University of Groningen

Minority Stress and Suicidal Ideation and Suicide Attempts Among LGBT Adolescents and
Young Adults
de Lange, Jennifer; Baams, Laura; van Bergen, Diana; Bos, Henny M. W. ; Bosker, Roel

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LGBT Health

DOI:
10.1089/lgbt.2021.0106

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de Lange, J., Baams, L., van Bergen, D., Bos, H. M. W., & Bosker, R. (2022). Minority Stress and Suicidal
Ideation and Suicide Attempts Among LGBT Adolescents and Young Adults: A Meta-Analysis. LGBT
Health, 9(4), 222-237. Advance online publication. https://doi.org/10.1089/lgbt.2021.0106

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 LGBT Health Review
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DOI: 10.1089/lgbt.2021.0106

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Minority Stress and Suicidal Ideation and Suicide Attempts

Among LGBT Adolescents and Young Adults:
A Meta-Analysis
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Jennifer de Lange, MSc,1 Laura Baams, PhD,1 Diana D. van Bergen, PhD,1
Henny M.W. Bos, PhD,2 and Roel J. Bosker, PhD1

Abstract

Purpose: This meta-analytic study examined associations between minority stressors and suicidal ideation and
suicide attempts among LGBT adolescents and young adults (aged 12–25 years).
Methods: Identified studies were screened using the inclusion and exclusion criteria. Studies had to include an
association between a minority stressor and a suicidality outcome and were categorized into 10 meta-analyses.
Overall effect sizes were calculated using three-level meta-analyses. In addition, moderation by sampling strat-
egy was examined.
Results: A total of 44 studies were included. Overall, LGBT bias-based victimization, general victimization, bul-
lying, and negative family treatment were significantly associated with suicidal ideation and/or suicide attempts.
Associations of discrimination and internalized homophobia and transphobia with suicidal ideation and/or sui-
cide attempts were not significant. No moderation effects were found for sampling strategy.
Conclusion: Although overall effect sizes were small, our meta-analytic study shows a clear link between var-
ious types of minority stressors and suicidal ideation and suicide attempts among LGBT adolescents and young
adults.

Keywords: adolescents, LGBT, meta-analysis, minority stress, suicidality

Introduction the (potential) transition to suicide attempts8; therefore, we ex-

R ates of suicidal ideation and suicide attempts
among LGBT adolescents and young adults are higher
compared with rates among heterosexual and cisgender
adolescents and young adults.1–3 Research has shown asso-
ciations between various types of minority stressors and
suicidal ideation and suicide attempts among LGBT adoles-
cents.4–7 However, it is not clear to what extent different
types of minority stressors are associated with suicidal idea-
tion and suicide attempts.
With this meta-analytic study, we synthesize and examine
the associations of different types of minority stressors with
suicidal ideation and suicide attempts among LGBT adoles-
cents and young adults. The ideation-to-action framework sug-
gests distinct processes for developing suicidal ideation and
amine associations for suicidal ideation and suicide attempts
separately. In this meta-analytic study, suicidality is used as
an umbrella term for suicidal ideation and suicide attempts.
Minority stress and suicidality
The minority stress framework explains how mental
health disparities among sexual minority individuals develop
from the experience of minority stress.9 Minority stressors
include distal stressors, for example, victimization and fam-
ily rejection, and proximal ones, for example, internalized
homophobia. These minority stressors are unique to sexual
minority groups and additive to general stressors.9
Extensions of the minority stress model have made it ap-
plicable to gender minority groups, including transgender

1
Department of Pedagogy and Educational Sciences, University of Groningen, Groningen, The Netherlands.
2
Department of Child Development and Education, University of Amsterdam, Amsterdam, The Netherlands.

222
 MINORITY STRESS AND SUICIDALITY: A META-ANALYSIS
and nonbinary individuals.10,11 The gender minority stress
framework added minority stressors that are unique to gender
minority individuals, such as internalized transphobia and
nonaffirmation of gender identity.10 Research shows that
LGBT young individuals are especially likely to experience
interpersonal rejection from friends and family,12 and this is
associated with mental health problems.13
The majority of studies among LGBT young individuals
on the links between minority stress and suicidality focused
on distal minority stressors such as family rejection or
victimization, including experiences that are not linked to a
minority identity, but may be interpreted in that way by mi-
nority groups (e.g., victimization). Fewer studies focused on
the association between proximal minority stressors and sui-
cidality, such as internalized homophobia, internalized trans-
phobia, and expected rejection.
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There is one meta-analytic review that examined internal-
ized homophobia and internalizing health problems. However,
this study did not focus solely on adolescents and young adults
and did not examine suicidality as an outcome.14 Overall, em-
pirical research among LGBT adolescents and young adults
shows that both proximal and distal minority stressors are
associated with suicidality.15–17
Studies on the association between minority stress and sui-
cidality use a wide range of instruments to assess minority
stressors and suicidality. For example, studies commonly
ask about experiences with victimization that are explicitly
related to young people’s sexual orientation,18–20 whereas
others examine victimization more broadly without defining
it as discriminatory.21,22 For suicidal ideation and suicide at-
tempts, there is also variability in the measures that are
used. Some studies assess lifetime suicidal ideation, whereas
others assess recent suicidal ideation. A synthesis of asso-
ciations by minority stressors and suicidality outcome will
improve our understanding of the extent to which different
types of minority stressors are related to suicidal ideation
and suicide attempts and gives crucial insights into short-
comings of the current literature.
To the best of our knowledge, there are currently two
meta-analyses23,24 on risk factors for suicidal ideation and
suicide attempts among LGBT youth. The meta-analysis
by Hatchel et al.23 demonstrated a medium effect size for
victimization and a small effect size for stigma and discrim-
ination in relation to suicidality. Of the studies that were in-
cluded in this meta-analysis, only two studies examined the
relationship between internalized homophobia and suicidal-
ity, and they found a small association.23 The meta-analytic
study included studies up to 2017, and since then, at least 20
additional studies examining associations between minority
stress and suicidality have been published.
A second meta-analytic study by Williams et al.24 found
that victimization among LGBT young people was associ-
ated with experiences of self-harm, suicidal ideation, or sui-
cide attempts. A merit of that study is that recent studies (also
after 2017) were included; however, ‘‘victimization’’ was
used as an umbrella term for experiences of victimization,
bullying, discrimination, and negative treatment. Further-
more, these two meta-analyses23,24 did not assess whether
study results differed by sampling strategy. Using fine-
grained analyses, the current meta-analytic study examines
the associations of various types of minority stressors with
suicidal ideation and suicide attempts.
223
Differences by sampling strategy in the association
between minority stress and suicidality
There are large differences in study designs and data col-
lection methods in studies on minority stress and suicidality
among LGBT young individuals. Some studies included
nonprobability samples, such as convenience and snowball
sampling, whereas others used probability or population-
based sampling. Although research indicated that there are
small or no differences between nonprobability and probabil-
ity samples in demographics of LGBT populations,25,26 re-
search also showed that nonprobability samples are more
likely to include individuals who identify as exclusively
same-sex attracted,26 gay, lesbian, and queer25 than probabil-
ity samples.
In addition, one study showed a stronger association be-
tween internalized homonegativity and suicidality for a com-
munity convenience sample than a randomly selected (from
a panel) sample.26 In the current meta-analytic study, we
therefore examine whether the sampling strategy in a study
moderates associations between minority stress and suicidal
ideation and suicide attempts.
The current study
The current study aimed to synthesize the associations
between various types of minority stressors and suicidal ide-
ation and suicide attempts among LGBT adolescents and
young adults aged 12–25 years. In addition, we examined
differences for sampling strategy in the associations between
minority stress and suicidal ideation and suicide attempts.
The current meta-analytic study includes studies up until
January 2020.
Methods
Study inclusion and exclusion
To be included in the meta-analytic study, the following
inclusion criteria had to be met: studies had to (1) report a
form of suicidal ideation or suicide attempts as an outcome,
(2) report a minority stressor, (3) report a relation between a
minority stressor and a form of suicidal ideation or suicide
attempt, or provide data to calculate an association, (4) in-
clude self-identified sexual or gender minority adolescents
and young adults, (5) include participants with a minimum
age of 12 years, (6) include a sample with a maximum
mean age of 25 years, and (7) be empirical articles, published
in English.
A database search on Web of Science was conducted for
studies published until January 2020. The search included
a combination of terms related to sexual orientation, gender
identity, minority stressors, and suicidal ideation and suicide
attempts (Table 1).
Five authors were contacted because of missing data in the
article; three of those articles were included in the final selec-
tion. In total, 44 studies were included in the meta-analytic
study. Data of included studies were extracted and en-
tered into a coding form. Extracted data included, for exam-
ple, country where the study was conducted, sample size, age
(range, mean), gender and sexual orientation composition of
the sample, ethnicity, sample procedure, predictor, type of
predictor (e.g., dichotomous, ordinal), outcome, type of out-
come, effect size, and type of effect size (e.g., odds ratio
 224 DE LANGE ET AL.

Table 1. Search strategy

Database Web of Science
Date 09/13/2018; 12/10/2019; 01/10/2020
Search query #1 TS = (‘‘sexual minorit*’’ OR LGB* OR LG OR lesbian OR gay OR homosexual OR bisexual OR
transgender OR transsexual OR transmen OR ‘‘trans men’’ OR transwomen OR ‘‘trans women’’
OR genderqueer OR queer OR ‘‘sexual orientation’’ OR ‘‘Sexual attract*’’ OR ‘‘Same-sex
attract*’’ OR ‘‘Sexual identit*’’ OR ‘‘same-sex sexual behav*’’ OR MSM OR ‘‘Men who have
sex with men’’ OR WSW OR ‘‘Women who have sex with women’’ OR ‘‘gender identit*’’ OR
‘‘non-binary’’ OR ‘‘gender nonconform*’’ OR ‘‘same-gender attract*’’ OR ‘‘same-gender sexual
behav*’’)
DocType = All document types; Language = All languages;
#2 TS = (‘‘minority stress’’ OR prejudice OR discrimination OR homophob* OR stigma OR rejection
OR concealment OR victimization OR bull* OR violen* OR disclos* OR harassment OR assault
OR abuse OR ‘‘internal* homonegativ*’’ OR transphob*)
DocType = All document types; Language = All languages;
#3 TS = (suicid* OR ‘‘deliberate self-harm’’)
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DocType = All document types; Language = All languages;

#4 #3 AND #2 AND #1
DocType = All document types; Language = All languages
TS, topic.

[OR], correlation). The data extraction and coding were con-
ducted by the first author. The first five completed coding
forms were discussed with the second author, as well as
any coding decisions and uncertainties about studies meeting
the inclusion criteria.
Measures
Suicidal ideation. Included studies used measures that
assessed suicidal ideation or used the term ‘‘suicidal
thoughts.’’ Suicidal ideation was assessed in the past month,
past year, or lifetime. Some studies7,27 used a scale to mea-
sure suicidal ideation, for example, Suicide Behaviors
Questionnaire-Revised (SBQ-R).7,27,28 Most studies used
one or two questions to assess suicidal ideation, for example,
‘‘During the past 6 months, did you have any thoughts of
ending your life. If yes, how often?’’6 These measures with
different time frames were combined for the purpose of the
current meta-analytic study.
about experiences such as being treated unfairly because of
one’s sexual orientation or gender identity, for example,
in-home, at school, or the workplace.19,32
General victimization. Included studies used measures
that assessed victimization that was not explicitly related to
one’s sexual orientation or gender identity. For example, a
question about being kicked or pushed at school.3,17,33,34
Bullying. Included studies used measures that assessed
experiences with bullying. For example, studies included
measures of cyberbullying or in-person bullying. An exam-
ple item of cyberbullying was ‘‘During the past 12 months,
have you ever been electronically bullied, such as through
e-mail, chat rooms, instant messaging, websites, or text mes-
saging?’’35 and an example item of in-person bullying was
‘‘During the past 12 months, have you ever been bullied
on school property?’’36

Suicide attempts. Included studies used measures that

assessed suicide attempts in the past month, past year, or
lifetime. Some studies7,18,27,29 used an item of a scale, for ex-
ample, an item of the Diagnostic Interview Schedule for
Children18 or SBQ-R.7,27,28 Most studies used one or two
questions to assess suicide attempts, for example, ‘‘Have
you ever attempted suicide?’’15 These measures with differ-
ent time frames were combined for the purpose of the current
meta-analytic study.
LGBT bias-based victimization. Included studies used
measures that assessed victimization related to one’s actual
or perceived sexual orientation or gender identity. For exam-
ple, studies assessed experiences of violence, physical or
verbal harassment or abuse, and property damage related to
youth’s LGBT identity.30,31
Discrimination. Included studies used measures that
assessed experiences with discrimination. Studies asked
Negative family treatment. Included studies used mea-
sures that assessed negative family treatment such as family
rejection, bad treatment by parents or siblings, or neglect
from parents. Studies asked about, for example, physical
and verbal abuse by family members because of sexual ori-
entation or gender identity.37,38
Internalized homophobia or transphobia. Included stud-
ies used measures that assessed internalized homophobia
or transphobia, or internalized heterosexism. Studies asked
about attitudes or self-concept of one’s sexual orientation
or gender identity, for example, feeling ashamed of one’s
gender identity7 or feelings of discomfort with one’s sexual
orientation.39
Moderator. Sampling strategy was used as a dichoto-
mous moderator and coded as probability sample (1) and
nonprobability sample (0).
 MINORITY STRESS AND SUICIDALITY: A META-ANALYSIS
Data synthesis and analysis
The initial search included several types of minority
stressors (Table 1). After data extraction, we created minor-
ity stress themes (see the Measures section) based on the
measures in the studies. For example, we combined studies
that examined parental or family rejection, or parental ne-
glect and named this negative family treatment. This resulted
in 10 different associations of a minority stress measure and a
suicidality outcome.
Each association included at least one study with multiple
effect sizes, and therefore, there was no independence among
effect sizes. Thus, we conducted a three-level meta-analysis
for each association.40 A three-level meta-analysis measures
variance at the within-study level and the between-study
level and accounts for the dependence among effect
sizes.41 Because there was variability in the study designs
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used, a random-effects model was used in all meta-
analyses.42 All analyses were conducted in R version 4.0.3
using the Metafor package version 2.4-0.43
FIG. 1. PRISMA46 flow diagram. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.
225
First, an overall effect size was calculated for each associ-
ation. When effect sizes needed to be converted, formulas of
Borenstein et al.44 were used as well as guidelines by Lipsey
and Wilson.45 Some studies did not provide standardized ef-
fect sizes for associations without control variables, and in
these cases, the adjusted effect size was included in our an-
alyses. Eight meta-analyses were conducted using log odds
as effect size, and two meta-analyses were conducted using
Fisher-z as effect size. Second, heterogeneity tests were con-
ducted for each meta-analysis to test whether within-study
variance and between-study variance were significant. We
also calculated the amount of variance that contributed to
each level. Third, moderator analyses were conducted for
all significant associations when the total amount of variance
that contributed to sampling variance was <75%.40
In addition, some studies met our inclusion criteria, but
there were too few associations for that particular minority
stressor to be included in a meta-analysis. These studies
and associations are synthesized in the Additional Minority
Stressors section.
 226 DE LANGE ET AL.

Table 2. Meta-Analyses of a Minority Stressor and Suicidal Ideation

Number of studies Overall Overall effect
(effect sizes) effect OR Pearson’s r 95% CI
LGBT bias-based victimization 10 (17) 1.52* — 1.23 to 1.89
Discrimination 3 (4) 1.47 — 0.79 to 2.77
General victimization 9 (14) — 0.23* 0.13 to 0.32
Bullying 4 (10) 2.31* — 1.53 to 3.47
Negative family treatment 5 (9) 2.01* — 1.57 to 2.57
Internalized homophobia and transphobia 7 (11) — 0.10 0.00 to 0.21
*p < 0.05.
CI, confidence interval; OR, odds ratio.

Results and/or transgender adolescents and young adults, whereas

Inclusion and exclusion of studies
k = 43,7,21,38 studies included only transgender adolescents
and young adults. Eleven studies3,17,21,33–36,61,67,75,78 used
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A total of 1137 records were identified through data-
base screening using the search terms. See Figure 1 for the
Preferred Reporting Items for Systematic Reviews and
Meta-Analyses (PRISMA)46 flow diagram. Of these 1137 re-
cords, 8 duplicates were removed. A total of 1129 titles and
abstracts were screened using the inclusion and exclusion
criteria, and this resulted in the exclusion of 927 records.
A total of 202 full-text records were screened, of which
142 were excluded for not meeting the inclusion criteria.
In addition, eight records that used the same data to assess
the same association,47–54 and eight studies16,20,22,55–59 that
did not provide separate effect sizes for suicidal ideation
and suicide attempts were also excluded. A total of k (num-
ber of studies) = 38 records3–7,15,17–19,21,27,29,31–34,36–39,60–77
were included for 10 meta-analyses on the associations be-
tween minority stressors and suicidal ideation and suicide at-
tempts (Tables 2 and 3), and k = 628,30,35,78–80 records met the
inclusion criteria but were not included in a meta-analysis
because of too few effect sizes or insufficient data to convert
the effect size.
Study characteristics
Sample sizes in the included studies varied from N = 50 to
N = 18,515. Most studies used a sample that included a com-
bination of (self-identified) lesbian, gay, bisexual, queer,
Table 3. Meta-Analyses of a Minority
Stressor and Suicide Attempts
Number
of studies Overall
(effect effect
sizes) OR 95% CI
a probability sampling method and k = 334–7,15,18,19,27–32,
37–39,60,62–66,68–74,76,77,79,80
studies used a nonprobability
sampling method. Studies were conducted in the United
States (k = 34), Europe (k = 4), Asia (k = 3), Australia
(k = 1), Brazil (k = 1), and West Africa (k = 1).
Of the included studies in the meta-analyses, a total of
k = 28 studies examined suicidal ideation and k = 24 studies
examined suicide attempts. All studies used self-report ques-
tionnaires to assess minority stress and suicidal ideation and
suicide attempts. Study characteristics are summarized in
Table 4.
LGBT bias-based victimization and suicidality
A total of k = 10 studies4,7,15,17,19,27,29,73–75 with 17 effect
sizes assessed the association between LGBT bias-based vic-
timization and suicidal ideation (total N = 10,203). Among
these studies, one included only transgender participants.7
Adolescents and young adults who experienced LGBT-
bias-based victimization were significantly more likely to re-
port suicidal ideation (overall OR = 1.52, 95% confidence
interval [CI] [1.23–1.89], p < 0.001). See Supplementary
Figure S1 for a forest plot.
A total of k = 13 studies7,15,17,18,27,29,31,37,64,68,70,74,77 with
24 effect sizes assessed the association between LGBT bias-
based victimization and suicide attempts (total N = 8562).
Among these studies, one included only transgender par-
ticipants.7 Adolescents and young adults who experienced
LGBT bias-based victimization were significantly more
likely to report suicide attempts (overall OR = 1.88, 95%
CI [1.49–2.36], p < 0.001). See Supplementary Figure S2
for a forest plot.
Discrimination and suicidality

LGBT bias-based 13 (24) 1.88* 1.49 to 2.36 A total of k = 319,32,61 and four effect sizes were included
victimization to assess the association between discrimination and suicidal
Discrimination 3 (4) — — ideation (total N = 5758). Taken together, discrimination was
General victimization 6 (11) 1.98* 1.64 to 2.39 not significantly associated with suicidal ideation (overall
Negative family 6 (13) 1.80* 1.42 to 2.28 OR = 1.47, 95% CI [0.79–2.77], p = 0.145). None of the stud-
treatment ies included only transgender participants. See Supplemen-
Bullying 2 (7) — — tary Figure S3 for a forest plot.
Internalized 6 (10) 1.15 0.97 to 1.35
homophobia Three studies61,70,79 provided data of the effect sizes for
and transphobia discrimination and suicide attempts; however, one study
reported an OR and did not provide the necessary data to cal-
*p < 0.05. culate a comparable effect size. Therefore, too few studies
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Table 4. Study Characteristics

Author (year) N Age (years) Gender (%) Sexual orientation (%) Minority stressor(s) Outcome(s)
Perez-Brumer 280 M = 15.3 60% Male 49% LGB School-based Suicidal ideation
et al. (2017)3 40% Female 36% Unsure victimization
100% Transgender 41% No reported
sexual orientation
Baams et al. 876 15–21 (M = 18.3) 47% Male 53% Gay/lesbian Sexual orientation Suicidal ideation
(2015)4 54% Female 47% Bisexual victimization
Goldbach et al. 346 14–17 44% Male 73% Gay/lesbian (1) Family rejection (1) Suicidal ideation
(2017)5 56% Female 27% Bisexual/pansexual (2) Internalized (2) Suicide attempts
homonegativity
Ryan et al. 224 21–25 (M = 22.8) 51% Male — Family rejection (1) Suicidal ideation
(2009)6 49% Female (2) Suicide attempt
Kuper et al. 1896 14–30 (M = 21.1) 100% Transgender — (1) Gender-related self- (1) Suicide attempt (past
(2018)7 22% Male concept negativity year)
78% Female (2) Gender-related (2) Suicidal ideation (past
victimization year)
(3) Sexual orientation-
related victimization
Lea et al. (2014)15 572 18–25 (M = 21.5) 56% Male 78% Lesbian/gay (1) Stigma (1) Suicide attempt ever
44% Female 22% Bisexual (2) Internalized (2) Suicidal thoughts in the

227
homophobia past month
(3) Homophobic physical
and verbal abuse
Taliaferro and 4960 13–19 (M = 15.5) — 13% Gay/lesbian (1) Bully victimization (1) Suicidal ideation
Muehlenkamp 45% Bisexual (2) Violence at school (2) Suicide attempts
(2017)17 42% Questioning
Mustanski and 237 16–20 (M = 18.8) Birth gender 62% Gay/lesbian LGBT victimization (1) Suicide attempt
Liu (2013)18 48% Male 29% Bisexual lifetime
52% Female 10% Unsure/ (2) Suicide attempt in the
questioning/other past year
Huebner et al. 1248 18–27 (M = 23) 100% Male 83% Gay (1) Verbal harassment Suicidal ideation
(2004)19 16% Bisexual (2) Discrimination
(3) Physical violence
Hatchel et al. 4778 10–18 (M = 14.7) Sex assigned at birth: — Peer victimization Suicidal ideation
(2019)21 55% Male
41% Female
Rimes et al. 3275 16–24 (M = 24.4) 51% Male 74% Gay/lesbian (1) Harassment (1) Suicidal ideation
(2018)27 49% Female 26% Bisexual (2) Crime (2) Suicide attempt
(3) Bad reaction father
(4) Bad reaction mother
(5) Bad reaction sibling

(continued)
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Table 4. (Continued)
Author (year) N Age (years) Gender (%) Sexual orientation (%) Minority stressor(s) Outcome(s)
Muehlenkamp 137 M = 19.9 16% Male 31% Gay/lesbian Minority stress Suicidal thoughts and
et al. (2015)a,28 74% Female 29% Bisexual behavior
3% Transgender 24% Questioning
15% Pansexual
17% Queer
13% Other
Wilton et al. 161 M = 24.1 91% Male 81% Gay Biased victimization (1) Suicidal ideation
(2018)29 9% Trans woman 14% Bisexual (2) Suicide attempts
6% Other
Liu and 246 16–20 (M = 18.3) Birth gender: 62% Gay/lesbian LGBT victimization Suicidal ideation
Mustanski 49% Male 29% Bisexual
(2012)a,30 51% Female 9% Unsure/
questioning/other
Woodford et al. 776 M cisgender = 22.7, Cisgender LGBQ: Cisgender: (1) LGBQ and trans Suicide attempts
(2018)31 M transgender = 22.8 44% Male 57% Gay/lesbian environmental
55% Female 39% Bisexual/other microaggressions
Trans*: Trans*: (2) LGBQ and trans
14% Male 21% Gay/lesbian interpersonal
14% Female 68% Bisexual/other microaggressions
38% Genderqueer (3) LGBQ and trans

228
14% Transgender victimization
21% Other identity
Thoma and 276 14–19 (M = 17.5) 59% Male 59% Gay/lesbian Anti-gay discrimination Suicidal ideation
Huebner 33% Female 27% Bisexual
(2013)32 8% Transgender 14% Queer/other
Poteat et al. 1981 — — — Victimization Depressed/suicidal
(2009)33 feelings
Hatchel et al. 713 12–18 (M = 15) 23% Male — Peer victimization (1) Suicidal ideation
(2019)34 66% Female (2) Suicide attempt
4% Transgender
6% Other
Duong and 951 — 31% Male — (1) Cyberbullying Suicide attempt
Bradshaw 69% Female (2) School bullying
(2014)a,35
Feinstein et al. 18,515 M = 16.2 23% Male 100% Bisexual (1) In-person bullying Suicidal ideation
(2019)36 77% Female (2) Electronic bullying
Walls et al. 142 14–21 52% Male 68% Gay/lesbian (1) In-school victimization Suicide attempt
(2008)37 44% Female 23% Bisexual (2) Familial abuse
4% Transgender 6% Questioning
4% Pansexual/other

(continued)
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Table 4. (Continued)
Author (year) N Age (years) Gender (%) Sexual orientation (%) Minority stressor(s) Outcome(s)
Peng et al. 385 12–18 (M = 16.7) 28% Trans boys — (1) Bullying or abuse in Suicidal ideation
(2019)38 43% Trans girls school
28% Gender nonbinary (2) Abuse, bullying,
neglect from family
Puckett et al. 61 14–23 (M = 18.0) 38% Male 48% Totally gay or (1) Guilt or shame about Suicide attempt
(2017)39 62% Female lesbian same-sex attraction
18% Almost totally (2) Internalized
gay or lesbian heterosexism
5% Mostly gay or
lesbian
Albuquerque 316 M = 24.3 74% Male 76% Gay/lesbian Physical violence Suicide attempt
et al. (2018)60 26% Female 17% Bisexual
10% Transgender
Blosnich and 4303 18–24 (M gay/ 39% Male 42% Gay/lesbian (1) Physical assault (1) Suicidal ideation
Bossarte lesbian = 20.3, 60% Female 58% Bisexual (2) Discrimination (2) Suicide attempt
(2012)61 M bisexual = 20.2)
Boyas et al. 451 — 35% Male 26% Gay/lesbian Bullying (1) Suicidal ideation
(2019)62 65% Female 74% Bisexual (2) Suicide attempt
D’Augelli et al. 350 14–21 (M = 19.2) 56% Male 75% Gay/lesbian Biased victimization Suicidal ideation:
(2002)63 44% Female 6% Bisexual (1) lifetime, (2) past year,
19% Bisexual but and (3) related to

229
mostly sexual orientation
gay/lesbian
D’Augelli et al. 361 15–19 (M = 17) 56% Male 28% Lesbian/gay Gay-related verbal abuse Suicide attempt
(2005)64 44% Female 21% Bisexual
20% Bisexual, but
mostly
gay/lesbian
16% Bisexual but
mostly
heterosexual
Gibbs and 2949 18–24 (M = 20.7) 76% Male 62% Gay or lesbian Internalized homophobia (1) Suicidal thoughts
Goldbach 22% Female 27% Bisexual (2) Suicide attempt
(2015)65 2% Transgender 10% Questioning
2% Other
Goodenow et al. 202 — — 21% LGB, no same-sex School victimization Suicide attempt
(2006)66 sexual contact
50% Same-sex
experience,
but do not identify as
LGB
28% LGB and same-sex
experience

(continued)
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Table 4. (Continued)
Author (year) N Age (years) Gender (%) Sexual orientation (%) Minority stressor(s) Outcome(s)
Hatchel et al. 934 14–18 (M = 15.9) 30% Assigned 16% Gay/lesbian Peer victimization (1) Suicidal ideation
(2019)67 male at birth 44% Bisexual (2) Suicide attempts
70% Assigned 22% Questioning
female at birth 6% Transgender
Hershberger et al. 194 15–21 (M = 18.9) 73% Male 75% Lesbian/gay Victimization: Suicide attempt
(1997)68 27% Female 19% Bisexual but (1) verbal insults
mostly gay (2) property damage
6% Bisexual (3) physical assault
(4) hurt by other
Kuyper and Bos 580 16–25 (M = 21.2) 32% Male 26% Lesbian/gay Internalized Suicidal ideation
(2016)69 68% Female 74% Mostly homonegativity
heterosexual
Livingston et al. 412 18–25 (M = 20.8) 29% Male 43% Gay/lesbian (1) Discrimination Suicide attempt
(2015)70 50% Female 30% Bisexual (2) Victimization
7% Transgender 30% Other (3) Internalized
14% Other heterosexism
(4) Concealment
Nguyen et al. 1936 18–52 (M = 22.6) 100% Female 54% Lesbian Family treatment: Lifetime suicide attempt

230
(2016)71 28% Bisexual (1) pressure history
15% Unsure (2) aggressive
(3) aggressive—severe
(4) aggressive—extreme
Reyes et al. 185 18–25 (M = 20.2) 67% Male 100% Gay/lesbian (1) Self-stigma Suicidal ideation
(2017)72 33% Female (2) Societal stigma
Stahlman et al. 1555 M = 23 Self-identified gender: — (1) Family exclusion, Suicidal ideation
(2016)73 77% Male gossip and rejection
23% Female/intersex (2) Physically hurt
Van Bergen et al. 274 M = 16.8 39% Male 82% (Mostly) same-sex Victimization by (1) Suicidal ideation
(2013)74 61% Female attracted (1) parents (2) Suicide attempts
8% Same- and opposite- (2) other family members
sex attracted (3) in school context
11% Other
Whitaker et al. 356 — 46% Male 36% Gay/lesbian (1) LGB-specific Suicidal ideation
(2016)75 54% Female 64% Bisexual victimization
17% Trans (2) General
bullying/victimization
at school

(continued)
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Table 4. (Continued)
Author (year) N Age (years) Gender (%) Sexual orientation (%) Minority stressor(s) Outcome(s)
Ybarra et al. 2162 13–18 (M GLQ = 16.1, 35% Cisgender male 59% Gay/lesbian/queer (1) Peer harassment Suicidal ideation
(2015)76 M bisexual = 15.9, 45% Cisgender female 30% Bisexual (2) Bully victimization
M questioning = 15.4) 19% Transgender or 10% Questioning/
nonconforming unsure/other
Russell et al. 245 21–25 (M = 22.8) 47% Male — Adolescent school (1) Suicidal ideation
(2011)77 45% Female victimization due to (2) Suicide attempt
9% Transgender LGBT status
Bontempo and 315 M = 16.2 38% Female — School victimization Suicide attempts
D’Augelli 62% Male
(2002)a,78
Hegna and 407 15–25 (M = 21.7) 57% Male 80% Gay/lesbian (1) Physical violence Suicide attempt
Wichstrøm 43% Female 8% Bisexual associated with sexual

231
(2007)a,79 9% Gay with elements orientation
of heterosexuality (2) Anti-gay harassment
2% Hetero with
elements
of same-sex
attraction
1% Unsure
Hill and Pettit 50 — — 28% Gay/lesbian Perceived acceptance of Suicidal ideation
(2012)a,80 52% Bisexual sexual orientation
8% Unsure/questioning
12% Other
a
Not included in a meta-analysis.
GLQ, gay, lesbian, queer; LGB, lesbian, gay, bisexual; LGBQ, lesbian, gay, bisexual, queer; M, mean.
 232 DE LANGE ET AL.

were included to assess this association. However, these
three studies showed that discrimination was significantly
associated with suicide attempts.
General victimization and suicidality
A total of k = 9 studies3,17,21,33,34,61,63,67,75 and 14 effect
sizes assessed the association between victimization and sui-
cidal ideation (total N = 10,505). Among these studies, two
included only transgender participants.3,21 Among ado-
lescents and young adults, victimization was significantly
associated with higher levels of suicidal ideation (overall cor-
relation r = 0.23, p = 0.001). See Supplementary Figure S4
for a forest plot. One study did not provide sufficient data
to calculate an effect size.78
A total of k = 6 studies17,34,60,61,66,67 and 11 effect sizes
assessed the association between victimization and suicide
Downloaded by University of Groningen Netherlands from www.liebertpub.com at 03/13/23. For personal use only.
lation r = 0.10, p = 0.053). See Supplementary Figure S9 for
a forest plot.
A total of k = 6 studies5,7,15,39,65,70 and 10 effect sizes
assessed the association between internalized homopho-
bia and transphobia and suicide attempts (total N = 6236).
Among these studies, one included only transgender partici-
pants.7 Internalized homophobia and transphobia were
not significantly associated with suicide attempts (overall
OR = 1.15, 95% CI [0.97–1.35], p = 0.094). See Supplemen-
tary Figure S10 for a forest plot.
Moderator analyses
For most significant associations between a minority stres-
sor and a suicidality outcome, we were able to conduct mod-
eration analyses for sampling strategy. However, included
studies for negative family treatment only consisted of non-

attempts (total N = 8562). None of the studies included probability samples, and we were unable to examine a mod-
only transgender participants. Adolescents and young adults eration analysis for this minority stressor. We did not find
who experienced victimization were more likely to report significant moderation by sampling strategy for the associa-
suicide attempts (overall OR = 1.98, 95% CI [1.64–2.39], tions of LGBT bias-based victimization, general victimiza-
p < 0.001). See Supplementary Figure S5 for a forest plot. tion, and bullying with either suicidal ideation or suicide
attempt (Table 5).
Bullying and suicidality
A total of k = 4 studies36,38,62,76 and 10 effect sizes Additional minority stressors
assessed the association between bullying and suicidal idea- We were unable to include some studies in a meta-analysis
tion (total N = 21,513). Among these studies, one included because there were too few effect sizes for a single minority
only transgender participants.38 Adolescents and young stressor and a suicidality outcome. One study80 among LGB
adults who experienced bullying were more likely to report (lesbian, gay, bisexual) college students found that higher
suicidal ideation (overall OR = 2.31, 95% CI [1.53–3.47], perceived acceptance is significantly associated with lower
p = 0.001). See Supplementary Figure S6 for a forest plot. suicidal ideation. Another study28 among sexual minority
Only two studies35,62 provided data on bullying and suicide college students showed that a higher level of experienced
attempts. Both studies found that adolescents and young discrimination and expected rejection (combined) was asso-
adults who were bullied reported significantly more suicide ciated with a higher level of suicidal ideation.
attempts. In addition, some of the studies that were included in
the meta-analytic study also examined other additional mi-
Negative family treatment and suicidality nority stressors that we could not include in a meta-analysis
A total of k = 5 studies5,6,38,73,74 and nine effect sizes (again due to few effect sizes). For example, LGB coming
assessed the association between negative family treatment
and suicidal ideation (total N = 5356). Among these studies, Table 5. Moderation Analyses by Minority
one included only transgender participants.38 Participants Stressor and Suicidality Outcome
who experienced negative family treatment were more likely
Probability samplea
to report suicidal ideation (overall OR = 2.01, 95% CI [1.57–
2.57], p < 0.001). See Supplementary Figure S7 for a forest B (SE) p k
plot.
A total of k = 6 studies5,6,27,37,71,74 and 13 effect sizes were LGBT bias-based victimization
included to assess the association between negative family Suicidal ideationb 0.09 (0.27) 0.752 17
treatment and suicide attempts (total N = 5247). None of Suicide attemptsb 0.22 (0.39) 0.574 24
the studies included only transgender participants. Partici- General victimization
pants who experienced negative family treatment were Suicidal ideationc 0.09 (0.16) 0.586 14
more likely to report suicide attempts (overall OR = 1.80, Suicide attemptsb 0.16 (0.33) 0.631 11
95% CI [1.42–2.28], p < 0.001). See Supplementary Figure Negative family treatment
S8 for a forest plot. Suicidal ideationb — — —
Suicide attemptsb — — —
Internalized homophobia and transphobia and suicidality Bullying
Suicidal ideationb 0.01 (0.44) 0.974 10
A total of k = 7 studies5,7,15,65,69,70,72 and 11 effect sizes
assessed the association between internalized homophobia Data presented are the coefficients and p-values of the moderator
and transphobia and suicidal ideation (total N = 6940). analysis with k = number of effect sizes included in the analysis.
a
Reference category is nonprobability sample.
Among these studies, one included only transgender partici- b
B is expressed in log odds.
pants.7 Internalized homophobia and transphobia were not c
B is expressed in Fisher’s z’s.
significantly associated with suicidal ideation (overall corre- SE, standard error.
 MINORITY STRESS AND SUICIDALITY: A META-ANALYSIS
out stress,4 perceived stigma,15,72 and friendships lost after
coming out39 were significantly associated with either sui-
cidal ideation or suicide attempts among LGBT adolescents
and young adults.
Discussion
This meta-analytic study examined to what extent differ-
ent types of minority stressors are associated with suicidal
ideation and suicide attempts among LGBT adolescents
and young adults, and whether there is a difference by sam-
pling strategy in the strength of these associations. We found
that 7 of 10 overall effect sizes showed a significant associ-
ation between minority stressors and suicidal ideation and
suicide attempts for LGBT adolescents and young adults.
Although overall effect sizes were small, adolescents and
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young adults who experienced LGBT bias-based victimi-
zation, general victimization, bullying, or negative family
treatment were more likely to report suicidal ideation and
suicide attempts.
These findings are in line with theoretical frameworks
such as the minority stress framework9 and its extensions10,11
that theorize how excess stress and minority stress in partic-
ular are associated with negative mental health outcomes, in-
cluding suicidality. Our findings are also in line with the only
two existing meta-analyses on minority stress and suicidal-
ity,23,24 showing that victimization is an important contribu-
tor to developing suicidality among LGBT adolescents and
young adults.
In the current study, we did not find an association of dis-
crimination with suicidal ideation for LGBT adolescents and
young adults. Inconsistent with a previous meta-analysis on
internalized homophobia and mental health (not specifically
among youth),14 we did not find an overall association be-
tween internalized homophobia and transphobia and suicidal
ideation or suicide attempts. For all other associations, we
found small effect sizes. The small and nonsignificant overall
effect sizes may be explained by aspects from the integrated
motivational–volitional model (IMV) of suicidal behavior81
or the ideation-to-action framework.8 The IMV model posits
that a combination of background factors such as stressful
events and individual characteristics can influence feelings
of humiliation and entrapment.
Subsequently, an interaction of humiliation and entrap-
ment with factors such as rumination, and lack of social sup-
port influences the development of suicidal ideation.81 The
ideation-to-action framework suggests that a combination
of emotional or psychological pain and hopelessness contrib-
ute to the development of suicidal ideation.8
Taken together, both models indicate that the interaction
of several factors contributes to the development of suicidal
ideation. In this meta-analytic study, we only assessed asso-
ciations between single minority stressors and suicidal idea-
tion or suicide attempt. It is possible that interactions of
minority stressors with interpersonal factors would give
more insight into these associations. In addition, for suicidal
ideation to develop, LGBT youth may have to endure these
minority stressors over a prolonged period, or they would
have to occur in combination with other minority stressors.
Furthermore, our findings point to the need for future re-
search on the meaning of internalized transphobia and homo-
phobia for LGBT young individuals, and whether these
233
constructs can be readily compared. In the association be-
tween internalized homophobia and transphobia with sui-
cidal ideation and suicide attempts, we were only able to
include one study assessing the association between inter-
nalized transphobia and suicide outcomes for transgender
youth.7 Thus, it is not clear to what extent internalized trans-
phobia is associated with suicidality.
In addition, some included studies used a measure that
assessed internalized homophobia65 or internalized hetero-
sexism,70 whereas they also included transgender individuals
in the study. Because transgender individuals may experi-
ence stress related to their gender identity, in some cases in
addition to stress related to their sexual orientation, these ex-
periences may not be fully grasped by measures of internal-
ized homophobia.10
Furthermore, in this meta-analytic study, we assessed
whether sampling strategy affected the strength of the asso-
ciation between minority stress and suicidal ideation and sui-
cide attempts, and we found no support for this. Similar to
research that did not find differences between a commu-
nity and a general sample regarding associations of minority
stress and psychological distress,26 our findings indicate that
the strength of associations between minority stress and sui-
cidality did not differ between probability or nonprobability
samples.
Moreover, because sexual orientation and gender identity
were assessed in different ways across the studies, we were
unable to assess moderation by sexual orientation or gender
identity. Differences by sexual orientation and gender iden-
tity are important to consider because there may be important
group differences in the impact of some minority stressors on
suicidality.82–85 Research on differences by sexual orienta-
tion and gender identity is still limited, and more research
is needed to understand their role in the development of sui-
cidality among LGBT young individuals.
Age also may play a role in the association between mi-
nority stress and suicidality. However, we were unable to as-
sess age as a moderator in the associations between minority
stress and suicidal ideation and suicide attempts because we
were limited by the ages reported and included in the meta-
analyses. Age range varied considerably across included
studies; hence, it was not possible to include age as a moder-
ator. Previous literature among sexual minority young indi-
viduals indicates that LGB individuals are at highest risk
for suicidal thoughts during adolescence compared with
young adulthood.86,87 Future in-depth studies of age- and
cohort-effects of adolescents and young adults may be able
to expand our knowledge of particularly risky developmental
stages.88,89
Strengths, limitations, and future directions
To the best of our knowledge, this is the first meta-analytic
study that examined associations between different types of
minority stressors and suicidal ideation and suicide attempts
among LGBT adolescents and young adults. Although em-
pirical work from past decades has shown the negative
impact of minority stress on mental health outcomes, we
were able to synthesize and quantify these associations
and examine potential group differences in the strength of
these associations. This meta-analytic study also has some
limitations. First, not all studies assessed or reported sexual
 234
orientation and gender identity in the same way, and most
studies did not provide separate effect sizes for the associa-
tion of minority stress and suicidal ideation or suicide at-
tempts by sexual orientation or gender identity.
In addition, bisexual participants were underrepresented
in the included samples, and few studies had included exclu-
sively transgender or cisgender adolescents and young adults
or provided effect sizes for transgender or cisgender partici-
pants. Hence, we were unable to assess moderation by sexual
orientation and gender identity. Second, as the current meta-
analytic study only included correlational and cross-sectional
research, we cannot make statements about the causality of
the relationship between minority stressors and suicidal ide-
ation. Third, the associations in the current meta-analytic
study may be inflated because we did not include the findings
from unpublished articles. Finally, few studies examined
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proximal stressors, such as concealment and expected rejec-
tion. Consequently, we were unable to assess the association
between these stressors and suicidality.
Future studies should focus on potential group differences
in the association between minority stress and suicidal idea-
tion and suicide attempts and whether some groups are more
vulnerable to the impact of particular minority stressors. This
would improve our understanding of risk and resilience
among LGBT young individuals. Furthermore, research
should include a range of minority stressors in interaction
with other important individual characteristics or factors to
examine suicidality development over time, during adoles-
cence, and into young adulthood. For example, interactions
between minority stressors and factors proposed by the
IMV model81 or the ideation-to-action framework.8 Last,
looking at minority stress with an intersectional lens could
provide helpful insights on adequate health care and policies
for LGBT youth.
Conclusion
Overall, this meta-analysis shows a clear and concerning
link between minority stress and suicidal ideation and sui-
cide attempts among LGBT adolescents and young adults.
Given the high rates of suicidal ideation and suicide attempts
among LGBT adolescents and young adults and the evident
role that interpersonal rejection and stigma play, our research
underlines the need for prevention and intervention work fo-
cused on peer and family victimization and rejection.
Authors’ Contributions
All authors contributed to the conception and design of the
study. Data extraction was performed by J.d.L and was sup-
ported by L.B. Analyses were conducted by J.d.L. The first
draft of the article was written by J.d.L. All authors critically
reviewed and revised multiple drafts of the article. All au-
thors approved the final article before submission.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
This study was supported by ZonMw, The Netherlands
Organisation for Health Research and Development (grant
no. 531 004005, 2017).
DE LANGE ET AL.
Supplementary Material
Supplementary Figure S1
Supplementary Figure S2
Supplementary Figure S3
Supplementary Figure S4
Supplementary Figure S5
Supplementary Figure S6
Supplementary Figure S7
Supplementary Figure S8
Supplementary Figure S9
Supplementary Figure S10
References
1. Marshal MP, Dietz LJ, Friedman MS, et al.: Suicidality and
depression disparities between sexual minority and hetero-
sexual youth: A meta-analytic review. J Adolesc Health 2011;
49:115–123.
2. Miranda-Mendizábal A, Castellvı́ P, Parés-Badell O, et al.:
Sexual orientation and suicidal behaviour in adolescents and
young adults: Systematic review and meta-analysis. Br J
Psychiatry 2017;211:77–87.
3. Perez-Brumer A, Day JK, Russell ST, Hatzenbuehler ML:
Prevalence and correlates of suicidal ideation among trans-
gender youth in California: Findings from a representative,
population-based sample of high school students. J Am
Acad Child Adolesc Psychiatry 2017;56:739–746.
4. Baams L, Grossman AH, Russell ST: Minority stress and mech-
anisms of risk for depression and suicidal ideation among les-
bian, gay, and bisexual youth. Dev Psychol 2015;51:688–696.
5. Goldbach JT, Schrager SM, Mamey MR: Criterion and di-
vergent validity of the sexual minority adolescent stress in-
ventory. Front Psychol 2017;8:2057.
6. Ryan C, Huebner D, Diaz RM, Sanchez J: Family rejection
as a predictor of negative health outcomes in white and lat-
ino lesbian, gay, and bisexual young adults. Pediatrics 2009;
123:346–352.
7. Kuper LE, Adams N, Mustanski BS: Exploring cross-sectional
predictors of suicide ideation, attempt, and risk in a large
online sample of transgender and gender nonconforming
youth and young adults. LGBT Health 2018;5:391–400.
8. Klonsky ED, May AM: The three-step theory (3ST): A new
theory of suicide rooted in the ‘‘ideation-to-action’’ frame-
work. Int J Cogn Ther 2015;8:114–129.
9. Meyer IH: Prejudice, social stress, and mental health in les-
bian, gay, and bisexual populations: Conceptual issues and
research evidence. Psychol Bull 2003;129:674–697.
10. Testa RJ, Habarth J, Peta J, et al.: Development of the
gender minority stress and resilience measure. Psychol
Sex Orientat Gend Divers 2015;2:65–77.
11. Hendricks ML, Testa RJ: A conceptual framework for clin-
ical work with transgender and gender nonconforming cli-
ents: An adaptation of the minority stress model. Prof
Psychol Res Pract 2012;43:460–467.
12. Baams L: Disparities for LGBTQ and gender nonconform-
ing adolescents. Pediatrics 2018;141:1–5.
13. Kiekens W, la Roi C, Bos HMW, et al.: Explaining health
disparities between heterosexual and LGB adolescents by
integrating the minority stress and psychological mediation
frameworks: Findings from the TRAILS Study. J Youth
Adolesc 2020;49:1767–1782.
14. Newcomb ME, Mustanski B: Internalized homophobia and
internalizing mental health problems: A meta-analytic re-
view. Clin Psychol Rev 2010;30:1019–1029.
 MINORITY STRESS AND SUICIDALITY: A META-ANALYSIS
15. Lea T, de Wit J, Reynolds R: Minority stress in lesbian,
gay, and bisexual young adults in Australia: Associations
with psychological distress, suicidality, and substance use.
Arch Sex Behav 2014;43:1571–1578.
16. Poteat VP, Mereish EH, DiGiovanni CD, Koenig BW: The
effects of general and homophobic victimization on adoles-
cents’ psychosocial and educational concerns: The impor-
tance of intersecting identities and parent support. J Couns
Psychol 2011;58:597–609.
17. Taliaferro LA, Muehlenkamp JJ: Nonsuicidal self-injury
and suicidality among sexual minority youth: Risk factors
and protective connectedness factors. Acad Pediatr 2017;
17:715–722.
18. Mustanski B, Liu RT: A longitudinal study of predictors of
suicide attempts among lesbian, gay, bisexual, and transgen-
der youth. Arch Sex Behav 2013;42:437–448.
19. Huebner DM, Rebchook GM, Kegeles SM: Experiences of
Downloaded by University of Groningen Netherlands from www.liebertpub.com at 03/13/23. For personal use only.
harassment, discrimination, and physical violence among
young gay and bisexual men. Am J Public Health 2004;
94:1200–1203.
20. Burton CM, Marshal MP, Chisolm DJ, et al.: Sexual
minority-related victimization as a mediator of mental
health disparities in sexual minority youth: A longitudinal
analysis. J Youth Adolesc 2013;42:394–402.
21. Hatchel T, Valido A, De Pedro KT, et al.: Minority stress
among transgender adolescents: The role of peer victimiza-
tion, school belonging, and ethnicity. J Child Fam Stud
2019;28:2467–2476.
22. Button DM, Worthen MGF: General strain theory for
LGBQ and SSB youth: The importance of intersectionality
in the future of feminist criminology. Fem Criminol 2014;9:
270–297.
23. Hatchel T, Polanin JR, Espelage DL: Suicidal thoughts and
behaviors among LGBTQ youth: Meta-analyses and a sys-
tematic review. Arch Suicide Res 2021;25:1–37.
24. Williams AJ, Jones C, Arcelus J, et al.: A systematic review
and meta-analysis of victimisation and mental health preva-
lence among LGBTQ+ young people with experiences of
selfharm and suicide. PLoS One 2021;16:e0245268.
25. Krueger EA, Fish JN, Hammack PL, et al.: Comparing na-
tional probability and community-based samples of sex-
ual minority adults: Implications and recommendations
for sampling and measurement. Arch Sex Behav 2020;49:
1463–1475.
26. Kuyper L, Fernee H, Keuzenkamp S: A comparative analy-
sis of a community and general sample of lesbian, gay, and
bisexual individuals. Arch Sex Behav 2016;45:683–693.
27. Rimes KA, Shivakumar S, Ussher G, et al.: Psychosocial
factors associated with suicide attempts, ideation, and future
risk in lesbian, gay, and bisexual youth: The Youth Chances
study. Crisis 2018;40:83–92.
28. Muehlenkamp JJ, Hilt LM, Ehlinger PP, McMillan T: Non-
suicidal self-injury in sexual minority college students: A
test of theoretical integration. Child Adolesc Psychiatry
Ment Health 2015;9:1–8.
29. Wilton L, Chiasson MA, Nandi V, et al.: Characteristics and
correlates of lifetime suicidal thoughts and attempts among
young black men who have sex with men (MSM) and trans-
gender women. J Black Psychol 2018;44:273–290.
30. Liu RT, Mustanski BS: Suicidal ideation and self-harm in
lesbian, gay, bisexual, and transgender youth. Am J Prev
Med 2012;42:221–228.
31. Woodford MR, Weber G, Nicolazzo Z, et al.: Depression
and attempted suicide among LGBTQ college students: Fos-
235
tering resilience to the effects of heterosexism and cisgen-
derism on campus. J Coll Stud Dev 2018;59:421–438.
32. Thoma BC, Huebner DM: Health consequences of racist
and antigay discrimination for multiple minority adoles-
cents. Cultur Divers Ethnic Minor Psychol 2013;19:404–
413.
33. Poteat VP, Aragon SR, Espelage DL, Koenig BW: Psycho-
social concerns of sexual minority youth: Complexity and
caution in group differences. J Consult Clin Psychol 2009;
77:196–201.
34. Hatchel T, Ingram KM, Mintz S, et al.: Predictors of suicidal
ideation and attempts among LGBTQ adolescents: The roles
of help-seeking beliefs, peer victimization, depressive
symptoms, and drug use. J Child Fam Stud 2019;28:2443–
2455.
35. Duong J, Bradshaw C: Associations between bullying and
engaging in aggressive and suicidal behaviors among sex-
ual minority youth: The moderating role of connectedness.
J Sch Health 2014;84:636–645.
36. Feinstein BA, Turner BC, Beach LB, et al.: Racial/ethnic
differences in mental health, substance use, and bullying
victimization among self-identified bisexual high school-
aged youth. LGBT Health 2019;6:174–183.
37. Walls NE, Freedenthal S, Wisneski H: Suicidal ideation and
attempts among sexual minority youths receiving social ser-
vices. Soc Work 2008;53:21–29.
38. Peng K, Zhu X, Gillespie A, et al.: Self-reported rates of
abuse, neglect, and bullying experienced by transgender
and gender-nonbinary adolescents in China. JAMA Netw
open 2019;2:e1911058.
39. Puckett JA, Horne SG, Surace F, et al.: Predictors of sex-
ual minority youth’s reported suicide attempts and mental
health. J Homosex 2017;64:697–715.
40. Assink M, Wibbelink CJM: Fitting three-level meta-
analytic models in R: A step-by-step tutorial. Quant Meth-
ods Psychol 2016;12:154–174.
41. Van den Noortgate W, López-López JA, Marı́n-Martı́nez F,
Sánchez-Meca J: Three-level meta-analysis of dependent
effect sizes. Behav Res Methods 2013;45:576–594.
42. Borenstein M, Hedges LV., Higgins JPT, Rothstein HR: A
basic introduction to fixed-effect and random-effects mod-
els for meta-analysis. Res Synth Methods 2010;1:97–111.
43. Viechtbauer W: Metafor. Available at https://cran.r-project
.org/web/packages/metafor/metafor.pdf Accessed May 18,
2020.
44. Borenstein M, Hedges LV, Higgins JPT, Rothstein HR:
Introduction to Meta-Analysis, 1st ed. West Sussex: John
Wiley & Sons, Ltd, 2009.
45. Lipsey MW, Wilson DB: Practical Meta-Analysis. Thou-
sand Oaks, CA: Sage Publications, Inc., 2001.
46. Moher D, Liberati A, Tetzlaff J, et al.: Preferred reporting
items for systematic reviews and meta-analyses: The
PRISMA statement. PLoS Med 2009;6:e1000097.
47. Button DM: Understanding the effects of victimization:
Applying general strain theory to the experiences of
LGBQ youth. Deviant Behav 2016;37:537–556.
48. Eisenberg ME, McMorris BJ, Gower AL, Chatterjee D: Bul-
lying victimization and emotional distress: Is there strength
in numbers for vulnerable youth? J Psychosom Res 2016;86:
13–19.
49. Espelage DL, Merrin GJ, Hatchel T: Peer victimization and
dating violence among LGBTQ youth: The impact of school
violence and crime on mental health outcomes. Youth Vio-
lence Juv Justice 2018;16:156–173.8
 236
50. Gnan GH, Rahman Q, Ussher G, et al.: General and
LGBTQ-specific factors associated with mental health and
suicide risk among LGBTQ students. J Youth Stud 2019;
22:1393–1408.
51. Hershberger SL, D’Augelli AR: The impact of victimization
on the mental health and suicidality of lesbian, gay, and bi-
sexual youths. Dev Psychol 1995;31:65–74.
52. Savin-Williams RC, Ream GL: Suicide attempts among
sexual-minority male youth. J Clin Child Adolesc Psychol
2003;32:509–522.
53. Chen R, Zhu X, Wright L, et al.: Suicidal ideation
and attempted suicide amongst Chinese transgender per-
sons: National population study. J Affect Disord 2019;
245:1126–1134.
54. D’Augelli AR, Hershberger SL: Lesbian, gay, and bisexual
youth in community settings: Personal challenges and men-
tal health problems. Am J Community Psychol 1993;21:
Downloaded by University of Groningen Netherlands from www.liebertpub.com at 03/13/23. For personal use only.
421–448.
55. Friedman MS, Koeske GF, Silvestre AJ, et al.: The impact
of gender-role nonconforming behavior, bullying, and so-
cial support on suicidality among gay male youth. J Adolesc
Health 2006;38:621–623.
56. McDermott E, Hughes E, Rawlings V: The social determi-
nants of lesbian, gay, bisexual and transgender youth suici-
dality in England: A mixed methods study. J Public Health
(Oxf) 2018;40:e244–e251.
57. McKay T, Berzofsky M, Landwehr J, et al.: Suicide etiology
in youth: Differences and similarities by sexual and gender
minority status. Child Youth Serv Rev 2019;102:79–90.
58. Wang PW, Ko NY, Hsiao RC, et al.: Suicidality among gay
and bisexual men in Taiwan: Its relationships with sexuality
and gender role characteristics, homophobic bullying vic-
timization, and social support. Suicide Life Threat Behav
2019;49:466–477.
59. Turpin R, Boekeloo B, Dyer T: Sexual identity modifies the
association between bullying and suicide planning among
adolescents with same-sex sexual partners. J LGBT Youth
2019;16:300–316.
60. Albuquerque GA, dos Santos Figueiredo FW, da Silva Paiva
L, et al.: Association between violence and drug consump-
tion with suicide in lesbians, gays, bisexuals, transvestites,
and transsexuals: Cross-sectional study. Salud Ment 2018;
41:131–138.
61. Blosnich J, Bossarte R: Drivers of disparity: Differences in
socially based risk factors of self-injurious and suicidal be-
haviors among sexual minority college students. J Am Coll
Health 2012;60:141–149.
62. Boyas JF, Villarreal-Otálora T, Alvarez-Hernandez LR,
Fatehi M: Suicide ideation, planning, and attempts: The
case of the Latinx LGB youth. Health Promot Perspect
2019;9:198–206.
63. D’Augelli AR, Pilkington NW, Hershberger SL: Incidence
and mental health impact of sexual orientation victimization
of lesbian, gay, and bisexual youths in high school. Sch Psy-
chol Q 2002;17:148–167.
64. D’Augelli AR, Grossman AH, Salter NP, et al.: Predicting
the suicide attempts of lesbian, gay, and bisexual youth. Sui-
cide Life Threat Behav 2005;35:646–660.
65. Gibbs JJ, Goldbach J: Religious conflict, sexual identity,
and suicidal behaviors among LGBT young adults. Arch
Suicide Res 2015;19:472–488.
DE LANGE ET AL.
66. Goodenow C, Szalacha L, Westheimer K: School support
groups, other school factors, and the safety of sexual minor-
ity adolescents. Psychol Sch 2006;43:573–589.
67. Hatchel T, Merrin GJ, Espelage AD: Peer victimization and
suicidality among LGBTQ youth: The roles of school be-
longing, self-compassion, and parental support. J LGBT
Youth 2019;16:134–156.6.
68. Hershberger SL, Pilkington NW, D’Augelli AR: Predictors
of suicide attempts among gay, lesbian and bisexual youth.
J Adolesc Res 1997;12:477–497.
69. Kuyper L, Bos HMW: Mostly heterosexual and lesbian/
gay young adults: Differences in mental health and sub-
stance use and the role of minority stress. J Sex Res 2016;
53:731–741.
70. Livingston NA, Heck NC, Flentje A, et al.: Sexual minority
stress and suicide risk: Identifying resilience through per-
sonality profile analysis. Psychol Sex Orientat Gend Divers
2015;2:321–328.
71. Nguyen TQ, Bandeen-Roche K, German D, et al.: Negative
treatment by family as a predictor of depressive symptoms,
life satisfaction, suicidality, and tobacco/alcohol use in
Vietnamese sexual minority women. LGBT Health 2016;
3:357–365.
72. Reyes MES, Davis RD, David AJA, et al.: Stigma burden as
a predictor of suicidal behavior among lesbians and gays in
the Philippines. Suicidol Online 2017;8:1–10.
73. Stahlman S, Grosso A, Ketende S, et al.: Suicidal ideation
among MSM in three West African countries: Associations
with stigma and social capital. Int J Soc Psychiatry 2016;62:
522–531.
74. Van Bergen DD, Bos HMW, Van Lisdonk J, et al.: Victim-
ization and suicidality among Dutch lesbian, gay, and bisex-
ual youths. Am J Public Health 2013;103:70–72.
75. Whitaker K, Shapiro VB, Shields JP: School-based protec-
tive factors related to suicide for lesbian, gay, and bisexual
adolescents. J Adolesc Health 2016;58:63–68.
76. Ybarra ML, Mitchell KJ, Kosciw JG, Korchmaros JD:
Understanding linkages between bullying and suicidal idea-
tion in a national sample of LGB and heterosexual youth in
the United States. Prev Sci 2015;16:451–462.
77. Russell ST, Ryan C, Toomey RB, et al.: Adolescent school
victimization: Implications for young adult health. J Sch
Health 2011;81:223–230.
78. Bontempo DE, D’Augelli AR: Effects of at-school victimi-
zation and sexual orientation on lesbian, gay, or bisexual
youths’ health risk behavior. J Adolesc Health 2002;30:
364–374.
79. Hegna K, Wichstrøm L: Suicide attempts among Norwegian
gay, lesbian and bisexual youths: General and specific risk
factors. Acta Sociol 2007;50:21–37.
80. Hill RM, Pettit JW: Suicidal ideation and sexual orientation
in college students: The roles of perceived burdensomeness,
thwarted belongingness, and perceived rejection due to
sexual orientation. Suicide Life Threat Behav 2012;42:
567–579.
81. O’Connor RC, Kirtley OJ: The integrated motivational-
volitional model of suicidal behaviour. Philos Trans R Soc
B Biol Sci 2018;373:20170268.
82. Mereish EH, Peters JR, Yen S: Minority stress and relational
mechanisms of suicide among sexual minorities: Subgroup
differences in the associations between heterosexist
 MINORITY STRESS AND SUICIDALITY: A META-ANALYSIS 237

victimization, shame, rejection sensitivity, and suicide risk. 88. Russell ST, Fish JN: Sexual minority youth, social change,
Suicide Life Threat Behav 2019;49:547–560. and health: A developmental collision. Res Hum Dev 2019;
83. Salway T, Ross LE, Fehr CP, et al.: A systematic review and 16:5–20.
meta-analysis of disparities in the prevalence of suicide ide- 89. Fish JN, Rice CE, Lanza ST, Russell ST: Is young adulthood
ation and attempt among bisexual populations. Arch Sex a critical period for suicidal behavior among sexual minor-
Behav 2019;48:89–111. ities? Results from a US national sample. Prev Sci 2019;20:
84. Thoma BC, Salk RH, Choukas-Bradley S, et al.: Suicidality 353–365.
disparities between transgender and cisgender adolescents.
Pediatrics 2019;144:e20191183.
85. Toomey RB, Syvertsen AK, Shramko M: Transgender ado- Address correspondence to:
lescent suicide behavior. Pediatrics 2018;142:e20174218. Jennifer de Lange, MSc
86. Russell ST, Toomey RB: Men’s sexual orientation and sui- Department of Pedagogy and Educational Sciences
cide: Evidence for U.S. adolescent-specific risk. Soc Sci University of Groningen
Med 2012;74:523–529. Grote Rozenstraat 38
87. Fedewa AL, Ahn S: The effects of bullying and peer victim- Groningen 9712TJ
ization on sexual-minority and heterosexual youths: A quan- The Netherlands
titative meta-analysis of the literature. J GLBT Fam Stud
Downloaded by University of Groningen Netherlands from www.liebertpub.com at 03/13/23. For personal use only.

2011;7:398–418. E-mail: jennifer.de.lange@rug.nl