Internalized Homophobia and Suicidal Ideation among LGB Youth

Objective: The objectives of this study are to evaluate the relation between internalized homophobia and suicidal ideation in young lesbians, gays, bisexuals and heterosexuals; and also assess the influence of gender, discrimination experiences and disclosure of sexual orientation on suicidal ideation. Method: Participantsthe sample consists of 389 participants, with a mean age of 19 years old. 51.9% were men and 48.1% were women. Regarding sexual orientation 36.0% were gay, 25.2% bisexual, 21.9% lesbian and17.0% heterosexual. The majority assume having already come out (61.4%). Most of the participants were in high school (51.4%).Instruments-we used a Demographic Questionnaire, the Suicide Ideation Questionnaire (SIQ) (Cronbach’s alpha=0,975), and the Internalized Homophobia Questionnaire (Cronbach’s alpha=0.81).Procedure – the data collection was done using the Internet. The questionnaires were available on a website built solely for this study. Publicity to this website was done through virtual communities, e-mail and several youth forums. Results: The results support the idea that there is a positive and statistically significant correlation between internalized homophobia and suicidal ideation. In addition, it was found that gay youngsters are the ones who have a stronger internalized homophobia, while young bisexuals are the ones who have higher levels of suicidal ideation. The teenagers who have not, yet, made their disclosure of sexual orientation and those who experienced discrimination, due to their sexual orientation, are those who had higher levels of suicidal ideation. Conclusion: More emphasis should be placed on suicide prevention for younger LGB individuals, in addition to the current emphasis on suicide prevention for adults. Future research should continue to examine unique, understudied LGB communities.


Introduction
Several studies have shown that the suicide rate is high among Lesbian, Gay and Bisexual (LGB) teenagers. Prevalence rates of suicide ideation have been estimated at 37% to as high as 50% for LGB populations [1][2][3][4][5][6][7][8]. There are a number of known risk factors for LGB suicidal behavior, including age (both young and older persons), sexual orientation, gender identity, gender, mental disorders, and stress [9]. The bulk of suicide research among LGB populations have been limited to adolescent and young adult samples, with the belief that after young adulthood, the risk of suicidal thinking or behavior decreases. There are also studies that find suicide behaviors across the lifespan for sexual minority persons [10,11]. This confirms that sexual minorities are confronting specific challenges related to their sexual minority status, such as acquiring a positive identity while experiencing social stigma and exclusion. Internalized homophobia (IH), defined as "the application of anti-LGB stigma to the self" [12], is one possible consequence of intimidation based on non-exclusive heterosexuality. There are few studies that have assessed the impact of peer bullying on IH among youths, demonstrating that homophobic bullying among teenagers with a negative LGB identity, a concept reflecting IH, accentuates difficulties in accepting one's sexual orientation [9,13]. Furthermore, recent studies have revealed that heterosexist harassment, rejection and discrimination is related to IH among young LGB individuals, and have shown that both factors increased psychological distress, depression and anxiety [3,14,15]. Lower self-esteem has also been associated to suicidal ideation [16], and suicidal attempt [17]. Finally, recent studies show that past victimization experiences and IH have a significant direct effect on suicide ideation [18], indicating that when compared with non-LGB youth, LGB youth had increased odds of suicide ideation [19].
Thus, considering the lack of literature and information regarding LGB youth in Portugal, and specially information that corroborates the link between internalized homophobia and suicide, this study was developed with the following aims: (a) assess internalized homophobia and suicidality in LGB and non-LGB teenagers and young adults; (b) assess internalized homophobia and suicidal ideation on related variables, such as gender, discrimination, disclosure of sexual orientation, and sexual orientation; and (c) establish the relationship between internalized homophobia and suicidal ideation. To this end we established the following hypothesis: H1: There are different levels of internalized homophobia when comparing different sexual orientations (lesbian, gay or bisexual).
H2: Gay and bisexual young men present higher levels of internalized homophobia than lesbian or bisexual young women.
H3: There are different levels of suicide ideation when comparing different sexual orientations (lesbian, gay, bisexual or heterosexual).
H4: Gay and bisexual young men present higher levels of suicide ideation than lesbian or bisexual young women.
H5: Suicide ideation varies among LBG youths when comparing different circumstances such as being out of the closet or having been exposed to discrimination experiences.
H6: There is a positive and strong correlation between internalized homophobia and suicide ideation.

Participants
This cross-sectional study used a non-probabilistic convenience sample of 389 participants from the population of young Portuguese individuals (N=1500000). The inclusion criteria for participation in the study were: (1) being lesbian, gay, bisexual or heterosexual selfidentified, (2) being over 13 years of age, (3) being Portuguese (either national or legal resident/citizen) and living in Portugal, and (4) willingness to participate voluntarily in the study after knowing its objectives. This sample included all the participants who completed successfully all the instruments, and the ages ranged between 13 and 32 years old, being that 18% were 19 years old and 16.5% were 20, and the average age was 21 years (SD=5, 14). Regarding gender, 51.9% were men and 48.1% were women.
Concerning (self-defined) sexual orientation, 36% were gay, 25.2% were bisexual, 21.9% were lesbian and, finally, 17% were heterosexual. As for assuming their sexual orientation, 61.4% had already come out. As for their educational attainment, 51.4% had a secondary education, 42.4% had tertiary education, 4.4% had a primary education and 1.8% and an undergraduate degree. Regarding the marital status, 67.9% were single and 32.1% had a partner.44% of the LGB participants, in this study, consider being discriminated frequently, where as 39.1% do not feel discriminated because of their sexual orientation. In relation to other life aspects, 64.5% consider being happy and 17.5% consider not being very happy.

Instruments
The investigation protocol used in this study consisted of three instruments: a) a Demographic Questionnaire (developed solely for this study); b) Reactions to Homosexuality Scale (RHS) [20] Portuguese version [21]; c) Suicide Ideation Questionnaire (SIQ) [22].
The Demographic Questionnaire was developed to gather specific (socio-demographic and personal) information about the participants. This questionnaire included three groupsof questions: sociodemographic questions, which included age, gender, sexual orientation, and educational attainment; questions about clinical information, to assess the existence (or not) of a mental disorder and possible medication (exclusion criterion); and finally questions about discrimination (specifically sexual discrimination).
The Portuguese version of the Reactions to Homosexuality Scale (RHS) was translated and validated (for the Portuguese population) by Pereira and Leal [21], from the original Ross and Rosser's scale (Ross & Rosser) [20]. The RHA is a 26-item questionnaire, being the answers given using 5-point Likert scale (I strongly agree, I agree, I don't agree nor disagree, I disagree, strongly disagree). The answers given had a good internal consistency (Cronbach's alpha=0.81). According to the Portuguese version and factorial analysis, this scale assesses the internalized homophobia based on two different dimensions: the internal perception of stigma related to homosexuality (α=0.818), and the external perception of stigma related to homosexuality (α=0.606).
The Suicide Ideation Questionnaire (SIQ), developed by Ferreira and Castela [22], assesses the seriousness of suicide thoughts in teenagers and adults. The SIQ has a total of 30 items, each one with seven response alternatives (never, almost never, rarely, sometimes, frequently, almost always, always). The results obtained can vary between 0-180 points, indicating the frequency of suicidal thoughts (higher scores correspond to higher frequency in suicidal thoughts). This questionnaire has an excellent internal consistency (Cronbach's alpha=0.975)

Procedures
For the purpose of data gathering, all the instruments were made available on the internet, in a website built specifically for this study. The advertising of this website was made by sending e-mails to potential participants using mailing lists, and joining Internet-based communities and several forums (school, religious, political).To participate in the study the users just had to select the link and access the webpage.
A short presentation of the study, listing the objectives and purposes, was given together with the participation request. The anonymity of the participants was always ensured. All the individuals that participated in this study gave their informed consent.

Data analysis
Data analysis was performed with SPSS Statistics 21.0. Basic descriptive analysis and the internal consistency by Cronbach's alpha coefficient for the SIQ were made. T-test and One-way ANOVA significant at p<0.05 were used to compare differences in the mean frequency of different scores. All tests were two-tailed.

Ethical approval
This study was approved by the scientific and ethical committees of the Research Unit of Health and Psychology (UIPES/ISPA-IU, Institute of Applied Psychology in Portugal).

Results
The results we obtained demonstrate statistically significant differences, regarding the levels of internalized homophobia, among different sexual orientations (gay, lesbian and bisexual), except for heterosexuals, who were not included in this comparison; and genders. Based on H1 we can observe that these differences are significant (F(3;385)=7.918; p<0.001), being that gay teenagers were the ones with the highest levels of internalized homophobia, although the difference between these and bisexual teenagers is not very significant. The lesbian teenagers were the ones with the lowest levels of internalized homophobia. statistically significant differences were found between genders, when regarding internalized homophobia (t (387)=-5.256; p<0.001), indicating that men have higher levels of homophobia than women. With regard to the experience of discrimination (H5), there are also significant differences when comparing individuals that had been discriminated to the ones who had no discriminating experiences (t (387)=2.934; p=0.004). The youngsters that had been discriminated present higher levels of suicidal ideation. All these results can be seen on Table1: Results of the comparison between the levels of internalized homophobia and suicidal ideation and sexual orientations, gender, disclosure of sexual orientation and discrimination, *<0.05 **<0.001
As to the disclosure of sexual orientation process (H5), the results show significant statistical differences (t (387)=-2.410; p=0.016). The LGB teenagers that had not "come out" yet were the ones with highest levels of suicidal ideation, when compared to the ones that had already gone through the disclosure of sexual orientation process.
Finally, in the attempt to ascertain the relation between the levels of internalized homophobia and suicidal ideation (H6), we did a correlation between these variables, having obtained a positive and statistically significant result (r=0.320; p<0.001) as can be seen in Figure 1. These results lead us to believe that the more homophobia is internalized in young LGB, the higher the levels of suicidal ideation will be.

Discussion
The aim of this study was to verify the relation between internalized homophobia and suicidal ideation, among LGB teenagers and young adults, as well as to explore the eventual relations between these two variables and gender, discrimination and disclosure of sexual orientation.
Consistent with prior studies [18,23,24], we confirmed the hypothesis of finding a higher level of internalized homophobia in gay participants compared to lesbian ones. In the Portuguese context, sexism plays a dominant role in the social pressure to conform to heteronormative gender roles. In these contexts, gay men are more visible targets than lesbian women and thus are more ostracized by heteronormative pressures [23]. Moreover, social changes in Portugal brought about new challenges as same-sex marriage created visibility for LGB rights. The concrete political demands for LGB rights could probably make the homophobic attitudes against the most visible targets in the sexual minorities-the gay men-more critical, especially in contexts where traditional gender roles and religious beliefs against homosexual orientation are dominant [24]. Figure 1: Results for the correlation between total levels of internalized homophobia (QHI_total) and total levels of suicidal ideation (QIS_total) (r = 0.320; p<0.001) The results scored by self-identified bisexual teenagers and young adults may fit into the classical view of bisexuality as a transitive phenomenon. Teenagers, who perceive themselves as bisexual, accommodate two types of feelings: one of a heterosexuality, that is socially valued, and another of isolation from an eventual homosexual identity. These opposite feelings, during adolescence, may lead the appearance of suicidal thoughts; confusion and not being able belong to any of these "two worlds".
The gender variable was also evaluated, and the results showed differences between men and women, when regarding suicidal ideation. As expected, these differences were not statistically significant. Nevertheless, women had slightly higher levels of suicidal ideation that are possibly due to social values which determine that women can suffer more and, thus, trigger self-destruction thoughts (Allison, Roeger, Martin & Keeves). In spite of these results, we cannot conclude that they are a tendency, since we did not obtain statistically significant differences, as mentioned above.
Concerning the association between discrimination and suicidal ideation, consistent with previous research [25,26] the results suggest that discrimination experiences (whether these are direct or indirect), may actually work as a confirmation of internalized homo-negativity, especially when there are no effective sources of social support. Gays, lesbians and bisexuals represent a sexual minority and as such, they face discrimination situations, stigma and violence by society. The most common manifestation of the internalization of that stigma is the sense of shame at the identification as LGB. This may have occurred in our sample and these negative feelings may have, once again, influenced the occurrence of suicidal ideation. orientation can have negative effects on the lives of LGB teenagers. As the coming out process is of the outmost importance in the life of these teenagers and young adults, many decide to reveal their sexual orientation to friends, family and even to society, in order to find a sense of honesty, self-esteem, towards themselves and others. Nevertheless, this process is still difficult, mostly due to the anticipation of rejection, thus it may be accompanied by great anxiety, depression and/or behavioral problems and even substance use [27]. The data that we obtained supports the idea that the young LGB, who do not come out, are those that are likely to anticipate the negative impact, of such disclosure, and have higher levels of internalized homophobia.
This study focuses on a public health problem (the suicidality), particularly among LGB adolescents, and its relationship to internalized homophobia. According to the literature [3,28], the hypothesis about a direct association of internalized homophobia and suicidal ideation was confirmed. Also, concealing one's sexual orientation, and past experiences of victimization plays an important role on suicidal attitudes.
When finding a positive, and statistically significant, correlation between internalized homophobia and suicidal ideation, we are contributing to a better understanding of this problem and offering clues on how to change both intervention in mental health, and social behaviors. This study also contributes for an enrichment if the literature regarding homophobia and suicidal ideation, in both LGB and non-LGB teenagers. We hope it generate new ideas for relevant research on health of sexual minorities. This study is not without limitations. First, internet recruitment could have differentially affected the associated variables to attitude towards life and death. Second, the surveys focused on unspecific urban areas of Portugal are not generalized able to all regions of the country. Third, the relation to suicidal ideation of only a limited number of variables was tested. Personality factors, social support, satisfaction with life, purpose in life, and cognitive were not examined. Fourth, concerns are raised over the reliability (test-retest, alternate-form and internal consistency) as well as validity (face, construct, content and criterion) of the demographic questionnaire developed solely for this study.
A number of implications can be drawn from the present research. In line with the literature [29], there is evidence that even in today's potentially more accepting culture, gay and lesbian persons are still at risk for internalized homophobia and suicidality. The role of internalized sexual stigma should be taken into consideration when working with sexual minorities. Additionally, the present research suggests potentially important implications for health professionals working with non-disclosing lesbian or gay people [27,30]. The finding that concealment is associated with suicidal ideation by way of greater internalized homophobia may suggest that the risk for suicide in nondisclosing gay and lesbian persons may be facilitated by helping them to accept themselves, reduce the hyper vigilance associated with the fear of being identified as gay or lesbian, and realistically assess the consequences of disclosure to family or friends.
Promoting accepting environments is necessary to improve the adjustment of sexual minorities. Therefore, it is important to work to educate teachers and other school personnel in creating supportive and welcoming environments where homophobic victimization is not tolerated.

Conclusion
This article is important for understanding suicidality among understudied LGB young populations. As the first known LGB study of Portuguese youth, these data help illuminate important realities for LGB individuals that are distinct in comparison to heterosexual individuals. While research consistently shows LGB individuals to be at heightened risk for suicidal behaviors, those concerns may be greater if they don't disclose their sexual orientation and are exposed to discrimination experiences. Further, more emphasis may need to be placed on suicide prevention for younger LGB adults, in addition to the current emphasis on suicide prevention for adults. Future research should continue to examine unique, understudied LGB communities. Also, qualitative investigations regarding the nature, context, and complexities of LGB suicidal behaviors would likely yield important findings to be incorporated into quantitative studies and mass marketing campaigns to address mental health, stigma, and LGB identity.