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IntroductionWhile the issue of youth suicide in rural Australia has received increasing attention, until recently the possible contribution of sexuality to youth suicide has rarely been acknowledged. An exploration of the existing literature of youth suicide, same-sex attracted youth (SSAY) suicide, and rural youth health may assist in determining whether there is a connection between same-sex attraction and rural youth suicide.
According to a recent report, suicide is now 'the leading cause of death by injury in Australia'1. Since the 1960s the Australian suicide rate has increased, with male suicide increasing at a rate greater than female. The social change of Australian women, an increased autonomy and greater access to health and welfare support during this time may explain this disproportionate increase2. For Australian men, suicide is now given as the greatest cause of death1,3,4. Between the years 1921 and 1998, the Australian Bureau of Statistics reported that the group with the greatest increase in death from suicide was male youth, or men aged 15 years to 24 years5. During this period, male youth suicide rose from 8.6 to 27.7 per 100 000 men5.
The statistics are even more alarming in rural areas where the male youth suicide rate is double that of metropolitan figures6,7. In 1964 metropolitan male youth suicide rates were greater than those of towns with populations less than 40006. However, by 1993 this had reversed and male youth suicide rates in towns with fewer than 4000 people had increased as much as 12-fold6.
Australian population numbers of SSAY range from 5% to 11%, although the actual figure is not known8. It is suggested that SSAY are six times more likely to attempt suicide than the population as a whole9. One study found that 28.1% of the 57 SSAY sample had attempted suicide8. This was consistent with studies that reported 18% to 42% of same-sex attracted young men aged 15-24 years had attempted suicide at least once8.
During the last 9 months of the 2001-2002 financial year, the South Australian Gay and Lesbian Counselling Service (GLCS) received 1517 telephone calls10. Of those calls, 342 were from women(22.5%) and 1175 were from men (77.5%). Of the total number of calls, 186 were from rural callers (12.3%), of which 28 were from rural women (15%) and 158 were from rural men (85%)10. Although rural callers were considerably fewer than urban callers, the percentages are important when the call content is considered. Most urban callers sought local venue information. However, rural callers predominantly sought guidance about health and relationship issues, and general support.
Literature review of issues for same-sex attracted youth
The literature highlights some of the issues and concerns of SSAY, and explores the impact of living in rural areas.
Homophobia
A 2003 report gave details of a study into homosexuality and youth suicide wherein all participants responded to designed scenarios involving a fictitious town and a person named Chris1. The respondents were told:
Chris goes to a high school teacher to talk about being teased at school about being gay. Classmates have prevented Chris from joining their group and sports activities by ignoring Chris, insulting and even threatening Chris. Chris is scared and very upset about this constant harassment. Chris began to think about the consequences of being gay and how others might react. After hearing what Chris said, the teacher was worried because Chris had been thinking about ending it all1.
Most of the participants assumed that Chris was a young man, despite the design of the scenario depicting the youth as gender neutral. As a result, most informants thought Chris' situation would be worse because he was male. They indicated that this would be the case because heterosexual men didn't accept gay men and were more open-minded about lesbians1. The authors of this study claim that this is important because young gay men 'may be less likely to confide in someone and therefore more likely to be isolated'1. The female respondents suggested that Chris should seek help and speak to a counsellor, while the male respondents wrote that they had little idea what they would do if confronted with a 'problem' such as Chris's. One school sport coach responded: Chris should just 'deal with it' and 'learn to deal with living outside the mainstream'1. While this remark cannot be generalised, it may be indicative of expected performances of masculinity that include self-sufficiency. These societal perceptions of masculinity, and femininity, become the frameworks against which SSAY evaluate themselves and by which others judge them3. This study also found that respondents overwhelming agreed that the gay community should and would look after its own1. When a young person needs support regarding her or his sexuality, there is little likelihood of accessing a 'gay community' in a rural area.
SSAY are vulnerable to both external and internalised homophobia. External homophobia might include negative reactions from friends and family after 'coming out'8. Internalised homophobia occurs if the young person was 'socialised into accepting widespread negative stereotypes of gay people'3 and their subsequent identity formation was contaminated by homophobic values3. The result may be depression, and suicidal thoughts and behaviour8. A lack of gay role models and gay community in rural areas could also contribute to internalised homophobia by reinforcing cultural assumptions that everyone is heterosexual.
Former Australian Human Rights Commissioner Chris Sidoti7 stated:
Lesbian, gay and bisexual young people in rural areas are severely disadvantaged. They experience the stigma associated with homosexuality, the disempowerment common among young people and the difficulties of contemporary rural life. Research also shows that in the face of these difficulties they often receive less than adequate support from families, schools, youth services and the broader community7.
Sidoti gave an example of harassment in rural Australia:
Gay and lesbian people get a hard time. One couple was hounded out of town. Another couple was harassed with eggs thrown at the house and their rubbish bins overturned7.
Although young gays and lesbians living in urban areas are likely to experience homophobia, coming-out issues, and anxiety about friends' and family reactions, in urban areas there are likely to be a greater number and variety of support systems than in rural areas. Furthermore, the mere numbers of SSAY and non-heterosexual-identifying people in urban areas is an advantage not known to rural gays and lesbians.
A study in 1996 examined rural-youth attitudes to sexual health, sexual practices and issues11. Of the 1168 student participants from Victorian rural towns and aged 12-16 years, 11% identified as homosexual, bisexual or were unsure about their sexual orientation11. The report noted that school staff and student comments revealed rural gays and lesbians as 'a highly stigmatised group', with student comments ranging from 'I reckon they're bloody weird' to 'The thought of a man touching another man or a woman touching another woman; it's just not natural'11 indicative of a general hostility to suspected gays and lesbians. The 'excessively aggressive attitudes' towards these young people was thought to be as a high motivator for rural SSAY to remain anonymous11.
Isolation
An alarming finding from the study was that rural youth generally reported a need for a high level of privacy and confidentiality concerning sexual issues11. This need was reported in the context of 'everyone knowing everyone else's business' but it translated to a mistrust of local doctors and health-care providers. Half the participants reported being unsure about the confidentiality of their doctor's consultation, and expressed concern about whether the doctor would inform their parents of the visit11. A further 20% were certain that their doctor could not be trusted in this regard11. This may be motivation for rural SSAY to remain hidden, and if their issues are unaddressed the potential for isolation is increased.
In a 1998 review of international studies of suicide and homosexuality3, one of the main contributing factors for attempted suicide among young gay men was that they felt they had no-one to confide in. The importance of the isolation factor was emphasised in the data of three young gay men who had attempted suicide3. Each man reported a period of inner turmoil and stress when they feared rejection by family and friends. The young men reported feeling isolated, lonely, guilty and confused and that this precipitated their suicide attempts3. One study suggests that SSAY who are in relationships have fewer problems with identity confusion and isolation, but that an end to the relationship could cause greater feelings of isolation and serve as a trigger for suicidal behaviour4. In rural settings the situation can be exacerbated by geographical isolation from mainstream cultural ideas, acceptance (or at least tolerance), and support networks. If there is the added pressure of religious demands for conformity, church leaders who are seen as someone to turn to for advice and support, often reject SSAY with homophobic rhetoric3.
Availability of information
The availability of health and lifestyle information to rural SSAY was an issue highlighted in a 1998 report conducted by the Australian Research Centre in Sex, Health and Society at Latrobe University, Melbourne, Victoria12. The study surveyed 750 same-sex attracted young people, aged 14-21 years, with 22% of whom were from rural areas. The rural SSAY experience was found to be '...a greater sense of isolation and lack of access to information' than urban SSAY12. Respondents reported easy access to information about heterosexual relationships from 'school, media, family and friends', with 70% of information coming from school. The figures changed markedly for information sources for gay and lesbian relationships with approximately half the participants reporting 'media and friends' as their primary resource, 10% citing 'family' and approximately 15% citing 'school':
Rural young people were particularly disadvantaged compared with urban dwellers, with regard to access to gay information from all sources, and also access to information about gay relationships from school12.
The information sought by the participants included gay safe sex, for which rural SSAY were less likely to obtain information from any of the four sources than their metropolitan peers.
A major concern of the study was the preferred source of information for SSAY was 'media and friends', '...the two groups whose information is most likely to be incorrect or misleading', and not from the two groups '...with the largest duty of care', namely 'family and schools'12. The study also reported that rural SSAY were more likely to have injected drugs and 'never' to have used condoms in gay or heterosexual sex, than were their urban peers12. The report concluded that same-sex attracted young people living in rural areas were disadvantaged when in terms of access to health and relationship information.
Aboriginal communities
The situation of SSAY in rural and remote Indigenous Australian communities was noted in 2001 when Prime Minister Howard announced funding for regional and metropolitan suicide-prevention projects. The Broome Regional Suicide Prevention Project (Western Australia [WA]), which sponsors the Broom Men's Outreach Service, received funding for its project directed at young suicidal Indigenous men who suffer from depression because of sexual abuse or sexual identity issues13. However the issues contributing to Indigenous suicide are still least researched and most neglected14.
Acknowledgement of issues facing rural SSAY
In 2002 the Victorian State Government acknowledged the issues facing rural SSAY by announcing funding to combat 'high rates of attempted suicide among gay and lesbian young people, particularly in rural Victoria'9. The three-year 'Youth Support Project' proposed to 'improve accessible and appropriate health and welfare services to gay and lesbian young people in rural and metropolitan areas'9. The project was undertaken by a number of community health and training services, and projects such as this and others like it address and highlight the lack of services available to rural SSAY.
Services available to rural SSAY
It is only recently, due to attention from university and funding bodies, that the health and well-being of rural youth and the limited availability of services to rural SSAY have become obvious. However Gay and Lesbian Counselling or Community Services (GLCS) help line has been widely available to gays and lesbians in most Australian States. Exceptions are the Northern Territory (no such telephone service) and Tasmania (no out-of-hours counselling service). In addition to GLCS in WA, South Australian and New South Wales, Victoria provides the Gay and Lesbian Switchboard, while Queensland has the Gay and Lesbian Welfare Association, and all provide non-heterosexual identifying people, their friends and families with telephone access to support and referral. The services also disseminate information about gay and lesbian issues via community literature and online resources.
'Here for Life' Sexuality and Youth Suicide Project was an initiative of the GLCS of WA and the WA AIDS Council, funded by the Australian Government. The GLCS in WA displayed an excerpt from the high selling Australian gay magazine publication 'Outrage', which commented on the Here for Life project15. Entitled, 'Sexuality and Youth Suicide', it identifies SSAY living in rural Western Australia as high-risk candidates for suicide. The article noted that despite the increased isolation felt by many SSAY in regional areas, '...the internet is proving to be a lifeline for young gay men and lesbians in country areas'15. Outside the WWW, communication facilities such as Internet Relay Chat (IRC) allow widely separated people to send 'live' messages to each other. Specific domains are available for access, including 'spaces' like 'Gay Country' where groups of people 'gather' and communicate. The authors of 'Outrage' say this 'allows people in isolated areas as well as those in urban areas but isolated from society due to their sexuality, to be part of a de facto community'15. Participants in Internet chat rooms have anonymity, and so experience safety as well as a sense of belonging.
In South Australia a community support group aligned with Gay Men's Health, called Country Men's Health co-ordinates rural and remote gay men, introducing them to each other and running support groups and gay community functions in rural areas. The national 'Outlink', organised by The Australian Human Rights and Equal Opportunity Commission16, and other outreach programs do similar work among rural Australian SSAY.
The disadvantage of such services is that they require Internet technology or already established supportive home environments before participation is possible. Apart from requiring privacy to make a phone call, in accessing any GLCS a young SSAY must be prepared for the possibility of having to explain or defend the call if it is recorded on their telephone bill. Individual Internet access may be unlikely in remote areas and Indigenous communities.
Conclusion
Although being a SSAY is not in itself a cause for rural youth suicide it may be a contributing factor. Many interventions have been suggested for reducing the risk profile of young non-heterosexual people3 but are not applicable to the rural setting where services are few or non-existant. However some interventions could be implemented in the rural setting. These include educating school staff and promoting community awareness about the issues faced by SSAY; developing anti-heterosexist programs while dispelling myths and misunderstandings surrounding homosexuality; and creating emergency crisis care and telephone counselling services3. This would begin to address identified risk factors such as isolation, discrimination and lack of access to information. Although same-sex attraction is not in itself a cause for rural youth suicide it may be a contributing factor; significant evidence is not yet available to support this hypothesis. However, this may change with well-constructed studies in the area designed to document specific lack of services and to more fully understand the issues facing rural SSAY.
References
1. Gilchrist H, Howarth G, Sullivan G. School's out: homosexuality, bullying and suicide. University of Sydney (online) 2003. Available from: http://www.aare.edu.au/02pap/gil02454.htm (accessed 30 April 2003).
2. Hassan R. Gender and suicide. In: Hassan R (Eds). Suicide explained: The Australian experience. Victoria: Melbourne University Press, 1995; 31-48.
3. Macdonald R, Cooper T. Young gay men and suicide: A report of a study exploring the reasons which young men give for suicide ideation. Youth Studies Australia 1998; 17(4): 23-27.
4. Nicholas J, Howard J. Better dead than gay? Depression, suicide ideation and attempt among a sample of gay and straight-identified males aged 18 to 24. Youth Studies Australia 1998; 17(4): 28-33.
5. Australian Bureau of Statistics. Health, mortality and morbidity: Suicide. Australian social trends 2000. (online) 2002. Available from: http://www.abs.gov.au/ausstats/abs@.nsf/94713ad445ff1425ca25682000192af2/ 2d9cecf2a5763a65ca256a7100188a5b!OpenDocument (accessed 30 April 2003).
6. Dudley MJ, Florio JK, Howard JP, Waters BG. Suicide among young Australians, 1964-1993: an interstate comparison of metropolitan and rural trends. Medical Journal of Australia 1998; 169: 77-80.
7. Sidoti C. Rural youth suicide: convention, context and cure. In: Australian College of Health Service Executives (SA) Seminar, 14 October 1999, Adelaide, South Australia. Available at: http://www.hreoc.gov.au/speeches/human_rights/rural_youth_suicide.html (accessed 30 April 2003).
8. Howard J, Nicholas J, Brown N, Karaca A. Same-sex attracted youth and suicide. In: Rowling L, Martin G, Walker L (Eds). Mental Health Promotion and Young People: Concepts and Practice. Sydney: McGraw Hill, 2002; 215-226.
9. Thwaites J. $520 000 for gay and lesbian youth suicide projects. Victorian Government Department of Health Services. (online) 22 January 2002. Available at: http://hnb.dhs.vic.gov.au/web/pubaff/medrel.nsf/ (accessed 30 April 2003).
10. Gay and Lesbian Counselling Service of South Australia (GLCSSA). Call Statistics for financial year, 2001-2002. In-house records (accessed 3 May 2003).
11. Hillier L, Warr D, Haste B. The Rural Mural: Sexuality and Diversity in Rural Youth. Melbourne, VIC: National Centre in HIV Social Research, Program in Youth/General Population Centre for the Study of Sexually Transmissible Diseases. Faculty of Health Sciences, La Trobe University, 1996.
12. Hillier L, Dempsey D, Harrison L, Beale L, Matthews L, Rosenthal D. Writing themselves In: National report on the sexuality, health and well-being of same-sex attracted young people. Melbourne, VIC: Australian Research Centre in Sex, Health and Society, Faculty of Health Sciences, La Trobe University, 1998.
13. Choosing life: Prime Minister announces funding for 22 community projects. Prime Minister John Howard Media Release. (online) 3 Nov 2001. Available at: http://www.pm.gov.au/news/media_releases (accessed 30 April 2003).
14. Cantor C, Neulinger K. The epidemiology of suicide and attempted suicide among young Australians. Australian and New Zealand Journal of Psychiatry 2000; 34: 370-387.
15. Gay and Lesbian Counselling Service of Western Australia (GLCSWA). Outrage. Available at: http://www.glcs.org.au/ (accessed 30 April 2003).
16. Outlink. Support service for rural gay and lesbian youth. Available at: http://outlink.trump.net.au/ (accessed 30 April 2003).