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Suicide Prevention among Lesbian, Gay, Bisexual, and Transgender Youth:� �A Workshop for Professionals �Who Serve Youth ��Developed by �the Suicide Prevention Resource Center

Insert Leader 1 name and Organization here

&

Insert Leader 2 name and Organization here

This training is available at http://www.sprc.org/training-institute/lgbt-youth-workshop.

July 2014

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Rationale for this Workshop

More suicidal behavior in LGBT youth

Opportunity to modify risk and protective factors

Opportunity to develop/adapt interventions to be culturally competent with LGBT youth

SPRC developed this workshop because we now have enough information to take action to prevent suicidal behavior among lesbian, gay, bisexual, and transgender (LGBT) youth.

We know that there is more suicidal behavior among LGBT youth than among youth who are not LGB and/or T.

Thanks to the research, we know some of the risk and protective factors associated with suicidal behavior. These present opportunities to intervene and make a difference in the lives of LGBT youth.

We also know the importance of cultural competence in affecting positive change in schools, youth serving organizations, and suicide prevention programs.

A note: Usually when we talk about cultural competence we mean working effectively with different ethnic, racial, and linguistic minorities by understanding and taking into consideration their experiences, knowledge, values, beliefs, attitudes, meanings, roles, and practices. As a distinct group, the LGBT community also has a culture. In addition to the positive culture that the LGBT community has been developing, its culture is also affected by the discrimination that people who are LGBT experience. As a result, LGBT youth need our special attention.

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Workshop Objectives

At the end of this training, you will be able to:

Use terminology for suicidal behavior and LGBT issues correctly
Describe research related to suicidal behavior among LGBT youth

Discuss risk and protective factors for LGBT youth and the implications

Assess your school’s or agency’s cultural competence with LGBT youth and plan next steps

Describe strategies to reduce suicidal behavior among LGBT youth

At the end of this training, you will be able to use the terminology and the research related to LGBT youth that we discuss.

You will also be able to discuss the risk and protective factors that we’re going to review from the research.

Then we’re going to take some time and bring it home, to assess individual as well as school or agency LGBT cultural competence and plan next steps.

We’ll also talk about designing program and practice adaptations.

For a small group:

I just want to take a moment to poll the group. Since it’s a small group, we’re going to use a round robin and quickly go around the room and have participants make a brief statement about the objectives listed on this slide. Specifically, how well do these objectives fit with your original hopes and/or expectations for this workshop? Do you have any other objectives for this workshop?

For a large group:

Same approach as for a small group except you ask a sample of participants to share their thoughts.

Trainer’s response:

You will have to address whether additional, suggested objectives can/will be covered in the training. You may wish to point participants to additional resources outside the training.

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Suicide

Suicide is a major public health issue, meaning:

Suicide affects large numbers of people.
Prevention is based on research that is mostly related to risk factors.

Most importantly, suicide can often be prevented.

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Suicide

Suicide is the 10th leading cause of death in the United States.¹
About 39,500 people die by suicide each year.¹
729,000 adults received medical attention and 500,000 adults reported spending at least one night in the hospital for suicide attempts in 2012.²
1.29 million adults reported attempting suicide in the past year.²�

1. Centers for Disease Control and Prevention, WISQARS, 2011.

2. Substance Abuse and Mental Health Services Administration, NSDUH, 2012.

For all U.S. residents, suicide is the 10th leading cause of death, but for some ethnic, racial, and age groups, suicide is a much more prevalent cause of death.

Each year, about 39,500 people die by suicide in the United States—that’s more than twice the number of people who die by homicide in the U.S. each year.

The death data was collected from the National Vital Statistics System, which contains data from death certificates and reports. The attempt data was collected from a large, representative national survey.

¹Centers for Disease Control and Prevention. (2011). Web-based Injury Statistics Query and Reporting System (WISQARS). Retrieved June 18, 2014 from http://www.cdc.gov/injury/wisqars/index.html

²Substance Abuse and Mental Health Services Administration. (2012). Results from the 2012 National Survey on Drug Use and Health: Mental Health Detailed Tables. Retrieved from

http://www.samhsa.gov/data/NSDUH/2k12MH_FindingsandDetTables/MHDT/NSDUH-MHDetTabsTOC2012.htm

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Youth and Young Adult Suicide

Suicide is the 2nd leading cause of death for youth and young adults ages 15–24 in the United States and the 3^rd leading cause of death for youth ages 10–14.¹
Over 4,800 youths and young adults ages 15–24 and about 280 youth ages 10–14 die by suicide each year.¹
About 1 out of every 13 high school students attempts suicide each year.²

1. Centers for Disease Control and Prevention, WISQARS, 2011.

2. Centers for Disease Control and Prevention, YRBS, 2014.

Suicide is the 2nd leading cause of death among youth and young adults ages 15 to 24 and the 3^rd leading cause of death among youth ages 10 to 14 compared to the 10^th leading cause among all age groups. From these data, the problem of suicide could be seen as having a greater relative impact on youth and young adults ages 10 to 24 when compared to other causes of death.

The rate of suicide for youth and young adults is defined as the proportion of suicides compared to the number of people in those age groups.

For youth and young adults the actual death rate is lower than for other age groups. For example, middle-aged and elderly people have higher suicide rates.

But for suicide attempts, youth and young adults ages 15 to 24 have the highest rates.

¹Centers for Disease Control and Prevention. (2011). Web-based Injury Statistics Query and Reporting System (WISQARS). Retrieved June, 18, 2014 from http://www.cdc.gov/injury/wisqars/index.html

² Centers for Disease Control and Prevention. (2014). Youth risk behavior surveillance - United States, 2013. Surveillance Summaries. MMWR, 63(4). Retrieved from http://www.cdc.gov/mmwr/pdf/ss/ss6304.pdf

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What causes suicide?

Suicide is a complex behavior, driven by multiple factors--individual, family, and social--that are more prevalent in people who die by suicide.
Although risk factors related to suicide have been identified, there are no identified causes of suicide.
Most people who die by suicide have mental illness and/or a substance use disorder.
There are other risk factors associated with suicide, including:

Previous suicide attempt(s)
Firearm ownership
Isolation
Hopelessness
Impulsivity and recklessness
Family discord and dysfunction

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Participant

Introductions

OK. Earlier we [the trainers] introduced ourselves.

Now that you’ve had a few minutes to settle in, let’s take some time for you to introduce yourselves.

Smaller participant group

Starting here [gesture to someone], let’s go around the room. When it’s your turn, please share your name, the organization you represent, and what you want to gain from attending this workshop.

Larger group

Given the size of this group, we don’t have time to hear from each of you. So, let’s just see a show of hands to get a sense of who is in the room.

Raise your hand if you...

work in suicide prevention…

work in a school…

work in child protective services or child welfare…

work as a counselor or mental health professional…

work with an LGBT organization…

work with youth in a setting I haven’t named yet…

Ask for settings that weren’t named, and feel free to comment on how broad the interest is in LGBT youth.

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Ground Rules

During the small group exercises and the large group discussions later in this workshop, we’ll be talking about two topics that can be quite difficult for some people:

(1) Suicide and (2) Sex and gender

So let’s take a moment to agree upon ground rules, so we can all feel as comfortable as possible sharing and learning from each other.

[You may wish to write ground rules on a flip chart.]

Some basic rules, which you’ve probably heard in other workshops, are:

Listen respectfully—respect others while they are talking.
Speak from your own experience instead of generalizing (Use “I” instead of “they”, “we,” and “you”).
Do not be afraid to respectfully challenge one another by asking questions, but refrain from personal attacks. Focus on ideas.
Participate to the fullest of your ability. Community growth depends on the inclusion of every voice.

Note: These ground rules came from Guide for Setting Ground Rules by Paul C. Gorski, available online at http://www.edchange.org/multicultural/activities/groundrules.html.

I will add one other rule—no cell phones or texting in this room. Cell phones can be distracting for the trainers and the participants. If you have something urgent you need to attend to, please take your call outside the room.

How about confidentiality? How would you like to handle that? [Invite suggestions.]

Other ground rules? [Invite suggestions. If you’re using a flip chart, write them down.]

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Icebreaker

Now we’re going to do a little icebreaker. First, I’ll tell a story:

Some of you may have heard of Roy and Silo, two male penguins in New York’s Central Park Zoo who, for six years, formed a couple. They behaved like penguins do when they are devoted to each other—they entwined necks, vocalized to each other… At one point they even tried to hatch a rock that resembled an egg. When the zookeepers realized that they seemed to want to parent together, they gave Roy and Silo a fertile egg that needed care to hatch. The pair of males took care of the egg and a chick, named Tango, was born. The pair raised Tango, keeping her warm and feeding her food from their beaks until she could go out into the world on her own.

(WAIT before relating to training:)

This story has a lesson for us about how the majority deals with the differences the minority has. There is a whole range of responses that we will begin to explore today—from rejection and isolation to acceptance and tolerance to alliance, advocacy, and celebration of minorities.

Stand Up/Sit Down Exercise

Now we’re going to do an exercise that may get you thinking about what it’s like to be in the minority or to be aware of being in a majority. We borrowed this exercise from the Maine Youth Action Network and the Maine Youth Suicide Prevention Program.

As I read a statement, please stand up if you identify with it. Remain standing briefly, and then sit back down. During the exercise, look around the room and see who is standing. If the statement does not apply to you, remain seated. I’ll read a number of statements.

[Trainer: Use the Stand Up/Sit Down resource sheet. Choose ahead which statements you plan to read aloud. Join in the exercise with the participants. ]

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Terms – LGBT Issues

Important distinction –

gender identity and sexual orientation

See handout –

“LGBT Glossary”

During the Stand Up/Sit Down exercise, I used terms such as “sexual orientation” and “gender identity”. So, what’s the difference between sex and gender?

Sex refers to biological differences that distinguish males from females, e.g., things like chromosomes and sex organs.
Gender refers to socially constructed roles, behaviors, activities, and attributes that a given society considers appropriate for men and women.

Think male/female (i.e., sex) versus masculine/feminine (i.e., gender)—even though, in common usage, this is not a uniform or clear-cut distinction.

Sexual orientation is a person’s romantic, emotional, and/or sexual attraction towards males, females, or both. Gender identity is one’s sense of self as male or female, or somewhere between or outside traditional genders.

“Transgender” is a term that refers to people who live differently than the gender presentation and roles expected of them by society. Transgender individuals can be straight, gay, lesbian, or bisexual. Gender identity is separate from sexual orientation. That’s why you’ll hear us say “LGB and/or T” when referring to individuals.

Please take a look at your handout titled “LGBT Glossary.” I’m going to give you a minute or two to read through it quietly… Any comments or questions?

Leader:

Questions may come up at this point or later in the workshop about language used in the transgender community, such as MTF, FTM, transmen, transgirls, transsexuals, etc.

For additional definitions, go to Transgender Terminology at

http://www.umass.edu/stonewall/uploads/listWidget/8758/trans%20terms.pdf.

Additional definitions/resources are available online. For example:

Girl's Best Friend Foundation and Advocates for Youth. Creating Safe Space for GLBTQ Youth: A Toolkit. Washington, DC: Advocates for Youth, 2005. Retrieved from http://www.advocatesforyouth.org/publications/607?task=view

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Terms – Suicidology

Suicide death
Attempted suicide
Suicidal ideation
Suicidal behavior

See handout –

“Suicidology Glossary”

In order to communicate clearly about risk of suicidal behavior among LGBT youth, we need to develop definitions of terms. The basic terms are listed on this slide.

A suicide is a death from injury, including poisoning or suffocation, where there is evidence that the injury was self‐inflicted and the person intended to kill himself or herself. A death such as a car accident or drug overdose is not considered a suicide if the person did not intend to kill himself or herself. However, it is often very difficult to determine intent.

An attempted suicide is a potentially self‐injurious act with at least some wish to die as a result of the act. The intent does not have to be 100%. If there is any intent or desire to die associated with the act, then it may be considered an actual suicide attempt. Non-suicidal self-injury, which we see a lot of, is done to relieve powerful emotions and is not a suicide attempt because there is not an intent to die. Self-injury is, however, a strong risk factor for suicide attempts.

Suicidal ideation is a term that describes thoughts of suicide, including talking about suicide. Suicidal ideation can range from fleeting thoughts and a vague “wish to be dead” to detailed planning and intent to act on the plan.

Suicidal behavior refers to all of the terms above.

Take a look at the “Suicidology Glossary” handout. Any questions or comments?

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Research Challenges

Most hospital and vital records – no information on sexual orientation or gender identity
Sexual orientation or gender identity hard to know for psychological autopsies
Respondents do not identify with these terms
Convenience sampling and small samples
Few studies include racial/ethnic data
Lack of longitudinal studies

Now that we’ve defined the words that we’re using to discuss LGBT youth suicidal behavior, we’ll move into a review of the research. Most of the research focuses on lesbian, gay, and bisexual youth, so I’m going to cover LGB youth first, and then I’ll tell you the small amount that the research tells us about transgender youth.

First, I’ll review the general limitations of the research.

Data on suicide are limited by the fact that sexual orientation is usually not included in a cause of death report or on a death certificate. Even if information on sexual orientation is included in a police or medical examiner’s report, the National Vital Statistics System that summarizes these reports at the state and national levels does not include this information. Another way data are gathered on suicide is through psychological autopsies, that is, an exploration of factors leading to the death by interviews with people close to the deceased. Yet LGBT individuals may not have disclosed their sexual orientation or gender identity to others, and if they did, family members may be unwilling to pass this information on.

Looking at other suicidal behavior, most hospital data on suicide attempts does not include sexual orientation or gender identity. Or if a hospital does collect this information, it may not be aggregated and available.

Suicidal ideation and suicide attempt data are largely based on self-reports. In surveys in which people self-report suicidal behavior, they may be asked to report their sexual orientation. However, respondents may not identify with the terms used. For example, many youth who consider themselves gay would not choose the term homosexual. Or youth who have sex with other youth of the same sex might not consider themselves gay or bisexual.

There are also a number of issues related to research methods. Many studies use convenience sampling to find subjects, and these results cannot be generalized. Or they may only be able to study a small number of people, which again cannot be generalized and precludes looking at the data by different demographics, such as race or ethnicity.

Longitudinal studies are needed to show how behaviors and risk and protective factors function over time.

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Suicide Data

A moment to remember…

Behind the data are individuals who thought about suicide, attempted suicide, or died by suicide, as well as survivors.

Before we proceed with our discussion of the research, let’s take a moment to pause.

In talking about statistics and research methodology, it’s easy to sound distant from the fact that…

We’re talking about individuals—young people—who thought about suicide, attempted suicide, or died by suicide.

Many people have lost a loved one to suicide—a son, a daughter, a brother, a sister, or a friend. Many more of us have cared about someone who attempted suicide.

Some of the people in this room may have seriously considered or attempted suicide in the past, perhaps even the recent past.

Let’s acknowledge that the discussions we’re having today may be difficult at times. If you find yourself having a hard time with our discussion at any point, feel free to speak up, ask for help, take a break, or whatever you need to do to take care of yourself.

And let’s remember that we’re not talking about “them” but “us”… our community.

(Note to trainers about the importance of acknowledging the individuals behind the data. An SPRC staff person used this slide in a presentation where she showed youth suicides for the state she was presenting in. On a break, one of the participants told the trainer, “That was my son you were talking about. Thank you for making him less anonymous and acknowledging my loss.”)

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Suicidal Ideation in LGB Youth

LGB youth are 1½ to 3 times more likely to report suicidal ideation than non-LGB youth.

Suicide Prevention Resource Center, 2008

Kann et al., 2011

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Suicidal Ideation in LGB Youth

47.3% of GB adolescent boys vs. 34.7% of non-GB adolescent boys (lifetime)

72.9% of LB adolescent girls vs. 53% of non-LB adolescent girls (lifetime)

Eisenberg & Resnick, 2006

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Suicidal Ideation in LGB Youth

42% of LGB males and 25% of LGB females ages 14-21 said they sometimes or often thought of killing themselves.

48% of LGB youth ages 14-21 said suicidal thoughts were clearly or at least somewhat related to their sexual orientation (lifetime).

D’Augelli et al., 2002

The next study about ideation that I want to refer to is from D’Augelli et al. He found that 42% of lesbian, gay, and bisexual male youth ages 14-21 and 25% of LGB females ages 14-21 said they sometimes or often thought of killing themselves. Nearly 50% of them said that their suicidal thoughts were clearly or at least somewhat related to their sexual orientation. For these youth, what kind of experiences do they have as lesbian, gay, and bisexual that lead them to think of killing themselves?

On the other hand, what about the nearly 60% of LGB youth who don’t consider suicide? Are there experiences in their lives or personality traits or cultural attitudes that keep them for considering suicide? Or are their lives going better generally?

We will be exploring these issues when we talk about risk and protective factors.

D’Augelli, Pilkington, & Hershberger. 350 LGB youth aged 14 through 21 years old who attended community-based programs in USA, Canada, New Zealand. (no heterosexual comparison group).

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Suicide Attempts in LGB Youth

LGB youth are 2 to 7 times more likely to have said they attempted suicide than non-LGB youth.¹

LGB youth attempts may be more serious, based on some initial findings about:

Intent to end their lives²
Lethality³

¹Haas et al., 2011

²Safren & Heimberg, 1999

³Remafedi et al., 1991

Based on research in a major review article by Haas et al., we can summarize that LGB youth are 2 to 7 times more likely to have said they attempted suicide than non-LGB youth.

Keep in mind that this is based on self-reports. In other words, it is based on students or youth answering survey questions about their own suicide attempts, which brings up a research question about whether LGB youth would be more or less likely to report suicide attempts. There are researchers that argue both sides of the question.

Youth who attempt suicide need our attention. Aside from medical attention, a mental health professional should do a thorough assessment of risk, and key adults need to know about the attempt and the youth’s status and plan for safety. Prior suicide attempts are one of the strongest predictors of a completed suicide. Yet many youth who attempt suicide don’t receive any medical attention or mental health services and go unrecognized.

We can also compare the seriousness of attempts made by LGB youth compared to non-LGB youth. By seriousness I mean, how strong was the intent to die when the person attempted? What was the potential lethality of the method they employed?

In a survey of LGB youth who attempted suicide, Safren and Heimberg found a stronger intent to die among LGB youth.

Remafedi found higher lethality—measured three ways:

More lethal means, such as firearms or jumping from a height
Higher rate of hospitalizations
Opportunity for rescues following attempts were less likely

Further research is needed to establish that LGB attempts are more serious because both of these studies were based on small, non-representative samples.

Safren & Heimberg, 1999. 56 LGB youth who participated in after-school programs for sexual minority youth and 48 heterosexual youth between ages 16 and 21.

Remafedi et al., 1991. 137 gay and bisexual males age 14 through 21 years old recruited from upper Midwest and Pacific Northwest.

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Suicide Attempts in LGB Youth

Sexual orientation is a stronger predictor of suicide attempts in young males compared to young females.¹
52.4% of LB females vs. 24.8% of non-LB females had attempted suicide (lifetime).²
29.0% of GB males vs. 12.6% of non-GB males had attempted suicide (lifetime).²

¹Haas et al., 2011

²Eisenberg & Resnick, 2006

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Suicide Deaths among LGB Individuals

There is no reliable or official way to determine rates of suicide deaths in people who are LGB because death reports and certificates do not usually include the person’s sexual orientation.

Haas et al., 2011

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Suicide Deaths among LGB Youth

Compared to non-LGB youth:

LGB youth have higher rates of suicide attempts.
LGB youth suicide attempts may be more serious.

The higher rate of suicide attempts, as well as the possibility that attempts among LGB youth are more serious, may mean that this group of youth has a higher rate of suicide. However, additional research is needed before we can draw that conclusion.

We can look at suicide deaths another way.

We established that lesbian, gay, and bisexual youth probably have a higher rate of suicide attempts based on a number of research studies.

Based on the disproportionate attempt rate, can we draw a conclusion about the number of suicides? For a moment, let’s look at another population—women. There are many more suicide attempts by women than men. Specifically, there are three female suicide attempts for every two male suicide attempts. And yet men die by suicide at four times the rate of women. The point here: You cannot conclude that a group that attempts suicide more often has more deaths by suicide.

Regarding gay, lesbian, and bisexual youth—they probably have a higher number of suicide attempts. But we just demonstrated that we cannot project a conclusion about the suicide rate based on the attempt rate alone. However, when we consider the seriousness of attempts—based on intent to die and lethality of means—it may be that this group actually does have a higher rate of suicide.

However, recall that the finding about the seriousness of attempts was based on small, non-representative samples. So we need larger studies that replicate these findings before we can reach this conclusion with certainty.

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Suicidal Behavior and Transgender Youth

Transgender youth:

Limited research exists.
Studies show higher rates of suicidal ideation and suicide attempts.
Risk factors: Which ones are in common with those for LGB youth?

We don’t know much about suicidal behavior in transgender youth. There is limited research, and most of the studies that are published have small samples and do not have comparison groups. Doing research about transgender youth is challenging. The national surveillance systems and surveys do not ask about gender identity. But even if they did, many transgender people are not willing to share that information publicly. Given these circumstances, the studies done so far have not been able to use randomized samples. The studies using convenience samples have findings worth noting, but they cannot be generalized to transgender youth overall.

The studies that have been done on transgender individuals do demonstrate high rates of suicidal ideation and suicide attempts. One large study of transgender adults ages 18 to 89 found among its youngest age group (18 to 24) that the lifetime suicide attempt rate was 45%.

Studies on transgender individuals also show a higher likelihood of victimization and family rejection, both risk factors for suicide. The good news is that the number of studies being done with transgender youth is increasing, and the quality is improving.

One question that I want to put to you: How comparable is the experience of being a transgender youth to being a gay, lesbian, or bisexual youth? For example, do transgender youth face risk around disclosing their gender identity? Are there differences in how they are victimized, or how family rejection occurs? When we talk later about risk and protective factors, we will discuss the similarities and differences between lesbian, gay, and bisexual youth, and transgender youth.

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Using the Research – Exercise

You want to bring a gay-straight alliance to your school, but the principal maintains there is only one gay student at the school, and there is no problem.
You want to add information about LGBT suicide risk to your training, but your funder says they don’t need special attention.
A journalist calls you because he has just read that research has not shown LGBT youth die by suicide at a higher rate. He wants to know why LGBT youth are a focus of your suicide prevention program.

Leader:

For a small group, break out into groups of 3 or 4.

For a larger group, divide the room into 3 sections.

Then assign one scenario to each group or section from the slide—choices A, B, and C. Give participants 5 minutes to discuss an appropriate response to their scenario. Then have a brief report back.

Issues that may come up:

Being able to use terminology and describe research results effectively
Building alliances

Possible responses from report backs:

A. LGBT youth are not easily identified, but it is unlikely there is only one student. We will be describing prevalence in a few minutes.

B. LGBT youth are at higher risk for suicidal behavior.

C. Explain the research challenges (no sexual orientation or gender identity on vital records, limited population-based data sets, etc.)

Data regarding suicides is difficult, but it is theorized—based on research findings—that LGBT suicide deaths are higher. Suicide prevention tries to prevent suicidal ideation and attempts as well deaths by suicide.

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Break

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LGB Developmental Models

Stages of sexual identity development:

Awareness, recognition
Testing, exploration
Identity, definition, adoption of a label
Disclosure (“coming out”)
Acceptance
Same sex contact, romantic or emotional involvement
Identity within a group, integration

Developmental models give us a way of looking at adolescence generally. But it’s important for us to understand the developmental challenges of LGBT youth before we go on to talk about risk and protective factors.

Sexual minority youth experience challenges that straight youth don’t, which can be referred to as “gay-related stressors.” On the other hand, they also experience some challenges in common with straight youth, such as victimization. But how they respond to victimization can relate to where they are in their development. For example, do they internalize homophobia? Do they delay coming out? Disclosure in particular is a key time that LGBT youth are at risk for suicide attempts and suicide.

Traditional developmental models are linear, and they are based on research with males. Developmental models tend to assume that later stages are more advanced than earlier stages. Immaturity is expected to progress to maturity, integration, and authenticity.

In fact, identity formation is a lifelong process.

When we look at the stages on the slide now—awareness and recognition, testing, exploration, identity, definition, adopting a label, disclosure, acceptance, same-sex contact and involvement in a same-sex romantic or emotional relationship, and identity within a group—there are potential gender differences. The stages in this model are based on males. For females, the timing, sequence, duration, and context could be different.

There could also be differences across culture, race, class, gender, and disability, and other factors could come into play.

For additional resources see:

Eliason, M. J., & Schope, R. (2007). Shifting sands of solid foundation? Lesbian, gay, bisexual, and transgender identity formation. In I. Meyer and M. Northridge (Eds.), The health of sexual minorities: Public health perspectives on lesbian, gay, bisexual, and transgender populations (pp. 3-26). New York: Springer.

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Transgender Developmental Models

Devor describes stages of transgender identity formation including:

Anxiety
Confusion
Discovery of trans identity
Tolerance
Delay before acceptance

Devor, 2004

Acceptance
Transition
Integration
Pride

Developmental models give us a way of looking at issues for transgender youth as well.

This slide describes a model proposed for stages of transgender identity development based on a long-standing model of gay and lesbian development by Vivienne Cass. The Devor model has not been empirically validated.

Devor’s model describes two social processes underlying the 14 stages of transgender identity development—witnessing (of transgender identity by others) and mirroring (seeing oneself in the eyes of someone who is similar). The model includes a couple of delay stages that represent stalled development. As with most developmental models, not all transgender individuals progress through all the stages in order.

In contrast to non-transgender youth, transgender youth have to confront cultural assumptions establishing two genders as distinct and separate.

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Nonlinear Model – �Themes for Identity Evolution

Differences
Confusion
Exploration
Disclosure (coming out)
Labeling
Distrust of the oppressor

Eliason & Schope in Meyer & Northridge, 2007

Degree of integration
Internalized oppression
Managing stigma
Identity transformation
Authenticity
Cultural immersion

This slide presents a nonlinear model with themes for identity evolution. This depicts a lifelong process with no beginning, middle, and end, and one in which themes will come up multiple times and not in a given sequence. The themes can apply to sexual and gender identity formation.

How much do these differences play a role in a youth’s life?

Is there confusion, exploration? Does the youth decide to come out or not?

How do they deal with labeling, by themselves and from other people?

How does their culture deal with sexual and gender minorities?

How do they deal with the person or the group that oppresses them?

Authenticity represents the opposite of secrecy and denial, which may be necessary to youth concerned with their safety. These themes provide issues to review in terms of risk and protective factors that we will discuss shortly. For example, what protective factors would help LGBT youth deal with these challenges?

[Invite comments and discussion.]

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Stages and Average Ages – LGB

First aware of same-sex attractions:

Age steadily declining
Age 10

First disclosure:

Age 14.5

D’Augelli et al., 2005

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Stages and Average Ages – Transgender

Feel different: 7 ½ years old

Consider self to be transgender:

FTM – 15 years old
MTF – 13 years old

First disclosure:

FTM – 17 years old
MTF – 14 years old

FTM = female to male; MTF = male to female

Grossman et al., 2005

This slide talks about the stages and ages for people who are transgender. This study was done with a convenience sample of 55 youth and is not considered representative. The youth participated in recreational programs in New York City and referred more youth to the study.

The ages for feeling different and first disclosure are younger than many people expect.

Thus, providers need to not only consider these issue possibilities for younger clients, but also to include families in their programs.

Leader:

Questions may come up at this point about language used in the transgender community, such as MTF, FTM, transmen, transgirls, transsexuals, etc.

For additional definitions, go to Transgender Terminology at

http://www.umass.edu/stonewall/uploads/listWidget/8758/trans%20terms.pdf.

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LGB Prevalence

Behavior, attraction, or identity

Same-sex behavior: 1% of students¹
Same-sex attraction (some degree of): 10% to 20% of young adults²
Self-identification as gay/bisexual: fewer than 2% of adolescents³
Possibly only 10% of youth who engage in same-sex behavior

self-identify as gay¹

1. Savin-Williams & Cohen in Meyer & Northridge, 2007

2. Savin-Williams, 2005

3. Garofalo et al., 1999

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Transgender Prevalence

There is no widely accepted estimate for the prevalence of people who are transgender.

There is no widely accepted estimate for the prevalence of people who are transgender. “Transgender” is an umbrella term for people whose gender identity, expression, or behavior is different from those typically associated with their assigned sex at birth, including but not limited to transsexuals, cross-dressers, and people who do not conform with common gender norms. The small number of studies conducted to establish the prevalence of transgender individuals have only studied individuals who are transsexual, which is only a minority of people who are transgender. In addition, these few studies have had some significant research limitations.

Another issue relevant to transgender prevalence is that many transgender individuals do not share their identity publicly, so they might not be counted in studies.

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Risk and Protective Factors

Being LGBT is not itself a risk factor for suicidal behavior

BUT

social stigma and discrimination

unsafe schools and bullying

ineffective providers

are associated with mood, anxiety, and substance use disorders, and suicidal behavior.

One of the objectives of this workshop is for you to correctly describe suicide risk for LGBT youth.

Towards that end, we’re going to review a couple of key concepts.

Perhaps you’ve heard people say that “being LGBT is a risk factor for suicide.” Has anyone heard that before?

Being lesbian, gay, bisexual, and/or transgender is not in and of itself a risk factor for suicidal behavior. Instead, it is the social stigma and discrimination that LGBT youth experience that results in feelings and behaviors which are, in turn, associated with suicidal behavior.

An example: A gay youth is harassed at school, even threatened with violence. He feels unsafe and starts missing school. He becomes isolated. He internalizes the homophobia. He starts thinking about suicide.

We’re here today to better understand how to prevent suicidal ideation among LGBT youth in the first place. And, when we fail in that regard, how to identify young people who are considering suicide so that we can help them find support and help.

And we must remember not to focus exclusively on risk. The fact is that many LGBT youth do not engage in suicidal behavior. The training today will help identify risk and protective factors that are key to suicide prevention.

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Risk and Protective Factors

Risk factors –

Increase the likelihood of a behavior but cannot predict it

Protective factors –

Decrease the likelihood of a behavior but cannot predict it

We have already referred to risk and protective factors quite a few times in this presentation, and I am about to discuss them in more depth. But before I do, I want to make sure that we are clear about the meaning of these terms.

A risk factor for suicidal behavior is a characteristic that has been demonstrated through research to be associated with—although not necessarily the direct cause of—suicidal behavior for a particular group of people. A risk factor indicates that an individual or population with a particular characteristic is more likely to think about suicide, or attempt or die by suicide, but it cannot predict any individual’s behavior. On the other hand, a protective factor indicates that an individual or population with a particular characteristic is less likely to engage in suicidal behavior.

Identifying risk and protective factors helps us determine the best way to implement suicide prevention programs and policies to help individuals and populations of people who may be at risk for suicide otherwise.

As we have already discussed, being lesbian, gay, bisexual, and/or transgender is not in itself a risk factor for suicide. Certainly, the research studies we just discussed demonstrate higher risk for LGBT youth, so there is a clear association between LGBT status and suicidal behavior. However, being lesbian, gay, bisexual, and/or transgender suicide has not been shown to be an independent risk factor for suicide. What is important is to explore that relationship and better understand it so that we can develop suicide prevention programs and policies to prevent suicide among LGBT youth.

As we discussed earlier, stigma and discrimination are risk factors for mental illness and suicidal behavior. In a few moments, we will learn about other risk factors. We will also identify protective factors, such as safe schools, caring adults, and family connectedness.

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Risk and Protective Factors

Synergistic

Dynamic

Complex

Modifiable and non-modifiable

Risk and protective factors help explain suicidal behavior—including suicidal ideation, suicide attempts, and suicides.

Risk and protective factors affect the likelihood of suicidal behavior in ways that are both synergistic and dynamic. For example, in the case of risk factors, synergistic means that the effect of a single factor is increased when an individual has additional risk factors and that risk factors are not simply additive. Dynamic refers to how a risk factor’s meaning to and effect on an individual changes over time.

Risk and protective factors are also complex. Suicidal behavior is often related to a combination of factors.

Adding to the complexity is the fact that two different youth can be exposed to the same kind of stressful event and respond to the event differently. This is a phenomenon that I’m sure many of you have observed. It appears that the meaning youth give to the risk factors they experience is a crucial variable.

In fact, modifying protective factors may be a very effective prevention approach. A study of suicide attempts among American Indian and Alaska Native youth found that increasing protective factors was more effective for reducing the likelihood of attempts than decreasing risk factors. Protective factors included the ability to discuss problems with family or friends, connectedness to family, and emotional health (Borowsky, I. W., Resnick, M. D., Ireland, M., & Blum, R. W. (1999). Suicide attempts among American Indian and Alaska Native youth: Risk and protective factors. Archives of Pediatrics & Adolescent Medicine, 153(6), 573-580).

From a public health perspective, the most important factors are the ones that are modifiable. In many cases, protective factors may be more modifiable than risk factors.

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Risk and Protective Factors

Consider:

Number of factors
Severity or strength of factors

Research basis in relation to:

Suicides, attempts, or ideation
Specific populations

The risk factors that apply to youth overall also apply to LGB youth. Kitts’ review of the research literature (2005) confirms this.

Kitts concludes that the elevated risk of suicide attempts among LGB adolescents is a consequence of the psychosocial stressors associated with being lesbian, gay, or bisexual, including gender nonconformity, victimization, lack of support, dropping out of school, family problems, suicide attempts by acquaintances, homelessness, substance abuse, and psychiatric disorders.

While heterosexual adolescents also experience these stressors, LGBT adolescents often experience more risk factors. Also, LGBT youth have fewer protective factors: Providers may be non-inclusive, and parents, friends, and faith communities may be rejecting.

LGB youth may experience these factors in greater strength. Think about victimization. The abuse an LGBT youth experiences is often repeated and severe.

Research studies establish these risk factors by asking youth specifically about suicidal ideation and attempts. We generalize when we call them risk factors for suicide. An academic journal article will usually describe how the researcher defined a factor, such as stigma or victimization, and will specify whether the survey question asked about ideation or attempts.

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Ecological Model

Individual

Family and peers

Institutional

Community

Society

No single factor explains why some individuals attempt suicide or die by suicide, or why suicidal behavior is more prevalent in some communities than others.

Suicidal behavior is the result of a complex interplay of individual, relationship, social, cultural, and environmental factors.

The model shown in this slide is called the socio-ecological model. It visually reminds us that there are multiple levels of influence on an individual’s behavior.

Consider the role of peers and family. LGBT youth who are not supported by their families are at greater risk for suicide. Family conflict is also a contributing factor to homelessness of LGBT youth.

Family connectedness, on the other hand, is a protective factor, as is support from other adults.

In our social environment, there is widespread discrimination and stigma against LGBT youth, which are associated with isolation, mental disorders, and suicidal behavior.

An important protective factor is access to effective health and mental health providers.

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Protective Factors

Family connectedness¹
Family acceptance²
Safe schools¹
Caring adult¹
High self-esteem³
Positive role models³

1. Eisenberg & Resnick, 2006

2. Ryan et al., 2009

3. Fenaughty & Harre, 2003

This slide shows some protective factors for LGB youth. Take a moment to read this slide to yourself. These protective factors also apply to youth generally, not just to LGB youth.

Eisenberg and Resnick concluded that sexual orientation on its own accounts for only a small portion of risk for suicidal behavior. They also found that lower levels of three factors—family connectedness, safe schools, and a caring adult— accounted for much of the increased risk of suicidal ideation and attempts.

Ryan’s research on family acceptance found that specific behaviors by parents and caretakers can reduce risk of depression, substance abuse, and suicidal behavior in their LGBT children and increase self-esteem, social support, and general health. We’ll talk more about these parent behaviors in a moment.

The Fenaughty and Harre study was based on interviews with LGB youth, some of whom had attempted suicide. They found that self-esteem and positive role models played an important function for LGB youth.

Let’s look at some of these factors in more detail.

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Protective Factors

Family connectedness plays an important role for LGB youth. Youth who are more protected say, My family…

“cares about my feelings”
“understands me”
“has lots of fun together”
“respects my privacy, and my parents care about me”

Eisenberg & Resnick, 2006

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Protective Factors

Family acceptance – parent and caregiver behaviors that help:

Talk with your child about his/her LGBT identity
Express affection when you learn that your child is LGB and/or T
Advocate for child when he/she is mistreated because of his/her LGBT identity
Bring your child to LGBT events
Connect your child with an LGB and/or T adult role model
Welcome your child’s LGB and/or T friends and partners into your home
Believe that your LGB and/or T child can have a happy future

Adapted from Ryan, 2009

Caitlin Ryan’s research has demonstrated that family acceptance of their LGBT child reduces the risk for health and mental health problems and helps promote their well-being. Ryan studied families who were accepting, unsure, or conflicted about their child’s gay or transgender identity, and identified over 100 behaviors that families use to respond to their LGBT child, some of which are listed here.

Ryan made important findings related to suicide prevention for LGBT youth. Gay and transgender teens who were highly rejected by their parents were at very high risk for mental health problems as young adults. Specifically, highly rejected LGBT young people were more than 8 times as likely to have attempted suicide.

Ryan found that even small shifts by families and caregivers towards being accepting made youth less likely to attempt suicide and other negative outcomes. She has published a list of rejecting behaviors as well so that parents can connect what they do to what could be damaging to their children.

For many parents and caregivers, just knowing which behaviors are harmful and which are supportive of their LGBT youth is not enough. Deeply held beliefs or emotions may present barriers hard to surmount without help. Professionals can play a role in the process of parents adopting supportive behaviors and focusing on keeping their family strong. Ryan recommends that parents find support groups and learn about their child’s sexual orientation or gender identity. She also suggests that parents listen to their LGBT youth without interrupting. PFLAG—Parents, Families, and Friends of Lesbians and Gays—is a national organization with local chapters that offer support and information.

Let’s discuss the implications for suicide prevention program staff and youth services professionals.

For a small group, leaders will lead a discussion or form break-out groups. For a large group, leaders will ask participants to volunteer how they can use this information in their work.

Some ideas to get the discussion going:

For suicide prevention program staff, how do you get this information to parents and caregivers? How do you reach out to and support parent and caregivers who are rejecting their LGBT sons or daughters? How can you support staff working with families with LGBT youth?
For youth-serving professionals, how do you reach parents and caregivers? Do you work directly with parents and caregivers?
What agencies could you partner with to further these messages and support parents (for example, GSA’s, PFLAG, schools)?

Adapted from Ryan, C. (2009). Supportive families, healthy children: Helping families support their lesbian, gay, bisexual, transgender children. Retrieved from http://familyproject.sfsu.edu/publications.

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Protective Factors

School safety includes:

“I feel safe going to and coming from school.”
“I feel safe at school.”
“Bathrooms in this school are a safe place to be.”

Eisenberg & Resnick, 2006

These were the survey questions about school safety—they include safety at school, especially in the bathrooms away from staff vigilance, and coming from and going to school. Other surveys, such as the Youth Risk Behavior Survey or the Gay Lesbian and Straight Education Network’s National School Climate Survey, use different questions but corroborate the finding that LGB youth feel unsafe at school.

Eisenberg and Resnick found that LGB students were less likely than non-LGB students to feel safe in school. Here is a comparison of the proportion of non-LGB students to LGB students:

While nearly 1 in 3 heterosexual males felt very safe in school, only 1 in 5 gay or bisexual males felt very safe in school.
For females, 1 in 4 heterosexual females felt very safe in school, while only 1 in 7 lesbian or bisexual females felt very safe in school.
School safety was found to be a significant protective factor against suicidal behavior.
The researchers say that school programs, policies, and resources are needed to support LGB adolescents. School safely is amenable to change and may protect young people from self-harm.

We will discuss safe schools shortly.

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Protective Factors

Other adult caring includes:

How much youth felt that other adults in their community, faith leaders, and other adult relatives cared about them.

Eisenberg & Resnick, 2006

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Risk Factors – Youth

Previous attempt(s)
Mental illness
Substance use disorder
Significant negative personality traits
Parent(s) with mental illness

Berman et al., 2006

Stress (rejection, feared punishment)
Isolation
Hopelessness
Access to means

And here are risk factors.

On this slide, you can see risk factors for youth overall. Many of these also apply to LGBT youth.

Naturally, this list is not complete. Not all the research is summarized here, and there may be factors that have not been established by research.

I’ll highlight a couple of risk factors:

Previous attempts: Youth who have attempted suicide are among those at highest risk, and future attempts may increase in lethality.
Mental illness: This includes depression and other mood disorders, conduct disorder, and other disorders.
Negative personality traits: These include impulsivity, low frustration tolerance, and aggression.
Access to means: This refers to having access to lethal ways of killing oneself, especially firearms. Youth suicides are often impulsive, during a short-lived crisis. If means are not available, the youth might not kill himself or herself. Firearms are especially lethal.

We talked earlier about the importance of modifiable risk factors, since those are things you can do something about. Which of these risk factors seem most modifiable to you and why?

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Risk Factors – LGB Youth

Gender nonconformity¹
Internal conflict about �sexual orientation²
Early coming out³
Low family connectedness⁴

1. Fitzpatrick et al. 2005

2. Savin-Williams 1990

3. D’Augelli et al. 2005

4. Eisenberg & Resnick 2006

Lack of adult caring⁴
Unsafe school⁴
Family rejection⁵
Victimization⁶
Bullying⁷
Stigma and discrimination⁸

5. Ryan et al., 2009

6. Bontempo & D’Augelli 2002; Russell & Joyner

2001

7. Suicide Prevention Resource Center 2011

8. Haas, et al., 2011

And here are risk factors established through research with LGB youth specifically. Unfortunately, the research on risk factors is more extensive than it is on protective factors.

Let’s talk about some of them specifically:

Gender nonconformity: This is a term for individuals whose gender expression is different from societal expectations. This term and the term “cross-gender roles and behaviors” are framed from a gender bias that assumes mainstream gender roles. A gender-nonconforming youth may or may not be LGBT. Heterosexual youth may also not conform to gender roles and behaviors thought by the mainstream to define genders. Fitzpatrick and others found that gender nonconformity is a significant contributor to suicidal risk, much greater than sexual orientation. They also found that gender-nonconforming youth had less support from their families and peers.

Internal conflict about sexual orientation: This can also be referred to as internalized homophobia, where a youth directs social disapproval inward. Internalized homophobia has been linked to depression.

Coming out: Disclosure is a developmental stage that is important to LGBT youth. On one hand, rejection and harassment are often related to coming out. Fear of rejection means that the risk is not just following disclosure, but it can precede it. Youth coming out at earlier ages means heightened risk. On the other hand, carrying a secret that is central to a youth’s identity—or a youth pretending to be other than what he or she is—carries its own stress.

Victimization and bullying are risk factors for suicide attempts and ideation as well as substance abuse and low self-esteem. LGB youth are victimized and bullied at higher rates than other youth. However, bullying itself does not cause suicide.

Let’s put these risk factors into a context for LGB youth.

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Risk factors – What’s different for LGBT youth?�

More risk factors or more severe ones:

Unsafe school
Rejection/abuse within family
Victimization/bullying
Previous attempt(s)
Exposure to suicide loss

Specific to or mostly relevant to LGBT youth:

Gay-related stress and minority stress
Gender nonconformity
Internal conflict regarding sexual orientation

The context of risk and protective factors for LGB youth is that they:

Have more risk factors and often experience more severe risk factors. For more severe risk factors, an example is suicide loss. LGB youth know more youth who have attempted or died by suicide, or who think about victimization. Other youth get victimized, but LGB youth get victimized and bullied repeatedly in different settings, and sometimes severely. LGB youth generally have fewer protective factors, such as safe schools and supportive families.

Some risk factors are specific to being LGBT and are called gay-related stress. They involve factors like those related to coming out. Others are related to the minority stress of social discrimination and stigma that sexual and gender minority individuals experience.

Again, not much research includes transgender youth, but we could make assumptions that transgender youth share experiences of rejection, discrimination, isolation, and victimization and lack many protective factors.

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Discussion

Small group discussions:

Risk and protective factors

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Break

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Cultural Competence – LGBT

Description:

LGBT cultural competence applies to sexual and gender minorities.

Behaviors, attitudes, and policies for a professional, agency, or system to work in cross-cultural situations

“a tandem process of personal and professional transformation… the journey towards cultural competency… an ongoing process”

Turner, Wilson, & Shirah in Shankle, 2006 (p. 62)

Before the break you learned about risk and protective factors specific to LGBT youth suicidal behavior. We’ve seen how larger social and cultural forces play an important role as risk factors themselves—such as discrimination or victimization—or leading to other risk factors—such as isolation and substance abuse. LGBT cultural competence is an approach to addressing these broad social forces and acknowledges that those who work with LGBT youth are working cross-culturally. Later, we will talk about approaches that are more specifically related to suicide prevention.

LGBT cultural competence does NOT refer to ethnic, racial, or linguistic minorities, but to LGBT minorities. To work across cultures, basic operating assumptions are questioned. For example, U.S. culture is hetero-dominant, and that can make it difficult for heterosexuals to identify operating assumptions and values.

As with other cultures that cultural competence addresses, LGBT individuals are minorities. Like members of other minorities, LGBT individuals are subject to discrimination and stigma, and they experience disparities in health and health services.

Cultural competence has to take place at the individual, agency, and systems level, and includes not just policies, but what staff believe and do when they work across cultures.

Many of us have experienced one-time trainings in cultural competence or diversity that meet some requirement, but cultural competence is comprehensive—throughout all aspects of a program or practice—and an ongoing process rather than a one-time event. The third point emphasizes that cultural competence must be ongoing, dynamic, and oriented to change.

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Cultural Competence – LGBT

Key elements:

Defined set of values
Effective cross-cultural work
Involvement of consumers and community
Capacity to manage the dynamics of difference

Incorporate these elements into policies, administration, practice, and service delivery.

Dunne, C. et al., 2004

The National Center for Cultural Competence has an excellent resource at the link shown below. Although it is not specifically written to LGBT youth cultures, it is a great resource to use in strategic planning, service design and delivery, and evaluation and quality assurance.

So let’s go through the key ingredients. What kind of values do you think it would be important to define?

See what participants volunteer, but you may want to cite social justice, human rights, importance of family or community, and access to health care; that community members are full partners in decision-making; and that non-discriminatory practice is a priority.

We will be describing shortly what we mean by effective cross-cultural work.

Involving consumers and community is vital to cultural competence, but it is not easy to reach people who have been marginalized or feel invisible. In what ways can you reach LGBT youth?

You may get responses from participants such as: outreach to LGBT organizations or partnerships with organizations that have a positive track record with LGBT youth; building relationships with LGBT youth; community events; plus all the ways we’ll address later to let people know that the organization is safe and welcoming.

Managing the dynamics of difference can mean that you have staff who are skilled at facilitation and conflict resolution. It also means that an organization has leaders—although perhaps not the official leaders—who identify needs as they arise and push for change.

Dunne, C., Goode, T., & Sockalingam, S., (2004). Planning for cultural and linguistic competence in state Title V programs serving children & youth with special health care needs and their families. Washington, DC: National Center for Cultural Competence, Georgetown University Center for Child and Human Development. Retrieved from http://nccc.georgetown.edu/documents/NCCC%20Title%20V%20Checklist%20%28CSHCN%29.pdf

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Cultural Competence – LGBT

LGBT cultural competence standards for agencies:

Make accurate information easily available
Train staff, volunteers, and board
Have staff and board reflect diversity
Have job descriptions, supervision, and performance review all reinforce cultural competence
Include diverse clients in program decisions
Make sure agency environment and policies are inclusive
Conduct ongoing agency self-assessments

You see that cultural competence is pervasive and comprehensive. It affects all aspects of an agency: outreach, staffing, policy, and supervision.

What helps make cultural competence successful? Here are some ideas:

Consumers and feedback are involved throughout.
The leader of the organization lives it.
Staff is prepared and given a context.
Cultural competence is consistently reinforced and supported, and successes are acknowledged.

I’ll address the first few bullets. Make accurate information available to consumers and staff. Keep abreast of what’s new in the field and make it available. Many national organizations provide information. Train your staff, volunteers, board, and consumers to submit information, and have channels for the agency to distribute it. Assure that it is not all needs- or problem-based but also includes strengths and accomplishments, such as LGBT individuals who receive awards or legislation that is passed. Use new technologies to reach youth audiences (e.g., Twitter, YouTube, Facebook).

Training includes pre-service training, orientation, in-service training, and mentoring. Include consumers in development of the trainings. Address the fact that LGBT youth have a higher risk of suicidal behavior.

Remember the ecological model that starts with an individual at the core and builds out. Not only is your staff and board going to reflect diversity to your community, they are also the individuals who have to be willing to examine their own beliefs and behavior. The policies, the forms, the welcoming waiting room, all mean little if your staff and board are not engaged in cultural competence.

Let’s talk about how some agencies go about this in a systematic way.

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Small Group Exercise – �Assessment and Next Steps

See handout

“Developing LGBT Cultural Competence: Agency Assessment and School Assessment”

Identify one or two steps you could take.
Identify one or two steps your agency or school could take.

HANDOUT – “Developing LGBT Cultural Competence: Agency Assessment and School Assessment”

We are going to work with the agency and school LGBT cultural competence assessments. While the assessments go through some key features, they should not be considered complete. There are sections describing attributes at the individual and organizational levels. As we have explained, commitments at the individual level will support changes at the organizational level and vice versa.

For example, a staff member explaining confidentiality procedures to a patient might hear a criticism or request that he or she can bring to the organization for change. Conversely, say the organization makes their waiting area more welcoming to LGBT youth. As a result, an individual staff member brings some books on LGBT issues to the office and makes them available to other staff and displays LGBT brochures and symbols in their office.

Ask the participants to break into small groups. Depending on group size, allow about 10 minutes. Instruct the group to discuss which attributes on the list their organization already has and which attributes they could commit to developing. Ask participants, using the form, to list one or two steps each of them could take, first, as an individual, and then, one or two steps that their school or agency could take.

Tell them that at the end of 10 minutes you will ask the whole group for volunteers to describe the steps they listed.

Ask for steps that the participants identified. The leader needs to acknowledge and support where participants are. Make sure you hear both individual steps and agency or school steps.

Now let’s watch a short video created by the Gay, Lesbian and Straight Education Network, a national education organization focused on ensuring safe schools for all students.

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GLSEN Video

Available from http://www.youtube.com/watch?v=sWS0GVOQPs0&feature=kp

(To play, click on the image and then the play arrow.)

Show video clip of “That’s So Gay” by Wanda Sykes.

You may wish to comment on the video. The following text is from the GLSEN web- site:

Lesbian, gay, bisexual and transgender (LGBT) teens experience homophobic remarks and harassment throughout the school day, creating an atmosphere where they feel disrespected, unwanted and unsafe. Homophobic remarks such as “that’s so gay” are the most commonly heard; these slurs are often unintentional and a common part of teens’ vernacular. Most do not recognize the consequences, but the casual use of this language often carries over into more overt harassment.

The Think Before You Speak campaign aims to raise awareness about the prevalence and consequences of anti-LGBT bias and behavior in America’s schools. Ultimately, the goal is to reduce and prevent the use of homophobic language in an effort to create a more positive environment for LGBT teens. The campaign also aims to reach adults, including school personnel and parents; their support of this message is crucial to the success of efforts to change behavior.

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Programs and Practice – A Start

Suggest that sexual and gender minority issues be added to diversity or cultural competence training
Post a rainbow on your office door
Check your school or agency anti-discrimination policies for both sexual orientation and gender identity
Review with LGBT youth your confidentiality safeguards and how staff are trained to implement them
Review availability of information on LGBT youth issues in local libraries (e.g., staff, school, or community libraries) and on the Internet
Distribute the SPRC white paper on LGBT youth suicide prevention and lead a discussion about it at a staff meeting

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Programs and Practice – Doing More

Interrupt a student who says “that’s so gay”
Lead a revision of agency forms to use more inclusive terms
Organize a LGBT consumer group to give feedback on the service space, forms, policies and procedures, and outreach materials
Attend a gay-straight alliance meeting at the school or help get a group started
Expand services to younger teens and families
Develop resources and attend training for your profession related to serving LGBT youth

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Youth Suicide Prevention

What is youth suicide prevention?

Case-finding of at-risk youth with referral for assessment or services

Gatekeeper programs
Screening
Crisis lines

Reduction of risk factors, increase in protective factors

Gould, M. S. et al., 2003

We’ve laid a lot of groundwork with the topics of risk and protective factors and LGBT cultural competence. Now let’s apply some of what we learned to youth suicide prevention.

What do we mean by LGBT youth suicide prevention?

First let’s consider what youth suicide prevention is. Mostly, youth suicide prevention follows one of two approaches:

Case finding with referral, such as gatekeeper programs, screening, and crisis lines. In these programs, a youth at risk is identified and referred for assessment or services, perhaps emergency services.
Risk factor reduction, protective factor enhancement. Many of you serve as a protective factor for LGBT youth, whether you represent a caring adult, an LGB and/or T role model, or provider of services, such as counseling or a safe residential placement. We talked about this approach earlier.

Gould, M. S., Greenberg, T., Velting, D. M., & Shaffer, D. (2003). Youth suicide risk and preventive interventions: A review of the past 10 years. Journal of the American Academy of Child & Adolescent Psychiatry, 42(4), 386-405.

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Suicide Prevention – �Case-Finding with Referral

Promote LGBT cultural competence through staff training
Refer LGBT youth to mental health services that are culturally competent
Reach out to providers and organizations who serve LGBT youth, particularly those at greatest risk

This slide outlines some ways that suicide prevention program staff can become LGBT culturally competent.

On the last point, LGBT youth at greatest risk for suicide include those who are homeless and runaway, living in foster care, and/or involved in the juvenile justice system.

Going back to the first two points, let’s take a specific example: gatekeeper training. These trainings generally refer to programs that seek to develop individuals’ knowledge, attitudes, and skills to identify those at risk, determine levels of risk, and make referrals when necessary.

Some ways to increase a training’s LGBT cultural competence include:

Provide accurate information about LGBT risk
Feature LGBT youth stories in role-plays in trainings
Train LGBT youth and adults as gatekeepers
Develop a list of assessment, treatment, and support services that are inclusive of LGBT youth, and use these services for referrals
Evaluate whether participants learn key information about LGBT youth suicidal behavior

Are there other ways to increase the cultural competence of gatekeeper trainings? Are there any ideas from cultural competence that you could use?

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Suicide Prevention – Addressing Risk and Protective Factors

Include the topic of LGBT youth risk in awareness materials, conferences, and state and local prevention plans
Provide training for all staff about LGBT issues
Include the topics of dealing with discrimination and victimization in life-skills training for youth
Institute protocols for when youth are identified at risk, youth have attempted suicide, or youth have died by suicide

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Resources: Training

Take a gatekeeper training (e.g., QPR, ASIST, Connect) to learn how to identify youth who may be having suicidal thoughts�http://www.sprc.org/search/bpr/Gatekeeper%20training?filters=sm_resource_type%3Abpr_listing
Take a gatekeeper training from the Trevor Project that focuses on LGBT youth

http://www.thetrevorproject.org/section/education-training-for-adults

Contact your state suicide prevention coalition to find gatekeeper training in your area�http://www.sprc.org/search/bpr/Gatekeeper%20training?filters=sm_resource_type%3Abpr_listing
Encourage your local referral network to be trained in assessing and managing suicide risk http://www.sprc.org/traininginstitute/amsr/clincomp.asp

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Warning Signs for Suicide

LEARN THE WARNING SIGNS AND WHAT TO DO

You can find the warning signs at:

http://www.sprc.org/basics/warning-signs-suicide

Or see the handout in this toolkit

“Warning Signs for Suicide Prevention”

Ask participants to refer to the handout “Warning Signs for Suicide Prevention.”

It is important to distinguish warning signs from risk factors. Warning signs are the earliest detectable signs that indicate heightened risk for suicide in the near-term (i.e., within minutes, hours, or days), as opposed to risk factors that suggest a longer term risk (i.e., a year to lifetime.)

Be alert to the warning signs of suicide. The risk of suicide is greater if a behavior is new or has increased and if it seems related to a painful event, loss, or change. Use the list on the handout “Warning Signs for Suicide Prevention.”

Note that imminent warning signs include:

Talking about wanting to die or to kill oneself
Looking for a way to kill oneself, such as searching online or obtaining a gun
Talking about feeling hopeless or having no reason to live

These behaviors should prompt you to immediately call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) or a mental health professional.

With the second group of signs it is often a constellation of them that raises concern, rather than one or two alone. Any questions about these warning signs? How often do you see youth who are suicidal?

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Resources: Crisis Lines

Suicide Prevention Crisis Lines

National Suicide Prevention Lifeline

Phone: 1-800-273-TALK (8255), available 24/7.

For Spanish, call 1-888-628-9454

Online chat: 2 pm – 2 am

http://www.suicidepreventionlifeline.org/GetHelp/LifelineChat.aspx

Trevor Lifeline: 866-488-7386, available 24/7

TrevorText: Available only specific hours. Text “Trevor” to 1-202-304-1200. TrevorChat: Online only specific hours.

For hours, go to http://www.thetrevorproject.org/pages/get-help-now

See handout for a list of services in your local area.

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Helping Youth After an Attempt

What you can do for a youth after an attempt:

Let him or her know you care. Try:

“I’m sorry you hurt that badly. I wish I could have helped you.”
“I want to help you. Tell me what I can do to help you now.”

Provide information on suicide and mental illness
Ask the family to remove guns from their home and reduce access to lethal means
Arrange a therapy session for the youth and family before the youth returns home from the hospital if possible
Help find support and services: consider mental health or faith-based services

Adapted from “After an Attempt: The Emotional Impact of a Suicide Attempt on Families”

What to do after a suicide attempt is not specific to LGBT youth but applies to all youth.

These suggestions are adapted from “After an Attempt: The Emotional Impact of a Suicide Attempt on Families,” produced by the Feeling Blue Suicide Prevention Council.

I won’t read this entire slide to you, but I do want to highlight the third bullet point. It is very important to restrict access to lethal means following a suicide attempt. Youth can be especially impulsive, and impulsivity combined with lethal means—such as guns or medications—can mean death by suicide for youth. Research shows that if lethal means are available, a person is more likely to die by suicide.

Recall that LGB youth tend to use more lethal means, so this is an important intervention.

As for the fourth and fifth bullet points, it can be challenging to find services that are inclusive for LGBT youth.

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Helping Youth After an Attempt

To help his or her recovery after getting out of the hospital, an individual who attempted suicide needs to:

Identify triggers for suicidal thoughts and plan to minimize their effects
Build a support system
Try to follow a routine

You can be an important support for LGBT youth who attempted suicide.

Adapted from “After an Attempt: A Guide for Taking Care of Yourself“

The recommendations above come from “After an Attempt: A Guide for Taking Care of Yourself after Your Treatment in the Emergency Department.”

It is important for youth service professionals to understand these objectives for youth who have attempted suicide. What might be different for LGBT youth?

Trainers can lead a discussion here and consider using the following examples:
Identify triggers for suicidal thoughts and plan to minimize their effects:

This difficult work often takes place with a therapist, support group, or clergy member and may be difficult if LGBT youth have not found LGBT-inclusive providers.
Create a list with contact information for key supporters.
It is important to ask about victimization and whether youth are safe where they live.

Build a support system:

A support system includes an ally that a youth can trust with suicidal feelings. LGBT youth who haven’t disclosed their sexual orientation or gender identity may not have this.

Try to follow a routine:

For LGBT youth, routines that other youth take for granted might be difficult. For example, if school feels unsafe, they might avoid it. Jobs might be difficult if employers discriminate against them.

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Resources: After an Attempt

National Suicide Prevention Lifeline brochure�“After an Attempt: Guide to Taking Care of Your Family Member after Treatment in the Emergency Department”

http://www.suicidepreventionlifeline.org/App_Files/Media/PDF/Lifeline_AfterAnAttempt_ForFamilyMembers.pdf

Feeling Blue Suicide Prevention Council booklet

“After an Attempt: The Emotional Impact of a Suicide Attempt on Families”

http://www.heidibryan.com/uploads/After_An_Attempt_2013_booklet_download.pdf

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Suicide Postvention: What You Can Do

Work with a community group to set up policies and procedures for postvention (interventions following a suicide)
Remember that the rationale for postvention is to both promote healthy grieving for survivors and limit contagion
Help to limit contagion by encouraging the media to follow recommended reporting practices, training those with public roles how to respond appropriately, and memorializing the deceased in a way that is safe
Review resources, including guidance on memorial services, talking to the media, caring for survivors, and data for your state

Following a suicide, there are a number of things you can do.

You can:

Promote healthy grieving by acknowledging the survivors’ loss. Survivors are those who have lost someone close by suicide. In addition to family and close friends, they can include therapists, teachers, and others who knew the youth who died.
Take steps to prevent contagion. Some vulnerable people are influenced to engage in suicidal behavior when they become aware of another person’s suicidal acts. This is called contagion. You may be aware of a community that has experienced a cluster of youth suicides. One way to limit contagion is to influence the media to use safe reporting guidelines in the coverage of suicides.

Before there is a suicide, it is important to set up community protocols. Protocols establish policies and procedures for postvention in your community, including the provision of crisis intervention, support, and assistance for those affected by a completed suicide.

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Resources: Suicide Postvention

Recommendations for Reporting on Suicide: http://www.sprc.org/library_resources/items/recommendations-reporting-suicide
Youth Suicide Prevention, Intervention, and Postvention Guidelines from Maine Youth Suicide Prevention Program: http://www.maine.gov/suicide/docs/Guidelines%2010-2009--w%20discl.pdf
After a Suicide: Recommendations for Religious Services and Other Public Memorial Observances:�http://www.sprc.org/library/aftersuicide.pdf
For data: http://www.cdc.gov/ncipc/wisqars/ and http://www.sprc.org/stateinformation/index.asp

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LGBT Youth Programs

Can support suicide prevention by strengthening protective factors and decreasing risk factors
Can train program staff and board in LGBT youth suicide risk, and risk and protective factors
Can advocate for LGBT youth leadership in suicide prevention programs
Can provide accurate information about LGBT youth suicide risk on the Web and in materials

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Evaluation of LGBT Youth Programs

Special considerations:

Respect the sensitivity and confidentiality of data during collection, analysis, and reporting
Respect group and individual privacy
Define terms clearly
Make the limitations of the findings explicit

When analyzing data and reporting results related to sexual orientation and/or gender identity, take care to ensure that sensitive data are not misused or abused, and data collected and/or analyzed are not used to stigmatize populations.�

Respect for individual (as well as group) dignity and privacy should guide the collection and analysis of data on any identifying personal characteristic—including sexual orientation and gender identity.�

Keep in mind that sexual orientation or gender identity can be an identifying piece of information especially in smaller communities and schools.

Clearly define the terms you use. For example, as we discussed earlier, be clear about whether sexual orientation is defined in terms of identity, behavior, or attraction. For more guidance on this topic, go to http://www.LGBTData.com.

Always discuss the limitations of your findings to assist people in interpreting and using your results.

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Discussion

How can we work to create supportive environments for all youth?
How can we begin to address the barriers facing LGBT youth who need help?
What can we do to raise awareness about the particular needs of transgender individuals?
What will you do to help prevent suicide among LGBT youth?

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Workshop Summary

Now that you have completed this training module, you can:

Use terminology for suicide and LGBT issues correctly
Describe research related to suicidal behavior among LGBT youth
Discuss risk and protective factors for LGBT youth and the implications
Assess your school’s or agency’s cultural competence with LGBT youth and implement next steps
Describe strategies to reduce suicidal behavior among LGBT youth

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Contact Information

Leader 1

Job title

Phone number

E-mail

Agency

Website

Leader 2

Job title

Phone number

E-mail

Agency

Website