4.49 (3.37, 5.99) <0.0001 5.32 (3.72, 7.60) <0.0001 4.74 (3.28, 6.85) <0.0001 4.55 (2.74, 7.57)
 Bisexual <0.0001 5.85 (4.66, 7.35) <0.0001 6.76 (4.98, 9.19) <0.0001 4.18 (3.37, 5.19) <0.0001 4.55 (3.40, 6.09) <0.0001 3.73 (2.84, 4.90) <0.0001 3.60
(2.40, 5.42)
 Not sure <0.0001 3.36 (2.69, 4.19) <0.0001 2.89 (2.14, 3.91) <0.0001 2.91 (2.19, 3.86) <0.0001 2.45 (1.63, 3.68) <0.0001 3.76 (2.92, 4.84) <0.0001 2.46 (1.74, 3.46)
Race/Ethnicity
 White 1.00 1.00 1.00 1.00 1.00 1.00
 Black 0.1419 0.87 (0.72, 1.05) 0.1574 0.87 (0.72, 1.05) 0.9493 0.99 (0.79, 1.25) 0.9728 1.00 (0.78, 1.26) 0.0002 1.72 (1.29, 2.27) 0.0002 1.70 (1.28, 2.25)
 Hispanic/Latino 0.3091 0.93 (0.81, 1.07) 0.3001 0.93 (0.81, 1.07) 0.9893 1.00 (0.88, 1.14) 0.9886 1.00 (0.88, 1.14) 0.0002 1.40 (1.17, 1.67) 0.0003 1.39 (1.16, 1.66)
 Asian 0.8022 1.04 (0.77, 1.41) 0.4308 1.04 (0.77, 1.42) 0.6097 1.08 (0.81, 1.42) 0.5981 1.08 (0.82, 1.42) 0.6533 1.12 (0.69, 1.80) 0.6333 1.12 (0.70, 1.81)
 Other 0.4410 1.08 (0.89, 1.30) 1.08 (0.89, 1.31) 0.0315 1.26 (1.02, 1.54) 0.0338 1.25 (1.02, 1.54) 0.0323 1.37 (1.03, 1.82) 0.0414 1.35 (1.01, 1.80)
Grade
 9th 0.0004 1.32 (1.13, 1.55) 0.0003 1.33 (1.14, 1.54) 0.0003 1.36 (1.15, 1.60) 0.0002 1.36 (1.15, 1.60) 0.0035 1.48 (1.14, 1.93) 0.0044 1.47 (1.13, 1.91)
 10th 0.0061 1.30 (1.08, 1.56) 0.0053 1.30 (1.08, 1.56) 0.0008 1.38 (1.14, 1.66) 0.0007 1.38 (1.15, 1.66) 0.0199 1.43 (1.06, 1.93) 0.0216 1.43 (1.05, 1.93)
 11th 0.0002 1.34 (1.15, 1.57) 0.0002 1.34 (1.15, 1.57) 0.0076 1.24 (1.06, 1.46) 0.0069 1.25 (1.06, 1.46) 0.0475 1.31 (1.00, 1.72) 0.0502 1.31 (1.00, 1.72)
 12th 1.00 1.00 1.00 1.00 1.00 1.00
Survey year 0.0752 1.03 (1.00, 1.07) 0.0631 1.03 (1.00, 1.07) 0.7175 1.01 (0.97, 1.05) 0.6859 1.01 (0.97, 1.05) 0.0561 1.05 (1.00, 1.11) 0.0481 1.05 (1.00, 1.11)
Interaction
Alcohol x sexual identity 0.0162 0.0892 <0.0001
Current vs non-drinkers
 Heterosexual 2.28 (2.00, 2.60) 2.18 (1.74, 2.73)
 Gay 1.69 (1.04, 2.76) 2.41 (1.14, 5.10)
 Bisexual 1.60 (0.98, 2.59) 2.37 (1.37, 4.11)
 Not sure 3.93 (2.58, 5.97) 7.04 (4.53, 10.95)
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Notes: Boldface indicates statistical significance (p<0.05).

YRBS, Youth Risk Behavior Survey.

In males, there was a significant interaction between current drinking and sexual identity for ideation and attempt (Table 4, Models A2 and C2), but not planning (Table 4, Model B2). Current drinkers were more likely to report ideation, compared with non-drinking peers, although the association was insignificant for bisexual male youth (OR=1.60; 95% CI=0.98, 2.59). Of particular note, not sure male youth who drank had almost four times the odds of suicidal ideation compared with those who did not; the magnitude was nearly twice that seen in other sexual identity categories. For suicide attempts, directionality of the association in the interaction analyses remained the same, and was significant for all identities. However, unlike for ideation, the magnitude of the association for attempts was similar for heterosexual (OR=2.18), gay (OR=2.41), and bisexual (OR=2.37) male youth. Strikingly, not sure youth who drank were seven times as likely to have attempted suicide as those who did not; the magnitude of this association was three times greater than that seen for any other sexual identity.

Female students who were current drinkers had more than double the odds of reporting all suicidality outcomes compared with non-drinking peers (Appendix Table 1), even after controlling for grade, survey year, race/ethnicity, and sexual identity. Current drinkers had 2.27 times the odds of ideation, 2.02 times the odds of planning, and 2.50 times the odds of attempt compared with non-drinking female peers. Unlike for male youth, there were no significant interactions between current drinking and sexual identity for any of the suicidality outcomes.

DISCUSSION

Previous literature has documented the relationship between alcohol use and poor mental health as bidirectional and mutually reinforcing across youth. Alcohol use can contribute to the onset and exacerbation of depression and suicide risk50 or poor mental health can precede alcohol use, with individuals who are suicidal using alcohol to cope with distress.51 Although the pathways and temporality cannot be established within these data, the high associations observed between alcohol use and suicidality further support the existence of bidirectionality. Furthermore, this dynamic relationship highlights the importance of considering upstream exposures that contribute to disproportionate alcohol use and poor mental health among adolescents.

The findings that SMY have a higher prevalence of both alcohol use and suicidality compared with heterosexual peers match existing health disparities research. Differences by sex also fit within prior literature, which has demonstrated that use of alcohol is more commonly implicated in suicidality among male than among female individuals40,41,52 (no work of which the authors are aware extends this analysis to include sexual identity). Accordingly, the interaction between sexual identity and alcohol was not a significant predictor of suicidality among female youth, whereas it held significance for male suicidal ideation and attempts.

Although the lack of stigma measures and the cross-sectional nature of the YRBS data set limit the ability to draw conclusions around causality, these differences may be attributable to the effects of minority stress. As mentioned, discrimination may contribute to increased maladaptive coping behaviors within either pathway (i.e., alcohol driving poor mental health symptoms or alcohol being used to cope with poor mental health),9,53 thus explaining high alcohol use, suicidality, and their interaction in SMY. Differences in the impact of minority stress on these pathways could also account for the differential effect size of the interaction associations by sex and sexual identity.

Although current alcohol use was associated with greater odds of suicidal ideation and attempts regardless of sexual identity, the magnitude was notably different among various subpopulations, particularly not sure male youth. This could be due to differential access to protective factors, such as social support, contributing to coping.54 For example, not sure youth may experience greater identity uncertainty than other SMY and therefore may be less likely to disclose this identity, which could result in coping in isolation. This could contribute to both minority stress-linked alcohol use and poor mental health outcomes.54 This interpretation is also consistent with literature that implicates factors such as identity centrality or identity commitment as protective factors against negative health outcomes among minority populations.55–57 Though this interpretation could not be tested within the current data set, future research should consider how identity development and minority stress may interact to produce health outcomes among youth who indicate a not sure sexual identity.

Surprising trends over time were observed in light of literature citing an increase in overall adolescent suicidality.58,59 Decreases among bisexual male and female youth were particularly notable, as they run contrary to surveillance data showing increasing suicidality among bisexuals even beyond that of other SMY.60,61 Future work should consider applying mixed methods approaches to illuminate what may be driving these decreases. Differences in trends among male and female youth during this time period are previously unexplored; additional research is needed to examine changes in associations over time by sex and sexual identity.

These results also have important implications for the prevention of adolescent suicidality. Given the continued disparities in suicide among SMY, cultural competency of clinicians is key in this population, including collecting improved demographics to create targeted services and more comfortable means of discussing sexual identity.62 These results also call for suicide prevention programs specifically aimed at SMY who may not be reached by traditional prevention campaigns.63 Finally, the strong associations observed between alcohol use and suicidality indicate that alcohol use interventions may also be effective in reducing suicidality, further emphasizing the need for multilevel approaches to substance use and suicidiality.64,65

Limitations

This study contains limitations. First, reporting alcohol use or suicidality may involve a risk of social desirability bias; however, given that the YRBS is administered anonymously, this risk is considered minimal.66 Additionally, suicidality and alcohol use were measured cross-sectionally using different time scales (past year versus past 30 days), making it difficult to assess temporal relationships. Further, as the authors did not control the demographic questions asked, they were unable to assess gender identity. Finally and relatedly, the YRBS does not account for outness (i.e., being open about one’s sexual minority status), which may be relevant to both victimization risk and individual resilience. These limitations should be addressed in future studies of the relationship between alcohol use and suicidality among SMY.

CONCLUSIONS

These findings add to the literature investigating alcohol-linked mechanisms that may contribute to suicide and alcohol use disparities among SMY and not sure youth compared with heterosexual youth. These results call for additional research into the relationship between contemporaneous alcohol use and suicidality, with attention to differences based on sex and sexual identity. There is a particular need to longitudinally examine the association between alcohol and suicidal behaviors such that evidence-informed interventions can be developed to reduce suicidality among SMY. Given the observed disparities, male SMY and male youth who identify as not sure should receive focused attention.

Supplementary Material

1

ACKNOWLEDGMENTS

The authors wish to acknowledge the Centers for Disease Control and Prevention for their role in creating and administering the Youth Risk Behavior Survey. The authors declare no competing interests. This study was supported by a grant from the National Institute on Alcohol Abuse and Alcoholism (R01 AA024409, Principal Investigator: Phillips) as well as a grant from the National Heart, Lung, and Blood Institute (K12 HL143959; Principal Investigator: Beach). The study sponsors had no role in the creation of this manuscript.

Footnotes

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No financial disclosures were reported by the authors of this paper.

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