Making a simplistic connection ignores complexity of the issue
The link between homosexuality and the instance of people dying by suicide is not proven, writes Patricia Casey
Former president Mary McAleese gave an interview to George Hook of Newstalk 106fm earlier this week. In the course of that interview, she referred to a meeting she had with the Papal Nuncio in Dublin in 2014: "The point I made with the Nuncio was the issue of self-harm and suicide. We have, in Ireland, a very serious problem of youth suicide and we now know from the evidence that one of the most at-risk groups or cohorts within that age group of 15 to 25 is the young male homosexual."
This comment has been widely interpreted as indicating that homosexual young men are dying by suicide more commonly than non-gay men. This claim was a surprise to me because I have been publishing scientific papers on suicidal behaviour for many years, the most recent being in December 2014, but I was not aware of any Irish or international study showing that death by suicide, specifically, was higher in young gay men than in other groups. Although I am aware that a question hangs over this.
Both nationally and internationally, there are studies showing that young gay men and women are more likely than non-gay people to suffer with a range of mental health problems.
The most comprehensive of these was by King and colleagues in 2008. He combined 28 studies and analysed the data as a single unit. He found increased rates of anxiety, depression, self-harm, suicide attempts, and substance misuse. Although, he was mindful to point out that their quality was limited. Interestingly, similar findings have also been identified in gay-friendly countries, including Holland (2013).
The question is, do these mental health problems, and in particular suicidal ideation and suicide attempts, actually translate into death by suicide among LGBT people, placing them at increased risk of suicide?
It is crucially important to answer this question in order that preventive strategies can be put in place. The answer is, we don't yet know.
King, in his paper, was unable to say if this was the case. The American Association of Suicidology says: "Because no reliable data exists, we do not know whether LGBT youth die by suicide more frequently than their straight counterparts."
Sexual orientation and gender identity data are not included in death certificates, so aggregated national death data do not include this information. In addition, many LGBT youths do not disclose this information to family members and friends. As a result, sexual orientation and gender identity do not show up in psychological autopsy interviews.
Writing in the Lancet in 2009, Keith Hawton, an Oxford-based suicidologist, reported: "Rates of attempted suicide in homosexual and bisexual men and women are high but evidence is lacking for suicide."
What seems to be occurring is that suicidal ideation, suicide attempts and death by suicide are being conflated. But the differences need to be unravelled in the public mind, since regarding them as similar is an inaccurate message of despair.
Suicidal ideas are common in the general population and the majority are fleeting. Only those that have crystallised into a definite plan with suicide intent are likely to lead to suicidal behaviour. Even "suicide attempts" are defined differently in studies and some do not even provide a definition.
Also, in the mind of an individual, what constitutes a suicide attempt - or what young men and women call a suicide attempt - also varies.
Patients tell me they have attempted suicide after they have scratched their wrists following a row with a friend. Others will use the phrase to describe a clearly planned course to lead to their death. This is not to suggest that acts of self-harm are not frightening for parents and family members. Nor is it to imply that those engaging in these actions do not need help - they do. But the approach to treatment varies with the degree of planning and intent.
The only certainty is the definition of suicide, which is the action of killing oneself intentionally. Other associated terms are diverse in their meaning and muddy our discourse on the subject.
In order to show that LGBT people had higher suicide rates, it would be necessary to identify a large sample of many thousands and follow them for a number of years to identify the number of suicide deaths among the gay and straight population separately.
This would necessitate the inclusion of information on sexual orientation in the data set. Studies such as this could happen in Scandinavian countries and with certain data-sets in the US that have begun to include this information.
It would not presently be possible to do this type of study in Ireland. The long-term studies carried out in Ireland did not mention suicide nor were they designed to because the sample size was too small.
A second approach would be to carry out psychological autopsy studies and explore the sexual orientation of each person dying by suicide.
Psychological autopsy studies are the psychological equivalent of a post-mortem, but their success would depend on an accurate record of the person's orientation.
The former president's comments are very concerning because of the link she seems to have made between being gay and dying by suicide when the answer to this is uncertain at this time. Although, it is a valid question to pose.
Suicide is a serious and emotive topic and to suggest that currently there are many more young men taking their lives than would be anticipated, is based on hypothesis rather than established fact. Making a simplistic connection between self-harm, suicide attempts and suicide ignores the complexity of suicide and the many definitions of these terms that exist.
If Mrs Mc Aleese has data from peer-reviewed studies to support her claim, then I would wish to know so that I can contribute to a campaign to reduce suicide among gay men and women.
I note that in this week too, Minister James Reilly accused those opposed to gay marriage of damaging the mental health of LGBT people simply by debating the issue.
Coming from the former minister for health, who cut mental health services and reduced the funding for suicide prevention services in 2013, this is a risible claim. Ask the families of those bereaved by suicide and who protested in Dublin last year (calling him the Minister for Death) what they think of his work for the mental health of their loved ones.
Instead of trying to stifle debate, he should be campaigning for a reinstatement of the services he so cruelly cut, so that gay people with mental health problems, who may be at risk of self-harm, can access and receive the treatment they so very much deserve.
Patricia Casey is Professor of Psychiatry UCD/Mater Hospital. She is a patron of the Iona Institute.