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.