Sexual Orientation and Suicidality

Abstract & commentary

Source: Herrell R, et al. Sexual orientation and suicidality: A co-twin control study in adult men. Arch Gen Psychiatry 1999;56:867-874.

As herrell and associates point out, the ameri-can Psychiatric Association declassified homosexuality as a pathological condition more than 20 years ago. However, the experience of being gay—in particular, homosexual feelings in the context of minimal social support and possible stigmatization—has been previously associated with an increased risk of suicide attempts. However, most previous studies suffer from methodological difficulties.

The current study provides some of the most methodologically sound data to date on the topic. Herrell et al used co-twins, a technique that maximally controls for genetic and many environmental confounds. Specifically, the subjects consisted of twins from the Vietnam Era Twin (VET) Registry who were discordant for adult same-sex sexual behavior. The current study also used a widely used instrument in psychiatric epidemiology, the Diagnostic Interview Schedule via telephone interviews. Forty-eight monzygotic and 55 dizygotic male twin pairs, discordant for adult homosexual behavior, were identified from the registry. Specifically, the VET Registry twins were asked the following: "Have you ever had sexual relations with a man at any time since you were 18 years old?" Four lifetime symptoms of suicidality were analyzed: Thoughts about death, wanting to die, thoughts about committing suicide, and attempted suicide. Herrell et al concluded that men who had engaged in homosexual activities had a significantly increased incidence of each of the suicidality measures. Unadjusted matched-pair odds ratios were: 2.4 for thoughts about death; 4.4 for wanted to die; 4.1 for suicidal ideation; 6.5 for attempted suicide; and 5.1 for any of the suicidal symptoms. After adjustment for substance abuse and depressive symptoms (other than suicidality), all of the suicidality measures remain significantly associated with same-gender sexual orientation except for wanting to die (odds ratio, 2.5). Herrell et al conclude that the substantially increased lifetime risk of suicidal behaviors in homosexual men is unlikely to be due solely to substance abuse or other psychiatric comorbidity. Although the sample was too small to draw definitive conclusions, zygosity did not seem to be a relevant contributor to the results.

Comment by lauren b. marangell, md

In many ways, this is a more representative sample than previous studies, particularly because this is a population-based registry, i.e., it was assembled without regard to sexual orientation. Several additional factors are worth noting. The sample was composed of Vietnam era veterans, most of whom were Caucasian. In addition, sexual orientation arguably involves feelings and desire, perhaps more than even behavior. Regrettably, the current available data only included a question about the behavioral dimension (i.e., a same-sex encounter). The presence or absence of same-sex sexual encounters may not accurately represent homosexuality, particularly in the absence of same sex fantasies. For example, a homosexual man may have only homosexual feelings and fantasies, but never act on these feelings. Similarly, a predominantly heterosexual man may have one same sex encounter on impulse. Addressing lifetime behavior provides only a limited characterization. Finally, although homosexuality per se is not pathological, the burden of potential stigmatization and discrimination undoubtedly takes its toll. Another interesting, albeit theoretical hypothesis, put forth in an accompanying commentary by Bailey,1 posits that intrauterine exposure to an altered prenatal endocrine environment may predispose to both male homosexuality and disorders that are more common in women, including depression and eating disorders. Further study appears warranted.

Reference

1. Bailey JM. Arch Gen Psychiatry 1999;56:883-884.