Understanding Suicidal Thoughts and Behaviors among LGBTQ+ Youth: Differential Associations between Bullying and Substance Use
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| Title: | Understanding Suicidal Thoughts and Behaviors among LGBTQ+ Youth: Differential Associations between Bullying and Substance Use |
|---|---|
| Language: | English |
| Authors: | Cayson W. Tiedge (ORCID |
| Source: | Prevention Science. 2025 26(3):449-461. |
| Availability: | Springer. Available from: Springer Nature. One New York Plaza, Suite 4600, New York, NY 10004. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-460-1700; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/ |
| Peer Reviewed: | Y |
| Page Count: | 13 |
| Publication Date: | 2025 |
| Document Type: | Journal Articles Reports - Research |
| Education Level: | High Schools Secondary Education |
| Descriptors: | Suicide, Mental Health, Bullying, Victims, Substance Abuse, Health Behavior, High School Students, At Risk Persons, Psychological Patterns, Adolescents, Correlation, Drinking, Marijuana, Drug Abuse, Alcohol Abuse, LGBTQ People |
| Assessment and Survey Identifiers: | Youth Risk Behavior Survey |
| DOI: | 10.1007/s11121-025-01783-1 |
| ISSN: | 1389-4986 1573-6695 |
| Abstract: | Rates of suicidal thoughts and behaviors (STB, i.e., suicidal thoughts, plans, and attempts), substance use, and bullying victimization are higher among lesbian, gay, bisexual, transgender, and/or queer (LGBTQ+) youth compared to their heterosexual peers. However, research examining the interactive and potentially compounding associations of concurrent bullying and substance use (alcohol, cannabis, hallucinogens, and opioids) with STB is sparse, especially among LGBTQ+ youth. Thus, the current study aims to understand how these substances moderate the association between bullying victimization and STB by utilizing data (N = 96,482) from the combined 2003-2019 Youth Risk Behavior Survey (YRBS). Using a cross-sectional design and hierarchical logistic regression, we found that, on average, LGBTQ+ youth who were bullied were more likely to report planning to attempt suicide (O.R. = 2.71, p < 0.01). Similarly, youth who reported using opioids/prescription drugs (O.R. = 4.60, p < 0.05) or hallucinogens (O.R. = 8.89, p < 0.01) were more likely to attempt suicide. No significant associations between alcohol use and STB were found. Lastly, cannabis emerged as a significant moderator of the associations between bullying victimization and suicidal ideation and plans, such that adolescents who were bullied and used cannabis were less likely to report suicidal ideation and planning compared to those who were bullied but did not use cannabis. These findings highlight that different substances are distinctively associated with STB among LGBTQ+ youth, providing a better understanding of how individuals who are being bullied may cope and to develop prevention programs to combat suicidal thoughts, planning, and attempts. |
| Abstractor: | As Provided |
| Entry Date: | 2025 |
| Accession Number: | EJ1470716 |
| Database: | ERIC |
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| FullText | Links: – Type: pdflink Url: https://content.ebscohost.com/cds/retrieve?content=AQICAHj0k_4E0hTGH8RJwT4gCJyBsGNe_WN95AvKlDbXJGqwxwGqvRI9uSgKNVReUx-ZW-aMAAAA4jCB3wYJKoZIhvcNAQcGoIHRMIHOAgEAMIHIBgkqhkiG9w0BBwEwHgYJYIZIAWUDBAEuMBEEDBki92b3FOEjhg7TuwIBEICBmrIkb7uhkEcEuHrc73JjJ551-YEEwHfa9qXKjXpIsa4wPHP8IHlIUYYHux0Hp-ZxdkVuKBr4Bzz8Vfmw4pKs7qHfey3h3Vy77lvgi-_8wdWIyQZUMOXJJFgWl2V3S6_jQ2MsGcF18AMrnnmGuCaopvpr0hEQMwwluYmmLkNLuGzw9dIeqPGoRjQz0dr-W96kDVmWsGRGYWR0VDE= Text: Availability: 1 Value: <anid>AN0185070826;n9p01apr.25;2025May13.02:28;v2.2.500</anid> <title id="AN0185070826-1">Understanding Suicidal Thoughts and Behaviors Among LGBTQ + Youth: Differential Associations Between Bullying and Substance Use </title> <p>Rates of suicidal thoughts and behaviors (STB, i.e., suicidal thoughts, plans, and attempts), substance use, and bullying victimization are higher among lesbian, gay, bisexual, transgender, and/or queer (LGBTQ +) youth compared to their heterosexual peers. However, research examining the interactive and potentially compounding associations of concurrent bullying and substance use (alcohol, cannabis, hallucinogens, and opioids) with STB is sparse, especially among LGBTQ + youth. Thus, the current study aims to understand how these substances moderate the association between bullying victimization and STB by utilizing data (N = 96,482) from the combined 2003–2019 Youth Risk Behavior Survey (YRBS). Using a cross-sectional design and hierarchical logistic regression, we found that, on average, LGBTQ + youth who were bullied were more likely to report planning to attempt suicide (O.R. = 2.71, p &lt;.01). Similarly, youth who reported using opioids/prescription drugs (O.R. = 4.60, p &lt;.05) or hallucinogens (O.R. = 8.89, p &lt;.01) were more likely to attempt suicide. No significant associations between alcohol use and STB were found. Lastly, cannabis emerged as a significant moderator of the associations between bullying victimization and suicidal ideation and plans, such that adolescents who were bullied and used cannabis were less likely to report suicidal ideation and planning compared to those who were bullied but did not use cannabis. These findings highlight that different substances are distinctively associated with STB among LGBTQ + youth, providing a better understanding of how individuals who are being bullied may cope and to develop prevention programs to combat suicidal thoughts, planning, and attempts.</p> <p>Keywords: Suicidality; LGBTQ+ youth; Substance use; Suicidal thoughts; Plans; Attempts; Medical and Health Sciences Public Health and Health Services</p> <p>Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/s11121-025-01783-1.</p> <hd id="AN0185070826-2">bIntroduction</hd> <p>Current research has found that youth who identify as lesbian, gay, bisexual, transgender, and/or queer (LGBTQ +) report higher rates of suicidal thoughts and behaviors (STB) compared to their heterosexual peers (Green et al., [<reflink idref="bib32" id="ref1">32</reflink>]; Johns et al., [<reflink idref="bib43" id="ref2">43</reflink>]; Morgan et al., [<reflink idref="bib54" id="ref3">54</reflink>]). According to the Trevor Project's ([<reflink idref="bib68" id="ref4">68</reflink>]) survey on LGBTQ youth mental health, 45% of LGBTQ youth seriously considered attempting suicide during the past year and 14% reported attempting suicide. Moreover, LGBTQ youth are disproportionately exposed to stigma and discrimination due to their non-normative sexual orientation or gender identity, which can increase the risk of bullying victimization, a contributing factor to STB (Johns et al., [<reflink idref="bib43" id="ref5">43</reflink>]; Nakamoto &amp; Schwartz, [<reflink idref="bib56" id="ref6">56</reflink>]; Polanin et al., [<reflink idref="bib61" id="ref7">61</reflink>]; Turner et al., [<reflink idref="bib71" id="ref8">71</reflink>]). A 2020 study found that after controlling for race, gender, weight, and grade, LGBTQ + youth significantly faced twice the rate of traditional and electronic bullying than their heterosexual peers and were eight times more likely to face bullying based on their sexual orientation (Kahle, [<reflink idref="bib44" id="ref9">44</reflink>]).</p> <p>Furthermore, research has found that bullying victimization is associated with increased rates of substance use in LGBTQ + youth populations, another risk factor for STB (Huebner et al., [<reflink idref="bib40" id="ref10">40</reflink>]; Radliff et al., [<reflink idref="bib63" id="ref11">63</reflink>]). Other studies have found that LGBTQ + identification is positively associated with substance use resulting from the disproportionate exposure to stigma and discrimination that LGBTQ + individuals face daily (Hughes et al., [<reflink idref="bib41" id="ref12">41</reflink>]; Morgan et al., [<reflink idref="bib54" id="ref13">54</reflink>]). Findings from the Centers for Disease Control and Prevention ([<reflink idref="bib20" id="ref14">20</reflink>], [<reflink idref="bib21" id="ref15">21</reflink>]) Youth Risk Behavior Survey show large disparities in substance use rates with about 26% of LGBTQ + high school youth reporting alcohol use and 22% cannabis use during the past 30 days, compared with 22% and 14%, respectively, among heterosexual youth.</p> <p>These disparities demonstrate the pressing need to further investigate the relations among bullying victimization, substance use, and STB among LGBTQ + youth (Dowshen et al., [<reflink idref="bib27" id="ref16">27</reflink>]; Hatzenbuehler &amp; Pachankis, [<reflink idref="bib38" id="ref17">38</reflink>]). However, few studies have examined the associations between specific types of substances and STB, particularly considering how substance use may moderate the associations between experiencing bullying victimization and STB among LGBTQ + youth. The current study aims to address this gap by analyzing bullying victimization, substance use (alcohol, cannabis, hallucinogens, and opioids), and their associations with STB using a large sample of LGBTQ + youth from the CDC's 2003–2019 Youth Risk Behavior Survey (YRBS). Findings from the present study can provide valuable insights that may help develop targeted interventions and support systems to address persistent disparities and improve the mental health and well-being of LGBTQ + youth.</p> <hd id="AN0185070826-3">Bullying Victimization and Suicidal Thoughts and Behaviors</hd> <p>Minority stress theory (MST) is a framework used to understand how environmental exposure to higher rates of discrimination and violence experienced by LGBTQ + youth may explain health disparities compared to heterosexual peers (Meyer, [<reflink idref="bib52" id="ref18">52</reflink>]). MST posits that in addition to stressors non-specific to LGBTQ + youth, sexual minority status, in the context of heterosexist environments, increases youth's exposure to unique minority stressors, such as homophobic bullying, biases targeted at youth with diverse gender expressions, and internalized negative attitudes toward oneself (Hatzenbuehler &amp; Pachankis, [<reflink idref="bib38" id="ref19">38</reflink>]). Over time, the physical and psychological responses to these stressors accumulate and lead to detrimental health outcomes.</p> <p>MST has been used to explain the association between higher exposure to discrimination and higher rates of STB, psychological disorders, and internalized homophobia in LGBTQ + individuals (Baams et al., [<reflink idref="bib5" id="ref20">5</reflink>]; Green et al., [<reflink idref="bib32" id="ref21">32</reflink>]; Hatchel et al., [<reflink idref="bib36" id="ref22">36</reflink>]). A recent meta-analysis and systematic review found that discrimination, limited social support, and identity-based biases are influential factors on STB among LGBTQ + youth (Hatchel et al., [<reflink idref="bib37" id="ref23">37</reflink>]). Further, MST has been employed to guide research correlating to higher rates of homophobic bullying to higher substance use among LGBTQ + youth (Goldbach et al., [<reflink idref="bib30" id="ref24">30</reflink>]). In the present study, we use MST to contextualize the effects of bullying victimization as a shared exposure to heterosexist environments that systematically disadvantage LGBTQ + youth.</p> <hd id="AN0185070826-4">Substance Use and Suicidal Thoughts and Behaviors</hd> <p>While research indicates that LGBTQ + individuals use substances at higher rates than their heterosexual counterparts, little is known about how or why LGBTQ + youth use substances in relation to coping with negative minority stressors such as bullying victimization (Klein &amp; Ross, [<reflink idref="bib46" id="ref25">46</reflink>]; Morgan et al., [<reflink idref="bib54" id="ref26">54</reflink>]; Schuler et al., [<reflink idref="bib66" id="ref27">66</reflink>]). Previous findings suggest that acute drug intoxication may negatively impact individuals' judgment, inhibition, and impulsive control which increases the possibility of STB (Bagge &amp; Borges, [<reflink idref="bib6" id="ref28">6</reflink>]; Mann, [<reflink idref="bib50" id="ref29">50</reflink>]; Wang &amp; Yen, [<reflink idref="bib73" id="ref30">73</reflink>]). However, the simplified assumption that substance use, in general, facilitates the impulsive act of suicide may not adequately explain the mechanisms resulting in increased risk of suicide attempts (Anestis et al., [<reflink idref="bib4" id="ref31">4</reflink>]; Witte et al., [<reflink idref="bib75" id="ref32">75</reflink>]). Different substances have varying subjective and physiological impacts on the brain, suggesting their associations with STB will likely differ based on the substance involved (Hamidullah et al., [<reflink idref="bib34" id="ref33">34</reflink>]; Hase et al., [<reflink idref="bib35" id="ref34">35</reflink>]).</p> <p>In a study examining the acute use of substances preceding a suicide attempt among patients presenting to a trauma hospital, researchers found increased odds of attempting among participants who drank alcohol or used another central nervous system depressant (sedatives or opioids) concurrently, within the last 24 h (Bagge &amp; Borges, [<reflink idref="bib6" id="ref35">6</reflink>]). Predominant theories of ideation-to-action hypothesize the disinhibitory effects of depressant substances as explanatory for the correlation between adolescent substance use, such as prescription opioids, and higher suicidal ideation, plans, and attempts (Baiden et al., [<reflink idref="bib8" id="ref36">8</reflink>]).</p> <p>Similarly, while there is currently no consensus on the pharmacotherapeutic value of cannabis use on STB, many studies emphasize cannabis use as a risk factor (Delforterie et al., [<reflink idref="bib25" id="ref37">25</reflink>]; Schmidt et al., [<reflink idref="bib65" id="ref38">65</reflink>]; Sellers et al., [<reflink idref="bib67" id="ref39">67</reflink>]). One study found that cannabis use did have a significant association with increased suicidal ideation and attempts on same-day use and over time for adolescent outcomes preceding psychiatric hospitalization (Sellers et al., [<reflink idref="bib67" id="ref40">67</reflink>]). For Latinx LGBTQ + youth specifically, cannabis use has been found to be significantly associated with elevated rates of depression and suicidality (Boyas et al., [<reflink idref="bib16" id="ref41">16</reflink>]). However, a study by Bagge and Borges ([<reflink idref="bib6" id="ref42">6</reflink>]) found that the use of cannabis in isolated occasions was not associated with suicide risk while chronic use was. Further, the study found that individuals who were sole users of cannabis and not other substances were associated with a decreased risk of suicide (Bagge &amp; Borges, [<reflink idref="bib6" id="ref43">6</reflink>]). Present studies have found that medical cannabis specifically, when used in controlled dosages, is associated with self-reported decreases in pain, anxiety, and depression (Childs et al., [<reflink idref="bib22" id="ref44">22</reflink>]; Cuttler et al., [<reflink idref="bib24" id="ref45">24</reflink>]; Webb &amp; Webb, [<reflink idref="bib74" id="ref46">74</reflink>]). While medical cannabis is only prescribed to adults, these findings show that its use may be helpful in the treatment of anxiety and depression, highlighting a need to better understand how cannabis use may be associated with depression and STB in LGBTQ + youth.</p> <p>Additionally, emerging evidence suggests that, unlike depressant substances, classical hallucinogens may be associated with improved mental health symptoms under controlled clinical settings and provide rapid antidepressant and anxiolytic effects (Baumeister et al., [<reflink idref="bib9" id="ref47">9</reflink>]; Grob et al., [<reflink idref="bib33" id="ref48">33</reflink>]). Emerging evidence among adult samples suggests that the use of hallucinogens such as MDMA, LSD, Ketamine, and Psilocybin mushrooms in a therapeutic setting may alleviate negative feelings from trauma or anxiety, decreasing rates of prolonged depression, STB, and PTSD (Al Jurdi et al., [<reflink idref="bib2" id="ref49">2</reflink>]; Galvão-Coelho et al., [<reflink idref="bib29" id="ref50">29</reflink>]; Krediet et al., [<reflink idref="bib48" id="ref51">48</reflink>]; Zhou et al., [<reflink idref="bib77" id="ref52">77</reflink>]). For this reason, LGBTQ + youth may seek classical hallucinogens and similar compounds to cope with the consequences of minority stress and bullying victimization, despite unclear evidence for their effectiveness among adolescents.</p> <p>However, coping with the effects of identity-based discrimination through hallucinogenic substances may resurface trauma, that, without proper care, may stimulate suicide-risk behaviors among hallucinogen users (Yang et al., [<reflink idref="bib76" id="ref53">76</reflink>]). Interestingly, research shows that specific psychoactive drugs such as LSD, amphetamines, phencyclidine (PCP), and cannabis may increase symptoms of latent psychosis, such as hallucinations and paranoia, among vulnerable individuals (Paparelli et al., [<reflink idref="bib57" id="ref54">57</reflink>]). Although substance-induced psychosis is possible with most hallucinogenic substances, research is inconclusive about the relation between psychosis and STB (Johansen et al., [<reflink idref="bib42" id="ref55">42</reflink>]; Hjorthoj et al., [<reflink idref="bib39" id="ref56">39</reflink>]; Yang et al., [<reflink idref="bib76" id="ref57">76</reflink>]). Given the mixed findings and lack of research among LGBTQ + adolescents, there is a critical need to examine the specific associations between bullying victimization, substances, and STB.</p> <hd id="AN0185070826-5">Sociodemographic Correlates of STB Among LGBTQ + Youth</hd> <p>Intersecting identities such as age, race/ethnicity, sex assigned at birth, gender expression, and past depressive symptoms are important factors that must be considered when studying the rates of STB among LGBTQ + youth. Research has found that LGBTQ + youth who come out before the age of 13 are at increased risk of suicidal ideation and attempts (The Trevor Project, [<reflink idref="bib69" id="ref58">69</reflink>]) and students of color face higher proportions of bullying victimization and STB than their white peers (Bostwick et al., [<reflink idref="bib15" id="ref59">15</reflink>]; Cubbage &amp; Adams, [<reflink idref="bib23" id="ref60">23</reflink>]; Peguero &amp; Hong, [<reflink idref="bib60" id="ref61">60</reflink>]). Youth assigned male at birth are more likely to die by suicide while youth assigned female are more likely to attempt suicide (Rhodes et al., [<reflink idref="bib64" id="ref62">64</reflink>]; Miranda-Mendizabal et al., [<reflink idref="bib53" id="ref63">53</reflink>]), and non-binary youth face higher rates of bullying victimization and STB than their peers (Advocates for Youth, [<reflink idref="bib1" id="ref64">1</reflink>]; Goldblum et al., [<reflink idref="bib31" id="ref65">31</reflink>]). Additionally, previous depressive symptoms have consistently been associated with increased STB for LGBTQ + and heterosexual youth (Cai et al., [<reflink idref="bib17" id="ref66">17</reflink>]; Hatchel et al., [<reflink idref="bib36" id="ref67">36</reflink>]; Marshal et al., [<reflink idref="bib51" id="ref68">51</reflink>]). Research highlights the importance of studying LGBTQ + youth identities to find the best points of intervention. Thus, we include these variables as covariates in our study.</p> <hd id="AN0185070826-6">Current Study</hd> <p>Currently, very little research exists on whether bullying victimization interacts with the use of specific substances to either increase or decrease risk of STB among bullied LGBTQ + youth. As LGBTQ + youth may seek substances to cope with experiences of bullying victimization, it is important to examine the role that specific substances may play in these associations. The present study aimed to better understand the specific effects of alcohol, cannabis, hallucinogens, and opioids on STB among LGBTQ + youth in relation to their experiences of bullying victimization. Consistent with previous research, we hypothesized that bullying victimization would be associated with higher rates of suicidal ideation, planning, and attempts among LGBTQ + youth. Further, we hypothesized that alcohol and opioid use would be positively associated with increased suicidal ideation, planning, and attempts.</p> <p>Based on the current evidence in the literature, we hypothesized that cannabis use would be associated with decreased suicidal ideation, planning, and attempts. While the literature on the association between cannabis use and STB remains inconclusive, such use may help decrease feelings of stress, anxiety, and depression, possibly alleviating some of the STB that these youth may experience. Similarly, we expected a negative association between hallucinogen use and suicidal ideation, planning, and attempts. We also hypothesized that specific substances used would moderate the association between bullying victimization and STB, with alcohol and opioids making the association stronger and hallucinogens and cannabis weakening the association. Lastly, we controlled for age, race/ethnicity, sex, gender expression, and symptoms of depression since previous research has found these covariates to be associated with increased rates of STB among LGBTQ + youth.</p> <hd id="AN0185070826-7">Methods</hd> <p>Using data from the combined 2003–2019 Youth Risk Behavior Survey (YRBS), the present study aims to understand how substance use may moderate the association between bullying victimization and STB among LGBTQ + youth (YRBS; Centers for Disease Control &amp; Prevention, [<reflink idref="bib20" id="ref69">20</reflink>], [<reflink idref="bib21" id="ref70">21</reflink>]). The YRBS is a biannual nationally representative cross-sectional survey that monitors a variety of health behaviors, unintentional injuries, and violence (Centers for Disease Control &amp; Prevention, [<reflink idref="bib20" id="ref71">20</reflink>], [<reflink idref="bib21" id="ref72">21</reflink>]). For this study, we examined a subset of participants who identified as LGBTQ + (<emph>N</emph> = 96,482, 48% White, 21% Hispanic, 15% Black, 16% other race, 66% female). Because the question assessing sexual orientation was only added to the YRBS after 2003, the current analysis employed data from the 2003 to 2019 survey administrations.</p> <hd id="AN0185070826-8">Measures</hd> <p></p> <hd id="AN0185070826-9">Outcomes: Suicidal Ideation, Plans, and Attempts</hd> <p>STB were assessed with three items, which asked participants if they had seriously considered attempting suicide, made a plan about how they would attempt suicide, or how many times they actually attempted suicide in the past 12 months. This measure, used extensively for the past 30 years on the Behavioral Risk Factor Surveillance System survey, provides direct questions with face validity regarding STB, making this a validated measure of suicidality in LGBTQ + youth (Centers for Disease Control &amp; Prevention, [<reflink idref="bib20" id="ref73">20</reflink>], [<reflink idref="bib21" id="ref74">21</reflink>]). Response options for thoughts of suicide and planning were 0 (<emph>No</emph>) or 1 (<emph>Yes</emph>). For suicide attempts, the survey asked, "During the past 12 months, how many times did you actually attempt suicide?" with options ranging from A (<emph>0 times</emph>) to E (<emph>6 or more times</emph>). Response items were dichotomized to either 0 (<emph>Never</emph>) or 1 (<emph>One or more times</emph>) to indicate if the individual had attempted suicide at least once during the past 12 months.</p> <hd id="AN0185070826-10">Independent Variables</hd> <p>Bullying victimization: Bullying victimization was assessed with one item asking participants if they had been bullied on school property in the past 12 months. The survey asked, "During the past 12 months, have you ever been bullied on school property?" with response options either 0 (<emph>No</emph>) or 1 (<emph>Yes</emph>). Substance use: Substance use was assessed by asking participants how many times they had used alcohol, cannabis, or opioids and other prescription drugs in the past 30 days. Participants were only asked about lifetime use rather than recent use for hallucinogens; therefore, we were unable to include recent use of hallucinogens in our analysis. Response options ranged from 0 (<emph>Never</emph>) through 6 (<emph>40 or more times</emph>). Participants' responses were dichotomized to 0 (<emph>Never</emph>) or 1 (<emph>One or more times</emph>) to indicate having used the substance during the past 30 days for alcohol, cannabis, and opioids, and to indicate lifetime use for hallucinogens.</p> <hd id="AN0185070826-11">Covariates</hd> <p>Covariates included age, race/ethnicity, sex assigned at birth, gender expression, and depressive symptoms. Age was measured in years ("How old are you?"; 1 = <emph>12 years old or younger</emph> to 7 = <emph>18 years old or older</emph>) and sex assigned at birth as either male or female ("What is your sex [assigned at birth]?" 0 = <emph>male,</emph> 1 = <emph>female</emph>). Race/ethnicity was categorized as White, Hispanic, Black, or other race. For the current analysis, the variable age was recoded to age in years (12 to 18), sex was entered in the model as female sex with reference category males, and race/ethnicity compared Hispanic, Black, and other race with the reference category White. Gender expression was measured by asking participants how they describe themselves, with response options ranging from 0 (<emph>Very masculine</emph>) to 6 (<emph>Very feminine).</emph> Lastly, we controlled for symptoms of depression during the past 12 months (e.g., "During the past 12 months, did you ever feel so sad or hopeless almost every day for two weeks or more in a row that you stopped doing some usual activities?"; 0 = <emph>No</emph>, 1 = <emph>Yes</emph>).</p> <hd id="AN0185070826-12">Analytic Approach</hd> <p>The Youth Risk Behavior Survey (YRBS) uses a complex sampling design including stratification, clustering, and unequal selection probabilities (Centers for Disease Control &amp; Prevention, [<reflink idref="bib19" id="ref75">19</reflink>]). The complex survey design may lead to biased results and incorrect estimates of the standard errors if not properly accounted for in the analysis (Bell et al., [<reflink idref="bib11" id="ref76">11</reflink>]; Cassy et al., [<reflink idref="bib18" id="ref77">18</reflink>]). Thus, we followed the recommended guidelines by the CDC to analyze the combined YRBS data (Centers for Disease Control &amp; Prevention, [<reflink idref="bib19" id="ref78">19</reflink>]). All analyses were conducted with the R software (R Core Team, [<reflink idref="bib62" id="ref79">62</reflink>]) and the "survey" package version 4.1, using the svydesign() and svyglm() functions (Lumley, [<reflink idref="bib49" id="ref80">49</reflink>]). Interaction plots and simple slopes were produced using the R package interactions.</p> <p>Hierarchical logistic regression models examined the associations between bullying victimization, substance use (alcohol, cannabis, hallucinogens, and opioids), and their interactions on STB (ideation, plans, and attempts) among US high school students who identified as LGBTQ +. Three models were run for each outcome following a hierarchical design, with a first block of predictors that included only control variables (age, race/ethnicity, sex, gender expression, and depression); a second model adding a block of independent variables (bullying victimization, alcohol use, cannabis use, opioids and prescription drugs, and hallucinogenic drugs); and finally, a third block adding the interaction terms between bullying victimization and each substance use variable. For significant interactions, simple slopes and plots of estimated probabilities were constructed for each level of the moderator variable. In addition to examining the simple slopes, Johnson-Neyman plots were generated to identify the specific range of cannabis use where the effect of bullying victimization on suicide ideation becomes statistically significant.</p> <hd id="AN0185070826-13">Results</hd> <p>Table 1 presents the descriptive statistics, and Supplemental Table 1 includes bivariate correlations of the study variables. The prevalence of STB was 22% for suicide attempts, 33% for suicide plans, and 39% for suicidal ideation. About 33% of the sample reported experiencing bullying victimization, and substance use prevalence rates were 35% for alcohol, 29% for cannabis, 16% for hallucinogens, and 15% for opioids and other prescription drugs.</p> <p>Table 1 Descriptive statistics</p> <p> <ephtml> &lt;table frame="hsides" rules="groups"&gt;&lt;thead&gt;&lt;tr&gt;&lt;th align="left"&gt;&lt;p&gt;&lt;italic&gt;N&lt;/italic&gt; = 96,482&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;&lt;italic&gt;n&lt;/italic&gt; (%)&lt;/p&gt;&lt;/th&gt;&lt;/tr&gt;&lt;/thead&gt;&lt;tbody&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Age&amp;#8212;&lt;italic&gt;mean&lt;/italic&gt; (&lt;italic&gt;SD&lt;/italic&gt;)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;15.77 (1.32)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left" colspan="2"&gt;&lt;p&gt;&lt;italic&gt;Sex at birth&lt;/italic&gt;&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Female&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;62,120 (66%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Male&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;32,023 (34%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Transgender&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;4,092 (14%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left" colspan="2"&gt;&lt;p&gt;&lt;italic&gt;Sexual orientation&lt;/italic&gt;&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Heterosexual&lt;sup&gt;a&lt;/sup&gt;&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;1,205 (1.3%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Gay/lesbian&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;17,787 (19%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Bisexual&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;48,570 (51%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Not sure&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;28,706 (30%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Gender expression&amp;#8212;&lt;italic&gt;mean&lt;/italic&gt; (&lt;italic&gt;SD&lt;/italic&gt;)&lt;sup&gt;b&lt;/sup&gt;&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;2.28 (1.68)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left" colspan="2"&gt;&lt;p&gt;&lt;italic&gt;Grade&lt;/italic&gt;&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;9th&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;26,225 (28%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;10th&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;25,173 (27%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;11th&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;23,022 (25%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;12th&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;19,528 (21%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Unknown&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;2,534&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left" colspan="2"&gt;&lt;p&gt;&lt;italic&gt;Race/ethnicity&lt;/italic&gt;&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;American Indian/Alaska Native&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;2,159 (2%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Asian&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;4,434 (5%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Black or African American&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;13,440 (15%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Hispanic/Latino&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;19,698 (21%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Native Hawaiian/Other Pacific Islander&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;1,842 (2%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;White&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;44,125 (48%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Multiple races (non-Hispanic)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;6,573 (7.1%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Unknown&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;4,211&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left" colspan="2"&gt;&lt;p&gt;&lt;italic&gt;Dependent variables&lt;/italic&gt;&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Suicide ideation&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;31,416 (39%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Suicide plan&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;27,020 (33%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Suicide attempts&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;13,008 (22%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left" colspan="2"&gt;&lt;p&gt;&lt;italic&gt;Independent variables&lt;/italic&gt;&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Bullying victimization&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;26,109 (33%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Alcohol use&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;29,761 (35%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Cannabis use&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;26,389 (29%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Opioids and presc. drugs&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;1,404 (15%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Hallucinogenic drugs&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;9,589 (16%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;/tbody&gt;&lt;/table&gt; </ephtml> </p> <p>Note. <sups>a</sups>Participants who identified as heterosexual were included in the sample if they indicated also identifying as transgender; <sups>b</sups>Higher gender expression indicates more masculine presentation (range 0–6); percentages calculated from the total number of participants who answered the question</p> <p>Table 2 presents the results of the hierarchical logistic regression models for the outcomes suicide ideation, plans, and attempts. The suicide ideation model including only control variables showed a significant association between depression and higher odds of suicide ideation (<emph>O.R.</emph> = 9.18, <emph>p</emph> &lt; 0.001). After adding independent variables, significant associations were also found between the control variable female sex (vs. male; <emph>O.R.</emph> = 3.10, <emph>p</emph> &lt; 0.05) on higher odds of suicide ideation. However, after controlling for sex assigned at birth, youth who present a more feminine gender expression were associated with lower odds of suicide ideation (<emph>O.R.</emph> = 0.75, <emph>p</emph> &lt; 0.05). Although there were no significant main effects between bullying and substance use variables on suicide ideation, a significant interaction was found between bullying victimization and cannabis use (<emph>O.R.</emph> = 0.12, <emph>p</emph> &lt; 0.05).</p> <p>Table 2 Hierarchical logistic regression results of suicide ideation, plans, and attempts among LGBTQ + youth</p> <p> <ephtml> &lt;table frame="hsides" rules="groups"&gt;&lt;thead&gt;&lt;tr&gt;&lt;th align="left" rowspan="2" /&gt;&lt;th align="left" colspan="2"&gt;&lt;p&gt;Ideation: controls&lt;/p&gt;&lt;/th&gt;&lt;th align="left" colspan="2"&gt;&lt;p&gt;Plan: controls&lt;/p&gt;&lt;/th&gt;&lt;th align="left" colspan="2"&gt;&lt;p&gt;Attempts: controls&lt;/p&gt;&lt;/th&gt;&lt;th align="left" colspan="2"&gt;&lt;p&gt;Ideation: ind. variables&lt;/p&gt;&lt;/th&gt;&lt;th align="left" colspan="2"&gt;&lt;p&gt;Plan: ind. variables&lt;/p&gt;&lt;/th&gt;&lt;th align="left" colspan="2"&gt;&lt;p&gt;Attempts: ind. variables&lt;/p&gt;&lt;/th&gt;&lt;th align="left" colspan="2"&gt;&lt;p&gt;Ideation: interactions&lt;/p&gt;&lt;/th&gt;&lt;th align="left" colspan="2"&gt;&lt;p&gt;Plan: interactions&lt;/p&gt;&lt;/th&gt;&lt;th align="left" colspan="2"&gt;&lt;p&gt;Attempts: interactions&lt;/p&gt;&lt;/th&gt;&lt;/tr&gt;&lt;tr&gt;&lt;th align="left"&gt;&lt;p&gt;&lt;italic&gt;O.R&lt;/italic&gt;&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;&lt;italic&gt;B (SE)&lt;/italic&gt;&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;&lt;italic&gt;O.R&lt;/italic&gt;&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;&lt;italic&gt;B (SE)&lt;/italic&gt;&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;&lt;italic&gt;O.R&lt;/italic&gt;&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;&lt;italic&gt;B (SE)&lt;/italic&gt;&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;&lt;italic&gt;O.R&lt;/italic&gt;&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;&lt;italic&gt;B (SE)&lt;/italic&gt;&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;&lt;italic&gt;O.R&lt;/italic&gt;&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;&lt;italic&gt;B (SE)&lt;/italic&gt;&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;&lt;italic&gt;O.R&lt;/italic&gt;&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;&lt;italic&gt;B (SE)&lt;/italic&gt;&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;&lt;italic&gt;O.R&lt;/italic&gt;&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;&lt;italic&gt;B (SE)&lt;/italic&gt;&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;&lt;italic&gt;O.R&lt;/italic&gt;&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;&lt;italic&gt;B (SE)&lt;/italic&gt;&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;&lt;italic&gt;O.R&lt;/italic&gt;&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;&lt;italic&gt;B (SE)&lt;/italic&gt;&lt;/p&gt;&lt;/th&gt;&lt;/tr&gt;&lt;/thead&gt;&lt;tbody&gt;&lt;tr&gt;&lt;td align="left" colspan="19"&gt;&lt;p&gt;&lt;italic&gt;Control variables&lt;/italic&gt;&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Age&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.95&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt; &amp;#8722; 0.05 (0.06)&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.94&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt; &amp;#8722; 0.06 (0.07)&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;1.03&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0.03 (0.07)&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;1.17&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0.16 (0.17)&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.88&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt; &amp;#8722; 0.13 (0.14)&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;1.09&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0.09 (0.19)&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;1.15&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0.14 (0.18)&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.84&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt; &amp;#8722; 0.18 (0.13)&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;1.06&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0.05 (0.20)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;African Amer&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;1.10&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0.09 (0.19)&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;1.26&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0.23 (0.32)&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;1.36&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0.31 (0.21)&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.75&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt; &amp;#8722; 0.29 (0.44)&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.48&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt; &amp;#8722; 0.74 (0.45)&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.54&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt; &amp;#8722; 0.61 (0.55)&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.78&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt; &amp;#8722; 0.24 (0.42)&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.50&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt; &amp;#8722; 0.69 (0.41)&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.54&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt; &amp;#8722; 0.62 (0.55)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Hispanic&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.92&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt; &amp;#8722; 0.09 (0.13)&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;1.05&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0.05 (0.15)&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&lt;bold&gt;1.41*&lt;/bold&gt;&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0.34 (0.17)&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.89&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt; 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&amp;#8722; 0.24 (0.25)&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;1.03&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0.03 (0.21)&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;1.79&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0.58 (0.61)&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;1.60&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0.47 (0.64)&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;1.33&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0.28 (0.64)&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;1.34&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0.29 (0.67)&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;1.18&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0.16 (0.70)&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.98&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt; &amp;#8722; 0.02 (0.70)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Female&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;1.24&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0.21 (0.15)&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;1.10&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0.10 (0.24)&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.88&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt; 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X cannabis&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char" /&gt;&lt;td align="left" /&gt;&lt;td char="." align="char" /&gt;&lt;td align="left" /&gt;&lt;td char="." align="char" /&gt;&lt;td align="left" /&gt;&lt;td char="." align="char" /&gt;&lt;td align="left" /&gt;&lt;td char="." align="char" /&gt;&lt;td align="left" /&gt;&lt;td char="." align="char" /&gt;&lt;td align="left" /&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&lt;bold&gt;0.12*&lt;/bold&gt;&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt; &amp;#8722; 2.11 (0.97)&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&lt;bold&gt;0.11*&lt;/bold&gt;&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt; &amp;#8722; 2.18 (1.01)&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.26&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt; &amp;#8722; 1.34 (1.16)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Bully. X opioids-presc&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char" /&gt;&lt;td align="left" /&gt;&lt;td char="." align="char" /&gt;&lt;td align="left" /&gt;&lt;td char="." align="char" /&gt;&lt;td align="left" /&gt;&lt;td char="." align="char" /&gt;&lt;td align="left" /&gt;&lt;td char="." align="char" /&gt;&lt;td align="left" /&gt;&lt;td char="." align="char" /&gt;&lt;td align="left" /&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.19&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt; &amp;#8722; 1.64 (1.37)&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.54&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt; &amp;#8722; 0.62 (1.2)&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;1.76&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0.56 (1.45)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Bully. X hallucinogenic&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char" /&gt;&lt;td align="left" /&gt;&lt;td char="." align="char" /&gt;&lt;td align="left" /&gt;&lt;td char="." align="char" /&gt;&lt;td align="left" /&gt;&lt;td char="." align="char" /&gt;&lt;td align="left" /&gt;&lt;td char="." align="char" /&gt;&lt;td align="left" /&gt;&lt;td char="." align="char" /&gt;&lt;td align="left" /&gt;&lt;td char="." align="char"&gt;&lt;p&gt;12.74&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;2.54 (1.45)&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;3.24&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;1.18 (1.33)&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.37&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0.86 (1.32)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left" colspan="19"&gt;&lt;p&gt;&lt;italic&gt;Simple slopes&lt;/italic&gt;&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Slope bully. cannabis = 0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char" /&gt;&lt;td align="left" /&gt;&lt;td char="." align="char" /&gt;&lt;td align="left" /&gt;&lt;td char="." align="char" /&gt;&lt;td align="left" /&gt;&lt;td char="." align="char" /&gt;&lt;td align="left" /&gt;&lt;td char="." align="char" /&gt;&lt;td align="left" /&gt;&lt;td char="." align="char" /&gt;&lt;td align="left" /&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.37&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0.86 (0.49)&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&lt;bold&gt;3.54*&lt;/bold&gt;&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;1.27 (0.53)&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char" /&gt;&lt;td align="left" /&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Slope bully. cannabis = 1&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char" /&gt;&lt;td align="left" /&gt;&lt;td char="." align="char" /&gt;&lt;td align="left" /&gt;&lt;td char="." align="char" /&gt;&lt;td align="left" /&gt;&lt;td char="." align="char" /&gt;&lt;td align="left" /&gt;&lt;td char="." align="char" /&gt;&lt;td align="left" /&gt;&lt;td char="." align="char" /&gt;&lt;td align="left" /&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.29&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt; &amp;#8722; 1.25 (0.90)&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.40&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt; &amp;#8722; 0.91 (0.89)&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char" /&gt;&lt;td align="left" /&gt;&lt;/tr&gt;&lt;/tbody&gt;&lt;/table&gt; </ephtml> </p> <p>Note. Bold indicates significant association <emph>p</emph>, <emph>p</emph>-value; <emph>O.R.</emph>, odds ratio; <emph>B</emph>, unstandardized estimate; <emph>SE</emph>, standard error <sups>*</sups><emph>p</emph> &lt;.05, **<emph>p</emph> &lt;.001, ***<emph>p</emph> &lt;.001</p> <p>Figure 1a shows the plot for the interaction between bullying victimization and cannabis use on suicide ideation, with the simple slopes of bullying victimization on suicide ideation for cannabis users and non-users reported in Table 2. The significant interaction suggests that the association between bullying victimization and suicide ideation is significantly lower among cannabis users (simple slope: <emph>O.R.</emph> = 0.29) compared to non-users (simple slope: <emph>O.R.</emph> = 2.37). In fact, for non-users, the odds of suicide ideation increase when experiencing bullying victimization, but the direction of the association reverses for cannabis users where those who are bullied have slightly lower odds of suicide ideation compared to those not experiencing bullying victimization. This suggests a protective effect of cannabis use in attenuating the association between bullying victimization and suicide ideation. However, the Johnson-Neyman plot (Fig. 1b) shows that neither of the simple slopes for bullying victimization are statistically significant at any observed levels of cannabis use, indicating that the effect of bullying victimization on suicide ideation is not statistically significant for either cannabis users or non-users when considered separately.</p> <p>Graph: Fig. 1 Interaction between bullying victimization and cannabis use on suicidal ideation (a), Johnson-Neyman plot for suicide ideation (b), interaction for suicide plan (c), and Johnson-Neyman plot for suicide plan (d)</p> <p>Similar to suicide ideation, a significant association was found between depression and higher odds of suicide plan in the model with only control variables (<emph>O.R.</emph> = 7.54, <emph>p</emph> &lt; 0.001; Table 2). Further, the model adding the independent variables showed a significant association between bullying victimization and higher odds of making a suicide plan (<emph>O.R.</emph> = 2.71, <emph>p</emph> &lt; 0.01). Lastly, the model adding the interaction terms also showed a significant interaction between bullying victimization and cannabis use on the odds of suicide plan (<emph>O.R.</emph> = 0.11, <emph>p</emph> &lt; 0.05).</p> <p>The interaction plot (Fig. 1c) suggests a similar protective effect for cannabis use, with a statistically significant difference in the simple slopes of bullying victimization on suicide plan between cannabis users and non-users. In this case, the simple slope between bullying victimization and suicide plan was statistically significant only for youth who did not use cannabis (<emph>O.R.</emph> = 3.54, <emph>p</emph> &lt; 0.05) while the association was much lower and in the opposite direction among cannabis users (<emph>O.R.</emph> = 0.40,<emph> p</emph> = 0.31). The Johnson-Neyman plot (Fig. 1d) confirms these findings showing that the association between bullying victimization and suicide plan is only statistically significant at the lower range of cannabis use (non-users).</p> <p>Table 2 presents findings for the suicide attempts outcome with the model including control variables showing significantly higher odds of suicide attempts among Hispanic LGBTQ + youth compared to White (<emph>O.R.</emph> = 1.41, <emph>p</emph> &lt; 0.05) and youth who reported being depressed (<emph>O.R.</emph> = 5.13, <emph>p</emph> &lt; 0.001). Further, the model adding the independent variables suggests significant associations between using opioids and prescription drugs (<emph>O.R.</emph> = 4.60, <emph>p</emph> &lt; 0.05) and hallucinogenic drugs (<emph>O.R.</emph> = 8.89, <emph>p</emph> &lt; 0.01) on higher odds of suicide attempts. While no significant interactions were found for suicide attempts, the model with the interaction terms also revealed a significant association between female sex compared to males and higher odds of suicide attempts (<emph>OR</emph> = 4.04, <emph>p</emph> &lt; 0.05).</p> <hd id="AN0185070826-14">Discussion</hd> <p>The current study examined the interactions between bullying victimization, substance use, and STB among a large, nationally representative sample of LGBTQ + youth. Our findings partially supported our hypotheses, revealing more nuanced and complex associations among bullying victimization, specific substances, and STB among LGBTQ + youth. Partially consistent with our hypothesis, bullying victimization was significantly associated with a higher likelihood of suicide plans but was not associated with a higher likelihood of suicide ideation or attempts. These findings suggest that it is important to consider how bullying victimization may precipitate suicide planning as this could indicate an escalation of suicidal behaviors and a potential point for intervention and prevention.</p> <p>However, this finding contrasts with previous literature that has found a higher incidence of suicide ideation and attempts among youth experiencing bullying victimization (Hatchel et al., [<reflink idref="bib36" id="ref81">36</reflink>]; Mueller et al., [<reflink idref="bib55" id="ref82">55</reflink>]). One potential reason for the lack of a significant association may be that the links between bullying victimization and suicide ideation and attempts are obscured after controlling for concurrent depression symptoms, substance use, and gender. Two past studies also controlled for previous symptoms of depression, with one finding that frequent bullying led to increased suicide attempts for girls but not boys (Klomek et al., [<reflink idref="bib47" id="ref83">47</reflink>]), and the other finding that direct bullying victimization was linked with increased suicidal ideation (Espelage &amp; Holt, [<reflink idref="bib28" id="ref84">28</reflink>]). In the current study, experiencing depression emerged as a strong predictor of all forms of STB among LGBTQ + youth, with higher odds among LGBTQ + youth experiencing depression compared to those who did not. Thus, concurrent depression may better explain the observed variance in ideation and attempts beyond the associations with bullying victimization. Similarly, depression may mediate the association between bullying victimization and STB, such that the effect of bullying victimization on STB may be explained by changes in depression symptoms.</p> <p>Regarding substance use, our results showed that the use of opioids and hallucinogenic drugs was significantly associated with a higher likelihood of suicide attempts among LGBTQ + youth. This finding is consistent with previous research (Baiden et al., [<reflink idref="bib7" id="ref85">7</reflink>]; Desai et al., [<reflink idref="bib26" id="ref86">26</reflink>]). However, inconsistent with previous research (Borges et al., [<reflink idref="bib13" id="ref87">13</reflink>], [<reflink idref="bib14" id="ref88">14</reflink>]; Kahn &amp; Wilcox, [<reflink idref="bib45" id="ref89">45</reflink>]), no significant direct associations were found between alcohol and cannabis use with suicide ideation, planning, or attempts. In this case, it is also possible that depression may better explain or mediate the direct associations between alcohol and cannabis use and STB given the high comorbidity between substance use and mood disorders, making it difficult to disentangle these associations (Boden &amp; Fergusson, [<reflink idref="bib12" id="ref90">12</reflink>]; Pedrelli et al., [<reflink idref="bib59" id="ref91">59</reflink>]).</p> <p>Interestingly, our findings revealed that cannabis use was a significant protective factor moderating the association between bullying victimization and suicide ideation and planning. Among students who experienced bullying victimization, cannabis users reported a lower likelihood of suicidal ideation and planning compared to non-users. This finding is novel and counterintuitive, as cannabis use has been typically considered a risk factor for STB (Borges et al., [<reflink idref="bib13" id="ref92">13</reflink>]; Sellers et al., [<reflink idref="bib67" id="ref93">67</reflink>]). One possible explanation for this finding is that cannabis use may provide temporary relief from the psychological distress associated with bullying victimization, thereby reducing the likelihood of suicidal ideation and planning among LGBTQ + youth.</p> <p>Our findings also revealed that LGBTQ + individuals who identify as female are significantly more likely to face suicidal ideation and attempt than males. This is consistent with existing research that has shown elevated symptoms of mental health issues and STB among female youth (Miranda-Mendizabal et al., [<reflink idref="bib53" id="ref94">53</reflink>]). Paradoxically, in terms of gender expression, individuals who present their gender as more feminine reported experiencing lower suicide ideation compared to those who identified as more masculine presenting. Previous research suggests that individuals who identify as more masculine may face higher social pressure to conform to gendered roles prioritizing mental toughness, self-reliance, and independence, which discourages speaking out about mental health and seeking help (Payne et al., [<reflink idref="bib58" id="ref95">58</reflink>]; Vickery, [<reflink idref="bib72" id="ref96">72</reflink>]). These findings support calls to shifting masculinity gender norms toward promoting mental health and help-seeking as a strategy for suicide prevention (Trail et al., [<reflink idref="bib70" id="ref97">70</reflink>]). It is also important to further examine these associations from an intersectional perspective as they are likely to vary among intersecting identities.</p> <hd id="AN0185070826-15">Limitations</hd> <p>While the present study used a national survey to gain an understanding of LGBTQ + youth from across the USA, there are a few limitations to note. First, the research data from the YRBS used a cross-sectional design, limiting our ability to establish causation between substance use and bullying victimization on the outcome of STB. Although longitudinal data also does not imply causation, moderating effects are best examined over time, highlighting an important limitation of our cross-sectional design. Additionally, the reliance on self-reported data may have introduced recall and social desirability bias in the survey's findings, leading to underreporting of substance use by participants. Moreover, the YRBS only includes data from youth attending high school, which may limit the generalizability of the findings in populations of youth who have dropped out, are truant, or are homeschooled.</p> <p>Furthermore, while our study aimed to understand how different substances moderate the association between bullying victimization and STB, the YRBS survey only measured substances in aggregate form, limiting the generalizability of our findings to specific substances. Another important limitation is that alcohol, cannabis, and opioids were measured on actual prevalence during the past 30 days, while hallucinogenic drugs were measured in lifetime prevalence. These discrepancies may impact the comparability of findings across substances, given that lifetime use of hallucinogenic drugs may not necessarily reflect recent use or immediate risk associated with STB. Therefore, we suggest caution when interpreting these findings and for future research examining the concurrent use of hallucinogenic drugs on the immediate risk of STB among LGBTQ + youth. Additionally, the present study used YRBS data from 2003 to 2019, a timeframe in which both culture and law surrounding substances can drastically change. Our study could not take this historical data into account, highlighting a large gap in how the effects of substances can change over time, specifically for substances such as cannabis that are becoming more socially acceptable and legal across states. Lastly, our study focused on LGBTQ + students in high school and did not take into account the various other identities that LGBTQ + individuals have, limiting our ability to generalize the results to younger and older populations of LGBTQ + individuals and to populations with varying identities based on race, sex, ability, and class. Future studies could address these limitations by using a longitudinal design to establish causal relationships, supplementing self-reported data with biomarkers or objective measures, or including a more diverse and representative sample of LGBTQ + youth. Despite these limitations, the present study provides important insights into the relationship between substance use and suicidal behavior in LGBTQ + youth.</p> <hd id="AN0185070826-16">Public Health Implications</hd> <p>As a historically marginalized and underrepresented group, this research highlights a critical need for leveraging large national datasets that inform population-specific approaches. The novel findings on bullying victimization and the use of opioids, alcohol, cannabis, and hallucinogenic drugs in this study provide profound implications for the formulation of public health policy and social programs aimed at reducing the risk of suicide in LGBTQ + youth. Compared to previous findings, this study emphasizes a need to outline mechanisms of use at a population level for specific substances, including synergistic effects with comorbidities, STB, and the impact on social mediators such as bullying victimization. Our findings link bullying victimization with increased suicide planning specifically and do not provide evidence for a link to ideation or attempt. Understanding the moderating effects of different substance use on the timing and quality of suicidal states could provide more specificity for future intervention development. Future research should consider a careful inventory of culturally specific risk and protective factors informed by qualitative methods and is needed to inform the why and how specific substances are used by LGTBQ + youth. When developing public health and clinical treatment interventions, leaders should be aware of the cultural limitations in broad, evidence-based, approaches to target specific risk behaviors.</p> <p>The current study found that at a time when the USA is facing a widespread opioid crisis, it is important for clinicians to understand how systematic disadvantages influence the higher use of opioids among LGBTQ + youth to understand their association with a higher risk of STB. Though previous studies have found that hallucinogens can aid in the treatment of certain disorders such as depression and anxiety in clinical settings (Baumeister et al., [<reflink idref="bib9" id="ref98">9</reflink>]; Grob et al., [<reflink idref="bib33" id="ref99">33</reflink>]), our study found that early exposure outside of clinical settings may have a harmful impact on STB among LGBTQ + youth, which warrants further investigation to evaluate the efficacy of hallucinogenic assisted therapy. This is especially important as we are seeing higher rates of hallucinogens being used in a clinical setting to treat anxiety, depression, and PTSD (Begola &amp; Schillerstrom, [<reflink idref="bib10" id="ref100">10</reflink>]). As cannabis becomes increasingly legal in the USA, it is important for physicians and researchers to understand the full range of the possible associations of cannabis use on STB. The current study's findings that cannabis use may moderate the association between bullying victimization and suicidal ideation or planning implicate cannabis use as a potential protective factor against some STB and would benefit from further research.</p> <p>In our sample, depression was found to be the strongest predictor of all STB, highlighting the importance of addressing mental health concerns among LGBTQ + youth. It is important to note that LGBTQ + youth are not inherently more depressed than other youth but experience higher rates of depression due to increased perceived discrimination when their identity is not accepted, directly or indirectly, within their families, schools, communities, and broader society (Almeida et al., [<reflink idref="bib3" id="ref101">3</reflink>]). Thus, systems should shift toward acceptance and respect for the diverse identities youth have, such that LGBTQ + youth know and feel that they are valued, protected, and that they belong in all the external spaces they navigate. As a result, policymakers, community leaders, school administrators, and parents or guardians must continue to intentionally work to protect LGBTQ + rights and to guarantee their physical and psychological safety. The pathway between bullying victimization and depression may provide insight into addressing the reduction of further suicide-related risk factors across populations.</p> <hd id="AN0185070826-17">Conclusion</hd> <p>This study examined the associations among bullying victimization, substance use, and STB in a diverse, national sample of LGBTQ + youth. Our findings highlight the complex interplay between these factors and the importance of considering substance-specific effects and their interactions. This study contributes to a growing body of research aimed at reducing health disparities and improving the well-being of LGBTQ + youth. More research is needed to gain a deeper understanding of the mechanisms linking bullying victimization, substance use, and STB to develop culturally sensitive prevention and intervention strategies for this at-risk population.</p> <hd id="AN0185070826-18">Data Availability</hd> <p>The data supporting this study are available online from the CDC.</p> <hd id="AN0185070826-19">Declarations</hd> <p></p> <hd id="AN0185070826-20">Ethics Approval</hd> <p>This study used publicly available data from the Youth Risk Behavior Survey. No IRB review was needed as the data collection did not qualify as human subjects research.</p> <hd id="AN0185070826-21">Consent to Participate</hd> <p>This secondary analysis of YRBS data used consent obtained during the original survey. Details on YRBS consent procedures are documented elsewhere.</p> <hd id="AN0185070826-22">Conflict of Interest</hd> <p>The authors declare no competing interests.</p> <hd id="AN0185070826-23">Supplementary Information</hd> <p>Below is the link to the electronic supplementary material.</p> <p>Graph: Supplementary file1 (DOCX 14 KB)</p> <hd id="AN0185070826-24">Publisher's Note</hd> <p>Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.</p> <ref id="AN0185070826-25"> <title> References </title> <blist> <bibl id="bib1" idref="ref64" type="bt">1</bibl> <bibtext> Advocates for Youth. (2018). Gender expansive students at higher risk for suicidal behavior. https://<ulink href="http://www.advocatesforyouth.org/resources/fact-sheets/gender-expansive-students-at-higher-risk-for-suicidal-behavior/">www.advocatesforyouth.org/resources/fact-sheets/gender-expansive-students-at-higher-risk-for-suicidal-behavior/</ulink>. 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| Header | DbId: eric DbLabel: ERIC An: EJ1470716 AccessLevel: 3 PubType: Academic Journal PubTypeId: academicJournal PreciseRelevancyScore: 0 |
| IllustrationInfo | |
| Items | – Name: Title Label: Title Group: Ti Data: Understanding Suicidal Thoughts and Behaviors among LGBTQ+ Youth: Differential Associations between Bullying and Substance Use – Name: Language Label: Language Group: Lang Data: English – Name: Author Label: Authors Group: Au Data: <searchLink fieldCode="AR" term="%22Cayson+W%2E+Tiedge%22">Cayson W. Tiedge</searchLink> (ORCID <externalLink term="http://orcid.org/0009-0005-3655-3349">0009-0005-3655-3349</externalLink>)<br /><searchLink fieldCode="AR" term="%22Alberto+Valido%22">Alberto Valido</searchLink><br /><searchLink fieldCode="AR" term="%22Matthew+Rivas-Koehl%22">Matthew Rivas-Koehl</searchLink><br /><searchLink fieldCode="AR" term="%22Brian+A%2E+Garcia%22">Brian A. Garcia</searchLink><br /><searchLink fieldCode="AR" term="%22Luz+E%2E+Robinson%22">Luz E. Robinson</searchLink><br /><searchLink fieldCode="AR" term="%22Graceson+Clements%22">Graceson Clements</searchLink><br /><searchLink fieldCode="AR" term="%22Dorothy+L%2E+Espelage%22">Dorothy L. Espelage</searchLink> – Name: TitleSource Label: Source Group: Src Data: <searchLink fieldCode="SO" term="%22Prevention+Science%22"><i>Prevention Science</i></searchLink>. 2025 26(3):449-461. – Name: Avail Label: Availability Group: Avail Data: Springer. Available from: Springer Nature. One New York Plaza, Suite 4600, New York, NY 10004. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-460-1700; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/ – Name: PeerReviewed Label: Peer Reviewed Group: SrcInfo Data: Y – Name: Pages Label: Page Count Group: Src Data: 13 – Name: DatePubCY Label: Publication Date Group: Date Data: 2025 – Name: TypeDocument Label: Document Type Group: TypDoc Data: Journal Articles<br />Reports - Research – Name: Audience Label: Education Level Group: Audnce Data: <searchLink fieldCode="EL" term="%22High+Schools%22">High Schools</searchLink><br /><searchLink fieldCode="EL" term="%22Secondary+Education%22">Secondary Education</searchLink> – Name: Subject Label: Descriptors Group: Su Data: <searchLink fieldCode="DE" term="%22Suicide%22">Suicide</searchLink><br /><searchLink fieldCode="DE" term="%22Mental+Health%22">Mental Health</searchLink><br /><searchLink fieldCode="DE" term="%22Bullying%22">Bullying</searchLink><br /><searchLink fieldCode="DE" term="%22Victims%22">Victims</searchLink><br /><searchLink fieldCode="DE" term="%22Substance+Abuse%22">Substance Abuse</searchLink><br /><searchLink fieldCode="DE" term="%22Health+Behavior%22">Health Behavior</searchLink><br /><searchLink fieldCode="DE" term="%22High+School+Students%22">High School Students</searchLink><br /><searchLink fieldCode="DE" term="%22At+Risk+Persons%22">At Risk Persons</searchLink><br /><searchLink fieldCode="DE" term="%22Psychological+Patterns%22">Psychological Patterns</searchLink><br /><searchLink fieldCode="DE" term="%22Adolescents%22">Adolescents</searchLink><br /><searchLink fieldCode="DE" term="%22Correlation%22">Correlation</searchLink><br /><searchLink fieldCode="DE" term="%22Drinking%22">Drinking</searchLink><br /><searchLink fieldCode="DE" term="%22Marijuana%22">Marijuana</searchLink><br /><searchLink fieldCode="DE" term="%22Drug+Abuse%22">Drug Abuse</searchLink><br /><searchLink fieldCode="DE" term="%22Alcohol+Abuse%22">Alcohol Abuse</searchLink><br /><searchLink fieldCode="DE" term="%22LGBTQ+People%22">LGBTQ People</searchLink> – Name: SubjectThesaurus Label: Assessment and Survey Identifiers Group: Su Data: <searchLink fieldCode="SU" term="%22Youth+Risk+Behavior+Survey%22">Youth Risk Behavior Survey</searchLink> – Name: DOI Label: DOI Group: ID Data: 10.1007/s11121-025-01783-1 – Name: ISSN Label: ISSN Group: ISSN Data: 1389-4986<br />1573-6695 – Name: Abstract Label: Abstract Group: Ab Data: Rates of suicidal thoughts and behaviors (STB, i.e., suicidal thoughts, plans, and attempts), substance use, and bullying victimization are higher among lesbian, gay, bisexual, transgender, and/or queer (LGBTQ+) youth compared to their heterosexual peers. However, research examining the interactive and potentially compounding associations of concurrent bullying and substance use (alcohol, cannabis, hallucinogens, and opioids) with STB is sparse, especially among LGBTQ+ youth. Thus, the current study aims to understand how these substances moderate the association between bullying victimization and STB by utilizing data (N = 96,482) from the combined 2003-2019 Youth Risk Behavior Survey (YRBS). Using a cross-sectional design and hierarchical logistic regression, we found that, on average, LGBTQ+ youth who were bullied were more likely to report planning to attempt suicide (O.R. = 2.71, p < 0.01). Similarly, youth who reported using opioids/prescription drugs (O.R. = 4.60, p < 0.05) or hallucinogens (O.R. = 8.89, p < 0.01) were more likely to attempt suicide. No significant associations between alcohol use and STB were found. Lastly, cannabis emerged as a significant moderator of the associations between bullying victimization and suicidal ideation and plans, such that adolescents who were bullied and used cannabis were less likely to report suicidal ideation and planning compared to those who were bullied but did not use cannabis. These findings highlight that different substances are distinctively associated with STB among LGBTQ+ youth, providing a better understanding of how individuals who are being bullied may cope and to develop prevention programs to combat suicidal thoughts, planning, and attempts. – Name: AbstractInfo Label: Abstractor Group: Ab Data: As Provided – Name: DateEntry Label: Entry Date Group: Date Data: 2025 – Name: AN Label: Accession Number Group: ID Data: EJ1470716 |
| PLink | https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1470716 |
| RecordInfo | BibRecord: BibEntity: Identifiers: – Type: doi Value: 10.1007/s11121-025-01783-1 Languages: – Text: English PhysicalDescription: Pagination: PageCount: 13 StartPage: 449 Subjects: – SubjectFull: Suicide Type: general – SubjectFull: Mental Health Type: general – SubjectFull: Bullying Type: general – SubjectFull: Victims Type: general – SubjectFull: Substance Abuse Type: general – SubjectFull: Health Behavior Type: general – SubjectFull: High School Students Type: general – SubjectFull: At Risk Persons Type: general – SubjectFull: Psychological Patterns Type: general – SubjectFull: Adolescents Type: general – SubjectFull: Correlation Type: general – SubjectFull: Drinking Type: general – SubjectFull: Marijuana Type: general – SubjectFull: Drug Abuse Type: general – SubjectFull: Alcohol Abuse Type: general – SubjectFull: LGBTQ People Type: general – SubjectFull: Youth Risk Behavior Survey Type: general Titles: – TitleFull: Understanding Suicidal Thoughts and Behaviors among LGBTQ+ Youth: Differential Associations between Bullying and Substance Use Type: main BibRelationships: HasContributorRelationships: – PersonEntity: Name: NameFull: Cayson W. Tiedge – PersonEntity: Name: NameFull: Alberto Valido – PersonEntity: Name: NameFull: Matthew Rivas-Koehl – PersonEntity: Name: NameFull: Brian A. Garcia – PersonEntity: Name: NameFull: Luz E. Robinson – PersonEntity: Name: NameFull: Graceson Clements – PersonEntity: Name: NameFull: Dorothy L. Espelage IsPartOfRelationships: – BibEntity: Dates: – D: 01 M: 01 Type: published Y: 2025 Identifiers: – Type: issn-print Value: 1389-4986 – Type: issn-electronic Value: 1573-6695 Numbering: – Type: volume Value: 26 – Type: issue Value: 3 Titles: – TitleFull: Prevention Science Type: main |
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