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. Author manuscript; available in PMC: 2021 Aug 10.
Published in final edited form as: Psychiatry Res. 2020 Feb 10;286:112863. doi: 10.1016/j.psychres.2020.112863

Sexual orientation, attraction and risk for deliberate self-harm: Findings from a nationally representative sample

Adam J Mann a,c,*, Tapan A Patel a,b, Eric B Elbogen a,c, Patrick S Calhoun a,b,c,d, Nathan A Kimbrel a,b,c,d, Sarah M Wilson a,c,d
PMCID: PMC7887939  NIHMSID: NIHMS1661502  PMID: 32086030

Abstract

To date, there has been limited investigation identifying predictors of deliberate self-harm (DSH) among sexual minority adults. The present study examined the likelihood of DSH by sexual minority status as measured by self-reported sexual identity and sexual attraction in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Among respondents who answered both the sexual identity and attraction items on the NESARC (N = 34,273), the link between sexual minority status and DSH was examined. Univariate analyses yielded greater risk of DSH for all sexual minority identities compared to heterosexual identity. Individuals with same-sex only attraction did not differ from those with different-sex only attraction. At the multivariate level, respondents reporting bisexual and unsure identity and bisexual attraction were at two to three times greater risk of DSH compared to their heterosexual/different-sex counterparts. Same-sex attracted and gay/lesbian individuals did not differ from different-sex attracted or heterosexual individuals in adjusted multivariate models. Findings from this nationally representative sample are consistent with previous research suggesting that sexual minority status is a risk factor for DSH. There is a vital need to incorporate varying measures of sexual minority status within research and in clinics, as well as to inquire about DSH among sexual minorities.

Keywords: Self-injury, Nonsuicidal self-injury, Sexual attraction, Sexual minority, LGBT, Questioning, Bisexual

1. Introduction

Sexual minorities are at greater risk for both mental health conditions including depression, anxiety, substance abuse, and suicide (DiPlacido, 1998; Marshal et al., 2011; Meyer, 2003). Notably, they are more than twice as likely to attempt suicide as heterosexual individuals (Bolton and Sareen, 2011; Hottes et al., 2016). One important risk factor for suicide is deliberate self-harm (DSH), which refers to the intentional destruction of one's body tissue (e.g., cutting, burning, scratching, and banging or hitting; Asarnow et al., 2011; Klonsky et al., 2013). DSH has only recently been studied in sexual minority populations (Batejan et al., 2015; Jackman et al., 2016). To date, much of the research examining DSH in sexual minority populations has been limited to adolescents and young adults (Bakken and Gunter, 2012; Blosnich and Bossarte, 2012). There is a lack of research focusing on DSH among adult sexual minority populations on a national scale.

DSH is estimated to occur in 4% in the adult general population and 21% in clinical populations (Briere and Gill, 1998). Regarding etiology of DSH, studies found that DSH may function as a mean for alleviating negative emotions (Klonsky, 2007). Self-harm has more recently been further clarified by specifying a lack of suicidal intent (i.e., nonsuicidal self-injury; NSSI); however, many public health datasets do not specify suicidal intent when assessing self-harm. DSH has been found to be a significant predictor of suicidal thoughts and behaviors, as well (Asarnow et al., 2011). In fact, DSH has been found to be a stronger predictor of suicide attempts than depression, anxiety, and borderline personality disorder (Klonsky et al., 2013). The findings from these studies suggest that DSH should be assessed and treated in the context of suicide prevention while also reducing DSH in these individuals.

Among adolescent sexual minorities, DSH prevalence rates (18–46%) exceed those among the general population (5–15%; Bakken and Gunter, 2012; Bostwick et al., 2014; Reisner et al., 2014). Among young adults, there is a similar elevation in DSH among sexual minorities (13–23% versus 4–7% among heterosexuals;Blosnich and Bossarte, 2012; Lytle et al., 2014; Whitlock et al., 2011). These heightened prevalence rates may be explained by the minority stress model (Meyer, 2003). This model postulates that sexual minorities incur distress above the ubiquitous stress of daily life, and, coupled with fewer social resources due to the stigma associated with their sexual minority status (Eisenberg and Resnick, 2006), are at increased risk to develop mental health concerns and engage in health risk behaviors (DiPlacido, 1998; McCabe et al., 2009; McLaren, 2016; Meyer, 2003).

Within sexual minority groups, bisexual people appear to be at increased risk for engaging in DSH (Swannell et al., 2016). In a sample of college-age adults (n = 414), Sornberger et al. (2013) found that 37% of individuals who identified as bisexual reported engaging in DSH, which was significantly higher than both heterosexual respondents (7%) and other sexual minorities (e.g., questioning 21%, gay/lesbian 11%). Additionally, Lucassen et al. (2011) found that youth attracted to both sexes had a 5.8 times greater risk of DSH compared to their heterosexual peers, while youth who were exclusively attracted to the same sex had a 2.8 times greater risk than their heterosexual counterparts. These findings suggest that bisexual individuals may face additional factors that contribute to their engagement in DSH. Lucassen et al. (2011) suggested that these higher risks are a result of the marginalization bisexual individuals face from both their heterosexual and sexual minority peers. Sornberger et al. (2013) suggested that bisexual individuals may be more likely to engage in DSH as a coping strategy due to feelings of isolation as a result of not being as visible as their other sexual minority peers. Moreover, results from an epidemiological study in Australia indicated a heightened prevalence rate of DSH among sexual minority identity groups compared to heterosexuals (Swannell et al., 2016).

1.1. Present study

To date, there has not been a U.S. adult nationally representative sample gauging risk for and predictors of DSH among sexual minority individuals. Sexual orientation is a multi-dimensional construct that can be difficult to assess due to the intersection of identity (i.e., a label that may or may not forecast actual behaviors and desires), attraction (e.g., to whom one is romantically or sexually attracted), and sexual behavior (Salomaa and Matsick, 2019; Mustanski et al., 2014). The observed prevalence of different sexual orientations can vary widely based on how orientation is measured (Mustanski et al., 2014). To date, the literature examining the association between DSH and sexual minority status has been limited by the focus on sexual identity rather than other measures of attraction or behavior. The present study sought to address this gap in the literature by investigating the likelihood of DSH as a function of sexual minority status measured by both self-reported sexual identity and sexual attraction among a representative U.S. national sample. Sexual behavior was not included given its reliance on access to sexual partners. We hypothesized that sexual minority individuals defined by sexual identity or by sexual attraction would have greater DSH prevalence rates compared to heterosexual individuals. We additionally hypothesized that among sexual minorities, individuals who reported bisexual attraction or identity and those who identified their sexual identity as unsure (i.e., questioning) would have the highest odds of DSH.

2. Methods

2.1. Subjects

The sample consisted of 34,653 respondents who participated in the second wave of the NESARC, a nationally representative probability survey of the non-institutionalized, civilian adult population (aged 20 years and older) in the United States. The NESARC is a face-to-face survey conducted by the National Institute on Alcohol Abuse and Alcoholism (Grant et al., 2005). A total of 380 respondents were excluded due to missing data, and the final sample consisted of the 34,273 respondents who answered both the sexual identity and sexual attraction items. We investigated those excluded from our analyses. Only small effect sizes were found when examining correlations predicting inclusion/exclusion. Those who were younger, Asian, female, and/or who were high school educated had a higher rate of answering the sexual orientation and sexual attraction prompts, thus being included in our analyses. Inclusion/exclusion was not correlated with reporting a suicide attempt, history of depression, or the other clinical covariates described below.

2.2. Procedures

Data were gathered from the second wave of the NESARC (2004–05). Face-to-face interviews were administered at participants’ households. The response rate for eligible respondents in Wave 2 of the NESARC was 86.7%.

2.3. Measures

Demographic characteristics:

Wave 2 of the NESARC included assessment of age, sex race, and level of educational attainment. Note that the NESARC assessed sex (male or female), but not gender identity. Education was dichotomized into less than high school versus high school graduate or equivalent or more. Race and ethnicity included American Indian or Alaska Native, Asian, Black, Hispanic, and non-Hispanic White.

Clinical characteristics:

Clinical covariates included history of lifetime major depression (present vs. absent), lifetime alcohol use disorder (present vs. absent), and lifetime drug use disorder (present vs. absent). Repeated meta-analyses have shown these covariates to be risk factors for DSH (e.g., Franklin et al., 2017).

Sexual minority status

was measured in two ways. First, sexual identity was measured by asking, “Which of the categories on the card best describes you?” Answer choices included: heterosexual (straight); gay or lesbian; bisexual; not sure. Second, sexual attraction was assessed with the following: “People are different in their sexual attraction to other people. Which category on the card best describes your feelings?” Responses were 1) Only attracted to females; 2) Mostly attracted to females; 3) Equally attracted to females and males; 4) Mostly attracted to males; and, 5) Only attracted to males. Same-sex attraction was defined using respondents’ answers to “What is your sex?” and matching their response with the same sex choice regarding “Only attracted to males/females.” Similarly, different-sex attraction was defined using respondents’ answers to “What is your sex?” and matching their response with the different sex choice regarding “Only attracted to males/females.” The bisexual attraction group was composed of respondents who answered with either mostly attracted to females, equally attracted to females and males, or mostly attracted to males.

Deliberate self-harm

was assessed with the item, “Have you ever cut, burned, or scratched yourself on purpose?” with answer choices of ‘Yes’ and ‘No.’

2.4. Data analysis

Statistical analyses were conducted using SAS 9.4 and SUDAAN software packages. The association between sexual minority status and DSH was first examined in bivariate χ2 analyses conducted using SUDAAN. Multivariate analyses that were adjusted for both demographic and clinical variables were conducted using logistic regression. To explore the unique association between sexual minority status and DSH, available clinical covariates with known associations with DSH were included in the adjusted model including depression, alcohol use disorder, substance use disorder. As a secondary analysis, the association of DSH with sexual minority status was examined stratified by sex. Odd ratios (ORs) with 95% confidence intervals (CIs) were estimated using SUDAAN, which uses the Taylor Linearization Method to adjust for the effects of the design of the sample survey.

3. Results

See Table 1 for sample characteristics. On average, participants were 48.97 years old (SD = 17.27). The prevalence of sexual minority status differed by assessment method. Based on identity, two percent (2.1%) of the sample identified as non-heterosexual. In contrast, 6.5% of the sample was identified as a sexual minority when using measures of non-heterosexual attraction. Sexual minority status was associated with lifetime history of depression (χ2 = 14.90, p < 0.001), alcohol use disorder (χ2 = 13.46, p < 0.001) and other substance use disorders (χ2 = 15.41, p < 0.001). Participants who identified as bisexual had the highest rates of lifetime major depression (46.87%) followed by those who identified as gay/lesbian (39.39%), unsure (29.87%), and heterosexual (21.59%). This pattern continued for rates of lifetime substance use disorder (35.48%, 29.45%, 17.35%, and 11.71%, respectively). Participants who identified as gay/lesbian had the highest lifetime rate of alcohol use disorder (58.65%), followed by individuals who identified as bisexual (53.07%), unsure (36.35%), and heterosexual (34.32%).

Table 1.

Demographics.

Characteristics Full sample N = 34,273
N (Weighted %)		 Positive history of DSH N = 664 (1.94)
N (Weighted %)		 Negative history of DSH N = 33,609 (98.06)
N (Weighted %)		 P-value
Sex: 0.09
 Male 14,431 (42.11) 260 (43.87) 14,171 (48.12)
 Female 19,842 (57.89) 404 (56.13) 19,438 (51.88)
Sexual identity: <0.001
 Heterosexual 33,536 (97.85) 612 (92.16) 32,924 (98.22)
 Gay or Lesbian 332 (0.97) 14 (1.63) 318 (0.83)
 Bisexual 241 (0.70) 30 (4.25) 211 (0.55)
 Unsure 164 (0.68) 8 (1.96) 156 (0.41)
Sexual attraction: <0.001
 Heterosexual attraction 32,045 (93.50) 571 (87.18) 31,474 (94.33)
 Gay or Lesbian attraction 506 (1.48) 12 (1.09) 494 (1.39)
 Bisexual attraction 1722 (5.02) 81 (11.73) 1641 (4.27)
Race/ethnicity: <0.001
 American Indian/Alaska Native 568 (2.17) 24 (3.79) 544 (2.14)
 Asian 940 (4.21) 14 (2.02) 926 (4.26)
 Black 6523 (11.04) 78 (6.71) 6445 (11.13)
 Hispanic 6290 (11.58) 113 (10.01) 6177 (11.62)
 Non-hispanic white 19,952 (70.99) 435 (77.47) 19,517 (70.85)
With high school education: 13,499 241 (38.11) 13,258 (37.68) 0.87
With depression lifetime: 7857 (21.95) 442 (63.83) 7415 (21.09) <0.001
With substance use disorder lifetime: 3888 (12.05) 319 (50.28) 3569 (11.27) <0.001
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Weighted population percentages of DSH by self-reported sexual identity and sexual attraction are included in Fig. 1. By sexual identity group, proportions endorsing DSH were: 1.9% of the heterosexual identity group, 3.9% of the lesbian/gay identity group, 13.7% of the bisexual identity group, and 8.9% of the unsure identity group. By sexual attraction group, proportions endorsing DSH were: 1.9% of the different-sex only attracted group, 1.6% of the same-sex only attraction group, and 5.3% of the bisexual attraction group. In unadjusted logistic regression models predicting likelihood of DSH by self-reported sexual identity, all sexual minority groups had significantly higher odds of DSH compared to the heterosexual identity group: gay/lesbian (OR = 2.09 [1.08–4.05], p = 0.03), bisexual (OR = 8.29 [5.22–13.16], p < 0.001), and unsure (OR = 5.12 [2.03–12.90], p < 0.001). In unadjusted logistic regression models predicting likelihood of DSH by sexual attraction, odds of DSH did not differ between same-sex attracted individuals and different-sex attracted individuals (OR = 0.85 [0.46–1.57] p = 0.60). However, bisexual attraction was associated with almost 3 times higher odds of DSH compared to the different-sex attracted group (OR = 2.97 [2.28–3.86], p < 0.001).

Fig. 1.

Fig. 1.

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Weighted proportion endorsing deliberate self-harm (DSH) by sexual identity and sexual attraction.

Figure note: Error bars denote 95% CI.

In adjusted multivariate logistic regression models that included demographic and clinical covariates including age, sex, race, education, and history of depression, alcohol and drug use disorders, and history of previous suicide attempt (see Table 2), gay/lesbian identity was no longer associated with odds of DSH compared to heterosexual identity status. However, bisexual identity and unsure identity remained associated with DSH. Compared to those with heterosexual identity, participants with bisexual identity had over three times the odds of endorsing DSH (OR = 3.23 [1.96–5.33], p = 0.00002. Those with unsure identity also had greater than three times the odds of DSH compared to heterosexual individuals (OR = 3.32 [1.06–10.42], p = 0.04). In the model examining sexual attraction adjusted for demographic and clinical covariates, same-sex attraction was not associated with likelihood of DSH. However, bisexual attraction remained associated with DSH in the multivariate model. Compared to those with different-sex attraction, participants with bisexual attraction had over twice the odds of endorsing DSH (OR = 2.19 [1.49–2.72], p = 0.00002; see Table 2).

Table 2.

Adjusted multivariate logistic regression model for deliberate self-harm by sexual identity and sexual attraction.

Variable Sexual identity model
 Sexual attraction model
Odds ratio 95% confidence interval P-value Odds ratio 95% confidence interval P-value
Sexual identity (Ref: heterosexual) – – – – – –
 Gay or Lesbian 1.13 (0.54–2.34) 0.74 – – –
 Bisexual 3.23 (1.96–5.33) <0.001 – – –
 Unsure 3.32 (1.06–10.42) <0.05 – – –
Sexual attraction (Ref: different-sex attraction) – – – – – –
 Same-sex attraction – – – 0.81 (0.41–1.59) 0.54
 Bisexual attraction – – – 2.01 (1.49–2.72) <0.001
Age 0.96 (0.95–0.96) <0.001 0.96 (0.95–0.96) <0.001
Female sex 1.28 (1.03–1.60) <0.05 1.26 (1.01–1.58) <0.05
Minority race/ethnicity (Ref: non-hispanic white) – – – – – –
 American Indian 0.99 (0.62–1.59) 0.98 1.00 (0.61–1.62) 0.99
 Asian 0.60 (0.34–1.07) 0.08 0.58 (0.34–0.99) <0.05
 Black 0.57 (0.40–0.82) <0.01 0.57 (0.40–0.82) <0.01
 Hispanic 0.73 (0.51–1.06) 0.10 0.74 (0.52–1.07) 0.11
Less than high school education 1.38 (1.11–1.72) <0.01 1.40 (1.13–1.75) <0.01
Lifetime major depression 4.22 (3.37–5.29) <0.001 4.21 (3.36–5.28) <0.001
Lifetime alcohol use disorder 1.58 (1.23–2.03) <0.001 1.57 (1.22–2.02) <0.001
Lifetime drug use disorder 3.54 (2.69–4.66) <0.001 3.55 (2.70–4.66) <0.001
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Models examining the association of DSH and sexual minority status stratified by sex are shown in Tables 3 and 4. Among men only those endorsing an unsure identity (i.e., questioning) were at higher odds of DSH (OR = 6.19 [1.78–21.48], p = 0.0003) compared to heterosexual men. Among women, persons who identified as bisexual were at higher odds of DSH (OR = 4.00 [2.33–6.88], p = 0.0003) compared to women who identified as heterosexual. Results examining attraction indicated that bisexual attraction (compared to different-sex attraction) remained consistently associated with higher odds of DSH for both men (OR = 2.5 [1.34–4.69], p = 0.005) and women (OR = 1.94 [1.37–2.75], p = 0.0003; see Table 4).

Table 3.

Adjusted multivariate logistic regression model for deliberate self-harm by sexual identity stratified by sex.

Variable Men
 Women
Odds ratio 95% confidence interval P-value Odds ratio 95% confidence interval P-value
Sexual identity (Ref: heterosexual) – – – – – –
 Gay/Lesbian 0.72 (0.25–2.09) 0.54 1.69 (0.56–5.09) 0.35
 Bisexual 1.38 (0.18–10.50) 0.75 4.00 (2.33–6.88) <0.001
 Unsure 6.19 (1.78–21.48) <0.01 2.28 (0.36–14.56) 0.38
Age 0.95 (0.94–0.96) <0.001 0.97 (0.95–0.98) <0.001
Minority race/ethnicity (Ref: non-hispanic white) – – – – – –
 American Indian 1.11 (0.48–2.57) 0.80 0.94 (0.53–1.69) 0.84
 Asian 0.42 (0.16–1.09) 0.07 0.74 (0.32–1.70) 0.47
 Black 0.76 (0.44–1.31) 0.32 0.45 (0.31–0.65) <0.001
 Hispanic 0.83 (0.51–1.35) 0.45 0.65 (0.41–1.03) 0.06
Less than high school education 1.64 (1.18–2.26) <0.01 1.16 (0.87–1.53) 0.31
Lifetime major depression 3.30 (2.42–4.49) <0.001 5.40 (3.97–7.35) <0.001
Lifetime alcohol use disorder 1.53 (0.97–2.43) 0.07 1.60 (1.17–2.19) <0.001
Lifetime drug use disorder 3.99 (2.66–5.99) <0.001 3.23 (2.32–4.50) <0.001
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Table 4.

Adjusted multivariate logistic regression model for deliberate self-harm by sexual attraction stratified by sex.

Variable Men
 Women
Odds ratio 95% confidence interval P-value Odds ratio 95% confidence interval P-value
Sexual attraction (Ref: different-sex attraction) – – – – – –
 Same-sex attraction 0.77 (0.28–2.14) 0.61 0.94 (0.37–2.37) 0.90
 Bisexual attraction 2.50 (1.34–4.69) 0.005 1.94 (1.37–2.75) <0.001
Age 0.94 (0.93–0.96) <0.001 0.96 (0.95–0.97) <0.001
Minority race/ethnicity (Ref: non-hispanic white) – – – – – –
 American Indian 1.14 (0.50–2.65) 0.74 0.93 (0.51–1.70) 0.82
 Asian 0.41 (0.15–1.09) 0.07 0.71 (0.32–11.56) 0.39
 Black 0.73 (0.41–1.27) 0.26 0.45 (0.31–0.65) <0.001
 Hispanic 0.83 (0.51–1.35) 0.44 0.65 (0.42–1.02) 0.06
Less than high school education 1.67 (1.21–2.32) 0.003 1.17 (0.88–1.56) 0.28
Lifetime major depression 3.25 (2.38–4.43) <0.001 5.39 (3.95–7.36) <0.001
Lifetime alcohol use disorder 1.53 (0.97–2.41) 0.07 1.59 (1.16–2.18) <0.01
Lifetime drug use disorder 3.95 (2.64–5.91) <0.001 3.28 (2.38–4.54) <0.001
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4. Discussion

The current study sought to demonstrate differences in risk for DSH by sexual minority status within a U.S. nationally representative sample. We utilized two measurements of sexual minority status—sexual identity and sexual attraction. The prevalence of sexual minority status was higher based on assessment of sexual attraction. In univariate models based on self-reported identity, sexual minority status was broadly associated with increased odds for endorsing DSH such that gay/lesbian, bisexual, and persons endorsing an unsure/questioning identity had higher odds of DSH compared to heterosexual men and women. In contrast, when defining sexual minority status by attraction, results indicated that same-sex attracted participants did not significantly differ in odds of DSH compared to different-sex attracted individuals.

In models adjusted for demographic and clinical variables, lesbian/gay identity and same-sex attracted individuals did not differ from heterosexual or different-sex attracted individuals in the odds of DSH. These results may suggest that increased odds of DSH observed in univariate results comparing gay/lesbian persons to persons identifying as straight may be in part mediated by higher prevalence of psychiatric distress in sexual minority populations. Differences in psychiatric diagnoses between lesbian/gay individuals and heterosexual individuals have been well documented (e.g., Bolton and Sareen, 2011).

Persons who endorsed bisexual identity or attraction, were found to consistently have higher odds of DSH in both unadjusted and adjusted models that included demographic and clinical covariates. Secondary analyses examining the association between sexual minority status and DSH stratified by sex indicated that women who identified as bisexual had increased odds of reporting DSH, while men who were unsure or questioning of their identity had higher odds of DSH.

These results, in which sexual minorities have higher odds of DSH at the univariate level and, in particular, bisexual individuals at the multivariate level, may be best explained by the minority stress model. Minority stress may cause deficits in emotion regulation capabilities, and these regulatory abilities have been shown to mediate the relationship between sexual orientation and DSH (Fraser et al., 2018). One unique factor for bisexual individuals (attraction and identity) is the concept of biphobia. Distinct from homophobia, bisexual individuals face stigma and discrimination from both heterosexual and sexual minority peers (Mereish et al., 2017). In addition to these added sources of distress, bisexual individuals may also experience less social support than their heterosexual and gay/lesbian counterparts, as they may find it difficult to navigate and benefit from the social support of either the gay/lesbian community and/or the heterosexual community (Anderson and McCormack, 2016; Friedman et al., 2014). Additionally, bisexual men report higher minority stress than gay men, which may explain the greater rates of DSH among bisexuals (Chard et al., 2015; Lucassen et al., 2011; Sornberger et al., 2013).

The unsure sexual identity group had higher odds of DSH compared to the heterosexual identity group; however, when stratified by sex, this association was only present with men. Those with unsure sexual identity may have fewer supports in and connections to the gay/lesbian and heterosexual communities as their identity is unfixed. Additionally, those who experience same-sex or bisexual attraction but do not identify as a sexual minority may be more susceptible to internalized homophobia or biphobia, as it may be difficult to reconcile an incongruent identity, or lack thereof, with their same-sex or bisexual attractions. Internalized homophobia occurs when sexual minorities adopt negative attitudes towards themselves and subsequently devalue themselves due to sexual minority status (Meyer and Dean, 1998). This in turn may cause greater distress and, therefore, risk for self-injury.

This study adds important data regarding the measurement of sexual minority status. Consistent with previous studies (Igartua et al., 2009; Mustanski et al., 2014), prevalence of sexual minority status differed depending on the measurement method (identity versus attraction). Of the sample, 2.2% of U.S. population reported identifying as a sexual minority, while 6.5% reported sexual minority attraction. These rates are similar to recent examinations of sexual minority status. In a large, population-based random sample of adults (aged 18–100) living in Australia (response rate 38.5%), 2.8% of the population identified as a sexual minority. In addition, in the largest U.S. nationally representative survey investigating sex, National Survey of Sexual Health and Behavior (2009), 5.6% of the population identified as lesbian, gay, or bisexual (Gates, 2011). Rates of sexual minority status, especially bisexual minority status, differed when it was measured with sexual attraction rather than self-reported identity. The measurement of sexual orientation or sexual minority status remains complicated by the intersection of identity, attraction and behavior. There is no consensus on what level of same-sex attraction constitutes sexual minority status (Savin-Williams, 2006). Sexual identity measures utilize gender identity markers that can be affected by social stigma or cultural expectations, and thus may fail to capture individuals with non-heterosexual attraction or behavior who do not identify with a sexual minority label (Savin-Williams, 2006). Results from numerous studies have shown that many people who have same-sex attraction do not identify as sexual minorities (Laumann et al., 1994; McCabe et al., 2009).

4.1. Limitations

Limitations in the current study should be considered. The DSH measure was a single item that was primarily developed for the assessment of borderline personality disorder and only specifically inquired about three behaviors (i.e., cutting, scratching, and burning), so our sample may be limited to more prototypical forms of DSH. More recently, newer definitions of self-harm have specified a lack of intent to die (i.e., nonsuicidal self-injury; NSSI); however, this distinction was not used during the time of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) dataset, remaining under the broader term of DSH. An additional limitation is the assumption within the NESARC dataset of binary gender. This constraint was present in both the demographics of the sample as well as the measurement of sexual minority attraction. This would limit responses from gender nonbinary, intersex, agender, and other gender minority respondents. This is an important consideration considering intersectionality between gender and sexuality within the LGBTQIA+ community. Furthermore, sexual orientation identities were limited to gay/lesbian, bisexual, and unsure, possibly forcing categorization or exclusion of other sexual orientation identities (e.g., asexual, queer, pansexual, etc.). Another limitation of the study is the dichotomizing of the clinical covariates into lifetime and absent categories. It is uncertain whether these lifetime covariates preceded, succeeded, or overlapped in time with the investigated DSH. Estimates stratified by sex should be viewed with some caution given small cell sizes. Future research should further explore racial/ethnic differences and how they affect DSH. Additionally, intersectionality between racial/ethnic minority status and sexual minority status as they relate to DSH will be important to observe. Although prevalence estimates of this sample are similar to results of more recent investigations (Gates, 2011; Swannell et al., 2016), this sample may no longer be representative as new generations mature amidst cultural shifts. For example, a survey noted that 46% of British millennials reported sexual minority attraction (YouGov, 2015). Future research should examine the association between DSH and sexual minorities with the inclusion of this new generation and corresponding cultural shifts.

4.2. Implications

This is the first study to estimate the risk of DSH among a nationally representative sample of U.S. sexual minority adults that utilized and compared two measures of sexual minority status. This study demonstrates higher risk of DSH among people who identify as bisexual, have bisexual attraction, or are unsure about their sexual identity. These results are consistent with the recent nationally representative study from Australia (Swannell et al., 2016). Consequently, community resources and healthcare for DSH may be particularly relevant for these sexual minority populations. Given the association between DSH and suicide along with the already increased risk of suicide in the sexual minority population, clinicians should seek to assess and treat DSH accordingly. Simultaneously, researchers should seek to better understand the mechanism by which DSH functions and develop appropriate evidence-based treatments to target these behaviors and the underlying reasons behind them.

Additionally, this study provides evidence to indicate that the measure with which researchers define sexual minority status matters. Measures of sexual attraction and sexual identity produced different associations between sexual minority status and risk of self-injury. Further research could elucidate the distinction between attraction and identity measures, as well as the unique factors of bisexuality that increase the risk of DSH. Researchers should also investigate the unique factors of the unsure group, with potential factors relating to cognitive dissonance or the coming out process. Additionally, clinicians, community health workers, and those who work in advocacy should be aware of the potential limitations of only using self-identified sexual identity and may need to devise strategies to gain access to individuals who endorse same-gender or bisexual attraction but do not identify as lesbian/gay/bisexual, or individuals who are unsure of their sexual identity.

4.3. Conclusion

In combination with other evidence of heightened DSH risk among sexual minorities, the current study's findings highlight the importance of research and treatment of DSH among sexual minorities, and in particular bisexual persons and those who are unsure of their sexual identity. Results from this study support previous research that has suggested that sexual minorities, especially bisexual individuals and those who are unsure of their sexual identity are at a higher risk of DSH. This study also highlights the importance of how sexual minority status is defined. Future research should seek to consistently incorporate varying measures of sexual minority status, rather than only measuring self-reported sexual identity.

Acknowledgments

Funding

This study was completed without external funding.

Footnotes

Decleration of Competing Interest

None.

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