Suicidality and sexual orientation among men in Switzerland: Findings from 3 probability surveys
Introduction
In Europe, rates of suicide vary strongly between regions—highest in the east and lowest in the south (Chishti et al., 2003)—and are correlated with rates of suicide attempts, especially among young men (Hawton et al., 1998). Although suicidality—i.e., suicidal ideation, suicide plans, and suicide attempts—is not regularly assessed in most countries, multi-national studies have presented compelling discrepancies across countries and by sex and age group (Nock et al., 2008; Kovess-Masfety et al., 2011). According to studies in western and northern Europe, the prevalence of suicidal ideation in the male general population is 3–14% lifetime (Weissman et al., 1999; Nock et al., 2008) or 2–7% in the past year (Hintikka et al., 1998; Kjøller and Helweg-Larsen 2000), whereas the prevalence of suicide attempts is 1–4% lifetime (Weissman et al., 1999; Nock et al., 2008; McManus et al., 2009) or 0.5–1% in the past year (Hintikka et al., 1998; McManus et al., 2009).
Generally, suicidality has been assessed more frequently in adolescent health surveys which have also yielded much higher prevalence estimates: in Europe, the mean prevalence of suicide attempts is 6.9% lifetime or 2.0% in the past year (Evans et al., 2005). Switzerland has one of the higher rates of completed suicides and occupies an intermediate position in attempted suicides (Bille-Brahe, 1999), yet population data on suicidality exist only for adolescents. According to the 1992 Swiss Multicenter Adolescent Survey on Health (SMASH), 26% of 15–20 year old students reported suicidal thoughts, 15% suicidal plans, and 3% suicide attempts in the past year (Rey Gex et al., 1998). According to the 1993 Swiss Recruit Survey of 20 year olds, 49.1% reported lifetime suicidal ideation and 2.3% suicide attempts (Mohler-Kuo et al., 2006).
Compelling evidence for higher risk of suicidal behaviors associated with homosexuality have come from a Christchurch (New Zealand) birth cohort (OR = 5.4 for lifetime suicidal ideation and OR = 3.0–6.2 for lifetime suicide attempts) (Fergusson et al., 1999; Skegg et al., 2003), a US male twin registry (OR = 4.1 for lifetime suicidal ideation and OR = 6.5 for lifetime suicide attempts) (Herrell et al., 1999), a Danish national population registry (OR = 1.9–8.2 for suicide incidence) (Mathy et al., 2011), several national health surveys in Europe and North America (OR = 1.9–7.7 for lifetime suicidal ideation and OR = 2.2–10.2 for lifetime suicide attempts among men and/or men and women combined) (Cochran and Mays, 2000; Gilman et al., 2001; de Graaf et al., 2006; Jouvin et al., 2007; Brennan et al., 2010; Bolton and Sareen, 2011; Chakraborty et al., 2011), and several national/regional adolescent health surveys in Europe and North America (OR = 4.3–6.7 for lifetime suicide attempts among male and/or male and female secondary school students combined) (Remafedi et al., 1998; Wichstrøm and Hegna, 2003) (NB: An excellent overview of findings on suicidality in the past 12 months by sexual orientation among high school students in the various Youth Risk Behavior Surveys is presented in Kann et al., 2011).
Reviews of studies examining suicidality among sexual minorities point out discrepancies by country/region, sex, and age group (Russell and Toomey, 2010; Haas et al., 2011), albeit with some noteworthy distinctions. Both fatal and non-fatal suicidality appear to be more pronounced among gay/bisexual men than women (Haas et al., 2011). Although suicidality among sexual minorities also appears to be especially elevated during adolescence (Russell and Toomey, 2010), prevalences of lifetime suicidality remain high among sexual minority adults whereas they fall among general population adults.
National health surveys with representative samples of self-reported gay/bisexual men in western Europe have yielded lifetime prevalences of 33–40% for suicidal ideation (Statens Folkhälsoinstitut, 2005; de Graaf et al., 2006) and 10–15% for suicide attempts (Statens Folkhälsoinstitut, 2005; de Graaf et al., 2006;Jouvin et al., 2007) as well as 12-month prevalence of 13% for suicidal ideation (Jouvin et al., 2007). A national survey among secondary school students in Norway reported a lifetime prevalence of 15.4% for suicide attempts among male and female homo/bisexual respondents (Wichstrøm and Hegna, 2003).
Studies with convenience samples of gay men in western Europe have found lifetime prevalences of 47% for suicidal ideation (Warner et al., 2004) and 15–25% for suicide attempts (Cochand and Bovet, 1998; Hegna et al., 1999; Warner et al., 2004; Mayock et al., 2009). Studies with convenience samples of young gay men (between 15–16 and 24–27 years) in western Europe have yielded lifetime prevalences of 71% for suicidal ideation (McNamee, 2006) and 12–27% for suicide attempts (van Heeringen and Vincke, 2000; Cochand et al., 2000; Hanner, 2002; McNamee, 2006; Hegna and Wichstrøm, 2007). Using convenience samples of gay men in French-speaking Switzerland, Cochand and colleagues have reported lifetime prevalences of 23% for suicide attempts among gay men (Cochand and Bovet, 1998) and 24% among young gay men aged 16–25 years (Cochand et al., 2000). In brief, the prevalences reported in convenience samples appear to be higher than those in probability samples. For an exhaustive overview of studies in Europe and internationally, please consult the website by Ramsey and Tremblay (2011).
This growing body of evidence has not always influenced public health action—or even mention—of sexual minorities in suicide prevention programs and strategies. As in most places, sexual minorities are largely invisible in suicide prevention efforts in Switzerland, and one reason may be the dearth of Swiss data. Given the relative paucity of population data on suicidality in Europe generally, for sexual minorities in Europe specifically, and for sexual minority adolescents in Europe in particular (to date, only one publication from Norway), this paper contributes to the evidence base by presenting findings for the key forms of suicidality from three distinct probability samples of men in Switzerland.
As the afore-mentioned findings all point to increased risk of suicidality among gay men and young gay men, our working hypothesis is that the three samples will also yield higher prevalences and risk for suicidality in this group. However, given the wide ranges in OR and prevalences reported in the literature, we wish to situate the actual levels—bolstered due to possible homogeneity across samples—for this group in Switzerland. Most studies collect and present data for only one or two forms of suicidality along a single time frame. Since differences by region, time frame, sex, and age also appear to be relevant among sexual minorities, we wanted to explore possible differences in time frame, age, and sampling design by directly comparing data on three forms of suicidality, across two time frames, from three different samples. The two nation-wide adolescent samples complement the gay male community sample by including young men who have not yet presented at meeting points. In turn, the gay male community sample complements the adolescent surveys with data on suicidality post-adolescence and the inclusion of gay-specific variables. Through their juxtaposition, we explore in a direct and explicit way whether a coherent picture for higher prevalences and risk among sexual minority men emerges.
Section snippets
Study samples and measures of sexual orientation and suicidality
The first Geneva Gay Men's Health Survey (GGMHS) was a comprehensive health interview survey conducted in 2002 among gay men in Geneva, using time-space sampling at both physical venues and virtual meeting points (for a detailed description of the methods, see Wang, Häusermann, Vounatsou et al., 2007). All 571 participants were either self-identified gay/bisexual men or other men who have sex with men. No age limits were imposed, and the final sample had a mean and median age of 35 years (range
Suicidality among gay men in the Geneva region
Table 1 shows the lifetime and 12-month prevalences of five suicide behaviors among men from the Geneva Gay Men's Health Survey (GGMHS). Overall, 69.8% of the respondents reported any of the five suicide behaviors in their lifetime and 32.5% in the past 12 months. Among those reporting at least one behavior, 87.1% reported more than one in their lifetime and 68.6% in the past 12 months. Although life weariness, death wishes, and suicidal ideation were equally prevalent at just over 50% lifetime
Discussion
Despite mounting evidence of higher risk of suicidality among sexual minorities, this issue has often been met with skepticism or inattention in Switzerland and elsewhere. This paper presents findings from 3 distinct surveys which all point to higher prevalences and risk of lifetime and 12-month suicidal ideation, suicide plans, and suicide attempts among gay and other homo/bisexually attracted men in Switzerland.
Despite heterogeneity in prevalence values for some indicators between surveys,
Funding sources
Data collection for the Geneva Gay Men's Health Survey was financed by the Swiss National Research Foundation grant 3326-062448 and the Swiss Federal Office of Public Health.
This publication and the analyses therein were financed by the Swiss National Research Foundation grant 3346C0-104189.
Dialogai is a non-profit organization supported by a grant from the canton of Geneva.
Contributors
Jen Wang designed the Geneva Gay Men's Health Survey (GGMHS), performed the literature review, designed the statistical analysis, analyzed the data from GGMHS, and wrote the manuscript. Michael Häusermann participated in the design of the Geneva Gay Men's Health Survey, led the data collection, and contributed to the discussion of the results. Hans Wydler designed the Swiss Recruit Survey (ch-x) and performed the statistical analysis with that dataset. Meichun Mohler-Kuo performed the
Conflicts of interest
None.
Acknowledgments
The authors wish to acknowledge 1) recruitment coordinator Vincent Jobin and the many volunteers and experts in Geneva who have contributed to the Geneva Gay Men's Health Survey, 2) Pierre-André Michaud of the University of Lausanne for his kind permission to use the data from SMASH 2002 for this analysis, and 3) two anonymous referees for their thorough and insightful comments on an earlier draft.
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