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Professor Patricia Casey’s latest contribution to public debate on the topic of suicide is that young gay men who have suicidal ideation or who attempt to harm themselves will not necessarily go on to kill themselves. She has told us that we should not “conflate” the act of self-harm with the completed act of suicide. Her argument is that, although suicidal behaviour is disproportionately more common in LGBT individuals, that the completed acts of suicide may not be higher.
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The reality is that every individual who presents with either self-harm or suicidal ideation, regardless of their sexual orientation, is at a greatly increased risk of going on to die by suicide. One in a hundred individuals, whether gay or straight, who present to medical services with self-harm or suicidal ideation will go on to kill themselves in the following year. Presentation with self-harm is the single most important risk factor in the prediction of completed suicide. We have a national programme in suicide prevention that is focused, almost exclusively, on interventions for individuals who present to A&E departments, or to GP surgeries, with self-harm or suicidal ideation.
I practise in Tallaght Hospital and in the HSE community clinics in the Tallaght area. We have set up a dedicated suicide-prevention service, called Ceangail, operating between 5pm and 9am, in recognition of the fact that most individuals who present with suicidal thoughts or behaviours do so outside of working hours. We are now in the final stages of implementing a specialist self-harm assessment programme in GP practices in Tallaght, led by my community mental health team and Professor Tom O’Dowd (Professor of General Practice, TCD and a GP in Tallaght).
The question that one has to ask is how might a relative risk, between gay and straight men, of progression from suicidal behaviour to completed suicide, be relevant to clinical practice? Why would it matter if the risk of completed suicide were less for gay, than for straight, men? Would it change medical practice?
Rates of suicide are 18/100,000 for men and 4/100,000 for women (http://nsrf.ie/statistics/suicide/). Do we treat a suicide attempt by a young women less seriously than that of a young man because, statistically, the chances of a woman dying by suicide are so reduced, compared to men? Individuals are treated, not statistics. Statistics inform medical practice, they do not dictate it. Doctors, whether practising in psychiatry, in A&E departments or in GP surgeries, treat a presentation with suicidal ideation or behaviours as being serious, regardless of gender or sexual orientation issues, because some of these patients will go on to die by suicide.
What is established beyond doubt and in all layers of our society is the very high rates of mental ill-health experienced by LGBT people. This is all indisputable. Neither is it disputed that this ill-health is caused by the discrimination experienced by LGBT persons. This can be directly experienced as a rejection of one’s identity and oneself, bullying or in being denied human rights available to heterosexuals. A more malignant process can occur when the social discrimination experienced by LGBT individuals is internalised and this self-stigma can give rise to feelings of depression and self-loathing. Social isolation inevitably follows, and individuals can spiral into a paranoid and profoundly unhappy mental state.
I remember trying to “treat” a man about 25 years ago, when I was in training, who was so tortured by being gay that he wanted me to chemically castrate him: to neutralise his male hormones with anti-androgen medication. I have often thought about his tortured life since then, and of how futile and unnecessary his suffering was.
Many doctors in Ireland have become advocates for equal rights for LGBT people, including the right to marry, because of the health problems associated with repressed or stigmatised sexual orientation. The Irish Medical Organisation, the largest medical organisation in the country, is in support of a ‘Yes’ vote in the marriage-equality referendum. A new organisation, Doctors for Marriage Equality, composed of doctors from all medical specialties, of all ages and sexual orientation, is gaining momentum on a daily basis as May 22 approaches (https://www.facebook.com/doctorsformarriageequalityireland). The support for LGBT rights globally within the medical community was reflected in an editorial this week in the New England Journal of Medicine, recently voted the most influential medical journal in the world by doctors. The editorial, titled “In support of same-sex marriage”, states, “Same-sex marriage should be accepted both as a matter of justice and as a measure that promotes health”.
Former president Mary McAleese was correct when she spoke out about this, and also correct about the link between being of homosexual orientation, having mental health problems and suicidal behaviours. She was also correct about the link between suicidal behaviours and completed suicide.
Does it really help make us a better or more healthy society to calculate whether gay men are over-represented in our suicide statistics? Is it not enough to know that the mental health of our LGBT citizens is suffering because of social discrimination? Psychiatry and medicine are frequently involved in issues related to ill-health, such as poverty, income inequality and discrimination, because these issues affect peoples’ health. Medics can only treat the ailment, but the power to alleviate this ill-health lies with all the citizens of our country. Choosing to vote ‘Yes’ is a vote that will lead to a healthier society for us all.
Veronica O’Keane, Professor in Psychiatry, TCD and Tallaght Psychiatry Services
