Archives of Sexual Behavior
https://doi.org/10.1007/s10508-019-01596-8
COMMENTARY
Extending a Rejection Sensitivity Model to Suicidal Thoughts
and Behaviors in Sexual Minority Groups and to Transgender Mental
Health
Tony T. Wells1   · Raymond P. Tucker2 · Morganne A. Kraines3,4
Received: 22 October 2019 / Revised: 19 November 2019 / Accepted: 25 November 2019
© Springer Science+Business Media, LLC, part of Springer Nature 2019
The Target Article by Feinstein (2019) articulates how a rejec-
tion sensitivity (RS) model contributes to the understanding of
the etiology and maintenance of mental health issues in sexual
minority individuals. This is a compelling and timely account
that complements and extends existing minority stress mod-
els of sexual minority mental health. While we commend this
contribution, we also identify two specific areas deserving of
additional consideration in the context of developing this RS
model, namely application of this model to (1) suicidal thoughts
and behavior, and (2) transgender and gender diverse (TGD)
individuals.
Rejection Sensitivity and Suicidal Thoughts
and Behavior
While Feinstein (2019) mentions suicidal thoughts and
behavior (STB) briefly in connection with the RS model of
sexual minority mental health, this topic deserves additional
exploration. Individuals who are members of sexual minority
groups experience elevated rates of suicidal ideation (e.g.,
Nystedt, Rosvall, & Lindström, 2019), suicide attempts (for
This commentary refers to the article available at https​://doi.
org/10.1007/s1050​8-019-1428-3.
* Tony T. Wells
tony.wells@okstate.edu
1
Department of Psychology, Oklahoma State University, 116
North Murray, Stillwater, OK 74078, USA
2
Department of Psychology, Louisiana State University,
Baton Rouge, LA, USA
3
Department of Psychiatry and Human Behavior, The Warren
Alpert Medical School of Brown University, Providence, RI,
USA
4
Psychosocial Research Group, Butler Hospital, Providence,
RI, USA
a review, see Hottes, Bogaert, Rhodes, Brennan, & Gesink,
2016), and deaths by suicide (Cochran & Mays, 2015; Plöderl
et al., 2013) when compared to sexual majority peers. As
such, there has been greater awareness and call to action in
identifying and preventing STBs in sexual minority com-
munities (Cochran & Mays, 2015; National Action Alliance
for Suicide Prevention: Research Prioritization Task Force,
2014). Given the importance of this topic, we explore the
potential for RS to contribute to models of STBs specifically
in sexual minority groups.
Few studies have directly examined RS and STBs (regardless
of sexual minority status), but initial work in this area has exam-
ined RS in the context of the interpersonal theory of suicide (ITS;
Van Orden et al., 2010). The ITS posits that thoughts and feelings
related to being a burden to loved ones (perceived burdensome-
ness) and thoughts and feelings related to a low sense of social
connection with others (thwarted belongingness) contribute to
increased suicidal ideation (SI). The interaction between SI and
experience with, or exposure to, events that reduce the natural
aversion to self-harm (acquired capability for self-harm) leads
to increased risk of suicide attempts. Conceptually, there is a
link between RS and perceived burdensomeness and thwarted
belongingness of the ITS; individuals high in RS are more likely
to perceive rejection in ambiguous situations and react negatively
to it, which would likely lead to a low sense of connection with
others (increased thwarted belongingness) and increased percep-
tions of being a burden to others.
The only study that we are aware of that examined the rela-
tionship between RS, elements of the ITS, and STBs (though not
among sexual minority individuals) found an indirect relation-
ship between RS and SI through thwarted belongingness (Brown,
Mitchell, Roush, La Rosa, & Cukrowicz, 2019). There are no
studies that have examined these elements in sexual minority
groups; however, there are studies that investigate constructs
that are similar to RS and components of the ITS that provide
evidence for a potential relationship. For example, a study involv-
ing psychological autopsies of sexual minority individuals who
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died by suicide identified social non-acceptance and relation-
ship problems as substantial contributors to the deaths of many
of these individuals (Skerrett, Kõlves, & De Leo, 2017). While
this study did not directly address RS or the ITS constructs, it
provides evidence of the importance of social relationships and
conflict in STBs in sexual minority individuals. Similarly, in
another study, higher levels of perceived or anticipated rejection
regarding sexual orientation moderated the relationship between
perceived burdensomeness and suicidal ideation in college stu-
dents (Hill & Pettit, 2012). Though this study did not directly
examine RS, perceived and anticipated rejection is likely related
to RS, and thus draws a connection between RS and perceived
burdensomeness. Taken together, these studies provide initial
evidence for a relationship between RS and factors related to
STB and elements of the ITS.
While the ITS is widely used and has led to a marked increase
in suicide research (Chu et al., 2017), it is important to note that
RS also has conceptual connections with other prominent models
of STBs. For example, in the integrated motivational volitional
(IMV) model of suicidal behavior, defeat (humiliation, social
rejection, or loss) and entrapment (an inability to escape from
emotional or physical pain and/or stressors) lead to increased
SI and suicidal intent (O’Connor & Kirtley, 2018). In the IMV
model, social rejection is specifically linked with defeat, and con-
ceptually related to entrapment, as social support, perceived bur-
densomeness, and thwarted belongingness are posited to mod-
erate the relationship between entrapment and SI. As such, RS
may play an important role in multiple stages of the IMV model.
Similarly, in the three-step theory of suicide, when emotional
pain is greater than one’s sense of social connectedness, this leads
to increased SI (Klonsky & May, 2015). Within the three-step
theory, RS would be expected to lead to decreased social connect-
edness, which would increase the likelihood of one experiencing
increased SI. Despite the conceptual connections between RS
and these models, no empirical research has investigated them
in general or specifically within sexual minority groups. As such,
Rejection
Sensitivity
Ambiguous Social
Experiences
(Perceived)
Rejection
Discrimination,
Victimization, etc.
Fig. 1  A conceptual framework incorporating rejection sensitivity in a model of suicide ideation applicable to sexual minority groups
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Archives of Sexual Behavior
there is considerable room for an increased understanding of how
RS and relevant factors from these models play a role in STB
among sexual minority individuals.
It is important to note that we will need to place general mod-
els of STBs (including those that incorporate RS) in the context of
the unique stressors experienced by members of sexual minority
groups. Some work has been done in this area and indicates that
perceived burdensomeness and thwarted belongingness of the
ITS interact with minority stress models of STBs. Specifically,
factors such as discrimination, victimization, and internalized
homophobia may lead to thoughts and feelings of burdensome-
ness and low belongingness, which then lead to increased STBs
(Baams, Grossman, & Russell, 2015; Plöderl et al., 2014). Here,
we propose a general framework for how RS may relate to STBs
in the context of sexual minority group experiences. Given that
the ITS, IMV, and three-step theory all demonstrate promise for
advancing our understanding of STBs, and none has been estab-
lished as superior to the others (Klonsky, Saffer, & Bryan, 2018)
our proposed framework is model-independent. This will allow
our framework to be applicable across STBs models.
As indicated in Fig. 1, we expect that sexual minority individ-
uals will experience both overt negative social experiences (e.g.,
discrimination, victimization) and ambiguous social experiences.
The effects of overt negative social experiences may be mitigated
by resilience factors, but are likely to lead to some experience or
perception of rejection, whereas the relationship between ambig-
uous social experiences and rejection is likely moderated by RS
with higher RS leading to increased perceived rejection. Rejec-
tion will lead to both negative affect and disruptions in social sup-
port and perceived social connectedness. Here, RS will moderate
the affective response to rejection with higher RS leading to more
intense negative affect in response to rejection. As posited by
several models of STB, the interaction between negative affect
and social support/connectedness will then lead to SI (Klonsky &
May, 2015; O’Connor & Kirtley, 2018; Van Orden et al., 2010).
We believe that this model of RS and STBs would be relevant to
Negative Affect
Suicide
Ideation
Disrupted Social
Support/Connectedness
Archives of Sexual Behavior
sexual majority individuals as well, though they may experience
overtly negative social experiences at a lower rate (depending on
their non-sexual minority status).
Rejection Sensitivity Application
to Transgender and Gender Diverse
Individuals
Like suicide, the RS model’s application to sexual minor-
ity mental health lends itself to the intuitive leap to study
transgender and gender diverse (TGD) populations. This type
of extension is certainly not new to the study of sexual and
gender minority health. Perhaps the most relevant example of
this is the extension of minority stress (Meyer, 2003) and the
psychological mediation framework (Hatzenbuehler, 2009)
to the study of TGD mental health concerns (Hendricks &
Testa, 2012) and suicide (Testa et al., 2017). As other scholars
have noted, this extension has arguably advanced the field’s
knowledge about TGD health; however, the simple extension
of these works to TGD populations is not without concern
(Ralston, Woodruff, Holt, Mocarski, & Hope, 2019). As the
RS model and its application to sexual minority mental health
may follow a similar pattern of extension to TGD populations,
we now take a moment to outline some potential concerns
about such an extension.
The first concern about a simple extension of RS to TGD
health is already delineated in Feinstein’s (2019) work but war-
rants explicit discussion. Like bisexual individuals (compared
to lesbian and gay peoples), TGD individuals experience both
similar forms of discrimination and prejudice as LGB peoples
(e.g., increased social rejection due to minority status) but also
additional and different marginalizing experiences. One of the
most notable marginalizing experiences for TGD individuals
may be in the realm of health care. It is a common experience
for TGD adults to feel the need to educate healthcare providers
about their unique healthcare needs. The 2015 U.S. Trans Study
found that upward of 30% of over 27,000 TGD adults surveyed
endorsed needing to educate healthcare providers (James et al.,
2016). It is not to say that sexual minority individuals do not
have unique experiences in interacting with healthcare systems
compared to sexual majority individuals, these marginalizing
experiences are simply different from TGD individuals (e.g.,
needing letters of support to earn medical procedures to physi-
cally affirm a basic sense of one’s self). As noted by Feinstein,
the RS model and existing measures of RS may not apply to
other specific populations (such as TGD communities). Stringent
review of the empirical literature regarding TGD stigma should
be applied (Hughto, Reisner, & Pachankis, 2015), the lived expe-
rience of TGD individuals should be considered (Chen, Granato,
Shipherd, Simpson, & Lehavot, 2017), and community involved
research designs should be adopted (Tebbe & Budge, 2016) to
determine the relevance of the RS model to TGD health.
An issue regarding the application of the RS model to TGD
communities that is less clearly defined in Feinstein (2019) is
the concern that comes with the use of a largely intrapersonal
model to explain minority health concerns and its subsequent
application to healthcare practices. Again, Feinstein does not
ignore this concern; Feinstein clearly notes that the way in which
early rejection experiences are curbed is through systems level
interventions to reduce sexual minority marginalization. How-
ever, systems level work is given little discussion compared to
individual-level interventions such as the ESTEEM intervention
(Pachankis, Hatzenbuehler, Rendina, Safren, & Parsons, 2015).
One concern with such interventions is the possibility that
“fixing” intrapersonal factors could be harmful. Take the exam-
ple of a TGD woman of color. The RS model posits that early
rejection experiences increase the likelihood that she will develop
vigilance to interpersonal rejection and misinterpret ambiguous
cues as social rejection. An interpersonal intervention may focus
on modifying the interpretation of such ambiguous cues to be
more benign (e.g., Burton, Wang, & Pachankis, 2017). Of course,
this is not only logical but also likely helpful in reducing distress.
On the other hand, these misinterpretations, in a very real way,
may help keep a TGD woman of color safe. It is estimated that
approximately 80% of TGD individuals murdered in the past
five years were women of color (Owen, 2019). Hypervigilance
to social rejection and/or threat and interpreting ambiguous cues
as threatening may serve a protective function in some scenarios.
Of course, there likely is a balance—the distress experienced
with constant misinterpretation versus the rare correct interpre-
tation of ambiguous threat that may (not always) prevent harm.
It should be noted that other intersections may also have a need
for vigilance for social rejection, such as TGD military members
who could be discharged from service and subsequently lose
access to health care and education if their gender identities were
discovered. Thus, it will be critical to carefully and thoughtfully
consider these potential issues when considering the application
and relevance of the RS model to TGD populations.
Conclusions
We are optimistic about the potential for the RS model proposed
by Feinstein (2019) to contribute to a better understanding of
sexual minority mental health. In particular, we see promise in
extending such a model to STBs in sexual minority individu-
als and integrating this with extant prominent models of STBs.
We offer a general conceptual framework for such an integra-
tion. We also see potential for the extension of a RS model to
TGD populations while encouraging a thoughtful and cautious
approach that is mindful of the unique issues relevant to TGD
individuals. Our hope is that, at a minimum, the RS model will
spur additional, innovative models and approaches to the con-
ceptualization and promotion of sexual minority mental health.
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 Archives of Sexual Behavior

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