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Black Bisexual Women in Rural Areas Are At Highest Risk for Suicidal Behaviors

Penn State College of Medicine-led research study highlights how gender, sexual orientation, race, ethnicity and rurality contribute to suicide ideation, planning and attempts

Non-Hispanic and Hispanic Black bisexual women who live in rural areas have the highest prevalence of experiencing suicidal thoughts and behaviors, according to a Penn State-led study. The researchers said this “first-of-its-kind study,” published in JAMA Psychiatry, revealed how various demographic factors intersect to affect a person’s risk of having suicidal thoughts and behaviors.

An estimated 12 million adults in the United States think about suicide every year, with nearly two million attempting suicide annually. While previous studies have examined how individual demographic factors, like race and gender, individually associate with suicide risk, no studies have demonstrated how different factors combine to influence overall risk. Lauren Forrest, assistant professor of psychiatry and behavioral health at Penn State College of Medicine, analyzed annual National Survey on Drug Use and Health responses from more than 189,000 individuals who provided information on their gender, race, sexual orientation, ethnicity and how rural their environment is, to study how these factors intersect or combine to affect risk of suicidal thoughts and behaviors. The researchers analyzed data from 2015 to 2019.

“We already know that some groups — like LGBTQIA+ individuals or women — are at increased risk for suicidal thoughts and behaviors,” Forrest said. “However, every person possesses multiple identities — including gender, race and sexual orientation, to name a few. Some combinations of identities, for example, Black bisexual women, may be associated with unique suicide risk profiles. But we can’t see these unique risk profiles if we only look at one identity at a time, which is what we’ve been doing thus far in research. It’s important to investigate how prevalence of suicidal thoughts and behaviors varies across intersectional identities, so we can identify populations most at risk and develop interventions specifically for those groups and their unique experiences driving their suicidal thoughts and behaviors.”

The researchers found that the intersectional group with the highest prevalence of suicidal ideation was Hispanic bisexual women living in rural areas — 20% of whom had thought about killing themselves in the last year before they took the survey. By contrast, the intersectional group with the lowest prevalence of suicidal ideation was Hispanic heterosexual men living in large metropolitan counties, where only 3% had contemplated suicide in the year before completing their surveys.

Forrest said the research is based on intersectionality theory, first proposed by Black feminist scholars. Intersectionality theory proposes that health inequities for any group — whether based on gender, sexual orientation, race and ethnicity and/or rurality — arise not due to people’s identities, such as gender, themselves but due to interlocking structural systems of power, privilege and oppression.

According to Forrest, a person can face various types of discrimination based on their gender, race, ethnicity, sexual orientation or simply by where they live. Discrimination can be experienced across levels of influence, which are layered, or nested, within one another. An individual person — the smallest level — is nested within an interpersonal network of peers, family, friends and immediate neighbors. That interpersonal network is nested within a community, and a community is nested within society — the structural systems — at large.

Structural discrimination occurs when there are laws that impose on certain individuals’ rights or welfare, and/or when certain prejudicial attitudes or behaviors are socially acceptable across society, Forrest said. For instance, laws opposing or restricting gay rights is an example of structural discrimination based on sexual orientation. This type of discrimination can set the stage for LGBTQIA+ people to experience more discrimination in their communities, since communities are nested within societies. This discrimination can become more intense on an interpersonal level, too, since interpersonal levels are nested within communities, which are nested within structures.

“When people face multiple types of structural discrimination, such as discrimination based on their sexual orientation and their race, which might be even more heightened in rural areas versus urban areas, it makes sense that the effects of discrimination could compound on one another,” Forrest said. “Discrimination, especially when it’s occurring across identities and levels of influence, is painful. Over time, these repeated and compounding painful discrimination experiences could ultimately contribute to some people contemplating or attempting suicide.”

According to Forrest, her research in this area is just getting started. She plans to continue studying how structural level risk factors, such as structural stigma, interact with individual-level risk factors, such as psychiatric disorders, to jointly impact suicide risk among LGBTQIA+ people living in rural areas. She said her ultimate goal is to collect and analyze data that can ultimately influence policy decisions, especially those relating to health equity.

“I’m passionate about this area of research because it’s important for mental health providers to understand that factors across levels of influence impact suicide risk,” Forrest said. “We often consider, assess and intervene upon individual-level risk factors, like psychiatric disorders. But I’d argue that we rarely, if ever, consider how the structural processes that drive health inequities may be impacting the person sitting in front of us in the therapy or assessment room.”

Forrest noted that better understanding how factors across levels of influence combine to impact suicidal thoughts and behaviors could help mental health professionals better determine the groups most at risk, determine the most potent intervention targets across levels of influence and develop and implement effective interventions for the underlying causes of health disparities and inequities (e.g., structural discrimination). She said that virtual interventions may be useful in rural settings where health care access may be limited and discrimination may be more severe, compared to more urban areas.

This research is part of Forrest’s training as a Penn State Clinical and Translational Science Institute KL2 Scholar. Project collaborators include Forrest’s KL2 mentor and senior author, Emily Ansell, associate professor of biobehavioral health at Penn State College of Health and Human Development and Penn State Social Science Research Institute scholar; Sarah Gehman, College of Medicine medical student; Cara Exten, assistant professor of biobehavioral health at Penn State Ross and Carol Nese College of Nursing; and Ariel Beccia of Harvard Medical School. The researchers declare no conflicts of interest.

This research was supported by the National Center for Advancing Translational Sciences through Penn State Clinical and Translational Science Institute. The views expressed are those of the researchers and do not necessarily represent the views of the National Institutes of Health.

If you or someone you know is experiencing suicidal thoughts or behaviors, help is always available. Call 988; contact the crisis text line by texting PA to 741741; call the Trevor lifeline, for LGBTQIA+ individuals, at 1-866-488-7386; and/or call the Trans Lifeline, for trans and gender diverse individuals, at 1-877-565-8860.

PTAC Solicits Public Input on Encouraging Rural Participation in Alternative Payment Models 

Last week’s announcements included a blurb on the Physician-Focused Payment Model Technical Advisory Committee (PTAC) Meeting that occurred on September 18-19.  PTAC is now soliciting public comment on a series of questions developed to encourage rural participation in the population-based total cost of care models. PTAC requests that input be submitted by Friday, October 20. Responses should be sent to PTAC staff at Input on these questions will be made publicly available. More information is available on the PTAC website. Comments are due by October 20, 2023. 

New Fact Sheet Highlights the Importance of Kinship Care

September is National Kinship Care Month, recognizing the countless relatives and caregivers who provide full-time nurturing and protection for children who cannot safely remain in the care of their biological parents. Placement in the foster care system is a traumatizing event, impacting all facets of a child’s life, such as their connection to extended family, school, friends, communities and cultures. If a child must be removed from their home, the best option is placement with kin. Too often, kin are arbitrarily disqualified from becoming licensed foster parents.

Our newly released fact sheet identifies policy solutions that can prioritize and simplify kinship placements, allowing children and youth to be raised by and connected to their families.

One policy solution identified in the fact sheet is passing HB 1058, which would give kin a voice in court proceedings. The bill, sponsored by Rep. Krajewski, would allow kin to be heard by the dependency judge overseeing a foster child’s case. When a kin caregiver is denied placement they are not allowed to present their case and facts to the judge tasked with making placement decisions. Giving kin a voice in court will let the judge hear directly from them about their qualifications and determine if reconsidering placement, ongoing visitation, or contact is appropriate.

HB 1058 passed the House earlier this year and was approved by the Senate Aging and Youth Committee last week. The bill is now in Senate Appropriations and still requires approval on the Senate floor. PPC will continue to advocate for the passage of the bill as one additional step to ensuring that all children can be placed with and connected to their families.

It’s Not All About Wages: What Workers Want In a Job

Enough money to cover the bills and help them get ahead. Fair treatment. Job security. Time to care for their families and themselves. These are things U.S. workers and job seekers without a four-year degree said they want in a job.

The topic of what makes a quality job emerged organically during listening sessions as part of the Worker Voices Project. Led by the Federal Reserve Banks of Atlanta and Philadelphia, Worker Voices looked beyond the numbers to understand the impact of the COVID-19 pandemic on how workers without a four-year degree perceive and navigate employment.

Worker Voices Special Brief: Perspectives on Job Quality takes a deep dive into a major theme that emerged during focus groups with 167 U.S. non-college workers and job seekers across the country — what workers want and expect from a job.

Read the report to learn more.

ADA Survey Report on Teledentistry Released

A new survey report was published from the American Dental Association Clinical Evaluators Panel. The report, “Teledentistry Adoption and Applications,” found that the adoption of teledentistry grew in the past three years, in part because of the COVID-19 pandemic, but the technology may be underused. Thirty percent of respondents said they use teledentistry, with 60% of users expressing satisfaction and noting increased access and quality of care, while 60% of those not using teledentistry said there wasn’t a need.

Click here to read the report.

Title V National Performance Measure on Oral Health Resource Announced

The National Maternal and Child Oral Health Resource Center recently shared a new resource, “Snapshot of the U.S. Jurisdictions’ Activities Addressing Title V National Performance Measure 13 (Oral Health) During Fiscal Year 2022.” The report presents a snapshot of jurisdictions’ experiences with implementing strategies to promote preventive dental visit for pregnant women, children, and adolescents. Challenges, accomplishments, and technical assistance needs related to each jurisdiction are discussed.

Click here to read the report.

Coverage for Half a Million Children and Families Will Be Reinstated

CMS Requires States to Pause Disenrollments and Reinstate Coverage for Impacted Individuals

The U.S. Department of Health and Human Services (HHS) announced that it has helped half a million children and families regain their Medicaid and Children’s Health Insurance (CHIP) coverage. On August 30, the Centers for Medicare & Medicaid Services (CMS) issued a call to action to states about a potential state systems issue where systems were inappropriately disenrolling children and other enrollees, even when the state had information indicating the person remained eligible. Thanks to CMS’ swift action, nearly 500,000 children and other individuals who were improperly disenrolled from Medicaid or CHIP will regain their coverage, and many more are expected to be protected from improper disenrollments going forward.

CMS sent a letter on August 30 to all states, the District of Columbia, Puerto Rico, and the U.S. Virgin Islands requiring them to determine and report whether they have a systems issue that inappropriately disenrolls children and families, even when the state had information indicating that they remained eligible for Medicaid and CHIP coverage. Today’s summary indicates that to-date 30 states report having this systems issue. As a result, to avoid CMS taking further action, all 30 states were required to pause procedural disenrollments for impacted people unless they could ensure all eligible people are not improperly disenrolled due to this issue.

“Thanks to swift action by HHS, nearly half a million individuals, including children, will have their coverage reinstated, and many more will be protected going forward. HHS is committed to making sure people have access to affordable, quality health insurance – whether that’s through Medicare, Medicaid, the Marketplace, or their employer,” said HHS Secretary Xavier Becerra. “We will continue to work with states for as long as needed to help prevent anyone eligible for Medicaid or CHIP coverage from being disenrolled.”

“Medicaid and CHIP are essential for millions of people and families across the country,” said CMS Administrator Chiquita Brooks-LaSure. “Addressing this issue with auto-renewals is a critical step to help eligible people keep their Medicaid and CHIP coverage during the renewals process, especially children. CMS will keep doing everything in our power to help people have the health coverage they need and deserve.”

CMS’ letter on August 30 alerted states to a potential eligibility systems issue related to automatic renewals for Medicaid and CHIP coverage. Auto-renewals (also known as “ex parte” renewals) are one of the strongest tools that states have to keep eligible people enrolled in Medicaid or CHIP coverage during the renewals process. Federal rules require states to use information already available to them through existing reliable data sources (e.g., state wage data) to determine whether people are still eligible for Medicaid or CHIP. Auto-renewals make it easier for people to renew their Medicaid and CHIP coverage, helping to make sure eligible individuals are not disenrolled due to red tape. CMS continues to provide technical assistance to states as they address these system issues.

Throughout the renewals process, CMS has offered states many strategies to assist them in making it easier for people to renew their coverage. Nearly all states have adopted at least some of these strategies, and CMS continues to urge states to adopt these strategies. Additionally, to help make transitions from Medicaid to other health coverage options more accessible in every state, CMS has launched national marketing campaigns and made available Special Enrollment Periods through, State-based Marketplaces, and Medicare. CMS’ top priority remains making sure everyone has access to affordable, quality health coverage.

For a preliminary overview of state assessments regarding compliance with Medicaid and CHIP automatic renewal requirements at the individual level (as of September 21, 2023), visit:

Join Us for PTAC Public Meeting on Rural Participation in Alternative Payment Models 

The next quarterly public Physician-Focused Payment Model Technical Advisory Committee (PTAC) meeting will focus on encouraging rural participation in population-based total cost of care models. PTAC was authorized under the Medicare Access and CHIP Reauthorization Act of 2015 to make recommendations on population-based total cost of care model proposals. Selected topics to be discussed in the two-day September PTAC meeting include challenges facing rural providers and patients and approaches for involving rural providers in such alternative payment models. For further information on the hybrid (in-person and livestream) meeting, please see the agenda, panelist bios, and registration form. The meeting will be held  September 18-19.