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How many gay and bisexual men die from

suicide each year in BC?

Travis Salway HottesOlivier Ferlatte

Gay Men’s Health SummitNovember 7, 2013

HIV as a health disparity

Gay and bisexual men are nearly 50 times more likely to be living with HIV than heterosexual men.*

* Purcell, Open AIDS, 2012

BCCDC, 2013

Beyond HIV

Institute of Medicine, March 2011

ViolenceProblematic substance useSmokingBody image and self-esteemSTI, HPV-related cancerDepression and anxietySuicide

Why suicide?

Burden Approx. 400 suicides

every year in BC, 311 among men

Second leading cause of death among males 15-44 years in BC

Theoretical implications Patterning of suicide

reveals social causes BC Vital Statistics, 2013Durkheim, Suicide, 1897

Syndemic process

Stall, 2008Ferlatte, CBRC, SexNow 2011-12

Marginalization and stigma

Development of psychosocial

health problems

Snowballing of

psychosocial problems

HIV risk

HIV infectio

n

Prevalence of suicidality (last 12 months) by numberof marginalization indicators

Canadian epidemiology of:

HIV Suicide

77% of cases are male(50% are gay or bisexual men)

Rates (new infection) are highest in adults 25-59 years of age

Aboriginal people are over-represented (24% of all new

positive tests)

77% of suicides in BC are among males

Rates are highest in adults 35-59 years of age

Aboriginal people experience a rate of suicide twice that of other

Canadians

PHAC, Estimates of HIV Prevalence, 2011PHAC, Population-Specific Status Report: Aboriginal Peoples, 2010

Navaneelan, Stats Canada, 2012Frohlich, Health Policy, 2006

Goal: To broaden the scope of our work within the field of gay men’s health.

Objective: To estimate the number of suicides among gay and bisexual men in BC and compare this to the number of HIV-related deaths.

Direct methods

Plöderl, Arch Sex Behav 2013BC Archives/Vancouver Sun, 2012

a)Death certificatesNo information about sexual identity

b) Autopsy studiesPoor information about sexual identity

“Six of the seven youth who were gay, lesbian, bisexual, or questioning their sexual orientation were known to have felt emotional distress relating to their sexual orientation. Three experienced family conflict relating to their sexual orientation. One youth experienced significant internal conflict regarding her sexual orientation.”

Indirect method

Population Attributable Fraction = % of the total amount of disease (death) that is “attributed” to the factor of interest (i.e., sexual orientation), on average

PAF is a function of:1) The magnitude of increased risk (RR)2) The size of the population at risk (p%)

(i.e., % of BC males who are gay/bisexual)

Tanuseputro, Am J Epi 2005

How much risk? (RRSUICIDE)

OR=3.18 (suicide attempt)18 studies (1995-2009)Lesbian, gay, bisexual persons <21 years of age

RR=4.28 (95% CI 2.32, 7.88) (suicide attempt)5 studies (1996-2005)Gay and bisexual adult men

How much risk? (RRHIV)

RR=42 (95% CI 38, 48) (living with HIV)Based on sexual behavior (MSM)

How many gay men? (p%)

Construct Source p% HIV Suicide

Identity CCHS (Canada, 2003) 2% X X

Behavior (past 5 years*)

Purcell, et al (US, 1988-2008) 4% X

Attraction USNSFG (US, 2006-2008)

7% X

Brennan, CJPH, 2010Purcell, Open AIDS, 2012

Chandra, Natl Hlth Stat Rep, 2011

Data

BC Vital Statistics Agencypublicly available mortality data1998-2011

Causes of death:HIV (ICD-10 codes B20-B24)Suicide (ICD-10 codes X60-84, X87.0)

Counts of death among males were multiplied by PAF based on varied assumptions.

Results

Disco Fallout Shelter. Instant Coffee (Toronto Sculpture Garden, 2009)

Mortality estimates, 2011Gay and bisexual men in BC

HIV Suicidep% = 2%

(identity)

RR = 42

p% = 2%

(identity)

RR = 4

PAF = 45%21 HIV-related

deaths

PAF = 6%18 suicides

Mortality trends:

Range of estimates (~RR):SUICIDE HIV

Range of estimates (~p%):SUICIDE HIV

Summary of findings

Assuming gay and bisexual men represent 2% of the population of BC males, in 2011:

Approximately 21 gay and bisexual men died from HIV disease, and

Approximately 18 died from suicide. Suicide estimates are highly sensitive

to assumptions (due to relatively small and uncertain magnitude of RR)

A plausible range of uncertainty includes 6-34 suicides per year.

Moving forwardHistorically high burden of HIV-related deaths among gay and bisexual menIf trends in HIV care & treatment continue, suicides will soon surpass HIV as a leading cause of death for gay and bisexual men.

Research questionsDefinition of “population at risk”

Causal pathway LIFECOURSE

Syndemic research with multiple outcomes

Marginalization and stigma

Development of psychosocial

health problems

Snowballing of psychosocial problems

…….

Is it more complex?

1. How do suicidality and HIV interact and intersect?

2. How does the experience of this syndemic differ across the diverse population of gay and bisexual men?

CBRC, Sex Now, 2011-12Carrico, JAIDS 2010

Ferlatte, AIDS Behav 2013

Caveat

Estimates were generated as exploratory analysis to prompt reflection about the relative importance of this topic within our work.

Indirect methods used are not sufficiently rigorous to cite precise estimates.

Additional study is sorely needed to more precisely characterize the scope and nature of suicide among (adult) gay and bisexual men.

Attention to suicide Gay health research?

PubMed search: gay men/MSM + HIV

= 9,021 citationsgay men/MSM + suicide

= 483 citations

Mental health policy?

It doesn’t always get better.

Statistics Canada, 2012

95% of suicides occur among those 20+ years of age

81% in those 30+ years

Meanwhile…The risk of suicide remains elevated for gay

and bisexual men throughout adulthood.

King, BMC Psych, 2008; Brennan, CJPH, 2010; Russell, Soc Sci Med, 2012

Is LGBT suicide predominantly an issue for teenagers?

Thank youDionne Gesink (University of Toronto)Anne Rhodes (University of Toronto)Mark Gilbert (BCCDC)Terry Trussler (CBRC)

Funding: Vanier CGS