A FAMILIAR BUT UNFAMILIAR CASE
A 16-year-old male with depression has committed suicide. He had been seeing a physician who placed him on an anti-depressant three weeks ago. His family, friends, and physician knew of his depression, but did not know why he was depressed or why he committed suicide. Was he hiding an unbearable secret? Homosexuality was never brought up. His parents could not conceive of the idea and it was not accepted by their religion. His male friends would always talk about girls with him, and occasionally made gay jokes, but he never seemed to mind. His physician assumed he was heterosexual because he had a girlfriend in the past. In actuality, he was confused, scared, and alone. He thought he liked girls, but he had been feeling more attracted to boys. He could not control these feelings despite the fear that his parents would disown him and his friends would turn on him. He had no one to talk to and was afraid his physician might be homophobic and reveal his feelings to his mother, who was always sitting right outside the office. Fortunately, this is a fictional case, but how many suicides resemble this?
Approximately one million adolescents attempt suicide per year (Gould et al., 2003). Every 90 minutes one adolescent commits suicide, making it the third leading cause of death among ten- to 19-year-olds (Gould et al., 2003; Kaplan & Sadock, 2003). To explain the high suicide rate, Kaplan and Sadock (2003) state, "Universal features in suicidal adolescents are the inability to synthesize solutions to problems and the lack of coping strategies to deal with immediate stressors. Therefore, a narrow view of the options available to deal with recurrent family discord, rejection, or failure contributes to a decision to commit suicide." For gay adolescents this reasoning is far more pronounced. The process of realizing that one is gay and having to accept it is not just an immediate stressor and can actually narrow one's options further by taking away coping resources, such as friends and family (Goldfried, 2001; Heimberg & Safren, 1999; Paul et al., 2002; Nelson, 1997). Gay adolescents who "come out" (disclose their sexuality) may experience great family discord, rejection, and even failure from the disappointment they elicit (Hart & Heimberg, 2001; D'Augelli et al., 1998). It would make sense to conclude that homosexuality is an important risk factor for adolescent suicide. However, many physicians disagree and textbooks fail to adequately emphasize this point. This reflects the need to understand the increased risk of suicide among gay adolescents.
This article explores why issues involving homosexuality are seldom discussed, provides evidence for an increased risk of suicide among gay adolescents, and attempts to facilitate an understanding of why these individuals are at such increased risk. With this understanding, a physician is more likely to adequately approach the issue of sexuality with an adolescent and ultimately play a more significant role in suicide prevention.
When considering possible reasons for patients' suicidal ideation or attempts, is their sexuality brought up? And if so, is it dismissed based on an assumption? "They are not gay because they have a girl/boyfriend."
Why is it Seldom Discussed?
Nusbaum and Hamilton (2002) reported a study in which only 35% of primary healthcare physicians reported that they often (75% of the time) or always take a sexual history. Two of their explanations for the low percentage were embarrassment and the belief that it is irrelevant to the chief complaint. Sex is still an uncomfortable and embarrassing subject for many people, even for physicians. As a result, the tendency is to avoid it. When interviewing an adolescent who is depressed or suicidal how often is sexuality questioned? And if it is brought up, is it discussed and in how much detail? How does …