RESEARCH AND PRACTICE
Mental Health and Suicidality Among Racially/Ethnically
Diverse Sexual Minority Youths
Wendy B. Bostwick, PhD, MPH, Ilan Meyer, PhD, Frances Aranda, PhD, MPH, MS, Stephen Russell, PhD, Tonda Hughes, RN, PhD,
Michelle Birkett, PhD, and Brian Mustanski, PhD
Over the past 20 years, research has docu-
mented elevated suicidality1dened as be-
havior related to contemplating, attempting, or
completing suicide2among sexual minority
youths (an umbrella term, generally including
those who identify as lesbian, gay, bisexual, or
transgender [LGBT]; engage in same-sex sexual
behavior; or have same-sex attractions). This
research has consistently demonstrated sub-
stantial sexual orientation disparities in suici-
dality, with sexual minority youths having
higher prevalence of suicidality than their
heterosexual peers.3---6 A recent review of the
literature indicated that sexual minority youths
are at least twice as likely as heterosexual
youths to contemplate suicide, and 2 to 7 times
as likely to attempt suicide.7 A meta-analysis
found that 28% of sexual minority youths had
a history of suicidality, compared with 12% of
their heterosexual peers.8
Despite the development of knowledge
about suicidality among sexual minority
youths, little is known about suicidality in
sexual minority youths of color. To the extent
that existing researchers have explored racial/
ethnic differences, analyses have rarely gone
beyond dichotomous (White vs youths of
color) or trichotomous (White vs Black vs
Latino) comparisons. As a result, there exists
scant literature exploring the full spectrum of
racial/ethnic differences in suicidality among
sexual minority youths.
The literature on suicide in the general
adolescent population demonstrates racial/ethnic
differences in suicide ideation and attempts. For
example, prevalence of suicide among Native
American and Alaska Native youths is twice that
of other youths,9 and Latino youths are more
likely than either Black or White youths to have
considered and attempted suicide.10 Differences
are further moderated by participants gender:
girls are more likely to consider suicide and
attempt suicide than boys,10 although boys are
more likely to complete suicide.11
June 2014, Vol 104, No. 6 | American Journal of Public Health
Objectives. We examined the relationships among sexual minority status, sex, and
mental health and suicidality, in a racially/ethnically diverse sample of adolescents.
Methods. Using pooled data from 2005 and 2007 Youth Risk Behavior Surveys
within 14 jurisdictions, we used hierarchical linear modeling to examine 6
mental health outcomes across 6 racial/ethnic groups, intersecting with sexual
minority status and sex. Based on an omnibus measure of sexual minority
status, there were 6245 sexual minority adolescents in the current study. The
total sample was n = 72 691.
Results. Compared with heterosexual peers, sexual minorities reported higher
odds of feeling sad; suicidal ideation, planning and attempts; suicide attempt treated
by a doctor or nurse, and self-harm. Among sexual minorities, compared with White
youths, Asian and Black youths had lower odds of many outcomes, whereas
American Native/Pacific Islander, Latino, and Multiracial youths had higher odds.
Conclusions. Although in general, sexual minority youths were at heightened
risk for suicidal outcomes, risk varied based on sex and on race/ethnicity. More
research is needed to better understand the manner in which sex and race/
ethnicity intersect among sexual minorities to influence risk and protective
factors, and ultimately, mental health outcomes. (Am J Public Health. 2014;104:
11291136. doi:10.2105/AJPH.2013.301749)
Studies that have considered racial/ethnic adulthood.14 These conicting results suggest
differences in suicidality among sexual minor- that there are important differences in suici-
ity youths have found differences, though the dality at the intersections of sexual minority
patterns have been inconsistent. A study based status and race/ethnicity, yet further study
on Youth Risk Behavior Survey (YRBS) data requires data of sufcient scale and scope to
from Massachusetts, reported that among self- enable analyses of low-prevalence behaviors
identied lesbian, gay, or bisexual (LGB) across small subgroups of youths.
youths3 Latinos were signicantly more likely To address the need for information about
than Whites to report past-year suicide attempt. suicidality among racially/ethnically diverse
Another study found that same-sex---attracted sexual minority populations, we assess suici-
Black and White youths were more likely than dality patterns among youths based on sexual
their other-sex---attracted peers to report sui- orientation, race/ethnicity, and sex. With this,
cidal ideation, whereas same-sex---attracted we respond to calls for public health to utilize
Latino and Asian/Pacic Islander youths did minority stress and intersectional frameworks
not differ from other-sex---attracted peers.12 as potential lenses through which to under-
In a nonprobability sample of urban LGBT stand health and health disparities among
youths,13 Black and White youths were more sexual minority populations.15,16 Rather than
likely to report suicidal ideation than Latinos; treating social identities as separate and dis-
however, Latinos reported the highest fre- crete phenomena, our inquiry allows that
quency of suicide attempts. A study of New co-occurring minority identities operate to-
York City adults found that Latino and Black gether. An intersectional approach suggests
LGB participants were more likely to report that sexual identity---race---sex intersections are
serious suicide attempts than were White informed by unique cultural, historical, social,
LGB participants, with most reported attempts and political factors that differentially inuence
occurring during adolescence and young life experiences, including discrimination based
Bostwick et al. | Peer Reviewed | Research and Practice | 1129

on such identities.17---19 In turn, minority stress
theory posits that discriminatory experiences
predispose populations to stress and adverse
mental health outcomes, including suicidality.20
The focus on health differences among
sexual minority youths across race/ethnicity
and sex is vital to creating effective health
interventions and programs. Such a focus is
particularly relevant within the context of youth
suicide, as risk and protective factors associated
with suicidality vary across both racial/ethnic
and sexual minority groups, and there is a need
to better integrate these bodies of research.21
METHODS
We conducted analyses using pooled 2005
and 2007 YRBS data from several jurisdictions
that included 1 or more measures of sexual
orientation. The general approach to pooling
the data and analyzing the pooled dataset,
along with the sexual orientation items and
characteristics of the sample by jurisdiction, are
described in detail elsewhere in this issue.22
The current study analyzed data from the 14
jurisdictions that measured sexual orientation
identication, sex of sexual partners, or sex of
sexual attraction, including Boston, Massachu-
setts; Chicago, Illinois; Connecticut; Delaware;
Hawaii; Maine; Massachusetts; New York City,
New York; San Diego, California; San Francisco,
California; Vermont; Rhode Island; Wiscon-
sin; and Milwaukee, Wisconsin. Because the
outcome variables were not assessed in all
jurisdictions, the total sample size varies for each
model depending on which outcome is exam-
ined. Respondents who did not answer the sexual
orientation questions were excluded from anal-
ysis. Nonresponse to questions about sexual
identity, behavior, and attraction was 3.2%,
3.9%, and 1.8% respectively.22
Also excluded were participants who were
12 years old or in seventh grade because of the
very small number of such participants and
concerns about the quality of the data among
this group. The unweighted nal sample size
was n = 73 154.
MEASURES
All measures, including demographic charac-
teristics and sexual orientation, were assessed
via self-report. The measurement and pooling of
1130 | Research and Practice | Peer Reviewed | Bostwick et al.
RESEARCH AND PRACTICE
sexual orientation and race/ethnicity questions
are described elsewhere.22
Sexual Orientation
A binary variable, constructed from self-
reported sexual identity, behaviors, and at-
tractions, indicated whether participants were
classiable as sexual minority versus sexual
majority. Participants who reported a nonhe-
terosexual identity, any same-sex behavior, or
any same-sex attractions were labeled as sexual
minority; all others were coded sexual majority.
The use of the omnibus sexual minority
status variable allowed for the broadest con-
ceptualization of sexual orientation and en-
sured sufcient power to detect effects among
many different racial groups. Given the de-
velopmental stage of participants, during which
each of these dimensions of sexuality emerges,
this broad denition of sexual minority status
is warranted.21 See Mustanski et al.22 for
a fuller discussion of how this variable was
created.
Race/Ethnicity
We constructed a nominal race/ethnicity
variable by collapsing 8 racial/ethnic groups
into 6 groups to assure adequate cell sizes. The
6 subgroups were: (1) American Native/Pacic
Islander (AN/PI, henceforth), which combined
American Indian/Alaska Native with Native
Hawaiians/Pacic Islanders; (2) Asian; (3)
Black; (4) White; (5) Hispanic/Latino; and (6)
Multiracial, which combined 2 existing multi-
racial categories (multiracial Hispanic/Latino
and multiracial Non-Hispanic/Latino) into
a single group. White participants were used
as the reference group for these analyses.
Sex
We asked the participants, What is your
sex? The response options were coded as
0 = male and 1 = female. In stratied analyses,
male participants were used as the reference
group. No jurisdiction included transgender as
an option.
Outcome Variables
Feel sad. We asked the participants, During
the past 12 months, did you ever feel so sad or
hopeless almost every day for 2 weeks or more
in a row that you stopped doing some usual
activities? (Yes = 1, No = 0).
American Journal of Public Health | June 2014, Vol 104, No. 6
Suicide ideation. We asked the participants,
During the past 12 months, did you ever
seriously consider attempting suicide?
(Yes = 1, No = 0). Because Vermont did not
assess suicidal thoughts, data from Vermont
was excluded from models of this outcome.
Suicide plan. We asked the participants,
During the past 12 months, did you make
a plan about how you would attempt suicide?
(Yes = 1, No = 0).
Suicide attempts. We assessed this variable by
asking, During the past 12 months, how many
times did you actually attempt suicide? The
response options ranged from 0 times to 6 or
more times. Responses were collapsed and
dichotomized as any or none.
Suicide attempt treated by a doctor or nurse.
We asked the participants, If you attempted
suicide during the past 12 months, did any
attempt result in an injury, poisoning, or over-
dose that had to be treated by a doctor or
nurse? The response options were (1) did
not attempt suicide during the past 12 months,
(2) yes, and (3) no. In the multivariate models,
only those who reported a suicide attempt
(answered 2 or 3 to the question) where
included. Because Connecticut did not assess
suicide attempt treated by a doctor or nurse,
data from Connecticut were excluded from
models of this outcome.
Self-Harm. In most jurisdictions that included
this item, we asked the participants, During the
past 12 months, how many times did you do
something to purposely hurt yourself without
wanting to die, such as cutting or burning
yourself on purpose? The responses ranged
from 0 times to 12 or more times. Variations to
question and response wording occurred in
Delaware in 2005 and 2007: During the past
12 months, have you done something to pur-
posely hurt yourself without wanting to die, such
as cutting, scraping, or burning yourself on
purpose? (Yes/No). In 2005, Massachusetts and
Boston asked, During the past 12 months, how
many times did you hurt or injure yourself on
purpose without wanting to die? with responses
ranging from 0 times to 20 or more times.
Finally, the Boston 2007 YRBS asked, During
the past 12 months, how many times did you do
something to purposely hurt yourself without
wanting to die, such as cutting or burning, or
bruising yourself on purpose? Responses were
collapsed and dichotomized as any or none.
 RESEARCH AND PRACTICE

Age. We used a continuous age variable as
a control in all multivariate models. Participants
included in the analyses were 13 to 18 years
old.
Data Analysis
Descriptive analyses were conducted using
SPSS version 21.0 (IBM, Somers, NY) to ex-
amine the distribution and associations of the
study variables. Given the complex sampling
design of the YRBS administration, the com-
plex samples module of SPSS 21.0 was uti-
lized for all analyses within SPSS. Final
models were t using the multilevel software
HLM version 7 (Scientic Software Interna-
tional, Lincolnwood, IL) to account for juris-
dictional clustering of the data. HLM analyses
accounted for the complex sampling design of
the YRBS by adjusting the relative weights
and altering the effective sample size using
design effects (DEFTs) calculated for each
jurisdiction. The approach to calculating
design effects and accounting for the clustering
of the data are described in detail elsewhere.22
Full-information maximum likelihood esti-
mation was used. We identied signicant
effects as having associated P values of less
than 0.05.
RESULTS
The demographic characteristics of the total
sample, as well as the racial/ethnic subsamples,
are presented in Table 1. Based on our omni-
bus denition, 8.4% of the respondents were
sexual minorities. There was some variability
across racial/ethnic groups in the proportion of
youths who were sexual minority, with pro-
portions ranging from 7.4% among Asian
youths to 14.0% among AN/PI youths.
Table 2 presents the prevalence of all out-
come variables among the 6 racial/ethnic
groups, based on sexual minority status and
sex. Table 3 presents the odds ratios and 95%
condence intervals for the differences in the 6
outcome variables among groups dened by
race/ethnicity, sex, and sexual minority status
for the entire sample. Compared with sexual
majority youths, sexual minorities had a higher
prevalence of each outcomeoften 3-fold the
odds. For example, suicidal ideation (OR = 3.2),
making a suicide plan (OR = 3.2), any suicide
attempt (OR = 3.8), and any self-harm (OR =
3.2) were all signicantly higher among sexual
minority youths.
There were signicant differences among
race/ethnicity groups, though the direction of
results was mixed. For example, compared with
White youths, Black respondents had signi-
cantly lower prevalence of 1-year suicidal
ideation and self-harm (OR = 0.9 and 0.8, re-
spectively), yet they had a signicantly higher
prevalence of suicide attempts (OR = 1.4).
Multiracial youths were at signicantly higher
odds than Whites on 4 of the 6 study outcomes,
whereas Asian youths did not differ signicantly
from Whites on any of the outcomes.
Female participants differed signicantly
from male particpants on all outcomes. Girls
had higher prevalence of all outcomes, except
that they were half as likely as boys to report
being treated by a doctor or nurse as a result of
a suicide attempt (OR = 0.49).
Table 4 shows results for sexual minority
youths by race/ethnicity and sex. Sex differ-
ences generally mirrored those found in the
total sample. That is, sexual minority females
had higher prevalence on all outcomes, with
the exception of lower prevalence of past year
treatment by a doctor or nurse after a suicide
attempt. However, there was no signicant
difference by sex for suicide attempts in the
past year.
Sexual minorities differed across race/
ethnicity on a number of outcomes. Compared

TABLE 1Sample Characteristics by Race/Ethnicity: United States, 2005 and 2007 Youth Risk Behavior Surveys

Total Samplea American Native/ Asian Black White Hispanic/Latino Multiracial

(n = 72 691), Pacific Islanderb (n = 7028), (n = 11 274), (n = 33 028), (n = 9626), (n = 7905),
Variable No. (%) (n = 2057), No. (%) No. (%) No. (%) No. (%) No. (%) No. (%)

Age, y
13 2183 (0.5) 63 (1.5) 59 (0.6) 50 (0.1) 1751 (0.7) 46 (0.2) 164 (0.6)
14 10 495 (12.6) 399 (20.7) 1025 (18.4) 1182 (11.7) 5260 (11.1) 1157 (13.3) 1250 (15.3)
15 17 656 (26.2) 532 (29.6) 1635 (25.6) 2677 (26.9) 7932 (24.8) 2384 (28.0) 2127 (30.1)
16 18 384 (25.6) 517 (25.3) 1739 (23.7) 3051 (25.6) 7929 (25.9) 2673 (26.0) 2079 (25.6)
17 16 127 (22.7) 371 (16.4) 1674 (19.7) 2841 (22.7) 7067 (24.2) 2231 (21.8) 1583 (19.1)
18 7550 (12.4) 174 (6.6) 890 (12.1) 1446 (13.0) 3066 (13.3) 1119 (10.7) 683 (9.3)
Sex
Male 35 501 (50.3) 1131 (55.1) 3596 (54.2) 5416 (48.0) 16 168 (50.9) 4588 (48.9) 3749 (48.4)
Female 36 678 (49.7) 912 (44.9) 3404 (45.8) 5813 (52.0) 16 730 (49.1) 5017 (51.1) 4102 (51.6)
Sexual orientation status
Sexual majorityc 66 446 (91.6) 1781 (86.0) 6462 (92.6) 10 255 (91.1) 30 657 (92.5) 8792 (91.7) 6930 (87.5)
Sexual minorityd 6245 (8.4) 276 (14.0) 566 (7.4) 1019 (8.9) 2371 (7.5) 834 (8.3) 975 (12.5)

Note. The sample size was n = 72 691.

a
Percentages are based on weighted data; reported numbers reflect unweighted data. Total and percentages may differ because of missing, excluded cases, and weighting.
b
Alaska Native/Native Hawaiian/Other Pacific Islander/American Indian.
c
Respondents who identified as heterosexual, and reported no same-sex behavior or same-sex attraction.
d
Respondents who reported either a lesbian, gay, bisexual, or unsure identity; any same-sex attraction; or any same-sex behavior.

June 2014, Vol 104, No. 6 | American Journal of Public Health Bostwick et al. | Peer Reviewed | Research and Practice | 1131
 TABLE 2Prevalence of Mental Health and Suicidality Outcomes by Race/ethnicity, Sexual Minority Status and Sex: United States, 2005 and 2007 Youth Risk Behavior Surveys

Feel Sad Suicide Ideation Suicide Plan Suicide Attempts Suicide Attempt Treated by Self-Harm (n = 17 679)
(n = 71 776) (n = 54 595) (n = 71 972) (n = 63 456) Doctor or Nurse (n = 61 004)
Sexual Sexual Sexual Sexual Sexual Sexual Sexual Sexual Sexual Sexual Sexual Sexual
Variable Minority, % Majority, % Minority, % Majority, % Minority, % Majority, % Minority, % Majority, % Minority, % Majority, % Minority, % Majority, %

Total sample 48.1 24.5 32.2 11.7 27.4 9.7 22.8 6.6 8.3 2.0 39.1 14.2
Sex
Male 37.6 18.1 25.4 8.6 22.4 8.0 20.9 5.4 9.1 2.0 30.9 10.1
Female 54.7 31.2 36.4 14.9 30.5 11.4 23.9 7.7 7.8 2.1 44.6 18.4
Race/ethnicity

1132 | Research and Practice | Peer Reviewed | Bostwick et al.

Alaska Native/Pacific Islander 53.8 33.4 33.6 18.1 36.5 15.6 32.2 14.5 12.8 4.4 59.9 14.8
Asian 42.9 24.5 25.2 13.2 22.4 11.5 21.1 6.4 8.7 1.8 31.3 13.7
Black 38.7 26.4 26.0 11.3 22.1 9.8 20.7 7.8 5.3 2.7 18.3 8.2
White 48.0 20.5 33.9 10.9 27.5 8.7 21.1 4.9 8.8 1.4 42.5 15.4
Hispanic/Latino 55.2 32.3 34.5 11.8 25.9 9.7 26.9 9.0 7.4 2.5 35.0 11.7
Multiracial 59.4 31.2 37.3 14.9 34.6 13.1 26.9 9.8 8.2 3.2 41.7 16.3
Females
Alaskan Native/Pacific Islander 65.5 43.4 42.9 25.2 36.1 20.0 30.8 17.9 14.5 3.1 64.0 19.7
Asian 51.6 29.0 28.6 16.5 27.1 14.3 23.6 8.7 5.9 1.9 42.3 18.5
RESEARCH AND PRACTICE

Black 45.1 33.2 29.5 14.1 25.0 11.0 20.1 7.9 4.5 2.5 11.7 10.1
White 55.5 26.6 38.4 13.8 31.6 10.2 22.6 5.9 9.3 1.6 50.4 20.4
Hispanic/Latino 56.4 40.3 38.5 14.9 29.4 11.4 30.4 10.8 7.3 2.6 36.0 13.7
Multiracial 63.3 40.0 38.2 20.1 35.0 16.7 27.4 11.5 6.2 3.2 39.0 18.8
Males
Alaska Native/Pacific Islander 42.6 25.3 25.8 12.4 36.9 12.0 32.7 11.7 10.9 5.4 55.1 12.6
Asian 34.8 20.7 22.1 10.4 18.0 9.2 19.0 4.2 11.4 1.7 17.7 9.7
Black 28.9 18.9 20.7 8.1 17.6 8.2 21.7 7.7 6.9 2.9 23.3 6.3
White 34.8 14.9 26.2 8.1 20.7 7.3 18.5 5.9 8.1 1.2 28.6 10.7
Hispanic/Latino 53.6 24.1 27.6 8.6 19.9 8.0 20.2 7.0 7.5 2.3 34.9 9.7
Multiracial 51.3 22.7 34.2 9.8 32.9 9.7 25.0 7.8 12.2 2.8 46.0 12.6

Note. Percentages are based on weighted data; reported numbers reflect unweighted data.

American Journal of Public Health | June 2014, Vol 104, No. 6

 RESEARCH AND PRACTICE

TABLE 3Main Effects for Sex, Sexual Minority Status, and Race/Ethnicity on Mental Health and Suicidality Outcomes: United States, 2005
and 2007 Youth Risk Behavior Surveys

Feel Sad, OR Suicide Ideation, Suicide Plan, Suicide Attempts, Suicide Attempt Treated by Self-Harm,
Variable (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) Doctor or Nurse,a OR (95% CI) OR (95% CI)

Female sex 2.03 (1.92, 2.14) 1.82 (1.70, 1.96) 1.48 (1.38, 1.59) 1.44 (1.31, 1.57) 0.49 (0.40, 0.61) 2.07 (1.86, 2.30)
Sexual minority 2.42 (2.22, 2.64) 3.20 (2.89,3.54) 3.21 (2.91, 3.55) 3.85 (3.42, 4.33) 1.32 (1.05, 1.66) 3.25 (2.79, 3.77)
Race/ethnicity (Ref: White)
Alaska Native/Pacific Islander 1.61 (1.36, 1.90) 1.21 (0.97,1.51) 1.52 (1.22, 1.88) 2.37 (1.83, 3.07) 1.20 (0.73, 1.97) 1.58 (1.14, 2.15)
Asian 1.07 (0.97, 1.18) 1.08 (0.89,1.14) 1.12 (0.99, 1.27) 1.13 (0.95, 1.34) 1.23 (0.86, 1.78) 0.85 (0.69, 1.06)
Black 1.08 (1.00, 1.18) 0.88 (0.80, 0.99) 0.96 (0.86, 1.08) 1.37 (1.20, 1.57) 1.24 (0.92, 1.68) 0.76 (0.59, 0.98)
Hispanic/Latino 1.58 (1.45, 1.72) 1.01 (0.90. 1.14) 1.03 (0.91, 1.16) 1.71 (1.48, 1.97) 0.98 (0.72, 1.34) 0.93 (0.76, 1.15)
Multiracial 1.56 (1.43, 1.69) 1.28 (1.15, 1.43) 1.42 (1.27, 1.58) 1.77 (1.54, 2.03) 1.16 (0.89, 1.53) 1.17 (0.98, 1.39)

Note. All models controlled for age.

a
Only includes those who reported a suicide attempt.

with White sexual minority youths, Asian and
Black youths were at signicantly lower odds of
suicidal ideation, suicide planning, and self-
harm. AN/PI, Latino and Multiracial youths,
however, were at signicantly higher odds of
feeling sad when compared with White youths,
and AN/PI and Latino youths were also at
signicantly higher odds of a suicide attempt in
the past year. This pattern differs from ndings
among the total sample: Asian youths did not
signicantly differ from Whites, and Multiracial
youths fared signicantly worse than White
youths on 4 of the 6 outcomes, as opposed to
just the single outcome (feeling sad) among
sexual minority youths.

TABLE 4Mental Health and Suicidality Outcomes by Race/Ethnicity and Sex, Sexual Minorities Only: United States, 2005 and 2007 Youth Risk
Behavior Surveys

Feel Sad, OR Suicide Ideation, Suicide Plan, Suicide Attempts, Suicide Attempt Treated by Self-Harm,
Variable (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) Doctor or Nurse,a OR (95% CI) OR (95% CI)

Female sex 1.84 (1.57, 2.15) 1.60 (1.35, 1.91) 1.46 (1.22, 1.73) 1.16 (0.95, 1.42) 0.47 (0.32, 0.69) 1.78 (1.21, 2.54)
Race/ethnicity (Ref: White)
Alaskan/Pacific Islander 1.49 (1.02, 2.18) 0.81 (0.54, 1.22) 1.48 (1.01, 2.18) 1.66 (1.06, 2.60) 0.75 (0.33, 1.68) 1.93 (0.48, 7.87)
Asian 0.86 (0.67, 1.10) 0.64 (0.48, 0.85) 0.71 (0.53, 0.95) 0.90 (0.65, 1.26) 1.10 (0.59, 2.07) 0.39 (0.23, 0.67)
Black 0.70 (0.57, 0.85) 0.69 (0.55, 0.86) 0.74 (0.60, 0.93) 0.89 (0.69, 1.16) 0.74 (0.44, 1.24) 0.45 (0.23, 0.87)
Latino 1.27 (1.01, 1.60) 1.01(0.79, 1.29) 0.92 (0.71, 1.18) 1.50 (1.14, 1.97) 0.52 (0.30, 0.89) 0.70 (0.35, 1.42)
Multiracial 1.35 (1.04, 1.73) 0.98 (0.75, 1.28) 1.24 (0.95, 1.61) 1.17 (0.86, 1.60) 0.88 (0.49, 1.59) 1.04 (0.59, 1.84)
Females
Alaskan/Pacific Islander 1.92 (0.82, 4.47) 0.80 (0.36, 1.79) 0.99 (0.45, 2.20) 1.32 (0.51, 3.43) 2.03 (0.71, 5.79) 2.01 (0.64, 6.30)
Asian 0.85 (0.57, 1.27) 0.54 (0.36, 0.82) 0.70 (0.46, 1.10) 0.83 (0.51, 1.42) 0.70, (0.24, 2.10) 0.41 (0.24, 0.73)
Black 0.62 (0.46, 0.84) 0.66 (0.48, 0.92) 0.72 (0.52, 1.01) 0.74 (0.49, 1.14) 0.88 (0.40, 1.94) 0.17 (0.06, 0.47)
Latino 1.04 (0.72, 1.39) 1.07 (0.77, 1.47) 1.01 (0.72, 1.41) 1.84 (1.26, 2.69) 0.72 (0.34, 1.53) 0.57 (0.31, 1.10)
Multiracial 1.26 (0.92, 1.72) 0.85 (0.62, 1.18) 1.11 (0.81, 1.54) 1.09 (0.74, 1.62) 0.87 (0.46, 1.63) 0.66 (0.42, 1.10)
Males
Alaskan/Pacific Islander 1.34 (0.60, 2.99) 0.77 (0.29, 1.99) 2.23 (0.99, 4.98) 2.29 (0.93, 5.64) 0.46 (0.05, 4.09) 2.01 (0.77, 5.21)
Asian 1.04 (0.68, 1.59) 0.76 (0.45, 1.27) 0.76 (0.47, 1.22) 0.99 (0.54, 1.67) 2.97 (0.67, 13.2) 0.33 (0.14, 0.77)
Black 0.82 (0.54, 1.24) 0.76 (0.47, 1.23) 0.82 (0.51, 1.33) 1.28 (0.75, 2.17) 1.13 (0.37, 3.44) 0.91 (0.42, 2.02)
Latino 1.98 (1.32, 2.97) 0.97 (0.60, 1.55) 0.83 (0.52, 1.35) 1.13 (0.65, 1.96) 0.51 (0.11, 2.31) 1.17 (0.44, 3.09)
Multiracial 1.59 (1.10, 2.31) 1.23 (0.80, 1.90) 1.43 (0.97, 2.13) 1.07 (0.66, 1.74) 1.75 (0.66, 4.67) 1.52 (0.74, 3.13)

Note. All models controlled for age.

a
Only includes those who reported a suicide attempt.

June 2014, Vol 104, No. 6 | American Journal of Public Health Bostwick et al. | Peer Reviewed | Research and Practice | 1133

When analyses were stratied by sex, few
signicant differences emerged. Compared
with White sexual minority females, Asian and
Black sexual minority females had lower prev-
alence of 1-year suicidal ideation and self-
harm. Sexual minority Latinas were the only
group with signicantly higher prevalence of
1-year suicide attempt compared with White
sexual minority females. Among sexual mi-
nority males, Latinos had twice the odds of
1-year prevalence of feeling sad (OR = 1.98)
and Asian sexual minority males had one third
the odds of self-harm (OR = 0.33) compared
with Whites.
DISCUSSION
We assessed mental health and suicidality
outcomes across groups based on sexual mi-
nority status, race/ethnicity, and sex. Results
add to existing evidence to support ndings
that sexual minority youths are at higher risk
for suicidality compared with heterosexual
youths. Results also reveal important nuances
that are often missing from extant literature.
For example, Asian and Black sexual minority
youths tended to fare better than White sexual
minority youths on a number of outcomes.
However, when we stratied results by sex, this
protective effect held only for Asian and Black
females, with the exception of Asian sexual
minority males being less likely to report self-
harming behavior than White sexual minority
males. Although female sexual minority par-
ticipants were at higher odds for most out-
comes than their male counterparts, there was
no signicant sex difference among sexual
minority youths in reports of suicide attempt in
the prior year.
These patterns accentuate the complexity
of multiple, intersecting identities and their
interaction with health, health behaviors, and
health outcomes. Intersectionality has been
suggested as an important conceptual frame-
work through which to understand sexual
minority health.15,16 These results afrm that
the consequences of possessing multiple mar-
ginalized identities are not simply additive
(i.e., that more marginalization necessarily
leads to more negative health outcomes).
Rather, it appears that for some health out-
comes and behaviors, in particular self-harm,
the intersection of minority identities conferred
1134 | Research and Practice | Peer Reviewed | Bostwick et al.
RESEARCH AND PRACTICE
a protective effect; this was the case for sexual
minority Asian and Black females compared
with their White counterparts.
Differences between groups in the current
study may stem, in part, from varying cultural
conceptions regarding the acceptability of self-
injurious behaviors, including suicide. In their
comprehensive synthesis of the suicide litera-
ture across cultural minority groups, including
LGBT populations, Chu et al.21 specically
address this issue. They note, for example, that
cultural sanctions around suicide, or messages
of disapproval or acceptability of suicide, vary
across racial and ethnic groups, pointing to
a number of studies in which Blacks are more
likely than their White counterparts to view
suicide negatively and as immoral.21 Our nd-
ings support the inter- and intrapersonal aspects
of identity and the interdependence of these
aspects.20 For some sexual and racial/ethnic
minority youths, their racial/ethnic identity may
be a prominent aspect of their self-schema. The
cultural values and norms associated with their
race/ethnicity may serve as a protective factor
or buffer against sexual minority stigma, which
may include strong sanctions against any self-
harming behaviors.
Results of the study point to the limitations
of using categories such as youths of color
when conducting research because salient dif-
ferences and distinctions among racial/ethnic
minorities can be blurred and nullied. This, in
turn, has consequences for how we design
mental health policies and interventions, for
both sexual minority youths and for youths in
general. An intersectional lens illuminates the
value of tailoring policies and interventions so
that they address the unique and particular
needs of specic groups.
An additional notable nding was that the
AN/PI group fared worse than other racial/
ethnic groups on many outcomes, irrespective
of sexual minority status or sex. This is consis-
tent with previous work among Native Amer-
ican and Alaska Native groups specically9
as well as a study of Asian/Pacic Islander
adolescents in Guam.23 Although signicant
differences were not found among sexual
minorities when stratied by sex, on the whole,
AN/PI youths reported the highest odds of
past-year suicide attempt. Comparability of the
ndings to other studies is highly provisional
given the manner in which the AN/PI category
American Journal of Public Health | June 2014, Vol 104, No. 6
was constructed in the current study. Never-
theless, results are a cause for concern, and
highlight the need for more focused studies on
Native American sexual minority youths and
for tailored intervention and prevention pro-
grams for this population.
The only other racial/ethnic differences
among sexual minorities were among Latino
youths: sexual minority Latinas were signi-
cantly more likely than their White counterparts
to report a past-year suicide attempt, and
Latinos were signicantly more likely than
White male sexual minority youths to report
feeling sad. Overall, these ndings are in concert
with some previous studies,3,12 which found
that Latino sexual minority youths were more
likely to report suicide attempts than their White
counterparts, but are inconsistent with ndings
from other studies that found Black sexual
minority youths13 and adults14 were also at
heightened risk for ideation and attempt.
Such differences across studies are likely
a function of variations in measurement of
both sexual orientation and suicidality, as
well as how samples were obtained. For
example, in the study by Mustanski et al.,13
they assessed suicidal ideation and attempt
in a structured psychiatric interview, whereas
in the current study, those aspects were
assessed via a single item in a paper-and-
pencil questionnaire.
Because all data reported in the current
study are based on self-report, there is the
possibility that ndings underrepresent the
prevalence of sexual minority youths and of
suicidal behaviors. Although we were unable to
estimate the extent of biased reporting, the
questions used to assess health-risk behaviors
in the YRBS have been shown to have good
test-retest reliability.24 Several other limitations
should also be considered. YRBS data are not
representative of sexual minority students in
other jurisdictions. This is particularly impor-
tant because regions with more liberal policies
may be more likely to include sexual orienta-
tion questions in their YRBS studies than
regions with less liberal attitudes. Regional
attitudes and policies toward sexual minorities
are also an important factor in determining
the health of sexual minorities, including
suicidality.25 Therefore, disparities between
sexual minority and sexual majority youths in
this study are likely to underrepresent the true

disparities across the United States.26 Further-
more, YRBS data are collected from youths
who attend public school. It is plausible that
sexual minority youths or those at highest
risk for suicidal behaviors are more likely to
drop out of school or attend private schools.
The etiology of suicidality is complex and
multifactorial. The current study did not
assess many factors that may contribute to
suicidality, such as violence and victimization;
nor did it assess protective factors, such as
social support, that may buffer suicidality
risks.27,28
A nal limitation is the use of an omnibus
sexual orientation variable. This approach
obscures variation between different dimen-
sions of sexual orientation (e.g., same-sex
behavior vs sexual minority identity), as well
as variation among sexual minority groups
(e.g., bisexual vs lesbian/gay identity), vis--
vis both race/ethnicity and mental health and
suicidality. However, our primary goal was to
present a broad analysis of racial/ethnic
differences based on sexual minority status.
Minority stress theory posits that sexual
minority status, regardless of how it is dened
(attraction, behavior, identity), is stigmatized,
and therefore, stressors resulting from this
stigma may be associated with any of these
dimensions. Future studies should address
the complexities of intersections of race/
ethnicity with multiple dimensions of sexu-
ality in adolescence.
A general omnibus measure allowed for
inclusion of the maximum number of partic-
ipants and jurisdictions, which assured suf-
cient statistical power and variability. We
note, however, the irony of using such
a measure of sexual orientation, while si-
multaneously making the case against a sim-
ilar measure of race/ethnicity (i.e., youths of
color). This trade-off highlights some of the
inherent conundrums and complications of
attempting to do a truly intersectional
analysis with secondary, quantitative data,15
and begs the question of whether such work
can effectively be accomplished with quanti-
tative dataor at least quantitative data alone.
In conclusion, the current study supports
previous ndings showing that sexual mi-
nority youths are at substantially higher risk
for suicidality. Beyond this, our ndings in-
dicate that among sexual minority youths,
June 2014, Vol 104, No. 6 | American Journal of Public Health
RESEARCH AND PRACTICE
sex and race/ethnicity interact to inuence
health and health behaviors in complex and
sometimes unpredicted ways. For example,
although some racial/ethnic sexual minority
youths appear to have higher risk for suici-
dality than White sexual minority youths,
others (e.g., Black and Asian youths), do not
show disparate risk and, in fact, are in some
cases at lower risk than Whites. Additional
research is necessary to better understand
patterns of risk, as well as how risk and
resilience function based on various combi-
nations of intersecting identities. j
About the Authors
Wendy B. Bostwick, is with the Public Health and Health
Education Programs, School of Nursing and Health Studies,
Northern Illinois University, De Kalb. Ilan Meyer is with the
Williams Institute, UCLA School of Law, University of
California, Los Angeles. Frances Aranda and Tonda
Hughes are with the College of Nursing, University of
Illinois at Chicago. Stephen Russell is with the Division of
Family Studies and Human Development and the Frances
McClelland Institute for Children, Youth, and Families,
University of Arizona, Tucson. Michelle Birkett and Brian
Mustanski are with the Department of Medical Social
Sciences, Northwestern University Feinberg School of
Medicine, Chicago, IL
Correspondence should be sent to Wendy B. Bostwick,
Assistant Professor, Public Health and Health Education
Programs, School of Nursing and Health Studies, Northern
Illinois University, De Kalb, IL 60115-2828 (e-mail:
wbostwick@niu.edu). Reprints can be ordered at
http://www.ajph.org by clicking the Reprints link.
This article was accepted October 20, 2013.
Contributors
All authors contributed to the conceptualization of
this article. W. B. Bostwick, I. Meyer and F. Aranda did
the writing. F. Aranda, M. Birkett, and W. B. Bostwick
conducted data analysis. All authors contributed to
the interpretation of the ndings and the review and
preparation of the nal article.
Acknowledgments
This project was supported by a grant from the Eunice
Kennedy Shriver National Institute of Child Health and
Human Development (award number R21HD051178)
and by the IMPACT LGBT Health and Development
Program at Northwestern University. Award Assis-
tance from the Centers for Disease Control and Pre-
vention (CDC) Division of Adolescent and School
Health and the work of the state and local health and
education departments who conduct the Youth Risk
Behavior Survey made the project possible. Prepara-
tion of this article was also supported, in part, by the
National Institute on Alcohol Abuse and Alcoholism,
2R01 AA013328 (T. H.).
The authors would like to thank Aimee Van Wagenen
for coordination and management of the pooled data set.
Note. The content is solely the responsibility of the
authors and does not necessarily represent the ofcial
views of the National Institutes of Health, the CDC, or
any of agencies involved in collecting the data.
Bostwick et al. | Peer Reviewed | Research and Practice | 1135
Human Participant Protection
Human participant protection was not required be-
cause data were acquired from secondary, de-identied
sources.
References
1. Remafedi G, Farrow J, Deisher RW. Risk factors for
attempted suicide in gay and bisexual youth. Pediatrics.
1991;87(6):869---875.
2. OCarroll PW, Berman AL, Maris RW, Moscicki EK,
Tanney BL, Silverman MM. Beyond the Tower of Babel:
a nomenclature for suicidology. Suicide Life Threat
Behav. 1996;26(3):237---252.
3. Garofalo R, Wolf RC, Wissow LS, Woods ER,
Goodman E. Sexual orientation and risk of suicide
attempts among a representative sample of youth. Arch
Pediatr Adolesc Med. 1999;153:487---493.
4. Russell ST, Toomey RB. Mens sexual orientation
and suicide: evidence for adolescent- specic risk. Soc
Sci Med. 2012;74(4):523---529.
5. Russell ST, Joyner K. Sexual minority youth and
suicide risk. Am Behav Sci. 2003;9:498---508.
6. Silenzio VM, Pena PR, Duberstein JC, Cerel J,
Knox KL. Sexual orientation and risk factors for
suicidal ideation and suicide attempts among adoles-
cents and young adults. Am J Public Health.
2007;97:2017---2019.
7. Haas AP, Eliason M, Mays V, et al. Suicide and
suicide risk in lesbian, gay, bisexual, and transgender
populations: review and recommendations. J Homosex.
2011;58:10---51.
8. Marshal MP, Friedman MS, Stall R, et al. Sexual
orientation and adolescent substance use: a meta-analysis
and methodological review. Addiction. 2008;103:
546---556.
9. Borowsky IW, Resnick MD, Ireland M, Blum RW.
Suicide attempts among American Indian and Alaska
Native Youth. Arch Pediatr Adolesc Med. 1999;153:573---
580.
10. Centers for Disease Control and Prevention. Youth
Risk Behavior Surveillance United States, 2011. MMWR
Surveill Summ. 2012;61(4):1---162.
11. Spirito A, Esposito-Smythers C. Attempted and
completed suicide in adolescence. Annu Rev Clin Psychol.
2006;2:237---266.
12. Consalacion TB, Russell ST, Sue S. Sex, race/
ethnicity, and romantic attractions: multiple minority
status adolescents and mental health. Cultur Divers
Ethnic Minor Psychol. 2004;10:200---214.
13. Mustanski BS, Garofalo R, Emerson EM. Mental
health disorders, psychological distress, and suicidality
in a diverse sample of lesbian, gay, bisexual, and
transgender youths. Am J Public Health.
2010;100:2426---2432.
14. ODonnell S, Meyer I, Schwartz S. Increased risk of
suicide attempts among Black and Latino lesbians, gay
men, and bisexuals. Am J Public Health. 2011;101(6):
1055---1059.
15. Bowleg L. The problem with the phrase women and
minorities: intersectionalityan important theoretical
framework for public health. Am J Public Health.
2012;102:1267---1273.
16. Committee on Lesbian Gay Bisexual and Trans-
gender Health Issues and Research Gaps and
 RESEARCH AND PRACTICE

Opportunities, Institute of Medicine. The Health of

Lesbian, Gay, Bisexual, and Transgender People: Build-
ing a Foundation for Better Understanding. Washington,
DC: National Academies Press; 2011.
17. McCall L. The complexity of intersectionality. Signs
(Chic). 2005;30:1771---1800.
18. Crenshaw K. Mapping the margins: Intersectionality,
identity politics, and violence against women of color.
Stanford Law Rev. 1991;1241---1299.
19. Davis K. Intersectionality as buzzword. Fem Theory.
2008;9(1):67---85.
20. Meyer IH. Prejudice, social stress, and mental health
in lesbian, gay, and bisexual populations: Conceptual
issues and research evidence. Psychol Bull. 2003;129(5):
674---697 .
21. Chu JP, Goldblum P, Floyd R, Bongar B. The cultural
theory and model of suicide. App Prev Psychol. 2010;
14(1):25---40.
22. Mustanski, B, Van Wagenen, A, Birkett, M, Eyster, S,
Corliss, H. Identifying sexual orientation health dispar-
ities in adolescents: analysis of pooled data from the
Youth Risk Behavior Survey, 2005 and 2007. Am J
Public Health. 2014;104(2):211---217.
23. Pinhey TK, Millman SR. Asian/Pacic Islander
adolescent sexual orientation and suicide risk in Guam.
Am J Public Health. 2004;94:1204---1206.
24. Brener ND, Kann L, McManus T, Kinchen SA,
Sundberg EC, Ross JG. Reliability of the 1999 Youth Risk
Behavior Survey questionnaire. J Adolesc Health.
2002;336---342.
25. Hatzenbuehler ML, Birkett M, Van Wagenen A,
Meyer IH. Protective school climates and reduced risk for
suicide ideation in sexual minority youths. Am J Public
Health. 2014;104(2):279---286.
26. Hatzenbuehler ML. The social environment and
suicide attempts in lesbian, gay, and bisexual youth.
Pediatrics. 2011;127.
27. Liu RT, Mustanski B. Suicidal ideation and self-harm
in lesbian, gay, bisexual, and transgender youth. Am J
Prev Med. 2012;42:221---228.
28. Mustanski B, Liu RT. A longitudinal study of
predictors of suicide attempts among lesbian, gay, bi-
sexual, and transgender youth. Arch Sex Behav.
2013;42:437---448.

1136 | Research and Practice | Peer Reviewed | Bostwick et al. American Journal of Public Health | June 2014, Vol 104, No. 6