Review

Suicidal behaviour among sexual-minority youth: a review

of the role of acceptance and support
Vita Poštuvan, Tina Podlogar, Nuša Zadravec Šedivy, Diego De Leo

Sexual-minority youth have a two to three times higher risk for suicidal behaviour than their peers. They also have Lancet Child Adolesc Health 2019
increased mental health risk factors, such as depression and substance abuse, and are often victims of homophobia Published Online
and discrimination. Available data are unable to provide a clear understanding of the psychosocial factors contributing January 21, 2019
http://dx.doi.org/10.1016/
to these unfavourable mental health indicators. In this Review, we assess current knowledge about the effect of
S2352-4642(18)30400-0
variables, such as acceptance and support, as possible risk factors or protective factors for the development of suicidal
Slovene Centre for Suicide
behaviour among sexual-minority youth (we consider youth as those aged 13–25 years). 34 articles were eventually Research, University of
included in the review process; and we contextualised their content at three different levels (society, social network, Primorska, Koper, Slovenia
and individual) before integrating the outcomes into a model. This Review shows how negative social environments (V Poštuvan PhD, T Podlogar BSc,
N Zadravec Šedivy PhD,
(such as a non-acceptant school climate), inadequate support within the closest social network, and an absence of
D De Leo DSc), and Australian
lesbian, gay, bisexual, transgender, intersex, queer or questioning support movements in communities contribute to Institute for Suicide Research
the development of suicidality in young people. Furthermore, the unsupportive reactions of others can be internalised, and Prevention, Griffith
manifesting as homophobic, biphobic, and transphobic patterns in the individual. To prevent suicidal behaviour, we University, Mount Gravatt
Campus, Brisbane, QLD,
suggest that all these aspects need to be taken into consideration when planning interventions.
Australia (D De Leo)
Correspondence to:
Introduction minorities.8,9 For the purpose of this Review, we will Dr Diego De Leo, Australian
Suicide represents a major cause of death in those aged mostly refer to all groups together. Institute for Suicide Research
25 years and younger.1 Globally, for people younger than Previous studies have indicated that in both youth and and Prevention, Griffith
University, 176 Messines Ridge
15 years old, the incidence of death by suicide has been adult populations, sexual minorities are at increased risk
Road, Mount Gravatt Campus,
reported as 0·94 per 100 000 for girls and 1·52 per of suicidal ideation, suicide attempt, and death by Brisbane, 4122 QLD, Australia
100 000 for boys,2 increasing with age. This number suicide.10–12 A longitudinal study in a large community- d.deleo@griffith.edu.au
rises to 8·4 cases per 100 000 for boys and girls aged based sample of gay and bisexual men showed that the
15–19 years.3 risk of suicide is greater during adolescence and young
Many changes that commonly occur during the adulthood: those in the youngest group (16–26 years)
develop­ment phase of adolescence are relevant to the risk were seven times more likely to have attempted suicide in
of suicide. For example, the transition to becoming more the previous year compared with those aged 45 years and
autonomous and independent frequently prevents young older.13 As sexual orientation is not usually recorded on
people from seeking help from adults or professionals in cause of death reports or death certificates, the exact
a crisis situation. When such circumstances arise, young prevalence of death by suicide for LGBTIQ people is not
people often do not recognise their severity.4 In addition, known.14 During the past decade, two systematic reviews
the development of mental health problems (such as focused on the epidemiology of suicidal behaviour among
feeling depressed or anxious) and unhealthy behaviours
(such as substance abuse) usually begins in adolescence
and is often accompanied by impulsiveness or other risk Key messages
factors for suicidal behaviour related to young age.5 • Sexual-minority youth generally have a higher risk for suicidal behaviour than their
Psychosocial factors, such as personality traits, and heterosexual peers
feelings of hopelessness or helplessness are also • The higher risk for suicidal behaviours of youth sexual minorities is a complex
recognised as important determinants of suicidal combination of common and specific risk factors related to sexual orientation and
behaviour. The interpersonal theory of suicide considers identity; social acceptance and support represent protective factors
aspects such as so-called thwarted belongingness and • Social acceptance and support can be represented at the level of societies, as public
perceived burdensomeness as the most proximal mental attitudes conform the legislative rights sexual minorities must benefit from; acceptant
states that precede the development of suicide ideation environments might prevent suicidal behaviour of young sexual minority people
across the lifespan.6 • Acceptance and support are of special importance in the case of close relationships,
Sexual orientation and gender identity also provide a such as those with friends and parents; accepting attitudes in the closest people could
framework for understanding the risk of suicide among prevent suicidal behaviour in sexual minorities
youth.1 In this period, young people are likely to be • Non-acceptance of sexual identity or orientation from societies or close networks
developing their sexual orientation (feelings of physical, might be internalised as homophobia, biphobia, transphobia, or self-stigmatisation at
emotional, or sexual attraction towards other people)7 the individual level; which can be linked to suicidal behaviour
as well as gender identity—understood as the gender, • Policy changes are required to achieve more integrated care for sexual minorities:
or genders, a person considers themselves to be defined from awareness programmes for societies to the development of more accepting
as.7 Lesbian, gay, bisexual, transgender, intersex, queer, social contexts
or questioning (LGBTIQ) people represent sexual

www.thelancet.com/child-adolescent Published online January 21, 2019 http://dx.doi.org/10.1016/S2352-4642(18)30400-0 1

 Review
Panel 1: Risk and protective factors for suicidal behaviour in sexual-minority youth
Risk factors
Common risk factors, which are often more prevalent among
sexual minorities, include:
• psychopathology: high levels of identified depression,
anxiety, alcohol abuse, drug abuse, or post-traumatic stress
disorder11,17
• having a high level of impulsivity18
• being of low socioeconomic status19 or being homeless20
• relational issues: perceived burdensomeness,6,21
interpersonal difficulties, or lack of social support22
Specific risk factors for sexual-minority youth include:
• having an experience of homelessness, being a runaway, or
being evicted from the home because of sexual preferences
or identity, which have persistent negative effects on health23
• perceived microaggressions (defined as brief and
commonplace verbal, behavioural, or environmental
indignities that communicate hostile, derogatory slights
and insults to the target person or group), which affect
mental health negatively24
Panel 2: Summary of articles focusing on the level of risk
for suicidal behaviour in sexual minority youth due to
non-acceptance and lack of support
During the review process, we found that the role of the social
factors (such as public attitudes, opinions, and acceptance) in
the development of suicidal behaviour of sexual-minority
youth could be considered at three different context levels:
• society level (12 articles): five articles focused on the direct
role of societies’ non-acceptance of sexual orientation in
suicidal behaviour, and seven articles focused on the role
of non-discriminating societal support systems in suicidal
behaviour
• close-network level, which includes family and friends
(18 articles): six articles addressed the acceptance of the
close network as a moderator in the development of
suicidal behaviour in sexual-minority youth, and 12 articles
focused on its effect in a more indirect way (through
offering support)
• individual level (four articles): the least represented
theme, with published articles addressing the issue of
internalised homophobia and shame
Three articles addressed more than one subtheme or theme;
in this case, we attributed to them the above category that
best represented the aims or findings of the study.
sexual-minority youth by comparing prevalence of
depression and suicidality with heterosexual youth.15,16
Sexual-minority individuals were found to be between
2·26 times15 and 2·92 times16 more likely to exhibit
suicidality (ideation, intent, plans, attempts, and serious
2 www.thelancet.com/child-adolescent Published online January 21, 2019 http://dx.doi.org/10.1016/S2352-4642(18)30400-0
• experience of homophobia, transphobia, self-hatred, fear, or
being shamed on social media, which are linked to self-harm25
• maternal rejection due to sexual orientation26
• homosexual or bisexual orientation as an independent risk
factor27
Protective factors
Common protective factors include:
• having a sense of belonging28
• adequate social support29
• possessing coping skills and displaying resilience30
Specific protective factors include:
• perceived parental support in cases of declaring sexual
preferences or identity26
• being in a school climate that protects sexual minorities31
• exposure to positive media representations of sexual
minorities32
• the use of self-affirming strategies or being involved in
activism33
attempts), numbers that grew with the increasing severity
of suicidal behaviour. Importantly, the prevalence of
commonly mentioned risk factors that contribute to
suicidal behaviour is also higher in sexual minorities.
Prevalence of depression, anxiety, and substance abuse
among lesbian, gay, and bisexual adults has been found to
be at least 1·5 times higher than heterosexual adults.11
Other investigations have reported additional and specific
suicide risk factors related to minority sexual orientation
(panel 1).
Although numerous studies have indicated elevated risk
of suicidal behaviour among sexual minorities, the
knowledge on exactly how different psychosocial factors
interact for a young gay, lesbian, bisexual, or transgender
person to progress towards suicidal behaviours remains
incomplete. Additionally, little research has been done on
possible protective factors. With increasing social
acceptance of sexual minorities, exploring these matters
more closely and discussing them in the framework of
changing societies could now be easier than before. This
Review aims to assess the current knowledge about the
role of psychosocial variables, such as acceptance and
support, as possible risk or protective factors for the
development of suicidal behaviour among sexual-minority
youth. For the purposes of this Review, we refer to youth
as those aged between 13 years and 25 years.
The role of psychosocial factors
To understand the roles and importance of psychosocial
factors in the development of suicidal behaviour, the
themes emerging from the published literature, in our
view, can identify three levels of psychosocial context:
society, close network, and individual (panel 2). These

contexts interact with each other because an individual’s
difficulties are likely to be interconnected at several levels
simultaneously.
Society level: public attitudes
Public attitudes toward sexual minorities have an
important role in determining the wellbeing of this group,
and vary across different cultures and historical periods.
The differences can be explained by the strength of
democratic institutions, level of economic development,
and religious context,34 however, different geocultural
regions can show commonalities. Generally, greater
acceptance of homosexuality can be found in more
developed countries, such as in northwestern Europe,
Australia, Canada, New Zealand, and the USA.35 Low
levels of acceptance appear to be evident in ex-communist
nations and Muslim countries. However, in many parts of
the world, reliable data regarding attitudes toward sexual
minorities are scarce.35
Since the end of the 1990s, relevant changes in attitudes
towards, and legislation concerning, sexual minorities
have occurred. Public events, such as gay pride parades—
which in the 1970s were only attended by a small number
of people—now attract broad masses. These increasingly
permissive attitudes have been shown by several studies.
In 2005, the World Values Survey found that the
prevalence of judgments describing homosexuality as
“never justifiable” had declined in 42 out of 51 countries
over the past 20 years.36 Although the acceptance of same-
sex attraction has increased overall, this increase is not
universal. In many countries, homosexuality is still
illegal35 and controversies exist around how legal statuses
affect diagnostic procedures, and what is considered
pathology.7,37
Media representations of sexual minorities also have an
important role in changing public attitudes.32 Nowadays,
sexual minorities are often represented in the mainstream
media; whether being featured in news stories, on talk
shows, or appearing as fictional characters. Apart from an
increase in the frequency of reporting about sexual
minorities over the past 20 years, reports often convey
more accepting attitudes towards this group.38 For many
young people, the media now aid identification with role
models and the learning of coping strategies that can help
them to face their own dilemmas.32 Alongside this, the
development of social media platforms has increased
opportunities for young people to connect with others in
a supportive atmosphere. In terms of suicidal behaviour,
all these aspects could constitute important protective
factors.32
Society level: acceptance and support, and the risk of
suicidal behaviour
At the societal level, understanding the psychosocial
determinants that might affect the development of suicidal
behaviour in sexual-minority youth possibly involves
two main factors. One factor could be the role that
www.thelancet.com/child-adolescent Published online January 21, 2019 http://dx.doi.org/10.1016/S2352-4642(18)30400-0
Review
non-acceptance of sexual minorities has on suicidal
behaviour. For a young individual experiencing same-sex
attraction in a country or environment open to homo­
sexuality, life can be very different to growing up in a
homophobic society characterised by discriminating
attitudes towards sexual minorities.35,39 LGBTIQ individuals
are more likely to experience victimisation and psycho­
logical distress in homophobic societies, and thus young
people might feel forced to conceal their sexual orientation.
However, suicidality in sexual-minority youth should not
be understood as a direct consequence of stressful life
events due to a non-accepting society.40,41 These circum­
stances should rather be considered additional risk factors
that increase the risk of suicide in adolescence, which is a
critical period for this risk in its own right.32 In their 2011
US study, Hightow-Weidman and colleagues33 found
that 85% of young men who had sex with men
experienced sexuality-related bullying, and this outcome
was significantly associated with psychopathology and
suicide attempts. Other studies support similar findings in
sexual-minority youth aged 14–19 years42 or among young
people on the trans spectrum of sexual identity.43
The harmful effects of negative attitudes towards sexual
minorities can also be observed regarding help-seeking
behaviour once an individual experiences suicidality. For
example, the attitudes of youth towards suicidal behaviour
of LGBTIQ community members following their so-
called coming out (overtly speaking out about one’s own
gender identity) were not viewed as forgiving or
empathic.44 In turn, this attitude can result in a reluctance
to seek professional help. These findings are in line with
the minority stress theory,40,41 which states a high
prevalence of violence, discrimination, harassment,
victimisation, stigmatisation, and other unpleasant
behaviours targeted at minorities are partly responsible
for the depressive symptoms and suicidality seen in this
group.11,45,46 However, some youths have been able to
reframe the social rejection of their identities by using a
variety of self-affirming strategies.43 These individuals
might respond to discrimination through activism, and
many of them are enthusiastic about the ways in which
they might impact their world in the future.43
The second important factor is represented by the
systems a society adopts to provide support for sexual
minorities. Young people struggling with their sexual
orientation or identity can benefit from support systems for
suicidal prevention. Studies have shown that anti­bullying
policies47 or initiatives such as gay–straight alliance groups
are associated with a reduced risk for suicide attempts
among lesbian and gay youth.48,49 The protective effect of a
good school climate has been found, even after controlling
for sociodemographic characteristics (sex, race, or ethnicity)
and exposure to peer victimisation.50 Lesbian, gay, and
bisexual youth living in provinces and cities with more
protective school climates report fewer past-year suicidal
thoughts.31 Furthermore, an inverse effect was also noticed,
with victimisation in the neighbourhood being linked to
3
 Review
suicidal ideation, and negative reactions at school being
related to both suicidal ideation and suicide attempts.51 Peer
and dating victim­isation (being treated badly because of
complaints about discrimination) were found to be related
to suicidality among LGBTIQ individuals, as were
perceptions of school violence and crime, which in those
cases indicated non-supportive school climates for LGBTIQ
youth.52 Victim­isation at school was also found to be a
stronger predictor of suicidal behaviour than negative
reactions from parents.51 These findings show the relevance
of fighting against negative reactions, bullying, and
victimisation towards sexual orientation, and providing
support that buffers the negative effect of these experiences
within the school systems.
Close-network level: acceptance and support from
family and friends
Close networks of an individual, such as family and
friends, and their acceptance of sexual orientations or
identities, form the next category that affects the suicidal
behaviour of sexual-minority youth. Two subthemes
emerge here; the first focuses on non-acceptance of
sexual orientation or identity of the LGBTIQ individual
by their close network. In their 1989 study, Schneider
and colleagues53 examined suicide ideation and attempts
in the previous 6 months of self-identified gay youths
attending supportive groups. The authors reported that
those who were suicidal perceived more people in the
close network as rejecting their sexuality than those who
were not suicidal, but at the same time they appeared to
be more dependent on these networks, attributing high
importance or value to them. These findings suggest
that suicidal crises could alienate the young individual
from their sources of support because they give rise to
additional feelings of shame and of burdensomeness on
others, even though emotional help from the network
would be especially important at these times. Schneider
and colleagues underlined that suicidal behaviour in gay
youths might be the by-product of both family-related
factors (family dysfunction) and social and intrapersonal
stressors involved in coming to terms with an emerging
homosexual identity.53
Parental reactions to non-heterosexual children can
serve as either risk factors or protective factors for
suicidal behaviour. For example, positive reactions and
acceptance from the mother appear to be important
protective factors.54 Family acceptance in adolescence is
associated with positive health outcomes for young
adults (higher self-esteem, better social support, and
better general health) and is protective against negative
health outcomes (depression, substance abuse, and
suicide ideation and attempts).55 Homophobic rejection
by parents has been shown to be associated with suicide
attempts, with greater severity of rejection associated
with higher risk of suicide ideation than for those
experiencing acceptance by parents.51 Also, a rejecting
maternal attitude has been shown to be more of a risk
4 www.thelancet.com/child-adolescent Published online January 21, 2019 http://dx.doi.org/10.1016/S2352-4642(18)30400-0
factor for suicide ideation than a rejecting paternal
attitude.26 Findings from Pearson and colleagues23
showed that the health risks associated with being evicted
from the home by parents due to homosexuality in
adolescence can have consequences that last into
adulthood. Sexual minority men that were rejected and
dismissed by parents were likely to report suicidal
ideation, smoking habits, and substance use as adults.23
However, not all sexual minority youth subgroups
experience the same quantity or quality of rejection. For
example, in a study done in Thailand, transgender
adolescents experienced more rejection from their family
than did their cisgender counterparts; they were more at
risk of physical punishment, financial deprivation,
exclusion from family activities, ejection from the house,
social discrimination, and suicide.56
Another important factor determining risk for suicidal
behaviour is the social support of the close network. In one
study, the majority of gay male youth and lesbian youth
who were open about their sexual orientation could
identify a clear number of people who were supportive to
them.57,58 Close friends were the most frequently reported
source of support, with almost all participants (97%) listing
at least one supportive close friend. Parents were cited by
80% of the respondents.57,58 Both gay and lesbian
individuals reported that they were from “moderately
satisfied” to “very satisfied” with the support received from
the people in their networks. In line with these findings,
family support was also shown to be significantly protective
against suicide attempts or other forms of suicidal
behaviour.59–62 Not having enough friends and feeling
lonely correlates positively with suicide ideation and
attempts.57,58 Stress and absence of social support mediates
about a third of the association between same-sex attraction
and suicidal tendencies.63 Support is especially relevant at
the time of disclosure of sexual orientation: results of a
study on young lesbian, gay, and bisexual youth done in
the late 1990s showed that those who had publicly disclosed
were generally more open about their sexual orientation
than those who had not.64 However, those who had
disclosed also reported verbal and physical abuse by family
members, and were more likely to have attempted suicide.
A history of suicide attempts was reported for 51% of those
who had disclosed, compared with 12% of those who had
not.64 Other research has shown that the presence of
mental health issues in youths can also be associated with
parents not knowing about their sexual orientation or
having negative reactions to it.65 In another study, youths
who lost a friendship when they came out as lesbian, gay,
or bisexual were at the greatest risk of suicide attempt.63
These findings underline the value of support within the
close network. The same study also found a correlation
between marginalisation by friends and psychological
maltreatment by family members or parents, and history
of suicide.63 Among sexual-minority youth, people who
have attempted suicide can be characterised by a higher
frequency of parental psychological abuse, parental
 Review

discouragement of atypical gender behaviour during

childhood, and lifetime gay-related verbal abuse.66
An important aspect of social support is perceived social Societies’ non-acceptance
of sexual minorities
closeness, represented in a warm and safe attachment
style, which has been identified in inter­vention studies as
an important protective factor for suicidal behaviour
among lesbian, gay, and bisexual adolescents.67 Studies Lack of systems in society providing
support for LGBTIQ community
show that the way that support is perceived depends on
who the provider of the support is.63 Moreover, a study has
shown that help-seeking cannot be understood in the
Non-acceptance of sexual orientation
same way for the different subgroups of sexual-minority in youth’s close network
youth.64 For example, of the four sexual-orientation
groups (heterosexual, lesbian, bisexual, and questioning),
bisexual female youth were at a characteristically high risk Lack of social support

for a combination of non-suicidal self-injury and suicidal in close network

ideation, with an inclination to rely on the informal

support of a partner, close family members, or friends
rather than professional help.68
Individual’s
non-acceptance:
Individual level: internalised (non-)acceptance internalised
Social and close-network aspects further affect the stigma and
development of suicidality at the individual level through homophobia
internalised aversion to their sexual orientation. So far,
only a few studies have explored this link, which could Society level
Close-network level
represent an important indicator of how social expectations Individual level
are absorbed and translated into an individual’s feelings.
Namely, views about oneself do not develop independently Figure: Model of the role of non-acceptance in LGBTIQ youths’ development of suicidal behavior
LGBTIQ=lesbian, gay, bisexual, transgender, intersex, queer, or questioning.
from the influences of others or society. This idea was
examined in a study on religious conflict and suicidal
behaviours among sexual-minority young adults, which sexual-minority youth could be integrated in a model that
conceptualised internalised homophobia as discomfort represents three levels: society, close network, and the
with being LGBTIQ, desire for not being LGBTIQ, and individual (figure). Non-acceptance seems to be one of
desire to change from being LGBTIQ.69 These feelings the main issues that affects suicidality, as it has been
found that social stress (eg, perceptions of prejudices by
were found to be associated with suicidal thoughts but not
with suicide attempts in the past year.69 others, victimisation experiences, or family problems)
and social support (feelings of social acceptance and
A study that compared heterosexual and lesbian or gay
people aged 16–25 years found internalised negativityperceptions that others care about an individual) mediate
about one third of the association between same-sex
towards same-sex attraction to be related to higher amounts
attraction and suicidality.63
of psychological distress (especially during the stage of
coming out) but not directly to suicidal behaviour.70 The levels of the model interact with each other since
Internalised sexual stigma was found to have a significant
individuals are unlikely to be totally isolated from society
substantial effect on hate for life as an aspect of suicidal
or cultural influences. Non-acceptance is recognised as a
ideation in Spanish and Italian gay and lesbian individuals
risk factor for, and support as protective factor against,
aged 18–35 years,71 and to be positively associated with
mental health problems and suicidal behaviour. This
model offers a suggestion of how the effect of these factors
lifetime history of suicide attempts in transgender people
on the different levels might contribute to the development
(mean age of 30 years) in Argentina.72 To summarise, at the
of suicidal behaviour. We assume that levels closer to the
individual level, non-accepting attitudes of society and
individual have a more direct influence on suicidal
close-network individuals, and related prejudices, stigma,
behaviour than the more distal ones, which is reflected by
victimisation, and dis­crimination can lead to internalised
the distance of the circles from the individual (figure).
homophobia, biphobia, or transphobia in sexual-minority
young people. These thought patterns can, in turn, At the level of society and social networks, the indirect
(but significant) role of non-acceptance of own sexual
exacerbate psychological distress and lead to feelings of
self-hatred and suicidality.39 orientation and the absence of support move the
individual into a non-favourable situation, which is—in
Interaction of non-acceptance and lack of support accordance with the minority stress theory—a risk factor
The role of non-acceptance and non-supportive en-​ for suicidal behaviour.40,41 If the people close to a sexual-
vironments as risk factors for suicidal behaviour of minority young person are non-acceptant or do not offer

www.thelancet.com/child-adolescent Published online January 21, 2019 http://dx.doi.org/10.1016/S2352-4642(18)30400-0 5

 Review
support, the effect can contribute to the risk of suicidal
behaviour. An important difference exists for the effect
of non-acceptance and support at each of the levels; with
greater proximity to the young person comes greater
effect. The most direct effect on suicidal behaviour of
this process is manifested in the internalised negative
patterns of the individuals. Young LGBTIQ people can
struggle with accepting their own sexual orientation, or
identity, because of internalised stigma or homophobia.
Resilience, or vulnerability, to mental health problems
and suicidal behaviour is associated with the ways an
individual responds to, copes with, or counteracts
stressors related to sexual minority non-acceptance.
When starting to explore their own sexuality, the young
LGBTIQ person can potentially face all mentioned
aspects of non-acceptance, which might affect mental
health outcomes. On the positive side, although societal
change is slow, progress has been noticeable in the past
two to three decades—reflected in the greater social
acceptance of sexual minorities and more encouraging
reactions of close networks (such as friends and family
in particular). This increased positivity might lead to
greater resilience of young people in coping with specific
minority stressors, diminishment of internalised stigma,
and self-acceptance. A study from the Netherlands—
where attitudes, acceptance, legal status, and rights of
sexual minorities are among the most advanced in the
world51—reflects this cascade of events.70 The authors
observed suicide risk and protective factors in
heterosexual and lesbian or gay youth, and found that,
generally, heterosexual youth reported higher suicidality
than their peers who were attracted to the same sex.70
In this study, heterosexual youth expressed more
internalised negativity, less openness to family and
others, and also less-specific community involvement
than homosexual youth.70
Conclusions and future directions
Non-acceptance and absence of support as risk factors for
suicidal behaviour can be considered at three different
levels: society, close network, and individual. The greater
acceptance of sexual minorities could have several
implications for suicidal behaviour in this group. We can
assume that young people would feel less burdened or
distressed in disclosing their sexual orientation or identity
than two decades ago. As a result, we might expect suicide
risk to decrease, and eventually sexual-minority youth
might no longer be considered a high-risk group. Greater
acceptance could encourage honesty with others, and,
hypothetically, increase the number of people prepared to
declare themselves as gay, lesbian, bisexual, transgender,
or members of other sexual minorities. Obviously, we
cannot assume that this progress will necessarily decrease
the risk of suicide. Indeed, besides acceptance, our model
suggests that sexual-minority young people also need to
have the support of others, and if not provided, number
of deaths by suicide might not decrease.
6 www.thelancet.com/child-adolescent Published online January 21, 2019 http://dx.doi.org/10.1016/S2352-4642(18)30400-0
Suggestions to minimise the risk of suicidal behaviour
in sexual-minority youth
To effectively address the problem of suicidality in
sexual-minority youth, we firstly need to secure the
availability of reliable datasets. Mortality databases
should always provide information on sexual orientation
of deceased individuals; this development would
improve the credibility of epidemiological data on
suicide in sexual minorities. Moreover, a more integrated
approach to research and prevention is needed, as
suicidal behaviour of sexual-minority youth is an issue
for several different disciplines, such as medicine,
psychology, sociology, anthropology, and law. For
example, to explore our proposed model, future studies
would need a broad enough research approach able to
address all three levels, such as qualitative research with
bottom-up principles. Exploring the proposed model
further and considering if changes in suicidal behaviour
could also be captured within it would be valuable. For
example, it would be useful to follow the experiences of
young people while they are struggling with their sexual
identity or declaration of it, and then to integrate the
acquired information in relation to the development of
their suicidal behaviour.
Future research in this field would benefit from better
methodological and conceptual standards. Here, we did
not focus on the critical evaluation of the quality of
research findings, which is a limitation of this Review.
Under­standing and conceptualisation of diverse sexual
orientations has developed with distinct pace and
sensitivity in countries around the world, but with
different timeframes. Consequently, there is considerable
variety in the quality of scientific research in the area.
Moreover, the concepts used do not have unified
definitions or common assessment procedures, and are
therefore hard to compare. As an example, sexual
orientation has been described as a continuum, rather
than a simple dichotomy of heterosexual and homosexual
orientation.73,74 A seven-point scale to measure sexual
orientation was introduced nearly 70 years ago by Kinsey
and colleagues.73 However, until now, the scale has rarely
been used in studies on suicidal behaviour of sexual-
minority youth. The model we have proposed might
provide a tentative framework to approach the problem of
standardising research on acceptance and support for
sexual-minority youth, but the overall nomenclature
issues in suicidology (eg, how we define and assess
suicide ideation) would remain.
Policy needs to emphasise a more integrated care
approach for sexual minorities. The three levels we have
identified can help to conceptualise different intervention
levels. At the societal level authorities should provide
more universal awareness programmes. Interventions
could address common myths about sexual minorities.
To prevent myths from representing an additional
problem, these awareness programmes need to start at
an early age. Another possible intervention could be

Panel 3: Creating a safe environment for sexual-minority
youth by promoting acceptance, positive coping, and
antibullying policies: practice recommendations for
schools and communities
• When exploring difficulties a young person might be
experiencing, enquire about sexual orientation47
• Use correct terminology and discourage the use of
offensive terms47
• Avoid making heterosexist assumptions47
• Offer information and resources for sexual-minority
youths (eg, books, posters, within-curriculum discussions,
workshops, support groups, and programmes with
specific topics on mental health and suicide prevention)47
• Offer resources for parents and friends of sexual-minority
individuals47
• Organise groups promoting social identification among
same-sex attracted youth, and positive support of sexual
minorities by heterosexual members of the society
(gay–straight alliance groups)20,48,49
• Implement antibullying policies50—eg, by forming a task
force on violence against sexual-minority youth47
aimed at promoting the develop­ment of compassionate
and integrative commun­ities, able to provide good living
conditions, and good quality of life to all community
members, regardless of their sexual preferences. Panel 3
provides examples of good practices at society level.
At the level of close networks, more selective and
targeted interventions would be needed, such as direct
work with relatives of sexual-minority youth to increase
their sensitivity and acceptance. The work at the level of
individuals should not only focus on psychiatric
interventions, but also emphasise greater self-acceptance
and promote resilience. For practitioners, the available
literature suggests that particular attention needs to be
given to the development of a therapeutic alliance with
sexual-minority young people.75 Acceptance and empathy
seem to be the key factors in this process; so professionals
need to be aware of these influences, especially around
the time that individuals are declaring their sexual
orientation, identity, or both.
In summary, randomised controlled studies able
to provide well documented, high-quality data on
effectiveness of different interventions are scarce in this
field. Most studies are cross-sectional in design, and
therefore provide little data that can be transferred
into policies. Future endeavours could focus on the
implement­ation of best practices at different levels. In
line with what has been discussed in this Review, we
speculate that the innermost circles of our model can
protect from the negative influences of more distal
circles. However, future studies should not only focus on
the identification of the most effective level for specific
interventions, but also try to gather information about
the synergistic effects of multilevel interventions.1
www.thelancet.com/child-adolescent Published online January 21, 2019 http://dx.doi.org/10.1016/S2352-4642(18)30400-0
Review
Search strategy and selection criteria
This narrative Review of the literature was done in accordance with international guidelines.
Articles were retrieved through PubMed, PsycINFO, and Web of Science databases including
the search terms “suicid*” and “gay”, “lesbian”, “bisexual”, “transgender”, “intersexual”, or
“lgb*”, and “youth*” or “adolesce*” with the limitation of English language and age group
filters (for adolescents 13–18 years in PubMed and 13–17 years in PsycINFO, as well as for
young adults aged 19–24 years in PubMed and 18–29 years PsycINFO). Search terms were
scouted in titles or abstracts of the papers (in PubMed and PsycINFO) or titles and topics of
the papers (in Web of Science). Based on this automated search, 182 items were returned in
PubMed, 101 in PsycINFO, and 86 in Web of Science. The search was conducted for the
period from Feb 1, 1966, to May 29, 2018. Additionally, we included one article that was
identified through other sources. After the elimination of duplicates, 288 abstracts were
screened, resulting in 85 full-texts, out of which, 34 met the eligibility criteria. Articles were
selected if they focused on the role of psychosocial factors, such as social perspectives,
attitudes, public opinions, supportive environments, and acceptance of sexual-minority
youth in connection to the broad spectrum of suicidal behaviour (including ideations,
thoughts, and attempts). We did not focus on epidemiological data or on other risk factors
rather than psychosocial ones. We excluded records if the main topic was not in line with
the aims of this Review, the connection between sexual-minority related risk factors
and suicidality was not empirically studied, or if the paper did not focus on the aspect of
social acceptance.
Contributors
All authors prepared this Review. TP and NZŠ did the initial
examination of the literature, and VP validated it. VP, TP, and NZŠ
selected the full texts of selected articles in the review process, and did
an in-depth analysis of their content; DDL supervised this process.
VP wrote the first draft of the manuscript, TP, NZŠ, and DDL
contributed to it. VP and DDL prepared the final version of the paper.
Declaration of interests
We declare no competing interests.
Acknowledgments
This Review was partially funded by the Slovenian Research Agency
(ID: J5-8244 and ID: P3-0384).
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