Abstract
Purpose:
This study examines the prevalence of reported family physical abuse and the concurrent association between abuse and suicide attempts by adolescent gender identity.
Methods:
This study used the Profiles of Student Life: Attitudes and Behaviors dataset (N = 121,150 adolescents aged 11–19 [mean = 14.74, standard deviation = 1.78]) collected from 61 participating school districts and programs across the United States by Search Institute from 2012 to 2015. Multigroup logistic regression was used to examine the association between family abuse and suicide attempts by gender identity. Correlates included race/ethnicity, age, parent education, rurality, binge drinking, and tobacco use.
Results:
Results indicated that cisgender adolescents (i.e., participants who did not select a transgender identity) reported significantly less family abuse compared to gender minority adolescents. Family physical abuse was associated with higher odds of suicide attempts among all adolescents. The association was stronger for female adolescents compared to male adolescents but not significantly different across gender minority adolescents, including those who identify as transgender female to male, transgender male to female, and transgender without identifying or being unsure of their gender identity. The association between family physical abuse and suicide attempts was stronger among heterosexual female adolescents compared to sexual minority female, heterosexual male, sexual minority male, heterosexual gender minority, or sexual and gender minority adolescents.
Conclusions:
Findings highlight the importance of identifying and treating family abuse to prevent suicide attempts, particularly among gender and sexual minority adolescents.
Keywords: adolescents, family abuse, gender identity, suicide behavior, transgender
Introduction
The prevalence of suicidal ideation and suicide attempts increases from childhood to adolescence, with suicide being the second leading cause of death among adolescents and young adults in the United States.1 In the 2019 High School Youth Risk Behavior Survey from the Centers for Disease Control and Prevention (CDC), about 19% of adolescents in grades 9–12 “seriously considered attempting suicide” and 9% “attempted suicide one or more times” over a 12-month period.1 Given the social, emotional, and economic consequences of suicide attempts and deaths by suicide,2 it is critical to understand risk factors and malleable intervention targets for adolescents to prevent these losses.
Emerging research documents that the prevalence of suicidal ideation and attempts is alarmingly high among transgender and nonbinary (referred to collectively as gender minority) adolescents and adults, particularly compared to their cisgender peers (i.e., whose gender identity aligns with their assigned sex/gender at birth).3–6 A national study of gender minority young adults (ages 18–24) found that 86.3% had considered suicide and 42.1% had attempted suicide.3 High rates of suicidal ideation and suicide attempts have also been documented among gender minority adolescents.5,6 For example, the 2021 LGBTQ Youth Mental Health survey, a national survey with nearly 35,000 lesbian, gay, bisexual, transgender, queer/questioning (LGBTQ) youth between 13 and 24 years of age, found that over 52% of gender minority adolescents considered suicide and about 20% had attempted suicide.7
Experiences in the family context, both nurturing and adverse, have a significant impact on adolescents' mental health and suicide attempts.8,9 Among family risk factors, familial physical abuse during childhood is one of major factors predicting suicide attempts.1,10 The CDC defines physical abuse from the family as experiences of any physical force from family members that can result in physical injury, such as hitting, shaking, or kicking.11 In a study of cisgender adults, Smith et al. found that childhood experiences of physical abuse were associated with higher levels of capability for suicide, such as fearlessness to death and tolerance to pain, which are considered key antecedents to suicide attempts.12 Given disparities in suicidal ideation and attempts among gender minority youth and the key role that families play in gender minority youths' lives,3,13–15 this study sought to examine differences by gender in experience of childhood family physical abuse, as well as the association between family physical abuse and suicide attempts.
Gender diversity and family relationships
Gender minority adolescents encounter various challenges, such as family rejection, school-based victimization and harassment, and societal discrimination, that contribute to elevated rates of suicidal ideation and attempt.3,13–15 Previous experience of maltreatment in the family context, such as physical and emotional abuse from family members, is particularly detrimental to gender minority adolescents' health and well-being.16–18 For example, the 2015 U.S. Transgender Survey found that experiencing familial physical abuse during childhood was strongly associated with higher levels of self-harm and suicide attempts among transgender adults.3 Therefore, understanding the risk factors for suicide attempts within the family context is critical for developing effective practice and policy to reduce disparities in suicide attempts among gender minority adolescents.
Moreover, gender minority adolescents are at greater risk of being mistreated in the family (e.g., being physically abused) compared to cisgender peers given their minoritized gender identities and familial rejection of those identities.8,19 Gender minority adolescents may attribute repeated and severe experiences of family abuse to their family members' rejection of their gender identity.19 The internalization of family rejection is found to contribute to negative self-evaluation and the feeling of abandonment, and restrict access to gender-affirming care for gender minority adolescents,13 which further increases the risk of attempting suicide.18,20 Therefore, it is possible that the adverse impact of family physical abuse is more detrimental among gender minority adolescents compared to cisgender peers. Yet, there continues to be a need for research to understand how gender minority adolescents' experiences in the family context compare to that of their cisgender peers and how these experiences contribute to suicide attempts differently.
Positive and healthy relationships with family members are essential for gender minority adolescents' health and well-being.12,21 In a community-based sample of gender minority children, there were no differences in depressive symptoms and only minimal differences in anxiety between gender minority children supported in their identities by their family and a comparative sample of cisgender children.9 A supportive family relationship plays a critical role in gender minority adolescents' social transitions, such as using their chosen name, pronouns, and gender expression in various social contexts, changing the sex marker on their birth certificate, or seeking access to gender-affirming health care.13 These findings highlight the profound importance of having supportive family relationships among gender minority adolescents such that supportive family relationships can protect gender minority adolescents from gender identity-based victimization and provide access to gender-affirming care and services.
Moreover, disparities across gender identity in suicide attempts, as well as its association with physical abuse, may be further magnified based on adolescents' sexual orientation. Sexual minority adolescents encounter unique challenges specific to their sexual orientation, also contributing to elevated risks of suicide attempt.22 Perpetuation of stigma and prejudice based on one's sexual orientation and gender identity may collectively contribute to amplified adverse effects for sexual and gender minority youth.23 Thus, there is an increasing need to explore the interaction between sexual orientation and gender identity to avoid biased understanding of, and to provide appropriate support for, adolescents with multiple minority identities.
In addition, prior studies have documented other variables that also contribute to suicide attempts among gender minority youth, including age, race/ethnicity, parent education, rurality, use of tobacco, and binge drinking.24–29 That is, older adolescents, ethnic minority adolescents, adolescents whose parents have lower educational attainment, adolescents who live in more rural areas, and adolescents who engage in tobacco use and frequent binge drinking are at greater risk of suicide attempts.
Current study
This study had two research aims. First, we examined whether the association between family physical abuse and suicide attempts differed by gender identity. We hypothesized a positive association between physical abuse in the family and suicide behavior for all youth and hypothesized that this association would be stronger among gender minority adolescents given that it could be indicative of, and exacerbate, rejection related to adolescents' gender identity. Second, we examined whether the association between family physical abuse and suicide attempts differed by gender identity and sexual orientation. We hypothesized that the positive association between family physical abuse and suicide attempts would be stronger among adolescents with both sexual and gender minoritized identities compared to heterosexual gender minorities, cisgender sexual minorities, or heterosexual and cisgender adolescents.
Methods
Procedure and sample
Secondary analysis was conducted of a sample of 121,150 U.S. adolescents who completed the Profiles of Student Life: Attitudes and Behaviors survey. Data were independently collected by 61 school districts and community-based programs who approached Search Institute with an interest in gathering data on youths' strengths and challenges. The average sample size was 468 youth (median = 314 youth). Search Institute provides support and detailed administration guides for the survey, including information about obtaining parental consent and youth assent, but has limited oversight over the data collection process. Detailed information is available on Search Institute's website about the survey and methodology.30
Data for the current study were collected between June 2012 and May 2015. Beginning June 1, 2012, Search Institute expanded its gender identity question on the survey to be more inclusive of gender minority adolescents. May 2015 was selected as the end date to avoid confounding the analyses with any potential effect of the landmark 2015 Obergefell v. Hodges U.S. Supreme Court decision.31 The secondary analyses for this project were exempt from Institutional Review Board approval by the University of Arizona.
Measures
Gender identity
Gender identity was self-reported by participants on a single question: “Which of the following best describes you?” Response options included: female; male; transgender, male to female; transgender, female to male; transgender, does not identify exclusively as male or female; and not sure. For analyses, gender identity was also trichotomized into female, male, and gender minority adolescents (i.e., a combined sample of youth who identified as transgender, male to female; transgender, female to male; transgender, does not identify exclusively as male or female; and not sure).
Sexual orientation
Sexual orientation was self-reported by participants on a single question: “Would you say that you are?” Response options included: only straight/heterosexual, mostly straight/heterosexual, bisexual, mostly lesbian/gay, only lesbian/gay. In addition, sexual orientation was dichotomized into only heterosexual and sexual minority adolescents (i.e., a combined sample of youth who identified as mostly straight/heterosexual, bisexual, mostly lesbian/gay, and only lesbian/gay).
Family physical abuse
Family physical abuse was assessed with a single item, “Have you ever been physically harmed (that is where someone caused you to have a scar, black and blue marks, welts, etc.) by someone in your family or someone living with you?” Responses were scored on a 5-point scale: 1 = Never, 2 = Once, 3 = 2–3 times, 4 = 4–10 times, and 5 = More than 10 times.
Suicide attempts
Suicide attempts were measured with a single item, “Have you ever tried to kill yourself?” (0 = No; 1 = Yes, once; 2 = Yes, twice; 3 = Yes, more than two times). The variable was dichotomized to reflect ever attempting suicide (0 = Never, 1 = Ever).
Covariates
Covariates included race/ethnicity, age, parent education, rurality, binge drinking, and tobacco use. Adolescents reported their age on a 9-point scale from “11 or younger” to “19 or older.” Highest parental education was measured by asking “What is the highest level of schooling your father/mother completed?” and reported on “1 = Completed grade school or less,” “2 = Some high school,” “3 = Completed high school,” “4 = Some college,” “5 = Completed college,” and “6 = Graduate or professional school after college.” Race-ethnicity was measured with a single item asking, “Would you say that you are [options],” with the response options: American Indian or Alaska Native, Asian, Black or African American, Hispanic or Latino/Latina, Native Hawaiian or Other Pacific Islander, White, Other. Rurality was measured by asking participants: “Where does your family now live?” Responses were dichotomized to reflect living in the country, in a small town or town, or small city (coded as 1 = Rural), or in a medium to large city (coded as 0 = Not rural).
Binge drinking was measured with a one item question, “Think back over the past two weeks, how many times have you had five or more drinks in a row? (for example, a ‘drink’ is a glass of wine, a bottle or can of beer, a shot glass of liquor, or a mixed drink)” and reported on “1 = None,” “2 = Once,” “3 = Twice,” “4 = 3–5 times,” “5 = 6–9 times,” and “6 = 10 or more times.” Tobacco use was measured with a one item question, “How frequently have you smoked cigarettes during the past 30 days?” and reported on “1 = I have never smoked a cigarette,” “2 = not at all,” “3 = less than 1 cigarette per day,” “4 = 1–5 cigarettes per day,” “5 = About ½ pack per day,” “6 = about 1 pack per day,” “7 = about 1½ packs per day,” “8 = 2 or more packs per day.”
Analytic approach
Descriptive statistics and results of analysis of variance (ANOVA) were conducted in SPSS (Version 23)32 to test differences in rates of family physical abuse by gender identity. Rates of suicide attempts can be found in another study.6 Multigroup logistic regression models were tested in Mplus v.7.31 to examine the association between family physical abuse and suicide behavior in each gender identity group with all paths freely estimated.33 This model was compared with additional models to determine whether the association between physical abuse in the family and suicide attempts varied across gender identity. Each comparison model constrained the association between family physical abuse and suicide behavior to be invariant in two of the gender identity subsamples.
To examine the association between family physical abuse and suicide attempts across both sexual and gender identity, a compound variable was created to group participants with different sexual and gender identities. A freely estimated model examining the association between physical abuse in the family and suicide attempts was compared, respectively, with models that constrained the association to be invariant in two of the sexual and gender identity subsamples. Model fit indices were used to compare invariance between models, such that if the change in the comparative fit indices (CFI) was less than 0.01 (ΔCFI <0.01), the path between family physical abuse and suicide attempts was determined to be significantly different in the two subsamples. Missing data were handled using multiple imputation (n = 20 imputations).34
Results
Descriptive statistics of demographic information, study variables, and covariates are presented in Table 1. Descriptive statistics indicated that the mean level of family physical abuse was 1.45 (SDpooled = 0.94) for the sample, suggesting that most adolescents ranged between never experiencing family physical abuse to experiencing it once within their family. An ANOVA was conducted to test for differences in family physical abuse across gender identities. As shown in Table 2, this test suggested significant differences in average levels of family physical abuse across gender identities. Post hoc comparisons revealed that levels of family physical abuse among gender minority adolescents were significantly higher than those of cisgender adolescents. Cisgender adolescents had significantly lower mean levels of family physical abuse compared to gender minority adolescents. Notably, there were no differences in levels of family physical abuse within gender minority subgroups (e.g., transgender, male to female compared to transgender, female to male).
Table 1.
Descriptive Statistics of Key Variables
| Variable | M | SD | N | % |
|---|---|---|---|---|
| Age | 14.74 | 1.78 | ||
| Gender identity | ||||
| Female | 60,973 | 50.6 | ||
| Male | 57,873 | 48.0 | ||
| Transgender, male-to-female | 203 | 0.2 | ||
| Transgender, female-to-male | 175 | 0.2 | ||
| Transgender, do not identify | 344 | 0.3 | ||
| Gender, not sure | 1052 | 0.9 | ||
| Ethnicity | ||||
| Asian | 9696 | 8.1 | ||
| Black | 8025 | 7.7 | ||
| Latinx | 12,350 | 10.3 | ||
| Native Hawaiian or other Pacific Islander | 659 | 0.6 | ||
| White | 75,801 | 63.0 | ||
| American Indian or Alaskan Native | 1376 | 1.1 | ||
| Other race/ethnicity | 4266 | 3.5 | ||
| Multirace/ethnicity | 8241 | 6.8 | ||
| Sexual orientation | ||||
| Only heterosexual | 105,933 | 90.2 | ||
| Mostly heterosexual | 5895 | 5.0 | ||
| Bisexual | 4070 | 3.5 | ||
| Mostly lesbian/gay | 728 | 0.6 | ||
| Only lesbian/gay | 847 | 0.7 | ||
| Rurality | ||||
| Medium to large size city | 85,529 | 75.8 | ||
| Farm to small size city | 27,273 | 24.2 | ||
| Parent's education | ||||
| Completed grade school or less | 2099 | 1.9 | ||
| Some high school | 3721 | 3.4 | ||
| Completed high school | 13,777 | 12.8 | ||
| Some college | 13,262 | 12.3 | ||
| Completed college | 38,047 | 35.2 | ||
| Graduate or professional school after college | 37,134 | 34.3 | ||
| Physical abuse in family | 1.45 | 0.94 | ||
| Suicide attempts | ||||
| Never | 101,995 | 86.5 | ||
| At least once | 15,930 | 13.5 | ||
| Binge drinking | 1.31 | 0.89 | ||
| Tobacco use | 1.34 | 0.88 | ||
M, mean; SD, standard deviation; N, sample size; %, percentage.
Table 2.
Group Differences on Physical Abuse in Family Across Gender Identity and Across Sexual and Gender Identity
| Group | N | M | SD | F[df1, df2] |
|---|---|---|---|---|
| Gender identity | 89.73*** [5, 114841] | |||
| Female | 58,689 | 1.431,2,3,4 | 0.92 | |
| Male | 54,493 | 1.455,6,7,8 | 0.95 | |
| Transgender, male-to-female | 182 | 1.971,5 | 1.35 | |
| Transgender, female-to-male | 166 | 1.922,6 | 1.33 | |
| Transgender, do not identify | 323 | 2.053,7 | 1.44 | |
| Gender, not sure | 994 | 1.864,8 | 1.32 | |
| Gender identity × sexual orientation | 343.00*** [5, 111939] | |||
| Heterosexual female | 50,162 | 1.39a,b,c,d,e | 0.87 | |
| Sexual minority female | 6952 | 1.79a,f,g,h | 1.20 | |
| Heterosexual male | 50,158 | 1.44b,f,i,j,k | 0.94 | |
| Sexual minority male | 3079 | 1.63c,g,i,l,m | 1.12 | |
| Heterosexual gender minority | 686 | 1.77d,j,l,n | 1.25 | |
| Sexual and gender minority | 908 | 2.03e,h,k,m,n | 1.40 |
Shared superscripts represent significant difference with other groups.
***p < 0.001.
Another ANOVA was conducted to test for differences in physical abuse in the family across gender identity and sexual orientation. As shown in Table 2, findings suggested significant differences in average levels of family physical abuse across gender identity and sexual orientation. Post hoc comparisons revealed that group differences emerged in all comparisons except for difference between sexual minority female adolescents and heterosexual gender minority adolescents.
Multigroup logistic regression was used to examine the association between family physical abuse and suicide attempts by gender identity. Race/ethnicity, age, parent education, rurality, binge drinking, and tobacco use were included in the model as covariates. Table 3 displays odds ratios and confidence intervals for predicting suicide attempts across gender identity. Family physical abuse was associated with higher odds of suicide behavior across all groups. Nested model comparisons revealed that there were significant differences between female and male adolescents (ΔCFI = 0.01), such that the association between physical abuse in family and suicide attempts was stronger for female adolescents compared to male adolescents. No other group differences were identified (Table 4).
Table 3.
Adjusted Odds Ratios and 95% Confidence Intervals of Suicide Attempts by Gender Identity
| Female |
Male |
Transgender, male to female |
Transgender, female to male |
Transgender, not exclusively male or female |
Not sure |
|||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| OR | CI[LL,UL] | OR | CI[LL,UL] | OR | CI[LL,UL] | OR | CI[LL,UL] | OR | CI[LL,UL] | OR | CI[LL,UL] | |
| Family abuse | 1.40 | 1.38, 1.41 | 1.30 | 1.29, 1.32 | 1.42 | 1.15, 1.75 | 1.41 | 1.17, 1.71 | 1.38 | 1.22, 1.56 | 1.25 | 1.17, 1.34 |
| Age | 0.99 | 0.98, 0.99 | 1.02 | 1.01, 1.03 | 0.99 | 0.84, 1.17 | 1.06 | 0.93, 1.20 | 1.00 | 0.90, 1.11 | 0.95 | 0.90, 1.00 |
| Rural (reference = urban) | 1.00 | 0.97, 1.03 | 0.96 | 0.93, 1.01 | 1.39 | 0.74, 2.61 | 1.03 | 0.54, 1.97 | 1.09 | 0.71, 1.67 | 0.96 | 0.75, 1.22 |
| Parent education | 0.95 | 0.94, 0.96 | 0.96 | 0.95, 0.98 | 1.14 | 0.93, 1.39 | 1.01 | 0.86, 1.17 | 0.96 | 0.86, 1.07 | 0.90 | 0.85, 0.96 |
| Sexual orientation (reference = only heterosexual) | ||||||||||||
| Mostly heterosexual | 1.54 | 1.47, 1.61 | 1.69 | 1.58, 1.81 | 2.46 | 1.04, 5.80 | 2.61 | 1.07, 6.34 | 0.66 | 0.34, 1.31 | 1.05 | 0.81, 1.36 |
| Bisexual | 2.33 | 2.22, 2.46 | 2.51 | 2.28, 2.76 | 2.21 | 1.13, 4.32 | 3.42 | 1.68, 6.96 | 1.34 | 0.76, 2.38 | 1.19 | 0.92, 1.53 |
| Mostly lesbian/gay | 2.10 | 1.82, 2.42 | 1.75 | 1.43, 2.15 | 2.88 | 1.34, 6.22 | 3.00 | 1.33, 6.77 | 1.40 | 0.75, 2.59 | 1.14 | 0.79, 1.64 |
| Only lesbian/gay | 1.89 | 1.61, 2.22 | 2.08 | 1.82, 2.37 | 3.63 | 1.76, 7.48 | 3.76 | 1.72, 8.20 | 1.13 | 0.62, 2.04 | 1.09 | 0.77, 1.54 |
| Race/ethnicity (reference = White) | ||||||||||||
| AIAN | 1.18 | 1.03, 1.36 | 1.17 | 1.02, 1.34 | 1.46 | 0.62, 3.44 | 0.89 | 0.15, 5.27 | 1.08 | 0.48, 2.42 | 0.97 | 0.59, 1.61 |
| Asian | 1.11 | 1.05, 1.17 | 1.15 | 1.08, 1.22 | 0.80 | 0.30, 2.14 | 0.72 | 0.34, 1.54 | 0.59 | 0.33, 1.06 | 0.95 | 0.68, 1.33 |
| Black | 1.16 | 1.10, 1.23 | 1.16 | 1.09, 1.23 | 0.81 | 0.26, 2.50 | 0.72 | 0.27, 1.91 | 0.72 | 0.38, 1.37 | 0.96 | 0.65, 1.41 |
| Latinx | 1.35 | 1.29, 1.41 | 1.27 | 1.21, 1.34 | 1.49 | 0.65, 3.43 | 0.99 | 0.42, 2.35 | 1.20 | 0.62, 2.33 | 0.99 | 0.68, 1.45 |
| NHPI | 1.35 | 1.13, 1.60 | 1.42 | 1.21, 1.67 | 0.83 | 0.29, 2.40 | 0.47 | 0.17, 1.32 | 0.90 | 0.38, 2.14 | 0.98 | 0.46, 2.09 |
| Other race/ethnicity | 1.18 | 1.10, 1.27 | 1.21 | 1.12, 1.32 | 1.27 | 0.43, 3.78 | 0.51 | 0.10, 2.65 | 0.91 | 0.50, 1.65 | 0.92 | 0.66, 1.30 |
| Multirace/ethnicity | 1.26 | 1.20, 1.32 | 1.31 | 1.23, 1.38 | 1.08 | 0.53, 2.23 | 0.92 | 0.45, 1.88 | 1.24 | 0.76, 2.03 | 0.96 | 0.72, 1.27 |
| Binge drinking | 1.06 | 1.05, 1.08 | 1.04 | 1.02, 1.06 | 1.03 | 0.86, 1.24 | 0.99 | 0.85, 1.16 | 0.92 | 0.82, 1.05 | 0.97 | 0.91, 1.04 |
| Tobacco use | 1.31 | 1.29, 1.33 | 1.20 | 1.18, 1.22 | 1.04 | 0.91, 1.19 | 0.95 | 0.83, 1.09 | 1.13 | 1.03, 1.23 | 1.23 | 1.16, 1.30 |
Confidence intervals that do not cross 1 are in bold.
AIAN, American Indian and Alaskan Native; CI, confidence interval; LL, lower level of confidence interval; NHPI, Native Hawaiian or Pacific Islander; OR, odds ratio; UL, upper level of confidence interval.
Table 4.
Model Fit Comparisons
| Reference | Comparison groups |
CFI | ΔCFI | Invariance | |
|---|---|---|---|---|---|
| Group 1 | Group 2 | ||||
| Free all | – | – | 1.00 | — | — |
| Female | Male | 0.99 | 0.01 | No | |
| Transgender: male to female | 1.00 | 0.00 | Yes | ||
| Transgender: female to male | 1.00 | 0.00 | Yes | ||
| Transgender: not exclusively male or female | 1.00 | 0.00 | Yes | ||
| Not sure | 1.00 | 0.00 | Yes | ||
| Male | Transgender: male to female | 1.00 | 0.00 | Yes | |
| Transgender: female to male | 1.00 | 0.00 | Yes | ||
| Transgender: not exclusively male or female | 1.00 | 0.00 | Yes | ||
| Not sure | 1.00 | 0.00 | Yes | ||
| Transgender, male to female | Transgender: female to male | 1.00 | 0.00 | Yes | |
| Transgender: not exclusively male or female | 1.00 | 0.00 | Yes | ||
| Not sure | 1.00 | 0.00 | Yes | ||
| Transgender, female to male | Transgender: not exclusively male or female | 1.00 | 0.00 | Yes | |
| Not sure | 1.00 | 0.00 | Yes | ||
| Transgender, not exclusively male or female | Not sure | 1.00 | 0.00 | Yes | |
CFI represents comparative fit indices; ΔCFI represents the change in the comparative fit indices.
Table 5 displays odds ratios and confidence intervals for predicting suicide attempts across sexual and gender identity. Nested model comparisons revealed that there were significant differences between heterosexual female adolescents and other adolescents (Table 6). That is, the association between physical abuse in family and suicide attempts was stronger for heterosexual female adolescents compared to sexual minority female, heterosexual male, sexual minority male, heterosexual gender minority, or sexual and gender minority adolescents. No other group differences were found.
Table 5.
Adjusted Odds Ratios and 95% Confidence Intervals of Suicide Attempts by Gender and Sexual Identity
| Heterosexual female |
Sexual minority female |
Heterosexual male |
Sexual minority male |
Heterosexual gender minority |
Sexual and gender minority |
|||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| OR | CI[LL,UL] | OR | CI[LL,UL] | OR | CI[LL,UL] | OR | CI[LL,UL] | OR | CI[LL,UL] | OR | CI[LL,UL] | |
| Family abuse | 1.41 | 1.39, 1.43 | 1.34 | 1.31, 1.38 | 1.31 | 1.29, 1.33 | 1.29 | 1.23, 1.34 | 1.26 | 1.15, 1.37 | 1.29 | 1.21, 1.37 |
| Age | 0.99 | 0.98, 1.00 | 0.95 | 0.93, 0.97 | 1.02 | 1.01, 1.03 | 1.00 | 0.97, 1.03 | 0.98 | 0.91, 1.06 | 0.98 | 0.93, 1.03 |
| Rural (reference = urban) | 1.02 | 0.98, 1.06 | 0.92 | 0.85, 0.99 | 0.96 | 0.92, 1.01 | 0.97 | 0.86, 1.09 | 1.19 | 0.87, 1.62 | 0.91 | 0.73, 1.13 |
| Parent education | 0.95 | 0.94, 0.96 | 0.96 | 0.93, 0.98 | 0.96 | 0.95, 0.98 | 0.97 | 0.93, 1.01 | 0.93 | 0.86, 1.01 | 0.96 | 0.91, 1.02 |
| Race/ethnicity (reference = White) | ||||||||||||
| AIAN | 1.16 | 1.00, 1.35 | 1.33 | 0.90, 1.98 | 1.21 | 1.05, 1.39 | 0.82 | 0.50, 1.35 | 1.12 | 0.56, 2.23 | 0.81 | 0.52, 1.25 |
| Asian | 1.16 | 1.10, 1.23 | 0.82 | 0.73, 0.93 | 1.20 | 1.13, 1.28 | 0.83 | 0.69, 0.99 | 0.72 | 0.45, 1.15 | 0.76 | 0.57, 1.03 |
| Black | 1.21 | 1.14, 1.29 | 1.00 | 0.89, 1.12 | 1.16 | 1.08, 1.23 | 1.18 | 0.96, 1.44 | 0.83 | 0.55, 1.26 | 0.85 | 0.59, 1.23 |
| Latinx | 1.39 | 1.33, 1.45 | 1.20 | 1.09, 1.32 | 1.25 | 1.19, 1.32 | 1.42 | 1.20, 1.68 | 1.14 | 0.71, 1.83 | 1.07 | 0.78, 1.46 |
| NHPI | 1.40 | 1.15, 1.72 | 1.08 | 0.76, 1.55 | 1.53 | 1.29, 1.82 | 0.85 | 0.52, 1.41 | 0.91 | 0.12, 6.83 | 0.90 | 0.59, 1.38 |
| Other race/ethnicity | 1.22 | 1.13, 1.32 | 1.03 | 0.87, 1.22 | 1.20 | 1.10, 1.31 | 1.28 | 1.01, 1.62 | 0.95 | 0.64, 1.42 | 0.64 | 0.46, 0.90 |
| Multirace/ethnicity | 1.30 | 1.23, 1.37 | 1.14 | 1.02, 1.26 | 1.32 | 1.25, 1.41 | 1.14 | 0.94, 1.37 | 0.91 | 0.64, 1.30 | 0.93 | 0.72, 1.21 |
| Binge drinking | 1.07 | 1.05, 1.09 | 1.04 | 1.01, 1.07 | 1.04 | 1.02, 1.06 | 1.04 | 0.99, 1.10 | 1.05 | 0.98, 1.14 | 0.93 | 0.87, 1.00 |
| Tobacco use | 1.33 | 1.31, 1.35 | 1.28 | 1.24, 1.32 | 1.20 | 1.18, 1.22 | 1.16 | 1.12, 1.21 | 1.14 | 1.07, 1.21 | 1.10 | 1.05, 1.16 |
Confidence intervals that do not cross 1 are in bold.
Table 6.
Model Fit Comparisons Across Sexual and Gender Identity
| Reference | Comparison groups |
CFI | ΔCFI | Invariance | |
|---|---|---|---|---|---|
| Group 1 | Group 2 | ||||
| Free all | – | – | 1.00 | — | — |
| Heterosexual female | Sexual minority female | 0.99 | 0.01 | No | |
| Heterosexual male | 0.99 | 0.01 | No | ||
| Sexual minority male | 0.99 | 0.01 | No | ||
| Heterosexual gender minority | 0.99 | 0.01 | No | ||
| Sexual and gender minority | 0.99 | 0.01 | No | ||
| Sexual minority female | Heterosexual male | 1.00 | 0.00 | Yes | |
| Sexual minority male | 1.00 | 0.00 | Yes | ||
| Heterosexual gender minority | 1.00 | 0.00 | Yes | ||
| Sexual and gender minority | 1.00 | 0.00 | Yes | ||
| Heterosexual male | Sexual minority male | 1.00 | 0.00 | Yes | |
| Heterosexual gender minority | 1.00 | 0.00 | Yes | ||
| Sexual and gender minority | 1.00 | 0.00 | Yes | ||
| Sexual minority male | Heterosexual gender minority | 1.00 | 0.00 | Yes | |
| Sexual and gender minority | 1.00 | 0.00 | Yes | ||
| Heterosexual gender minority | Sexual and gender minority | 1.00 | 0.00 | Yes | |
CFI represents comparative fit indices; ΔCFI represents the change in the comparative fit indices.
Discussion
This study examined the prevalence and the association between family physical abuse and suicide attempts across gender identity subgroups. Preliminary analysis showed that gender minority adolescents experienced higher levels of family physical abuse compared to cisgender adolescents. This trend may be a reflection of higher family rejection or lack of support because of adolescents' gender identity which, in turn, contributes to adverse familial relationships and potential physical abuse from family members.19
No differences emerged for within-group comparisons of familial physical abuse among gender minority adolescents, suggesting that gender minority youth experience similarly high levels of family physical abuse regardless of gender identity. We also found that youth who identified with multiple minority identities experienced higher levels of family physical abuse compared to those who identified with fewer or no minority identity (i.e., female, gender minority, sexual orientation). Future studies are needed to document how and why gender and sexual minority adolescents experience higher levels of family abuse to better intervene through policy or practice.
We also examined the association between family physical abuse and suicide behavior, and whether this association was differentiated by gender identity. Consistent with previous research, family physical abuse was associated with higher odds of suicide behavior across all gender identity groups.3,12,21 There were no differences in the strength of this association between cisgender adolescents and gender minority adolescents, as we initially hypothesized there might be. The only difference found was between female and male adolescents, such that the association was stronger for female adolescents compared to that of male adolescents. Although the detrimental contribution of family abuse to suicide attempts appears to be universal across gender, male adolescents are found to use more lethal methods of suicide in general.35 That is, when adolescents experience family abuse, male adolescents are more likely to die by suicide, which may explain lower rates of suicide attempts among male adolescents compared to female adolescents.
Notably, the adverse contribution of family physical abuse on suicide attempts was invariant between gender minority adolescents and cisgender adolescents. However, this does not suggest that gender minority adolescents are not at greater risk of experiencing family physical abuse and suicide attempts. Our findings and a prior study6 with participants from the same sample* indicate that gender minority adolescents experience both differentially higher levels of suicide attempts and family physical abuse compared to cisgender adolescents. It is possible that as gender minority adolescents grow up, they encounter more challenges especially specific to their gender minority identity (e.g., access to gender-affirming care). The experiences of multiple challenges, including physical abuse in the family, may collectively result in more suicide attempts among gender minority adolescents.
We also found that adolescents' sexual orientation did not further exacerbate the adverse contribution of physical abuse in the family on suicide attempts for gender minority adolescents. Yet, the levels of family physical abuse were lowest among adolescents with no minority identities (i.e., sexual and gender minority identity) and highest among adolescents with multiple minority identities. Consistent with our interpretation of invariance in the adverse contribution of physical abuse in the family on suicide attempts across sexual and gender identity, while all adolescents experience adverse contributions of family physical abuse, adolescents with more minority identities experience more frequent physical abuse in the family. Although this elevated level of physical abuse did not contribute to higher levels of suicide attempts among these groups, it is critical to understand the factors that contribute to the mean-level differences in both family abuse and suicide attempts for multiple marginalized adolescents.
Implications
The current study suggests a need for family-focused interventions and policies that target adolescents and their families to protect against physical abuse in family. Although extant research empirically reinforces the importance of school-based mental health services,36 our findings underscore the importance of family-based interventions and outreach. Future research should explore how clinicians or child protective services can prevent these risk factors and effectively find interventions suitable for each family. Given the disparities documented in this study, more proactive steps need to be taken to promote mental and physical well-being and resiliency among gender minority adolescent populations, such as programs aimed to help families and parents accept and nurture their gender minority children.
Limitations
The current study is not without limitations. First, we used self-reported, cross-sectional data to test our research questions. Thus, even though our hypothesis is driven by theory and prior empirical work, we were not able to disentangle the directionality of associations between family physical abuse and suicide attempt. Longitudinal research is needed to address temporal associations, with key attention to whether families of gender minority adolescents respond with physical abuse (that had not been previously abusive) when they learn about their child or adolescent's gender identity. In addition, the original survey used a one-item question to measure participants' gender identity. An additional measure should be used in future studies to access more inclusive information about participants' gender identity (e.g., comparing sex assigned at birth with reported gender identity).
Another limitation in our study was the lack of information on the outness of participants' gender minority identity to family, which may contribute to different experiences of family physical abuse.37 Moreover, prior studies identify common predictors of suicide, such as feelings of inferiority, burdensomeness, and lack of belonging, which account for the adverse impact of family abuse on suicide attempts.10,38 To better protect adolescents from suicide behaviors, it is important to understand other factors in various social contexts (e.g., family support, school victimization) that may contribute to the disparities in suicide attempts across gender identity. Furthermore, the current study examined a specific type of family abuse (i.e., physical abuse); it is possible that cisgender and gender minority adolescents experience various forms of family abuse differently (e.g., emotional abuse, sexual abuse), which may result in differential contributions to suicide attempts. Future studies need to examine the multidimensional aspects of family abuse among gender minority adolescents.
Conclusion
Gender and sexual minority adolescents reported higher levels of family physical abuse compared to cisgender adolescents. In addition, family physical abuse was associated with higher odds of suicide behavior for all youth, regardless of gender and sexual identity. Given that gender minority adolescents are exposed to both general risk factors (e.g., depression, poverty) and unique risk factors related to their gender identities (e.g., family rejection of gender identity),8 these findings highlight the importance of studying and developing gender and sexuality-inclusive prevention programs and policies that aim to prevent or reduce physical abuse in families for adolescents, especially among gender and sexual minority adolescents.
Authors' Contributions
E.B. and R.B.T. conceptualized the study. E.B. and M.S. conducted initial sets of statistical analyses. Z.Z. assisted with study design and conducted final statistical analyses. Z.Z. and E.B. co-led article writing. All coauthors were involved with review and interpretation of results. All coauthors reviewed and approved the current article.
Disclaimer
The Profiles of Student Life: Attitudes and Behaviors Survey data are independently collected by communities and school districts across the United States in partnership with Search Institute. Search Institute provides survey administration support to these organizations but has minimal oversight of the data collection process. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
The analysis and dissemination phases of this study were supported by a Loan Repayment Award from the National Institute on Minority Health and Health Disparities to R.B.T. (L60 MD008862).
A study with the same analytic sample showed that transgender female to male adolescents reported the highest levels of suicide attempts, followed by non-binary, transgender male to female, questioning, female, and male adolescents. Yet, no difference was found between transgender male to female and questioning adolescents, and between transgender female to male and nonbinary adolescents.
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