LGBT Health

Volume 00, Number 00, 2023

ª Mary Ann Liebert, Inc.
DOI: 10.1089/lgbt.2021.0428

Open camera or QR reader and

scan code to access this article
and other resources online.

Sexual Orientation and Age-Related Patterns of Suicidal

Ideation Among U.S. Adults
Downloaded by University of Rochester School of Medicine & Dentistry from www.liebertpub.com at 08/11/23. For personal use only.

Caleb C. Cooley, MA,1 Zhe (Meredith) Zhang, PhD,2,* and Justin T. Denney, PhD1

Abstract

Purpose: We aimed to explore whether and how suicidal ideation differs according to specific sexual orientations
(i.e., heterosexual, gay/lesbian, bisexual orientation) and age groups in gender-stratified analyses.
Methods: We identified state health departments from nine U.S. states that collected Behavioral Risk Factor Sur-
veillance System data on both sexual orientation and suicidal ideation from 2011 to 2018 for adults aged 18 and
older (n = 113,337). Logistic regression and average marginal effects (AME) were used to examine the likelihood
of suicidal ideation by sexual orientation, gender, and age.
Results: We found that after important sociodemographic and socioeconomic controls, sexual minority adult
men and women experienced significantly higher odds of suicidal ideation than their same-gender heterosexual
counterparts. After all adjustments, lesbian women had more than three times higher odds and bisexual women
had almost four times higher odds than heterosexual women. Compared with heterosexual men, gay men
reported twice higher odds and bisexual men exhibited 3.67 times higher odds of suicidal ideation. Analysis
of the AME revealed age-specific disparities. The likelihood of suicidal ideation for bisexual men aged 18–24
years was significantly higher than that for gay and heterosexual men of the same age. Among women, bisexual
women closer to middle age (35–44 years) experienced a higher likelihood of suicidal ideation than heterosexual
or lesbian women of the same age.
Conclusion: The elevated risk of suicidal ideation among sexual minority people throughout different stages of
adulthood has important implications for policies and support services.

Keywords: aging, mental health, sexual minority adults, suicidal ideation

Introduction
S uicide is historically a leading cause of death for
adults in the United States, as high as the fourth leading
cause among adults aged 35–54.1 In addition, a substantial
number of Americans report having serious thoughts about
suicide, which is termed suicidal ideation. According to the
Substance Abuse and Mental Health Services Administra-
tion, an estimated 12.2 million Americans report contemplat-
ing suicide annually.2 However, much prior research was
based on data from nonprobability samples.3–10 Nationally
representative surveys have begun collecting sexual orienta-
tion information, and recent studies utilized these novel data
to examine relationships between sexual orientation and sui-
cidal ideation.11,12
A large portion of research investigating sexual minority
suicidal ideation has primarily focused on youth, adoles-
cents, and young adults,13–16 finding a higher rate of suicidal
ideation for sexual minority adolescents and young adults
than their heterosexual peers.17–20 However, less is known
about suicidal ideation among adult sexual minority popula-
tions. In this article, we aim to address the paucity of knowl-
edge regarding adult sexual minority suicidal ideation by
providing a demographic portrait of the odds of experiencing

1
Department of Sociology, Washington State University, Pullman, Washington, USA.
2
Department of Sociology, Rice University, Houston, Texas, USA.
*Current affiliation: Department of Sociology and Criminology, University of Arkansas, Fayetteville, Arkansas, USA.

1
 2 COOLEY ET AL.
suicidal ideation for adult heterosexual, gay or lesbian, and
bisexual men and women.
Theoretical framework for understanding sexual minority
identity and suicidal ideation
Minority stress is described as a unique stressor experi-
enced by sexual minority people and is believed to have a
significant impact on individual’s mental health and well-
being.21(p. 1)
Specifically, minority stress is a juxtaposition of minority
and dominant values and the resulting conflict with the social
environment experienced by minority group members.22(p. 39)
Before individuals begin to realize their own sexual orien-
Downloaded by University of Rochester School of Medicine & Dentistry from www.liebertpub.com at 08/11/23. For personal use only.
tation, same-sex-oriented people may internalize societal
antihomosexual attitudes.22 Internalizing negative attitudes
toward their own identity may induce excess stress for sexual
minority people and increase the likelihood of experiencing
suicidal ideation.22
There are still gaps in our understanding of the ages at
which the damaging effects of minority stress may manifest
in terms of suicidal ideation among sexual minority adults.
Although we did not measure minority stressors directly in
this study, it is a useful guide to contextualize disparities in
suicidal ideation among sexual minority people at different
stages in the life course.
Age, sexual orientation, and suicidal ideation
Suicidal ideation, thinking about, or planning a suicide is,
unfortunately, a relatively common experience among a gen-
eral population.23 Lifetime proportions of suicidal ideation
have been reported to range from 7% to 18% among adult
populations.24–27 Not all individuals who experience suicidal
ideation will attempt suicide.28 However, it is important to
investigate factors related to suicidal ideation, as it represents
one of the first steps toward a suicide attempt.24,29
Death from suicide is found to have age-related character-
istics.23 Although the rate of suicide deaths is generally
higher among the elderly, younger adults more often report
suicidal ideation, suicide planning, and attempts.28,30 In the
general U.S. population, an inverse relationship is found be-
tween age and suicidal ideation where suicidal ideation is
highest in younger adults. However, a positive relationship
exists between age and suicide deaths, where suicide deaths
are highest among older adults.1,31
In a robust meta-analysis,16 Williams et al. found that the
prevalence of suicidal ideation among Lesbian, Gay, Bisex-
ual, Trans, Queer+ individuals aged 12–25 was significantly
higher than heterosexual individuals.16 However, this study
combined all sexual and gender minority people together
and did not examine patterns by specific sexual orientation
and gender. Furthermore, this study was not able to explore
the prevalence of suicidal ideation among older adults.16
Evidence suggests that suicide attempts among sexual mi-
nority people may be more closely linked to the ages at
which lesbian women32 and gay men33 disclose their sexual
orientation to others, rather than to chronological age.30
Despite increasing social acceptance of sexual minority iden-
tities,34–36 recent research shows that younger cohorts of sex-
ual minority adults still experience a higher prevalence of
suicidal ideation.35
Methods
The data were compiled from the Behavioral Risk Factor
Surveillance System (BRFSS), an ongoing cross-sectional
probability-based health survey of U.S. adults aged 18 and
older. This study was certified as exempt by the Washington
State University Institutional Review Board (IRB no. 19394-
001). Each year, the Centers for Disease Control and Preven-
tion (CDC) develops the BRFSS, with individual state and
territorial health departments fielding the survey. In addition
to core questions required by the CDC, individual states and
territories can include optional modules. Beginning in 2000,
some states added a module that included a measure of sex-
ual orientation. Due to important methodological changes
made in 2011, the CDC recommends not combining data
sets before 2011 for contemporary analyses.
Given an increasing prevalence of suicidal ideation, some
states began adding mental health modules that include mea-
sures of suicidal ideation. Through communication with co-
ordinators from individual state health departments, we
identified nine states that collected data on both sexual orien-
tation and suicidal ideation from 2011 to 2018. The data re-
quests resulted in an initial sample size of 142,795 adults.
We then limited the sample to men and women with no miss-
ing values for sexual orientation or suicidal ideation, result-
ing in a final sample of 113,337 adults, including 1213 gay
men, 864 lesbian women, 704 bisexual men, and 1322 bisex-
ual women. Table 1 provides information on the states and
years included in the analytical sample.
Dependent variable
Our dependent variable is a measure that asks if the re-
spondent has had thoughts or plans about suicide or to hurt
themselves. Specifically, most states in the sample (i.e.,
Maine, Massachusetts, Nevada, Ohio, Rhode Island, and
Texas) asked: ‘‘During the past 12 months, did you (have
you) ever seriously consider (considered) attempting sui-
cide?’’ New Mexico and Washington included slightly dif-
ferent versions: ‘‘In the past year, have you felt so low at
times that you thought about committing suicide’’ and ‘‘at
any time in the past 12 months, did you seriously think
about trying to kill yourself?’’ respectively. The question
in the Connecticut BRFSS was the only one that did not
refer to the past 12 months: ‘‘Have you ever thought of tak-
ing your own life?’’
Table 1. Behavioral Risk Factor Surveillance
System States and Interview Years, 2011–2018
Interview state Data years
Connecticut 2 (2016, 2018)
Maine 4 (2011, 2012, 2014, 2015)
Massachusetts 6 (2011, 2012, 2013, 2016, 2017, 2018)
Nevada 4 (2015, 2016, 2017, 2018)
New Mexico 3 (2016, 2017, 2018)
Ohio 1 (2017)
Rhode Island 1 (2018)
Texas 3 (2016, 2017, 2018)
Washington 1 (2018)
Total 25 years
 SEXUAL MINORITY ADULT SUICIDAL IDEATION
Independent variables
Our sexual orientation measure is based on self-reported
sexual identity. Despite variation in question wording across
states, the question mostly asked was as follows: ‘‘Do you
consider yourself to be heterosexual, gay/lesbian, bisexual,
other, or don’t know?’’ Response categories across all states
and years distinguished heterosexual, gay, lesbian, and bi-
sexual adults and included options of ‘‘refuse’’ and ‘‘don’t
know.’’ To maintain consistency across states, we treated re-
fusals and ‘‘don’t know’’ as missing data. To assess gender,
we used a variable that asked the surveyor to indicate the sex
of the respondent, either male or female. This gender mea-
sure was included in the survey from 2011 to 2017.
Downloaded by University of Rochester School of Medicine & Dentistry from www.liebertpub.com at 08/11/23. For personal use only.
In 2018, the gender measure in the survey was changed to
what is your sex or what was your sex at birth? Response options
were ‘‘male, female, do not know/unsure, or refuse.’’ Given the
wording of the questionnaire for the survey years in our study
and small sample sizes for gender minority people, we were
only able to analyze binary male/female gender differences.
Demographic controls included race (non-Hispanic
White, non-Hispanic Black, Hispanic, other), age group
(18–24, 25–34, 35–44, 45–54, 55–64, 65+), and relationship
status (married, never married, a member of an unmarried
couple, and formerly married). Socioeconomic status con-
trols included education (less than high school, high school
or general educational development, some college, college
or more), employment status (employed or not), income
(<$25,000, $25,000–$49,000, $50,000–$74,999, >$75,000),
and health insurance status (insured or not).
Analytic plan
All covariates had <2% missing data, except for income,
which had 13.9% missing. We used multiple imputation
with chained equations to impute all missing values.37 Fol-
lowing prior research,38 we included respondents who had
missing values on suicidal ideation and the main independent
measures (i.e., sexual identity and gender) in the imputation
and then dropped them from the subsequent descriptive and
multivariate analyses. We used the ‘‘mi impute chain’’ com-
mand in Stata 15.0, to generate five imputations.
First, we present the weighted descriptive statistics for
men and women. Next, we included weighted descriptive
statistics of suicidal ideation for each covariate by sexual ori-
entation. Given evidence of gender differences in suicidal
ideation,39 we estimate all results separately for men and
women. To account for differences in the control measures
by sexual orientation, we estimated the odds of experiencing
suicidal ideation by using logistic regression models. We in-
cluded (but do not present) state of residence and year of in-
terview controls to account for differences in the LGB
climate over the study period. All analyses were weighted
according to suggestions from the CDC, and we adjusted
all results for a complex survey design using Stata’s ‘‘svy’’
commands.40
To explore whether age shapes the association between
sexual orientation and suicidal ideation, we conducted an av-
erage marginal effects (AME) analysis by estimating fully
adjusted logistic regression models with interactions be-
tween age and sexual orientation. From these interaction
models, we produced predicted probabilities and conducted
statistical tests for pairwise comparisons between the
3
groups.41,42 To avoid inaccurate statistical conclusions,41,42
we do not present the interaction coefficients in the regres-
sion tables, but rather present the predicted probabilities
and tests of differences from the AME in Figures 1 and 2.
Results
Table 2 provides weighted proportions for suicidal idea-
tion for men and women, respectively. Overall, *4% of
both men and women experienced suicidal ideation. For
both men and women, suicidal ideation was highest among
the 18–24 age group and generally decreased at each subse-
quent age group. Table 2 also shows a much higher propor-
tion of suicidal ideation among gay men (9.76%), lesbian
women (13.12%), and bisexual men (16.83%) and women
(18.72%) than among heterosexual men (3.66%) and
women (3.71%).
Tables 3 and 4 show the weighted proportions of suicidal
ideation by sexual orientation for men and women, respec-
tively. For heterosexual men and women, suicidal ideation
was generally low, and consistently declined with age.
This decline with age appears to be nonlinear for sexual mi-
nority men and women. In Table 3, 13%–14% of gay men
younger than 35 experienced suicidal ideation. This declined
to 2.2% among 35–44-year-old men but was higher among
45–54 (10.5%) and 55–64 (5.6%)-year-old men and then de-
clined to 3.2% among the oldest gay men in the sample. In
Table 4, more than a quarter of lesbian women aged 18–24
(28.8%) reported suicidal ideation. For lesbian women
aged 35–44, the proportion declined to around 8%, but the
proportion remained near 10% for all older lesbian women,
except for the 55–64 age group, where the proportion drop-
ped to 4.9%.
Finally, Tables 3 and 4 show large proportions of bisexual
men and women who contemplated suicide. The proportion
was 29% for bisexual men aged 18–24. The proportion de-
clined steadily with age, but nearly a quarter (23.2%) of bi-
sexual men aged 25–34 years reported suicidal ideation.
Among bisexual women, the proportion of suicidal ideation
for women younger than 55 was steadily 15% or higher, de-
clining to <3% among the oldest bisexual women.
Table 5 (men) and Table 6 (women) show the baseline and
adjusted odds ratios of suicidal ideation from the logistic re-
gressions. Model 1 of Table 5 shows that, relative to hetero-
sexual men, gay men had 3.0 times higher and bisexual men
had 5.5 times higher odds of suicidal ideation. For women
(Table 6, Model 1), relative to heterosexual women, lesbian
women had more than four times higher odds and bisexual
women had 6.4 times higher odds of suicidal ideation. Adding
controls in Models 2 and 3 attenuated the higher odds for sex-
ual minority men and women. However, the fully adjusted
odds of suicidal ideation, relative to their same-gender hetero-
sexual counterparts, were more than two times higher for gay
men, 3.7 times higher for bisexual men, 3.3 times higher for
lesbian women, and 3.9 times higher for bisexual women.
To assess how age moderated the association between sex-
ual orientation and suicidal ideation among men and women,
we estimated an additional model that added an interaction
term between age and sexual orientation to Model 3 for
men and women. Following the guidance from Mize,42 we
do not show those interactions in Tables 5 and 6, but instead
conducted AME analyses on the results from these models.
Downloaded by University of Rochester School of Medicine & Dentistry from www.liebertpub.com at 08/11/23. For personal use only.

FIG. 1. Fully adjusted predicted probability of suicidal ideation for men, by sexual orientation and age. *Statistically sig-
nificant difference ( p £ 0.05) between heterosexual and sexual minority men. bStatistically significant difference ( p £ 0.05)
between gay and bisexual men.

FIG. 2. Fully adjusted predicted probability of suicidal ideation for women, by sexual orientation and age. *Statistically
significant difference ( p £ 0.05) between heterosexual and sexual minority women. bStatistically significant difference
( p £ 0.05) between lesbian and bisexual women.

4
 SEXUAL MINORITY ADULT SUICIDAL IDEATION 5

Table 2. Weighted Proportions for Suicidal Table 3. Weighted Proportions for Suicidal
Ideation by Gender Ideation by Sexual Orientation, Men
Men Women Heterosexual Gay Bisexual
% % % % %
Overall 4.07 4.35 Overall 3.66 9.76 16.83
Sexual identity/orientation Age groups
Heterosexual 3.66 3.71 18–24 6.11 12.95 29.00
Gay/Lesbian 9.76 13.12 25–34 4.44 14.13 23.24
Bisexual 16.83 18.72 35–44 3.98 2.20 5.23
Age groups 45–54 3.38 10.45 3.72
18–24 7.45 10.70 55–64 3.07 5.58 4.87
25–34 5.37 4.41 65–80+ 1.84 3.22 1.25
35–44 3.97 4.77 Race
Downloaded by University of Rochester School of Medicine & Dentistry from www.liebertpub.com at 08/11/23. For personal use only.

45–54 3.58 4.46 White, non-Hispanic 3.57 10.61 16.53

55–64 3.14 3.25 Black, non-Hispanic 4.57 1.37 21.46
65–80+ 1.84 1.47 Hispanic 3.42 10.57 8.08
Race Other 4.24 10.06 34.46
White, non-Hispanic 3.99 4.36 Relationship status
Black, non-Hispanic 4.78 3.93 Married 1.84 4.56 23.91
Hispanic 3.67 4.04 Unmarried couple 6.40 2.36 20.12
Other 5.24 5.72 Formerly married 4.87 5.46 5.92
Relationship status Never married 6.22 12.70 14.13
Married 2.11 2.58 Education
Unmarried couple 6.79 6.62 Less than high school 5.92 23.72 14.91
Formerly married 4.90 4.52 High school, 3.74 9.66 27.82
Never married 6.89 8.05 GED, or less
Education Some college 4.01 8.45 14.64
Less than high school 6.46 4.86 College or more 2.21 8.73 5.70
High school, GED, or less 4.33 5.62 Employment status
Some college 4.36 4.63 Not employed 5.08 12.82 7.51
College or more 2.45 2.58 Employed 2.90 8.22 22.70
Employment status Income
Not employed 5.31 4.69 <$25,000 6.51 15.56 12.09
Employed 3.41 4.02 $25,000–$49,000 4.01 11.12 29.64
Income $50,000–$74,999 3.26 8.89 8.03
<$25,000 6.96 6.65 >$75,000 1.80 3.10 11.33
$25,000–$49,000 4.88 3.96 Health insurance
$50,000–$74,999 3.44 3.77 Not insured 5.11 12.30 24.10
>$75,000 1.95 2.54 Insured 3.42 9.29 14.32
Health insurance n 46,441 1213 704
Not insured 5.98 5.37
Insured 3.75 4.22
n 48,358 64,979 gender heterosexual counterparts and within sexual minority
groups (i.e., gay men vs. bisexual men). Using Figure 1 as an
All variables besides suicidal ideation, sexual orientation, and example, we see that the difference in predicted probability
gender were imputed.
GED, general educational development. between heterosexual men aged 18–24 (0.05) and bisexual
men aged 18–24 (0.22) is statistically significant.
In fully adjusted models, more than one in five bisexual
In Figures 1 and 2, we provide the predicted probabilities of men aged 18–24, a statistically significantly larger propor-
suicidal ideation by age group and sexual orientation and tion than both heterosexual (0.05) and gay (0.08) men of
tests of pairwise differences from the AME analyses. The the same age, contemplated ending their lives. Figure 1 addi-
AME approach affords us the opportunity to calculate a tionally demonstrates that gay men aged 25–34 (0.15) and
fully adjusted predicted probability of suicidal ideation for aged 45–54 (0.12) were more likely than heterosexual men
each sexual orientation and age group combination using at those ages (25–34 = 0.05 and 45–54 = 0.04) to have con-
the regression equation from our interaction models.41 For templated suicide. Next, Figure 1 shows that the probability
example, Figure 1 shows that the predicted probability of sui- of suicidal ideation was statistically indistinguishable in
cidal ideation for heterosexual men aged 18–24 is 0.05. Thus, older heterosexual and sexual minority men, that is, those
we estimate that 5% of heterosexual men aged 18–24 had aged 55–64 and those aged 65 and older. Finally, compared
suicidal thoughts, after all adjustments in our interaction re- with gay men, although bisexual men had a higher probabil-
gression model for men. The pairwise comparisons from ity of suicidal ideation in the 18–24 (0.22) age group, the
AME analyses allow us to test differences in predicted prob- probability of suicidal ideation in all the older age groups
abilities both between sexual minorities and their same- was statistically indistinguishable.
 6 COOLEY ET AL.

Table 4. Weighted Proportions for Suicidal Table 5. Logistic Regression on Suicidal Ideation
Ideation by Sexual Orientation, Women (Odds Ratios)—Men (n = 48,358)
Heterosexual Lesbian Bisexual Model 1 Model 2 Model 3
% % %
Sexual orientation (heterosexual, reference)
Overall 3.71 13.12 18.72 Gay 3.00*** 2.62*** 2.24***
Age groups Bisexual 5.48*** 4.39*** 3.67***
18–24 8.31 28.78 23.58 Age groups (18–24, reference)
25–34 3.65 7.58 16.32 25–34 0.74 0.99
35–44 4.33 7.67 15.65 35–44 0.59** 0.90
45–54 4.03 12.68 22.63 45–54 0.50*** 0.77
55–64 3.19 4.85 7.55 55–64 0.44** 0.55*
65–80+ 1.40 11.31 2.48 65–80+ 0.25*** 0.25***
Race Race (non-Hispanic White, reference)
Downloaded by University of Rochester School of Medicine & Dentistry from www.liebertpub.com at 08/11/23. For personal use only.

White, non-Hispanic 3.89 8.86 15.78 Black, non-Hispanic 0.76

Black, non-Hispanic 3.34 6.08 17.29 Hispanic 0.52***
Hispanic 3.33 28.49 16.11 Other 0.96
Other 3.38 17.33 42.59
Relationship status (married, reference)
Relationship status Unmarried couple 1.83*
Married 2.40 6.70 11.83 Formerly married 1.79***
Unmarried couple 5.76 5.56 15.76 Never married 1.54*
Formerly married 4.05 18.22 18.18
Never married 6.39 17.78 23.12 Education (less than high school, reference)
High school, 0.66*
Education GED, or less
Less than high school 3.70 19.22 33.56 Some college 0.74
High school, 4.69 28.06 22.17 College or more 0.60*
GED, or less
Some college 4.01 8.03 18.07 Employment status (not employed, reference)
College or more 2.41 6.34 6.38 Employed 0.62**
Employment status Income (<$25,000, reference)
Not employed 4.09 9.97 20.03 $25,000–$49,000 0.85
Employed 3.33 15.46 17.50 $50,000–$74,999 0.64
>$75,000 0.37***
Income
<$25,000 5.69 22.12 23.72 Health insurance (not insured, reference)
$25,000–$49,000 3.09 10.73 21.20 Insured 0.84
$50,000–$74,999 3.39 9.09 15.96 *p < 0.05, **p < 0.01, ***p < 0.001.
>$75,000 2.30 6.03 9.09
Health insurance
Not insured 4.51 13.66 18.51
Insured 3.61 13.06 18.76 Discussion
n 62,793 864 1322 Suicidal ideation is an indicator of severe and debilitating
mental anguish.43 Over a lifetime, the proportion of adults
who have experienced suicidal ideation has been reported
Figure 2 shows that lesbian and bisexual women generally to range from 7% to 18%.24–27 Prior research investigating
had higher probabilities of suicidal ideation across all age sexual minority suicidal ideation has primarily focused on
groups than heterosexual women, with a few exceptions. youth and adolescents.13–16,20 In this article, we address the
For example, for women aged 65 and older, heterosexual paucity of knowledge regarding adult sexual minority sui-
(0.01) and bisexual (0.02) women had low and statistically cidal ideation by providing a portrait of the odds of experi-
indistinguishable ideation probabilities. However, lesbian encing suicidal ideation throughout adulthood among
women 65 and older had a higher probability (0.09) than heterosexual, gay, lesbian, and bisexual men and women.
both groups and were statistically different from heterosex- We identified considerably heightened odds of suicidal idea-
ual women 65 and older. Figure 2 shows that most of the sig- tion in sexual minority adults for both men and women.
nificant differences lie between heterosexual and lesbian Compared with their same-gender heterosexual counterparts,
women and between heterosexual and bisexual women. the estimates were more than three times higher for lesbian
That is indicated by the notations above the bars for the dif- women, nearly four times higher for bisexual women, and
ferent groups. more than 3.5 times higher for bisexual men.
Although lesbian and bisexual women each had higher However, we also found that differences in suicidal idea-
probabilities of ideation than heterosexual women, differ- tion by sexual orientation were shaped by the stage of life.
ences within lesbian and bisexual women did not reach sta- Among bisexual men, we found that higher odds of suicidal
tistical significance. The only exception was among ideation were most prevalent for younger adults, aged 18–
women aged 35–44, where bisexual women (0.15) had a sig- 24—significantly higher than both gay and heterosexual
nificantly higher probability of ideation than heterosexual men of the same age group. Among gay men, the odds of ex-
(0.05) and lesbian (0.07) women. periencing suicidal ideation were statistically higher than
 SEXUAL MINORITY ADULT SUICIDAL IDEATION 7

Table 6. Logistic Regression on Suicidal Ideation Limitations

(Odds Ratios)—Women (n = 64,979)
This study is not without limitations. Our sexual orienta-
Model 1 Model 2 Model 3 tion measure is restricted and does not account for the di-
verse array of sexual identities. We were also unable to
Sexual orientation (heterosexual, reference) consider gender identity aside from sex assigned at birth,
Lesbian 4.13*** 3.44*** 3.27*** which excluded transgender and nonbinary individuals.
Bisexual 6.35*** 4.19*** 3.85*** Future research should consider the intersectional nature of
Age groups (18–24, reference) gender and sexual identity with age in shaping mental health
25–34 0.44*** 0.55** and suicidal ideation.
35–44 0.50*** 0.69 In addition, we were limited in our ability to account for
45–54 0.48*** 0.64* minority stressors with the cross-sectional nature of our
55–64 0.34*** 0.41***
data source. The BRFSS does not collect data on discrimina-
65–80+ 0.15*** 0.13***
tion or social rejection based on sexual identity. Future data
Race (non-Hispanic White, reference)
Downloaded by University of Rochester School of Medicine & Dentistry from www.liebertpub.com at 08/11/23. For personal use only.

collection efforts focused on the lived experience of sexual

Black, non-Hispanic 0.61*
minority people over the life course may go a long way to-
Hispanic 0.57***
Other 0.86 ward better understanding the relationship between sexual
orientation and suicidal ideation.
Relationship status (married, reference)
Unmarried couple 1.30
Formerly married 1.60*** Conclusion
Never married 1.40*
Education (less than high school, reference) The current study contributes to our understanding of the
High school, GED, or less 1.21 relationship between sexual orientation and suicidal ideation,
Some college 1.08 as well as how age interacts with sexual orientation to predict
College or more 0.76 suicidal ideation. Understanding these patterns can help pol-
Employment status (not employed, reference) icymakers and social service providers to improve mental
Employed 0.80 health support systems, eliminate differences in suicidal ide-
Income (<$25,000, reference) ation, and prevent countless early and avoidable deaths.
$25,000–$49,000 0.61**
$50,000–$74,999 0.62 Acknowledgments
>$75,000 0.40*** We thank the CDC for BRFSS Survey Data, Atlanta,
Health insurance (not insured, reference) Georgia: U.S. Department of Health and Human Services,
Insured 1.04 CDC, 2011–2018; Connecticut Department of Public Health
*p < 0.05, **p < 0.01, ***p < 0.001.
and CDC; Maine Center for Disease Control and Prevention;
BRFSS staff in Massachusetts; Nevada BRFSS office; New
Mexico BRFSS office; Ohio BRFSS office; Rhode Island
BRFSS, (2018) Center for Health Data and Analysis,
heterosexual men, only for the 25–34- and 45–54-year-old Rhode Island Department of Health, and supported, in part,
age groups. This pattern diverges from the established age- by the National Center for Chronic Disease Prevention and
related risk established among the general population and Health Promotion, CDC Cooperative Agreement Number,
reflected in our results for heterosexual men, where suicidal U58 DP006067; Texas BRFSS program; and the Washington
ideation generally decreases as age increases. State BRFSS program. This work was supported, in part, by
This age pattern for gay men may reflect minority stress the William Julius Wilson Graduate Student Summer Health
processes that manifest or are exacerbated closer to middle Equity Fellowship at Washington State University.
age for gay men. There may be an association with becoming
established in work and family life that intersects with stress
Authors’ Contributions
and thoughts of suicide unique to gay men. This finding war-
rants further exploration in future studies. Study concept and design: C.C.C. and J.T.D.; data acqui-
Among sexual minority women, we found elevated odds sition: Z.Z.; statistical analysis: Z.Z.; drafting of the article:
of experiencing suicidal ideation through nearly every C.C.C., Z.Z., and J.T.D.; supervision: J.T.D.; interpretation
stage of life relative to heterosexual women. The only excep- of data and analysis: C.C.C., Z.Z., and J.T.D. All the coau-
tions were a similar likelihood of ideation for heterosexual thors reviewed and approved the article before submission.
and lesbian women aged 35–44 and a similar likelihood of
ideation among heterosexual and bisexual women aged 65
Disclaimer
or older. Young adult lesbian and bisexual women, aged
18–24 and 25–34, experienced much higher likelihoods of The content is the sole responsibility of the authors and
suicidal ideation than heterosexual women in those same does not necessarily represent the official views of the
age groups. Although we lack life course covariates to exam- BRFSS.
ine these patterns, we suspect that marital history, history of
same- and different-sex relationships, and age at coming out
Author Disclosure Statement
might help explain the unique risks among younger adult
sexual minority women.34,44,45 No competing financial interests exist.
 8 COOLEY ET AL.
Funding Information
No funding was received for this article.
References
1. Hedegaard H, Curtain S, Warner M. NCHS Data Brief: Sui-
cide Mortality in the United States, 1999–2017; 2018;
p. 330. Available from: https://www.cdc.gov/nchs/data/
databriefs/db330-h.pdf [Last accessed: April 6, 2023].
2. Substance Abuse and Mental Health Services Administra-
tion. Key substance use and mental health indicators in
the United States: Results from the 2020 National Survey
on Drug Use and Health. (HHS Publication No. PEP21-
07-01-003, NSDUH Series H-56). Center for Behavioral
Health Statistics and Quality, Substance Abuse and Mental
Downloaded by University of Rochester School of Medicine & Dentistry from www.liebertpub.com at 08/11/23. For personal use only.
Health Services Administration: Rockville, MD; 2021.
Available from: https://www.samhsa.gov/data/report/2020-
nsduh-annual-national-report [Last accessed: January 26,
2023].
3. Bell A, Weinberg M. Homosexualities: A Study of Diver-
sity among Men and Women. Simon and Schuster: New
York, NY, USA; 1979.
4. Bradford J, Ryan C, Rothblum ED. National lesbian health
care survey: Implications for mental health care. J Consult
Clin Psychol 1994;62(2):228–242; doi:10.1037/0022-006X
.62.2.228
5. Herek GM, Gillis JR, Cogan JC. Psychological sequelae of
hate-crime victimization among lesbian, gay, and bisexual
adults. J Consult Clin Psychol 1999;67(6):945–951; doi:10
.1037/0022-006X.67.6.945
6. Herek GM, Gillis JR, Cogan JC. Internalized stigma among
sexual minority adults: Insights from a social psychological
perspective. Stigma Health 2015;1(S):18–34; doi:10.1037/
2376-6972.1.S.18
7. Martin JL, Dean L. Developing a community sample of gay
men for an epidemiologic study of AIDS. Am Behav Sci
1990;33(5):546–561; doi:10.1177/0002764290033005004
8. Riggle EDB, Rostosky SS, Reedy CS. Online surveys for
BGLT research: Issues and techniques. J Homosex 2005;
49(2):1–21; doi:10.1300/J082v49n02_01
9. Rothblum ED, Factor R. Lesbians and their sisters as a con-
trol group: Demographic and mental health factors. Psychol
Sci 2001;12(1):63–69; doi: 10.1111/1467-9280.00311
10. Rothblum ED, Balsam KF, Mickey RM. Brothers and sis-
ters of lesbians, gay men, and bisexuals as a demographic
comparison group: An innovative research methodology to
examine social change. J Applied Behav Sci 2004;40(3):
283–301; doi:10.1111/1467-9280.00311
11. Ramchand R, Schuler MS, Schoenbaum M, et al. Suicidality
among sexual minority adults: Gender, age, and race/ethnic-
ity differences. Am J Prev Med 2022;62(2):193–202; doi:
10.1016/j.amepre.2021.07.012
12. Ivey-Stephenson AZ, Demissie Z, Crosby AE, et al. Suicidal
ideation and behaviors among high school students—Youth
Risk Behavior Survey, United States, 2019. MMWR Suppl
2020;69(1):47–55; doi: 10.15585/mmwr.su6901a6
13. Hatzenbuehler ML, Link BG. Introduction to the special
issue on structural stigma and health. Soc Sci Med 2014;
103:1–6; doi: 10.1016/j.socscimed.2013.12.017
14. Stone DM, Luo F, Lippy C, et al. The role of social connect-
edness and sexual orientation in the prevention of youth sui-
cide ideation and attempts among sexually active
adolescents. Suicide Life Threat Behav 2015;45(4):415–
430; doi: 10.1111/sltb.12139
15. Russell ST. Sexual minority youth and suicide risk. Am
Behav Sci 2003;46(9):1241–1257; doi: 10.1177/
0002764202250667
16. Williams AJ, Jones C, Arcelus J, et al. A systematic review
and meta-analysis of victimization and mental health prev-
alence among LGBTQ+ young people with experiences of
self-harm and suicide. De Luca V. ed. PLoS One 2021;
16(1):e0245268; doi: 10.1371/journal.pone.0245268
17. McDaniel JS, Purcell D, D’Augelli AR. The relationship be-
tween sexual orientation and risk for suicide: Research find-
ings and future directions for research and prevention.
Suicide Life Threat Behav 2001;31(Suppl.):84–105; doi:
10.1521/suli.31.1.5.84.24224
18. Meyer IH. Prejudice, social stress, and mental health in les-
bian, gay, and bisexual populations: Conceptual issues and
research evidence. Psychol Bull 2003;129(5):674–697;
doi: 10.1037/0033-2909.129.5.674
19. Plöderl M, Fartacek R. Childhood gender nonconformity
and harassment as predictors of suicidality among gay, les-
bian, bisexual, and heterosexual Austrians. Arch Sex Behav
2009;38(3):400–410; doi: 10.1007/s10508-007-9244-6
20. Russell ST, Joyner K. Adolescent sexual orientation and
suicide risk: Evidence from a national study. Am J Public
Health 2001;91(8):1276–1281; doi: 10.2105/AJPH.91.8
.1276
21. Puckett JA, Feinstein BA, Newcomb ME, et al. Trajectories
of internalized heterosexism among young men who have
sex with men. J Youth Adolesc 2018;47(4):872–889; doi:
10.1007/s10964-017-0670-z
22. Meyer IH. Minority stress and mental health in gay men.
J Health Soc Behav 1995;36(1):38–56.
23. Bennardi M, Caballero FF, Miret M, et al. Longitudinal re-
lationships between positive affect, loneliness, and suicide
ideation: Age-specific factors in a general population. Sui-
cide Life Threat Behav 2019;49(1):90–103; doi: 10.1111/
sltb.12424
24. Bernal M, Haro JM, Bernert S, et al. Risk factors for suici-
dality in Europe: Results from the ESEMED study. J Affect
Disord 2007;101(1–3):27–34; doi: 10.1016/j.jad.2006.09
.018
25. Kessler RC, Borges G, Walters EE. Prevalence of and risk
factors for lifetime suicide attempts in the National Comor-
bidity Survey. Arch Gen Psychiatry 1999;56(7):617–626;
doi: 10.1001/archpsyc.56.7.617
26. Lee JI, Lee MB, Liao SC, et al. Prevalence of suicidal ide-
ation and associated risk factors in the general population.
J Formos Med Assoc 2010;109(2):138–147; doi: 10.1016/
S0929-6646(10)60034-4
27. Nock MK, Borges G, Bromet EJ, et al. Cross-national prev-
alence and risk factors for suicidal ideation, plans and at-
tempts. Br J Psychiatry 2008;192(2):98–105; doi: 10.1192/
bjp.bp.107.040113
28. May AM, Klonsky ED. What distinguishes suicide attemp-
ters from suicide ideators? A meta-analysis of potential fac-
tors. Clin Psychol Sci Pract 2016;23(1):5–20; doi: 10.1111/
cpsp.12136
29. Haas AP, Eliason M, Mays VM, et al. Suicide and suicide
risk in lesbian, gay, bisexual, and transgender populations:
Review and recommendations. J Homosex 2011;58(1):10–
51; doi: 10.1080/00918369.2011.534038
30. King M, Semlyen J, Tai SS, et al. A systematic review of
mental disorder, suicide, and deliberate self-harm in lesbian,
gay and bisexual people. BMC Psychiatry 2008;8(1):70;
doi: 10.1186/1471-244X-8-70
 SEXUAL MINORITY ADULT SUICIDAL IDEATION
31. Cochran SD, Mays VM. Lifetime prevalence of suicide
symptoms and affective disorders among men reporting
same-sex sexual partners: Results from NHANES III.
Am J Public Health 2000;90(4):573–578; doi: 10.2105/
AJPH.90.4.573
32. Hughes TL. Lesbians’ drinking patterns: Beyond the data.
Substance Use Misuse 2003;38(11–13):1739–1758; doi:
10.1081/JA-120024239
33. Paul JP, Catania J, Pollack L, et al. Suicide attempts among
gay and bisexual men: Lifetime prevalence and antecedents.
Am J Public Health 2002;92(8):1338–1345; doi: 10.2105/
AJPH.92.8.1338
34. Meyer IH, Blosnich JR, Choi SK, et al. Suicidal behavior
and coming out milestones in three cohorts of sexual minor-
ity adults. LGBT Health 2021;8(5):340–348; doi: 10.1089/
Downloaded by University of Rochester School of Medicine & Dentistry from www.liebertpub.com at 08/11/23. For personal use only.
lgbt.2020.0466
35. Russell ST, Fish JN. Sexual minority youth, social change,
and health: A developmental collision. Res Hum Dev 2019;
16(1):5–20; doi: 10.1080/15427609.2018.1537772
36. Institute of Medicine (U.S.) Committee on Lesbian, Gay,
Bisexual, and Research Gaps and Opportunities. The Health
of Lesbian, Gay, Bisexual, and Transgender People: Build-
ing a Foundation for Better Understanding. National Aca-
demies Press: Washington, DC, USA; 2011.
37. Allison PD. Missing Data. Sage Publications: Thousand
Oaks, CA, USA; 2002. 93 p. (Sage university papers. Quan-
titative applications in the social sciences).
38. von Hippel PT. Regression with missing Ys: An improved
strategy for analyzing multiply imputed data. Sociol Meth-
odol 2007;37(1):83–117; doi: 10.1111/j.1467-9531.2007
.00180.x
39. Ivey-Stephenson AZ, Crosby AE, Hoenig JM, et al. Suicidal
thoughts and behaviors among adults aged ‡18 years—
United States, 2015–2019. MMWR Surveill Summ 2022;
71(1):1–19; doi: 10.15585/mmwr.ss7101a1
9
40. Centers for Disease Control and Prevention. 2020. Complex
Sampling Weights and Preparing 2019 BRFSS Module Data
for Analysis. Available from: https://www.cdc.gov/brfss/
annual_data/2019/pdf/complex-smple-weights-prep-module-
data-analysis-2019-508.pdf [Last accessed: January 26,
2023].
41. Mize T. Best practices for estimating, interpreting, and pre-
senting nonlinear interaction effects. Soc Sci 2019;6:81–
117; doi: 10.15195/v6.a4
42. Mood C. Logistic regression: Why we cannot do what we
think we can do, and what we can do about it. Eur Sociol
Rev 2010;26(1):67–82; doi: 10.1093/esr/jcp006
43. Klonsky ED, May AM, Saffer BY. Suicide, suicide at-
tempts, and suicidal ideation. Annu Rev Clin Psychol
2016;12(1):307–330; doi: 10.1146/annurev-clinpsy-
021815-093204
44. Haney JL. Suicidality risk among adult sexual minorities:
Results from a cross-sectional population-based survey.
J Gay Lesbian Soc Serv 2021;33:2:250–271; doi: 10.1080/
10538720.2021.1875946
45. McCabe SE, Hughes TL, Bostwick WB, et al. Sexual orien-
tation, substance use behaviors and substance dependence in
the United States. Addiction 2009;104(8):1333–1345; doi:
10.1111/j.1360-0443.2009.02596.x
Address correspondence to:
Caleb C. Cooley, MA
Department of Sociology
Washington State University
P.O. Box 644020
Pullman, WA 99164
USA
E-mail: caleb.cooley@wsu.edu