Pathways to Hope: Redefining Suicide Prevention for Black LGBTQ Youth

Abstract

The deleterious impact of suicidal thoughts and behaviors (STBs) on Black LGBTQ youth is alarming and exponentially growing, as suicide is one of the leading causes of death among this population (Centers for Disease Control and Prevention 2020; Centers for Disease Control and Prevention 2023; Ream 2022). In 2023, 44% of Black LGBTQ youth reported active suicide ideation and 16% reported past-year suicide attempts (The Trevor Project 2024). Rates of active suicide ideation were significantly higher among Black transgender and nonbinary youth compared to cisgender Black LGBQ youth (59% vs. 37%, respectively; The Trevor Project 2021). Rates of suicide attempts were also significantly higher among Black transgender and nonbinary youth, as 26% reported past-year suicide attempts compared to 14% of their cisgender Black LGBQ counterparts. Black LGBTQ youth reported higher rates of suicide ideation and attempts compared to their white or Asian American/Pacific Islander LGBTQ youth counterparts (The Trevor Project 2024). Rates of STBs are much higher among Black LGBTQ youth, likely due to the impact of having multiple marginalized identities that are subject to STB risk factors such as racism, discrimination, anti-LGBTQ legislation and policies, and experiencing violence (Crenshaw 1989; The Trevor Project 2021). Other influential structural and systemic factors include various structures of domination (e.g., white supremacy, cisgenderism, and capitalism; Parchem, Poquiz, and Rider 2024). These structures, systems, and processes perpetuate the disproportionate rates of suicidal thoughts and behaviors among Black LGBTQ youth, underscoring the dire need for suicide prevention programs to address this public health priority.

Youth suicide prevention programs have been implemented in schools, communities, and healthcare systems. Youth suicide prevention programs of all types and in all settings are variable in their ability to reduce STBs, as not all programs are effective in reducing STBs (Calear et al. 2016; Walsh, Herring, and McMahon 2023; York et al. 2013). The existing suicide prevention programs tend to have the largest impact on increasing suicide awareness rather than reducing STBs (Brann et al. 2021). Additionally, there is a lack of outcome data specific to Black LGBTQ youth who participate in these programs. Given the disproportionate and increasing rates of STBs among Black LGBTQ youth, it is unknown if these prevention programs sufficiently prevent or reduce suicidal thoughts and behaviors among Black LGBTQ youth. It is likely that the success of suicide prevention programs among Black LGBTQ youth is hindered by the research gaps regarding STB risk and protective factors, inaccurate screening tools, lack of available culturally specific and LGBTQ-competent suicide prevention programs, barriers to treatment, and differences in help-seeking behaviors for Black LGBTQ youth.

While there are several established risk factors for Black or LGBTQ youth, (e.g., bullying, discrimination, school victimization, rejection, and internalized stigma [Gorse 2022; Green, Taliaferro, and Price 2022; Molock et al. 2022]) and protective factors for these Black or LGBTQ youth (e.g., being hopeful, positive attitudes about self-identity, social and community support, stable environment, and affirming and inclusive schools [Gorse 2022; Green, Taliaferro, and Price 2022; Molock et al. 2022]), little is known about the specific risk and protective factors for youth who identify as Black and LGBTQ. There needs to be more nuanced research that considers the impact of having multiple marginalized identities on STB risk and protective factors, as risk and protective factors likely differ for those who identify as Black LGBTQ, nonblack LGBTQ, and cisgender heterosexual Black youth.

Not only does research fail to comprehensively capture the unique stressors Black LGBTQ youth face due to their intersecting marginalized identities, but current research on Black LGBTQ youth STB risk and protective factors does not recognize the significant diversity within the Black LGBTQ youth community. For instance, over 25% of Black LGBTQ youth use pronouns that fall outside the binary gender construction (The Trevor Project 2021). Research on risk and protective factors for suicidal thoughts and behaviors should acknowledge and reflect the diversity of Black LGBTQ youth. The success of any comprehensive suicide prevention program relies on the ability to accurately assess risk and protective factors. It is likely that this dearth in knowledge of STB risk and protective factors among Black LGBTQ youth stymies the efficacy of existing youth suicide prevention programs. To more accurately identify the risk and protective factors for STBs, it is recommended that qualitative interviews and focus groups be conducted with a diverse group of Black LGBTQ youth who have experienced suicidality. Learning more about the experiences of suicidality among this population can result in more accurate information regarding STB risk and protective factors.

The lack of culturally specific measures that assess multilevel risk and protective factors of suicide poses another hindrance to the success of suicide prevention efforts among Black LGBTQ youth. There are no culturally specific suicide prevention measures or screeners to assess for suicide risk among Black youth (Molock et al. 2023). The existing measures tend to assess suicide risk at the individual level and neglect important identity-related factors, such as salience of racial, sexual, and/or gender identity. The lack of comprehensive and accurate suicide risk measures is problematic, as these measures do not ask relevant questions to assess risk (e.g., presence of affirming or discriminatory peers, organizations, or laws). Thus, it is likely that the existing suicide prevention programs do not accurately identify all at-risk Black LGBTQ youth. An accurate measure for suicide risk among Black LGBTQ youth should include a comprehensive set of culturally specific risk and protective factors at the individual, neighborhood, and structural level. To address this issue, existing quantitative suicide measures can be normed on and adapted for a sample of Black LGBTQ youth. Another solution consists of creating a youth advisory board to assist with the development of a suicide screening instrument. The new screening instrument, specific for Black LGBTQ youth, should incorporate relevant information from qualitative interviews with Black LGBTQ youth who have experienced suicidality.

The lack of available culturally sensitive and LGBTQ-competent suicide prevention programs is another proposed factor that thwarts the success of suicide prevention efforts among Black LGBTQ youth. Suicide prevention programs can be conceptualized as universal, selective, or indicated. Universal suicide prevention programs target all youth, regardless of suicide risk. Selective suicide prevention programs target youth at-risk for engaging in suicidal thoughts and behaviors and indicated prevention programs are for youth who already engage in suicidal thoughts and behaviors. While there are many universal suicide prevention programs for youth, there is a lack of selective or indicated suicide prevention programs for Black LGBTQ youth. The disproportionate rates of STB engagement among Black LGBTQ youth indicate that the existing universal suicide prevention programs are not effective for Black LGBTQ youth. Perhaps universal suicide prevention programs are not effective in reducing STB rates among Black LGBTQ youth because they do not incorporate important identity-related constructs relevant to suicide prevention among this population. It is also possible that these programs do not address these constructs through an affirming and culturally sensitive lens.

Since Black LGBTQ youth comprise an at-risk group for engaging in STBs, suicide prevention programs for Black LGBTQ youth would function as a selective or indicated prevention program, depending on whether STB engagement is present among the participating youth. While there are several theorized suicide prevention programs for Black LGBTQ youth, no programs exist. Thus, Black LGBTQ youth do not have available or effective suicide prevention programs that specifically target identity-related factors in a culturally sensitive and LGBTQ-competent manner.

Even if effective suicide prevention programs were available, disparities in access to care can thwart the success of suicide prevention programs among Black LGBTQ youth. Black LGBTQ youth noted that affordability of treatment and the challenges to obtaining parental permission were two primary hindrances of accessing mental health treatment (The Trevor Project 2021). Additionally, difficulty finding an LGBTQ competent provider was another barrier to care. Specifically, 40% of Black transgender and nonbinary youth had difficulty finding an LGBTQ competent provider compared to 20% of their Black cisgender youth counterparts (The Trevor Project 2021). Furthermore, Black transgender and nonbinary youth reported nearly twice the rate of previous negative healthcare experiences compared to their Black cisgender LGBQ youth counterparts (21% and 12%, respectively). Personal negative experiences with healthcare providers, as well as historical distrust of healthcare institutions and providers constitute another barrier to accessing care.

Differences in help-seeking behaviors is another factor that impedes the effectiveness and availability of suicide prevention programs for Black LGBTQ youth. An overwhelming amount of both Black and LGBTQ youth do not seek professional help for suicidal thoughts and behaviors (Goldston et al. 2008; Lytle et al. 2018). Distrust of professional mental health care, lack of cultural sensitivity, healthcare discrimination, and laws prohibiting gender-affirming care are several reasons that underly this deep distrust. Both Black and LGBTQ youth seek help through informal sources of help and support. For instance, Black youth are more likely to seek help from church clergy (Goldston et al. 2008). LGBTQ youth, on the other hand, prefer to seek social or family (if available) support for STB concerns (Lytle et al. 2018). To address disparities and differences in access to help, suicide prevention efforts should focus on contexts and locations that are salient to the identities of Black LGBTQ youth (e.g., churches or embedded within existing social groups).

The disproportionate impact of STBs among Black LGBTQ youth is a major concern. Thus, modifying or creating selective or indicated suicide prevention programs to be more culturally sensitive, affirming, and effective is a public health priority. The increased funding for suicide prevention efforts (e.g., U.S. Department of Health and Human Services' National Strategy for Suicide Prevention) underscores this priority and signals that more advances to suicide prevention research and efforts will follow. Identifying more accurate factors related to suicidal thoughts and behaviors, creating more accurate suicide risk measures, and addressing disparities and differences in access to care are all steps needed to improve suicide prevention efforts. A new approach to suicide prevention for Black LGBTQ youth can create more affirming, culturally sensitive, and effective prevention programs. In doing so, this new approach serves as a pathway to hope in preventing and reducing suicidal thoughts and behaviors among Black LGBTQ youth.