Effective Screening and Treatment to Reduce Suicide Risk Among Sexual and Gender Minority Youth
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Effective Screening and Treatment to
Reduce Suicide Risk Among Sexual
and Gender Minority Youth
Pamela J. Murray, MD, MHP,a,b Brian C. Thoma, PhDc
In this issue of Pediatrics, Luk et al1 questions about suicidal ideation.
describe the risk of suicidal behavior Validated instruments to identify
within a 7-year nationally suicide risk are available, and
representative longitudinal sample of accurate identification of risk allows
US adolescents. They found that referral for emergency consultation
sexual minority adolescents had an or treatment that has the potential to
earlier onset of suicidality and faster prevent suicidal behavior.
progression from suicide ideation to
a suicide plan, compared with that of In addition to screening all youth for
heterosexual adolescents. The depressive symptoms and suicidal
increased risk for suicidal ideation ideation, routine screening for sexual
and behavior among this vulnerable minority status has the potential to
population of youth is well enhance prediction of suicide risk
described.2 The findings in this among youth, given the early and
report regarding the early emergence elevated risk among sexual minority
and rapid progression of suicide risk youth. Higher risk for suicidal a
Adolescent & Young Adult Medicine, Boston Children’s
among sexual minority adolescents behavior among gender minority Hospital, Boston, Massachusetts; bPediatrics, Harvard
suggest that early identification of adolescents, including transgender Medical School, Boston, Massachusetts; and cDepartment
and gender diverse adolescents, has of Psychiatry, School of Medicine, University of Pittsburgh,
risk and implementation of risk Pittsburgh, Pennsylvania
reduction interventions are critical. been increasingly documented,12
indicating that screening for both DOI: https://doi.org/10.1542/peds.2021-051831
Rates of suicide3 and suicide-related sexual and gender minority (SGM) Accepted for publication Jul 14, 2021
emergency department visits4 are status has the potential to improve Address correspondence to: Dr Pamela Murray, Boston
Children’s Hospital, 333 Longwood Ave, Boston, MA 02215.
increasing among adolescents in the care for SGM youth. Screening for E-mail: pamela.murray@childrens.harvard.edu
United States. Screening for SGM status during adolescence PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online,
depression is currently would also allow providers to make 1098-4275).
recommended at annual visits from more effective referrals for SGM Copyright © 2021 by the American Academy of Pediatrics
the age of 12 years,5 and the youth to mental health service FINANCIAL DISCLOSURES: The authors have indicated
they have no financial relationships relevant to this
American Academy of Pediatrics providers who are competent in SGM article to disclose.
(AAP) has developed resources, tool issues and can provide validating
FUNDING: Dr Thoma was supported by National Institute
kits, and trainings to facilitate this care, directly addressing psychosocial of Mental Health grant K01 MH117142. Dr Murray
activity.6,7 In recent research, it is stressors experienced by SGM youth received no external funding. Funded by the National
Institutes of Health (NIH).
suggested that screening for that have known associations with
POTENTIAL CONFLICT OF INTEREST: The authors have
depression alone may not capture risk for suicidal behavior. Beginning indicated they have no potential conflicts of interest to
many suicidal youth8,9 because 32% screening for SGM identities at the disclose.
of patients at risk for suicide in an age of 12 years, to coincide with
inpatient medical sample were not initiation of screening for depressive
identified by depression screening. In symptoms, would capture SGM status To cite: Murray PJ, Thoma BC. Effective Screening
and Treatment to Reduce Suicide Risk Among
other reviews,10,11 authors cite data when youth typically begin to
Sexual and Gender Minority Youth. Pediatrics.
accumulating evidence that suicide experience same-sex attractions.13,14 2021;148(4):e2021051831
risk is better captured by direct Because sexual attractions emerge
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PEDIATRICS Volume 148, number 4, October 2021:e2021051831 COMMENTARYbefore self-identified sexual to more medical record components to SGM adolescents and their
orientation, the assessment of sexual is often beneficial and has become families. Rarely, there are services
attractions during adolescence more direct under the 21st Century that are SGM-focused, and they are
captures the widest swath of sexual Cures Act that implements “no cost” usually located in urban
minority youth,15 and providers can access to most clinical notes neighborhoods and mostly absent
assess attractions in-person by using “without bureaucratic delays.” This from suburban and rural areas.
the following prompt: “Many poses additional challenges for Thus, these specialized services
children your age experience sexual providers when ensuring the cannot meet the needs of SGM youth
attraction to other people. Do you confidentiality and safety of SGM alone. It is critical that primary care
feel attraction to boys, girls, both, or adolescent patients.19 Confidentiality and mental health service providers
neither?” In addition, using self- protection of content in the medical receive training to provide culturally
report survey items to assess record varies by state, electronic competent care for SGM youth and
attraction, identity, and sexual medical record (EMR), and health their families. This training is
behavior will yield the most reliable system, and it currently falls on the currently not offered within the vast
information about sexual minority providers of care to adolescents to majority of medical and mental health
status during adolescence.15 Finally, maintain the confidentiality of training curricula,25 and systemic
assessing gender identity is also specific content or entire notes in change is required to emphasize and
critical during this developmental their EMR, by following specific prioritize training in cultural
period, and it has been procedures to protect content and competence with SGM populations. In
recommended that providers use document the reason for addition, continuing education
validated measures to assess confidentiality.20–22 Both in verbal programs can reduce provider biases
whether youth have questions about and written communication, toward SGM patients and increase
their gender identity.16 providers should ensure they do not comfort providing care for SGM
inadvertently disclose their patients’ individuals.26 Training for all medical
Because many parents of SGM SGM status to parents, with the
and mental health providers to build
adolescents are not aware of their ultimate goal of assisting the family
competence with SGM populations is
child’s SGM identity, providers must to facilitate both communication
pivotal to ensure SGM youth and their
take caution when assessing this about topics related to SGM
families receive high quality services,
information because inadvertent identities and appropriate mental
providing a path toward parity in
disclosure of SGM status to parents health referrals for SGM youth when
mental health services for this
necessary.
can exacerbate risk for conflict with vulnerable population.27,28
or mistreatment by family members
If we screen youth for suicide risk
and lead to a rupture of For mental health services in general
and SGM status, the tenets of
provider–patient rapport if not and SGM services in particular, we
screening assume we can offer
handled sensitively. Providers need an aggressive development plan,
services that will have an impact on
should assess SGM status privately exploring models of workforce
outcomes.23 In the United States, we
without parents present, including development and training, service
are facing a pediatric mental health
level of parental knowledge of their delivery of remote and face-to-face
and behavioral health care crisis of
patient’s SGM identities.17 Beginning growing proportions. Importantly, mental health care, and quality,
at the 11-year-old patient visit, the the coronavirus disease 2019 evaluation, and outcome measures to
AAP recommends discussion of pandemic has escalated experiences grow and modify practice and care. If
confidentiality and time alone for of distress among adolescents.24 pediatricians and other primary care
the adolescent.18 The same attention Behavioral health providers and providers are to screen adolescents
to confidentiality applied to the institutions are stretched and unable for risk for suicide and SGM identities
typical adolescent social history that to handle the demand for inpatient with the goal of treating depression
includes questions about sexual care, intensive outpatient services, and preventing suicide, pediatricians
behaviors, depression and/or and outpatient care. Waiting times need to be prepared to refer or offer
suicide risk, and substance use, and wait lists are longer. care and services to the individuals
among other topics, should be and families identified through
applied to information related to This crisis is exacerbated among screening efficiently, effectively, and
SGM status. However, additional SGM adolescents because many within accessible payment and care
challenges include parents’ ability to mental health providers are delivery systems. Unless parity is
access their child’s medical records unprepared to effectively provide addressed, we will not reduce
during adolescence. Increased access validating and accepting clinical care disparities.
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2 MURRAY and THOMAenough? J Adolesc Health. 2021;68(6): 19. Carlson J, Goldstein R, Hoover K, Tyson N.
ABBREVIATIONS 1183–1188 NASPAG/SAHM statement: the 21st Cen-
AAP: American Academy of 9. Kemper AR, Hostutler CA, Beck K, Fonta- tury Cures Act and adolescent confidenti-
Pediatrics ality. J Pediatr Adolesc Gynecol. 2021;
nella CA, Bridge JA. Depression and sui-
EMR: electronic medical record 34(1):3–5
cide-risk screening results in pediatric
SGM: sexual and gender minority primary care. Pediatrics. 20. Rafferty J; COMMITTEE ON PSYCHOSOCIAL
2021;141(8):e2021049999 ASPECTS OF CHILD AND FAMILY HEALTH;
COMMITTEE ON ADOLESCENCE; SECTION ON
10. Asarnow JR, Mehlum L. Practitioner
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PEDIATRICS Volume 148, number 4, Downloaded
October 2021from www.aappublications.org/news by guest on November 4, 2021 3Effective Screening and Treatment to Reduce Suicide Risk Among Sexual and
Gender Minority Youth
Pamela J. Murray and Brian C. Thoma
Pediatrics originally published online September 27, 2021;
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Services http://pediatrics.aappublications.org/content/early/2021/09/24/peds.2
021-051831
References This article cites 25 articles, 9 of which you can access for free at:
http://pediatrics.aappublications.org/content/early/2021/09/24/peds.2
021-051831#BIBL
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Downloaded from www.aappublications.org/news by guest on November 4, 2021Effective Screening and Treatment to Reduce Suicide Risk Among Sexual and
Gender Minority Youth
Pamela J. Murray and Brian C. Thoma
Pediatrics originally published online September 27, 2021;
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/early/2021/09/24/peds.2021-051831
Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
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