Post on 09-Jun-2015
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