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Intersecting Identities and the Association Between BullyingandSuicideAttemptAmongNewYorkCityYouths: Results From the 2009 New York City Youth Risk Behavior Survey Michael T. LeVasseur, MPH, Elizabeth A. Kelvin, PhD, MPH, and Nicholas A. Grosskopf, EdD, MCHES

In 2010, several high-profile suicides of lesbian, gay, and bisexual (LGB) youths shed new light on bullying in schools in the United States. Nation- ally, suicide is the third leading cause of death among 12- to 19-year-old youths and fourth in New York State.1 Estimates from the 2011 Youth Risk Behavior Survey (YRBS) indicate that 7.8% of US youths reported attempting suicide in the past year.2 According to the New York City (NYC) Department of Health and Mental Hy- giene, suicide attempts among NYC teens had remained constant at 7% until 1999 when suicide attempts increased to 10%.3

In 2011, an estimated 20% of US youths reported bully victimization in the past year.2

Research into understanding the effect of bul- lying on health outcomes among youths has focused on those who perpetrate bullying, those who are victims of bullying, and those who are both perpetrators and victims.4 Youths who are involved in bullying as either victims or perpetrators experience higher levels of psychosocial harm,5,6 depression,7 and sub- stance use8 than those who are not involved in bullying, but those who are victims of bullying are more likely to experience depressive symptoms than are perpetrators.4

Bullying is a significant risk factor for suicide ideation independent of other suicide risk factors.9,10 Youths who report any involvement in bullying are more likely to report seriously considering or attempting suicide than those who report no involvement.11 A survey of the literature on bullying and suicide has suggested that the relationship between bullying and suicide may have different effects among dif- ferent minority groups, including racial, gender, and sexual minorities.

Both the US Surgeon General and the In- stitute of Medicine have listed LGB youths as

a high-risk group for suicide, and the Institute of Medicine and the Centers for Disease Con- trol and Prevention (CDC) recommended in- creasing national surveillance on the health of LGB people to better assess the health disparities of sexual minorities in the United States.12---15 As many as one third of youth suicide deaths have been estimated to occur among sexual minorities.16 A 2011 Morbidity and Mortality Weekly Report showed that the prevalence of suicide attempt was higher among sexual minority youths than among heterosexual youths,14 and in a 2007 report, 1 in 3 sexual minority youths in NYC reported attempting suicide compared with 1 in 12 heterosexual youths.3

LGB youths are also at increased risk for peer victimization compared with heterosexual youths.17,18 In 2005, a survey of school safety

among a national sample of students found that LGB students were 3 times more likely to feel unsafe at school than heterosexual peers, and 90% of LGB students reported having been verbally or physically harassed.19 Among New York state students, 61.1% felt unsafe in school because of their sexual orientation, and 84.6% of LGB students reported verbal harassment, 40.1%, physical harassment, and 18.8%, phys- ical assault.20

Abelson et al. 21 suggested that suicidality among LGB youths is not the result of in- dividual pathologies but rather a direct result of peer victimization. Hunter22 reported that 34% of gay male youths and 41% of lesbian female youths who sought services at the Hetrick-Martin Institute in NYC reported attempting suicide because of the antigay vio- lence they experienced.

Objectives. We examined the intersections of sexual minority, gender, and

Hispanic ethnic identities and their interaction with experiences of bullying in

predicting suicide attempt among New York City youths.

Methods. We performed secondary data analysis of the 2009 New York City

Youth Risk Behavior Survey, using logistic regression to examine the association

of sexual identity, gender, ethnicity, and bullying with suicide attempt. We

stratified results on these measures and reported adjusted odds ratios.

Results. Compared with non–sexual minority youths, sexual minority youths

had 4.39 and 1.96 times higher odds, respectively, of attempting suicide and

reporting bullying. Identity variables did not interact with bullying in predicting

suicide attempt individually; however, a four-way interaction term was signifi-

cant. The effect of bullying on suicide attempt was strongest among non-

Hispanic sexual minority male youths (odds ratio = 21.39 vs 1.65–3.38 for other

groups).

Conclusions. Sexual minority, gender, and ethnic identities interact with

bullying in predicting suicide attempt among New York City youths. Interven-

tions to limit both the prevalence and the effect of bullying among minority

youths should consider an intersectional approach that considers ethnic,

gender, and sexual identities. (Am J Public Health. Published online ahead of

print April 18, 2013: e1–e6. doi:10.2105/AJPH.2012.300994)

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Although female youths are twice as likely as male youths to report suicide attempt,23 male youths are 3 to 5 times more likely than female youths to successfully commit suicide.12 Brent et al.24 suggested that this may be because female adolescents are more likely to attempt suicide using reversible methods, such as pill overdose, and are also less likely to attempt suicide under the influence of alcohol, which may increase the likelihood of death during a suicide attempt. According to the 2011YRBS, female youths were more likely than male youths to report attempted suicide both na- tionally and in NYC.2 However, male adoles- cents are 6 times more likely to successfully commit suicide than female adolescents.25

Studies have suggested that male youths are more likely to perpetrate bullying than are female youths.26---28 Nationally, female youths are more likely to report bullying than are male youths, but in NYC, no difference was found in reported bullying by gender.2 Some studies have suggested that gender may be an effect modifier of the relationship between bullying and suicide attempt and that female youths who experience peer victimization have higher odds of suicide attempt than male youths, but these associations are inconsistent across studies.9---11,29---33

A 2002 report from the Institute of Medicine showed that suicide rates vary significantly across race/ethnicity. The global burden of suicide falls disproportionately on Whites.12

According to the CDC’s WONDER mortality database, the crude rate of suicide death per 100 000 of those aged10 to19 years from1999 to 2008 was 5.0 for non-Hispanic Whites, 2.9 for non-Hispanic Blacks, and 3.2 for His- panics.25 A study exploring self-harm and sui- cide attempt among high-risk urban youths in the United States suggested that Hispanics have higher rates of suicide attempt and self-harm than do non-Hispanic Whites or non-Hispanic Blacks.23 Despite lower rates of completed suicide, results of the 2011 YRBS suggested that Hispanic youths were more likely to report a suicide attempt than were White or Black youths.2

Taken together, these 2 results suggest that Hispanics are more likely to attempt but less likely to be successful at suicide than are Whites and Blacks. With respect to bullying, a nationally representative study of US youths has suggested that Blacks report lower rates of bully victimiza- tion than do Whites or Hispanics.34

The literature on minority identity develop- ment is becoming populated with new perspec- tives on the development of intersectionality specifically related to race and sexual identity formation.35---38 A relatively new paradigm in the literature, intersectionality suggests that as with many social constructs such as race, gender, and class, sexuality can serve as a basis for social power and oppression. Theorists have argued that without acknowledging the cross- construction of several conflicting identities, it is impossible to understand the effects of victimi- zation on varying groups of sexual minority youths.39 The acknowledgment of these often complex identity development trajectories served as the theoretical framework for this study.

Theorists have hypothesized that youths who are both sexual and racial minorities may experience different identity development tra- jectories as a result of heterosexism, homone- gativity, and homophobia often present in ethnic minority communities.40 Studies ex- ploring the relationship between racial and sexual identities have suggested that sexual identity developmental milestones, such as age of same-sex attraction and same-sex sexual debut, do not differ by race/ethnicity.41 None- theless, the literature has revealed that racial minority families often attempt to socialize their children to cope with the realities of covert and overt racism experienced within the context of White heterosexual communities.42

Although systematic attention is increasingly being paid to White LGB youths, little attention has been paid to racially diverse same-sex--- attracted youths. Therefore, these youths confront many interpersonal issues simulta- neously: their racial and sexual identity de- velopmental changes, heterosexism within their respective ethnic and cultural communi- ties, heterosexism within the White cultural community, racism within the LGB community, and racial disparities associated with the HIV epidemic.42

A study exploring psychiatric disorders among racial minority LGB individuals found that Black and Latino LGB individuals were more likely to report serious suicide attempts despite having a lower prevalence of psychiat- ric disorders than Whites.43 With respect to gender and sexual identity, D’Augelli et al.44

assessed suicide attempts that were specifically

associated with sexual identity. Although fe- male youths were more likely to report suicide attempt than were male youths, male youths were more likely to report that their suicide attempt was related to their sexual identity. The association between peer victimization and suicide attempt may be further modified by the intersections between race and gender. In a study of young Black and Hispanic students in Texas, male students reported a higher prevalence of both verbal and physical bullying than did female students. Black students of both genders had a higher prevalence of verbal and physical bullying than did Hispanic stu- dents.45 In a study exploring the correlates of adolescent bullying, Carlyle and Steinman4

reported that gender differences in reported bullying were only significant among Whites and Native Americans.

The literature has suggested a complex re- lationship among sexual identity, gender, race/ ethnicity, and bullying in the probability of suicide outcomes that has not yet been explored in previous research. In this research, we used data from the 2009 NYC Youth Risk Behavior Survey to explore the associations among these 4 factors—sexual identity, gender, Hispanic ethnicity, and bullying—on suicide attempt in a sample of 9th- through 12th-grade students in NYC.

METHODS

We conducted secondary data analysis of the 2009 NYC YRBS to assess the role of bullying on suicide attempt. The NYC YRBS is a biennial survey conducted by the NYC De- partment of Health and Mental Hygiene in collaboration with the NYC Department of Education and the CDC to assess health risk behaviors among NYC youths. The survey uses a stratified, 2-stage cluster sample design to get a representative sample of students in grades 9 through 12 and is administered in school settings. Excluded from this survey are students in juvenile detention centers and children absent from class on the day the survey is administered. English as a second language and special education students were also excluded. The survey is self-administered, anonymous, and voluntary. One week before the survey is conducted in classrooms, parents are sent a letter with an opt-out form should they not

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want their child to participate in the survey.46

The 2009 survey includes data from 11 887 respondents. The school response rate was 95% and the student response rate was 83%, with an overall response rate of 79%.47

Measures

We dichotomized sexual identity into an indicator for having a sexual minority identity, which included those who identified as LGB, versus those who did not, which included those identifying as heterosexual or straight and those who were unsure. We included those who identified as being unsure in the non---sexual minority group because we did not have suffi- cient power to examine them as a separate group.

We did not have sufficient power to examine race as a polytomous variable. As such, we chose to explore Hispanic ethnicity rather than race because (1) the NYC YRBS oversampled Hispanics, and (2) Hispanics are the largest minority in NYC.48 We classified youths reporting any Hispanic ethnicity as Hispanic and all non-Hispanic Whites, non-Hispanic Blacks, non-Hispanic Asian/Pacific Islanders, and non-Hispanic others as non-Hispanic.

Suicide attempt was determined by asking “During the past 12 months, how many times did you actually attempt suicide?” This measure was dichotomized into an indicator for having attempted suicide in the past year. An indicator for school bullying was based on the question “During the past 12 months, have you ever been bullied on school property?” Gender and His- panic ethnicity were self-reported.

Statistical Analysis

Frequencies of the proportion of students who experienced bullying were calculated overall and by gender, sexuality, and ethnicity. We used logistic regression to determine unadjusted odds ratios for suicide attempt by reported bullying, gender, sexuality, and ethnicity. The final adjusted logistic regression model explored the odds of suicide attempt among those who were bullied, adjusting for gender, sexuality, and ethnicity. Data were weighted, and the complex sampling method was taken into account according to the New York City YRBS.47

Interaction and Model Selection

To explore whether intersecting identities result in differential experiences of bullying

and outcomes in suicide attempt, we examined whether there was interaction among bullying, gender, identifying as a sexual minority, and Hispanic ethnicity in predicting suicide attempt. Significant interaction indicates that the main effect of bullying is not parallel across strata of sexual minority identity, Hispanic ethnicity, and gender and that stratum-specific odds ratios (ORs) rather than adjusted ORs should be reported.49 To test for interaction in a re- gression model, we analyzed the significance of product terms consisting of the exposure of interest and covariates.49 To assess for 4-way interaction between bullying, ethnicity, gender, and sexuality, we constructed a model con- taining all possible product terms, including all 2-way and 3-way product terms.49 We then compared this saturated model with 3 other models. The first model was a main effects model. The second contained all 2-way in- teractions between bullying, sexual identity, gender, and ethnicity. The third contained all 2- and 3-way interactions. To compare these nested models, we used Akaike’s information criterion (AIC) values for each model. AIC is a measure of goodness of fit and is the difference between twice the number of parameters and twice the maximized log likelihood.50 We chose the model with the lowest AIC value as the best model. Statistical significance was set at .05 for assessing main effects.

Because of decreased power when assessing effect modification, we increased the a level for testing interaction to .1, which has been done previously and shown to improve power in some scenarios of moderate interaction.51

In the presence of significant interaction, final results were stratified and stratified ORs reported. We achieved stratification using a domain statement as per guidelines set by the CDC for analysis of YRBS data.52 All signifi- cance tests were 2-tailed. Statistical analyses were conducted using SAS 9.2 (SAS Institute, Cary, NC).

RESULTS

Sexual minority youths represented 7.9% of the study population; 52.2% of respondents were female, and 34.5% were Hispanic. Nearly 12% of youths reported bullying in the past 12 months, and 9.9% reported having attempted suicide in the past 12 months. Those who had attempted suicide in the past year were more likely to report having been bullied (P < .001). Sexual minority youths were more likely to report bullying in the past month (P < .001), but we found no difference in reported bullying by gender or ethnicity (Table 1).

In the unadjusted logistic regression models, NYC youths who were bullied had 2.98 times higher odds of suicide attempt than those

TABLE 1—Descriptive Statistics of New York City Youth Overall and Separately by

Experiences of Bullying: 2009 New York City Youth Risk Behavior Survey

Total (%) Bullied, No. (%) Not Bullied, No. (%) OR, (95% CI) P

Total 11 488 1281 (11.2) 10 207 (88.8)

Suicide attempt 2.98 (2.40, 3.69) <.001

Yes 1015 (9.9) 211 (24.9) 720 (75.1)

No 8454 (90.1) 855 (10) 7461 (90)

Sexual minority 1.96 (1.56, 2.46) <.001

Yes 951 (7.9) 158 (18.2) 742 (81.8)

No 9763 (92.1) 981 (10.2) 8512 (89.8)

Gender 0.99 (0.81, 1.21) .915

Male 5549 (47.8) 593 (11.1) 4746 (88.9)

Female 6334 (52.2) 688 (11.2) 5458 (88.8)

Ethnicity 1.18 (1.00, 1.39) .051

Hispanic 4947 (34.5) 566 (12.2) 4206 (87.8)

Not Hispanic 6657 (65.5) 676 (10.6) 5776 (89.4)

Note. CI = confidence interval; OR = odds ratio.

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who were not bullied (P < .001). Sexual mi- nority youths had 4.39 times higher odds of suicide attempt than non---sexual minority youths (P < .001). Male youths had 0.83 times the odds of suicide attempt than female youths (P = .045). Hispanics had 1.62 times the odds of suicide attempt than non-Hispanics (P < .001). In the multivariate model, adjusting for sexual minority, gender, and ethnic identi- ties, those who were bullied had 2.80 times the odds of suicide attempt than those who were not bullied (P < .001). The adjusted model showed that sexual minority youths had 3.65 times the odds of reported suicide attempt than nonsexual minority youths, controlling for all covariates (P < .001). Hispanic youths had 1.54 times the odds of reporting suicide attempt than non-Hispanic youths, controlling for all covariates (P < .001). Male youths had 0.76 times the odds of suicide attempt than female youths, controlling for all covariates (P = .032; Table 2).

The model with the lowest AIC was the saturated 4-way interaction model, which we chose as the best-fitting model. Analyzing the P value of the 4-way product term, we deemed the interaction to be statistically significant (P = .081). After stratifying on gender, ethnic, and sexual minority identities, the association between bullying and suicide attempt was strongest among non-Hispanic sexual minority male youths (OR = 21.39, P < .001), followed by non-Hispanic non---sexual minority female youths (OR = 3.38, P < .001), Hispanic non--- sexual minority male youths (OR = 3.30, P < .001), and Hispanic non---sexual minority female youths (OR = 2.76, P = .01). The associ- ation was not significant among sexual minority female youths of either ethnicity (Table 3).

DISCUSSION

We believe this study to be one of the first to examine how gender, ethnic, and sexual mi- nority identities may modify the relationship between bullying and suicide attempt. These results show that (1) sexual minority youths are more likely to report bullying than are non--- sexual minority youths, but we found no difference in reported bullying by either gen- der or ethnicity; (2) those who reported bully- ing, those who identified as sexual minorities, those who identified as Hispanic, and those

who were female were more likely to report suicide attempt; and (3) these identities appear to interact with one another to modify the relationship between reported bullying and reported suicide attempt. To this end, we found that the effect of bullying on suicide attempt was strongest among non-Hispanic sexual minority male youths. What was of particular interest is that being female and identifying as Hispanic seemed to lessen the impact of bullying on suicide attempt among sexual minority youths, although Hispanics and female youths had higher odds of suicide attempt. This finding may indicate that sexual minority youths who have experienced gen- der- and ethnicity-based discrimination are more resilient against sexual identity---based bullying than are youths who have not expe- rienced such discrimination. Conversely, this finding may be indicative of a ceiling effect for the impact of discrimination on suicidal behavior.

Several factors may mitigate the negative impact of bullying and victimization in school settings among LGB youths, including family acceptance of LGB identity, positive represen- tation of LGB individuals in the media, peer support, support in schools through gay--- straight alliances, and faculty support.53 In fact, according to Hatzenbuehler,54 sexual minority youths in negative social environments had 20% higher odds of suicide attempt than sexual minority youths in positive social envi- ronments.

The CDC55 has recommended that to re- duce aggression and violence, school commu- nities should focus on the development of safe social and physical environments; provide health, counseling, and social services; provide safe physical education and extracurricular activities; train faculty and staff to promote safety; and implement curricula that help students learn and adopt healthful choices. An important consideration in developing

TABLE 2—Unadjusted and Adjusted Models of Suicide Attempt Among Those Who

Are Bullied by Sexual Minority Identity, Ethnicity, and Gender: 2009 New York City Youth

Risk Behavior Survey

Unadjusted Models Adjusted Model (n = 8363)

Variable No. OR (95% CI) P OR (95% CI) P

Bullied in the past y 9247 2.98 (2.40, 3.69) <.001 2.80 (2.21, 3.55) <.001

Sexual minority 8701 4.39 (3.46, 5.57) <.001 3.65 (2.71, 4.93) <.001

Hispanic 9275 1.62 (1.34, 1.97) <.001 1.54 (1.28, 1.85) <.001

Male 9465 0.83 (0.69, 0.99) .045 0.76 (0.60, 0.97) .032

Note. CI = confidence interval; OR = odds ratio.

TABLE 3—Odds of Suicide Attempt Among Those Who Are Bullied, Stratified on Sexual

Minority Identity, Gender, and Ethnicity: 2009 New York City Youth Risk Behavior Survey

Non-Sexual Minority Youth Sexual Minority Youth

Variable No. OR (95% CI) P No. OR (95% CI) P

Non-Hispanic

Female 3028 3.38 (1.99, 5.74) <.001 286 2.38 (0.86, 6.62) .096

Male 2583 2.27 (1.15, 4.47) .018 122 21.39 (5.69, 80.35) <.001

Hispanic

Female 2076 2.76 (1.28, 5.95) .01 383 1.65 (0.81, 3.36) .17

Male 1887 3.30 (2.08, 5.24) <.001 134 1.93 (0.51, 7.27) .333

Note. CI = confidence interval; OR = odds ratio.

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a successful intervention is that schools cannot exclusively solve the problem. Any effort made to address this problem effectively must be the result of an ecological approach to the problem with specific, comprehensive, and conjoined influences made at the individual, interpersonal, and group, community, organi- zational, and public policy levels.

This study has several important limitations to consider. First, cross-sectional studies do not allow one to determine causal relationships. Second, all measures used were based on self- report. Third, we did not have sufficient power to look at sexual identity as a polytomous variable including a category for those who were unsure of their sexual identity, nor could we include race in addition to ethnicity in our models. Furthermore, because of the low power when assessing complex interaction terms, we decided to increase our a to < .1 a priori. Doing so may have increased the likelihood that we made a type I error. Fur- thermore, some of our associations, especially when stratifying on sexual minority identity, ethnicity, and gender, were very wide, and thus our estimates of the strength of some associa- tions are imprecise. Future studies exploring health outcomes of sexual minority youths compared with those of non---sexual minority youths should be sufficiently powered to make better causal assumptions.

Fourth, our study only included noninstitu- tionalized students who were enrolled in the NYC school system. More importantly, it did not include youths who were high school dropouts, incarcerated, homeless, or runaways. Because sexual minority individuals are more likely to be homeless,56 this study may lack generalizability. Moreover, because NYC youths may be different from youths elsewhere in the United States or in other countries, these results may not be generalizable outside of this area. Similarly, although we explored suicide attempt, data on the sexual identity of youths who successfully commit suicide were not available. Given that youths in this study who attempted suicide were unsuccessful in their attempt, our estimates include a survivor bias. Fifth, homophobia and homonegativity, sexism, and racism were not captured in this survey, and we are therefore unable to as- sume that the bullying experienced by these youths is identity based. In fact, a recent report

by Russell et al.57 showed that youths who experience bias-based peer victimization have worse health outcomes, such as depression and substance abuse, than youths who experi- ence non---bias-based peer victimization or no peer victimization at all. Future studies should address homonegativity, racism, and sexism specifically.

Another important limitation to discuss is whether sexual identity, behavior, attraction, perceived sexual identity, and gender ex- pression act independently on the health outcomes of sexual minorities.58 We did not have data to examine these constructs separately.

In conclusion, the intersections of sexual minority identity, gender, and ethnicity ap- pear to interact with bullying in predicting suicide attempt among NYC youths. Inter- ventions that address ecological perspectives as a basis for planning successful prevention programs are needed to reduce suicide at- tempt by at-risk youths. To this end, public health researchers and practitioners must be able to properly identify predisposing, enabling, and reinforcing factors that con- tribute to health disparities among multiple--- minority-identity youths. j

About the Authors Michael T. LeVasseur and Elizabeth A. Kelvin are with The City University of New York (CUNY) School of Public Health at Hunter College, New York, NY. Elizabeth A. Kelvin is also with The Graduate Center, The City Uni- versity of New York. Nicholas A. Grosskopf is with the School of Health and Behavioral Sciences, York College, The City University of New York and The Graduate Center, The City University of New York. Correspondence should be sent to Elizabeth A. Kelvin,

Epidemiology and Biostatistics Program, CUNY School of Public Health at Hunter College, 2180 3rd Avenue, New York, NY 10035 (e-mail: [email protected]). Re- prints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted July 15, 2012.

Contributors M. T. LeVasseur conceptualized the study, performed all analyses, drafted the initial article, and approved the final article as submitted. E. A. Kelvin aided in statistical analysis and edited drafts of the article. N. A. Grosskopf provided the theoretical framework for the study and aided in the drafting of the Discussion and edited drafts of the article.

Acknowledgments We thank the New York City Department of Health and Mental Hygiene for supplying the data for the 2009 Youth Risk Behavior Survey.

Human Participant Protection The institutional review board of the New York City Department of Health and Mental Hygiene approved this study.

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