An Intersectional Approach Towards understanding Suicidality among Black LGB+ Adolescents, USA, 2023

An Intersectional Approach Towards understanding Suicidality among Black LGB+ Adolescents, USA, 2023 | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article An Intersectional Approach Towards understanding Suicidality among Black LGB+ Adolescents, USA, 2023 Amber Amis, Aminul Apu, Lillian Drane, Elise Devier, Cate Drane, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9087260/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background Suicide remains a leading cause of death among U.S. adolescents, with notable disparities based on race/ethnicity and sexual orientation. Black adolescents and those identifying as lesbian, gay, bisexual, or using alternative sexual identity labels (LGB+) face higher risks for suicidal thoughts and behaviors, yet research on the intersection of these identities is limited. The aim was to assess the prevalence of suicidal thoughts and planning among Black youth in the U.S. and examine disparities by sexual identity using a nationally representative dataset. Methods We performed a secondary analysis of 1,146 Black adolescents from the 2023 National Survey on Drug Use and Health (NSDUH). Suicidal ideation and planning were measured through self-reports of thoughts or plans in the past 12 months. Covariates included demographics, sexual orientation, mental health, and substance use. Analyses involved weighted frequencies, Rao-Scott Chi-square tests, and multivariate logistic regression to explore associations. Results Among Black adolescents, 12.0% reported suicidal ideation in the past year, and 5.76% reported planning suicide. Compared with heterosexual peers, adolescents identifying as gay/lesbian, bisexual, or using alternative identity labels had significantly higher adjusted odds of suicidal ideation (AOR = 4.19–7.69) and planning, with the highest risk seen among those using different terminology (AOR: 4.74). The interaction between sex at birth and sexual identity was not significant. Youth using alternative identity labels showed the greatest risk for both outcomes. Conclusions Black LGB+ youth, especially those with nonconventional sexual identities, experience disproportionately high rates of suicidal thoughts and planning. These findings highlight the urgent need for culturally responsive, identity-affirming prevention strategies, better access to mental health care, and tailored interventions for this underserved population. Future research should investigate protective factors and mechanisms that can buffer suicide risk among Black LGB+ adolescents. Epidemiology prevention suicidality Introduction Suicide was the third-leading cause of death among adolescents aged 14 to 18 years in 2021, with an estimated 1,952 suicide-related deaths annually in the United States, resulting in a rate of 9.0 per 100,000 adolescents.¹ National data from the Youth Risk Behavior Surveillance System (YRBSS) indicated that in 2023, 20% of high school students seriously considered attempting suicide, 16% made a suicide plan, and 9% attempted suicide.² Moreover, significant increases in hospitalizations for suicide attempts and ideation—nearly doubling from 2008 to 2015³—have made suicide a focus of several government initiatives (eg, Healthy People 2030). However, little progress in reducing suicidality among adolescents has been achieved.⁴ Significant disparities in suicidality have been recorded among adolescents who identify as lesbian, gay, or bisexual (LGB+). Additional data from the 2023 YRBSS found that compared with non–LGB+ adolescents, LGB+ adolescents were more likely to seriously consider suicide (41% vs 13%), make a plan (32% vs 11%), and attempt suicide (20% vs 6%).² Further, research using National Violent Death Reporting System data indicated that from 2014 to 2019, significant increasing trends in deaths by suicide were observed among LGB+ adolescent populations.⁵ In recent years, significant racial and ethnic disparities have also been noted, with suicide among Black youth rising at a notable rate. From 2003 to 2017, 1,810 Black adolescents died by suicide, an overall rate of 1.36 per 100,000. Black youth aged 15 to 17 years experienced the most significant increases during this period.⁶ Additionally, Black/African American girls experienced suicide rates more than twice those of Black boys.⁶ Although suicidality among LGB+ youth and among Black youth has been widely documented, comparatively little research has examined their intersection.⁷ This omission is notable given that more than one in five Black adolescents identify as LGB+.⁸ Intersectionality theory and Minority Stress Theory provide a critical framework for understanding why Black LGB+ youth may experience heightened suicide risk. Meyer’s Minority Stress model posits that sexual minority individuals experience chronic stressors—such as discrimination, concealment, and internalized stigma—that elevate mental health risk.¹² For Black LGB+ youth, these stressors are compounded by racism, heterosexism, and age-related vulnerabilities, creating a qualitatively distinct stress experience that cannot be understood by examining race or sexual orientation in isolation.¹²˒¹³ Importantly, identity is not merely additive but relational and context dependent. For some youth, racial identity may be more salient than sexual orientation (“Black and gay”) 8,9 , whereas for others, sexual minority identity may be foregrounded (“gay and Black”), depending on family context, community norms, and exposure to stigma. Navigating multiple marginalized identities during adolescence 12 —a developmental period characterized by identity formation and heightened sensitivity to social evaluation—may intensify psychological distress, social isolation, and feelings of burdensomeness, all of which are well-established correlates of suicidal ideation and planning. These intersecting identity processes may help explain why recent increases in suicidality have been particularly pronounced among Black LGB+ youth. The inclusion of the “+” in LGB+ further reflects important heterogeneity within sexual minority identities. Adolescents who identify as bisexual, pansexual, queer, questioning, same-gender loving, or who report uncertainty about their sexual identity often report equal or greater levels of psychological distress compared with their gay and lesbian peers. 7 Prior research suggests that bisexual and questioning youth may experience unique stressors 5 , including identity invalidation, pressure to “choose” an identity, and marginalization within both heterosexual and LGBTQ+ spaces. Identity fluidity and uncertainty may independently contribute to suicide risk by increasing rumination, concealment, and exposure to stigma, particularly in environments where nonbinary or culturally specific identity labels are poorly understood or rejected. Additionally, barriers to mental health care remain pervasive. Black adolescents, particularly those who are LGB+, often report limited access to identity-affirming care, mistrust of health systems, and lower engagement with mental health services.¹⁴-¹⁵ Systemic inequities—including underrepresentation of Black clinicians, cultural stigma about mental illness, and socioeconomic challenges—compound these barriers.¹⁶-¹⁷ Consequently, Black LGB+ youth may experience the highest unmet mental health need of any adolescent group in the United States. 8 , 18 Although elevated suicide risk among sexual minority youth is well documented, major gaps remain in understanding within-group heterogeneity among Black youth and why these disparities exist. Most nationally representative studies either aggregate all LGB+ youth 12 —masking meaningful differences between gay/lesbian, bisexual, and questioning identities—or lack sufficient power to examine Black sexual minority youth separately. As a result, it is unclear whether disparities in suicidal ideation and planning are uniform across sexual orientations or whether certain subgroups (e.g., bisexual or questioning Black youth) experience disproportionately higher risk. Further, existing research often treats sexual identity as fixed and clearly defined, overlooking youth who use alternative terms (e.g., queer, same-gender loving) or who report being unsure, despite evidence that identity uncertainty and identity-related stress may independently contribute to psychological distress. This gap limits theory development and the targeting of prevention efforts, as risk mechanisms and support needs may differ by specific sexual identity labels and levels of identity clarity within Black youth populations. The purpose of this study was to examine suicidal ideation and planning among a large sample of Black youth and investigate disparities by sexual identity using a nationally representative dataset. We hypothesized that compared with non–LGB+ youth, Black LGB+ youth would be more likely to report suicidal ideation and planning. Methods We conducted a secondary analysis of data from the 2023 National Survey on Drug Use and Health (NSDUH), a nationally representative, cross-sectional survey designed to assess substance use and mental health among the U.S. civilian, non-institutionalized population aged 12 years and older. The NSDUH employs a complex, multistage area probability sampling design to produce reliable estimates at national, regional, and state levels. In the first stage, primary sampling units (PSUs), typically consisting of counties or groups of contiguous counties, are selected across all 50 states and the District of Columbia. Within PSUs, smaller geographic units are sampled sequentially, including census tracts, census block groups, and individual housing units. Within selected dwelling units, one or two individuals are randomly chosen using an automated selection procedure to ensure equal probability of selection within households. To improve the precision of estimates for key demographic groups, the NSDUH incorporates differential sampling and oversampling strategies, particularly for adolescents (ages 12–17), young adults (ages 18–25), and racial and ethnic minority populations. These procedures allow for more stable subgroup estimates while maintaining overall representativeness through the application of sampling weights. Data collection is conducted through in-person interviews administered by trained field staff using a combination of computer-assisted personal interviewing (CAPI) for less sensitive items and audio computer-assisted self-interviewing (ACASI) for sensitive questions, such as substance use and mental health symptoms. The ACASI method allows respondents to privately read and/or listen to questions and enter responses directly into a computer, thereby enhancing confidentiality and reducing social desirability and reporting biases. The NSDUH also implements rigorous quality control procedures, including interviewer training, field monitoring, and data validation protocols. Final survey weights account for the complex sampling design, nonresponse, and post-stratification adjustments to align the sample with U.S. population benchmarks. Additional methodological details, including response rates, weighting procedures, and variance estimation techniques, are documented in publicly available NSDUH methodological reports. 19 Measures Suicide Planning and Ideation Two self-report items assessed suicidal thoughts and planning within the past 12 months: “At any time in the past 12 months, did you seriously think about trying to kill yourself?”; “During the past 12 months, did you make any plans to kill yourself?” Responses were coded dichotomously (Yes/No). Sexual Orientation Participants were asked which of the following best described their sexual orientation: heterosexual (straight), gay/lesbian, bisexual, not sure, or “use a different term.” Responses were categorized into five groups: heterosexual (reference), gay/lesbian, bisexual, unsure, and other term. Mental Health and Substance Use The presence of a major depressive episode (MDE) in the past year was measured using DSM-5 criteria derived from self-reported symptoms. 20 Past-year alcohol use, past-year marijuana use, and past-year opioid misuse were included as covariates due to their known associations with suicide risk. 21 Demographics Demographic variables included age (years), sex at birth (male/female), race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, other), sexual orientation (heterosexual, gay/lesbian, bisexual, unsure, use a different term), and county status (large metropolitan, small metropolitan, nonmetropolitan). Analysis Plan For all analyses, when available, we used multiple-imputed variables provided by NSDUH to limit the amount of missing data. The NSDUH employs a fully integrated imputation strategy, most commonly based on predictive mean matching and logistic regression frameworks, to address item-level missingness for sensitive measures (e.g., income, substance use, and mental health indicators). Multiple imputed datasets are released as part of the public-use files, and analyses incorporated these imputations following recommended guidelines to preserve variance and reduce bias associated with missing data. When applicable, imputed variables were used in place of raw variables, and estimates were combined using Rubin’s rules to account for between- and within-imputation variability. Frequencies were estimated to describe participant characteristics. Bivariate comparisons were estimated with Rao-Scott Chi-square tests. Multivariate logistic regression analyses were built to determine conditional associations to past-year suicidal ideation and planning. To operationalize intersectionality, interaction terms between sex at birth and sexual identity were included in regression models. All analyses accounted for the NSDUH’s complex survey design, including stratification, clustering, and unequal probabilities of selection. Sampling weights provided by NSDUH were applied to generate nationally representative estimates of Black/African American youth in the United States. These weights incorporate adjustments for differential selection probabilities, nonresponse, and post-stratification to U.S. Census population controls. Variance estimation was conducted using Taylor series linearization to produce appropriate standard errors and confidence intervals under the complex design. To operationalize an intersectional framework, interaction terms between sex at birth and sexual identity were included in regression models to assess whether associations with suicidal ideation and planning differed across intersecting identities (with white LBG+ youth as a reference). Where statistically significant interactions were observed, stratified estimates or predicted probabilities were examined to aid interpretation. All analyses were conducted in R (version 4.5.1), primarily using the dplyr package for data management and the survey package for design-based estimation, ensuring that all point estimates and inferential statistics appropriately reflected the NSDUH’s sampling design and weighting structure. Results The sample consisted of 1,146 Black youths (Table 1 ) were distributed almost evenly by sex at birth (53.5% male and 46.4% female). Large metropolitan regions accounted for the majority (60.9%), small metro counties (30.3%), and nonmetro counties (8.76%). An estimated 12.0% ( n = 137) thought about suicide in the past year and 5.76% ( n = 66) of youth planned suicide in the past year. Table 1 Sample Demographics (N = 1,146) Variable Weighted % [95% CI Sex at birth Male 53.5 [49.4,57.6] Female 46.4 [42.3, 50.6] Age 12-13-Year Olds 33.2 [29.3, 37.3] 14-15-Year Olds 34.5 [30.7, 38.4] 16–17 Year Olds 32.3 [28.6, 36.3] Sexual Identity Heterosexual, that is, Straight 83.9 [80.8, 86.5] Gay/Lesbian 2.23 [1.41, 3.51] Bisexual 7.90 [6.09, 10.2] I use a different term 1.43 [0.80, 2.55] I am not sure about my sexual identity 4.58 [3.17, 6.58] County Level Large Metro 60.9 [56.9, 64.8] Small Metro 30.3 [26.7, 34.1] Non-Metro 8.76 [6.86, 11.1] Major Depressive Episode (Past-Year) Yes 10.9 [8.66, 13.7] No 89.1 [86.3, 91.3] Past Year Alcohol Use Yes 10.2 [7.94, 13.1] No 89.8 [86.9, 92.1] Past Year Marijuana Use Yes 11.5 [9.15, 14.5] No 88.5 [85.5, 90.8] Past-Year Non-Medical Opioid Use Yes 2.74 [1.75, 4.28] No 97.2 [95.7, 98.2] After adjusting for biological sex, county type, past-year use of alcohol/opioids/marijuana, grade level, and family income, Table 2 shows the adjusted odds ratios (AORs) for suicide ideation and suicide planning across various sexual identity categories. Compared to adolescents who identified as heterosexual, adolescents who reported describing their sexual identity with a different term had the highest chances of suicidal thoughts (AOR = 7.69, 95% CI 2.83, 20.9) and planning (AOR = 4.74, 95% CI 1.19, 18.9). Additionally, those who identified as gay or lesbian had higher risks of suicidal thoughts (AOR = 5.81, 95% CI 1.10, 30.6), but no differences on planning. Adolescents who identify as bisexual had higher odds of suicidal thoughts (AOR = 4.15), but not planning. Adolescents who were unclear of their sexual orientation had significantly reduced risks of suicidal thoughts (AOR = 3.32) and planning (AOR = 4.81). The interactions between sex at birth and sexual identity and their associations with suicide ideation and planning were not significant. Table 2 Adjusted Odds Ratios towards Suicide Ideation and Planning among Black/African American Youth Sexual Identity Suicide Ideation Suicide Planning Heterosexual, that is straight Reference Reference Gay or lesbian 5.81 [1.10, 30.6] 5.27 [0.81, 34.2] Bisexual 4.15 [1.41, 12.2] 1.27 [0.41, 3.86] I use a different term 7.69 [2.83, 20.9] 4.74 [1.19, 18.9] I am not sure about my sexual identity 1.49 [0.52, 4.21] 1.88 [0.69, 5.13] Sex at Birth * Sexual Identity 0.23 [0.04, 1.38] 0.45 [0.04, 4.83] White LGB+ Youth (reference) vs. Black LGB Youth 1.09 [0.34, 11.5] 1.35 [0.49, 23.1] *Models controlled for biological sex, past year use of alcohol//marijuana/opioids, major depressive episode, income, county status, and grade-level. Bolded ORs indicate p <.05. Discussion Main Findings This study sought to examine suicidal behavior among Black LGB+ youth in relation to adverse mental health outcomes such as depression and substance use. Compared to Black non-LGB+ adolescents, Black LGB+ adolescents were at increased risk for suicidal ideation and planning. Moreover, youth who used a different term to describe their identity were at the highest risk for both outcomes, highlighting the need for further research into specific identities and intersectional components and their relationship to poor mental health. Findings in Context Adolescent suicide remains a critical public health issue in the United States and globally. 23 Moreover, from 2011 to 2020, the number of emergency department visits in the US associated with suicide attempts and self-harm increased nearly 20%. 24 These rates are of concern, given the low providerment of health services and screening opportunities to address suicide among youth. 25 Adolescence represents a sensitive developmental period characterized by identity formation, heightened peer influence, and ongoing neurocognitive maturation, which together may amplify vulnerability to social stressors and limit youths’ capacity to regulate distress or seek support. As a result, suicidal ideation and planning during this life stage often reflect cumulative exposure to interpersonal, institutional, and structural adversity rather than isolated events. Disparities in suicidality are especially pronounced among adolescents who identify as lesbian, gay, or bisexual (LGB+), substantiating our findings. According to the 2023 YRBSS, LGBT+ adolescents were significantly more likely than their non-LGB+ peers to report seriously considering suicide (41% vs. 13%), planning a suicide attempt (32% vs. 11%), or attempting suicide (20% vs. 6%).² Minority stress theory provides a useful framework for understanding these disparities, as LGB+ youth are disproportionately exposed to stigma, victimization, and identity concealment, all of which increase psychological distress and reduce access to affirming support systems. In addition, the observed increase in suicide rates for Black youth highlight a lack of progress for this growing disparity. Previous research has shown that Black youth ages 15–17 experienced the largest increase in suicide, and Black females were twice as likely to attempt suicide compared to Black males. 26 These patterns suggest that suicidality among Black adolescents may be shaped by intersecting stressors 13 related to racism, gendered expectations, and reduced access to culturally responsive mental health care. Educational context may play a particularly important role, as Black youth are more likely to experience school-based discrimination and reduced school connectedness 8 , which have been identified as factors that have been independently linked to depression and suicidality. 23 Additionally, the findings in our study contribute to the growing but low amount of research that has been conducted on Black LGB+ youth. An estimated 12.8% of Black youth in the NSDUH study sample reported experiencing a major depressive episode (MDE), a known risk factor for suicidality. Data from the 2024 Human Rights Campaign 2024 Black LGBTQ+ Youth Report 8 revealed that 53.3% of Black LGB+ youth screened positive for depression, but less than half (46.5%) of youth wanted therapy but could not receive it, highlighting the ongoing awareness of increasing mental health resources for underserved youth. As research focusing on risk factors for Black and LGB+ youth continues, evidence-based protective factors remain significantly less studied, and research barely intersects the two. 27 Prior reviews have found that religious, social, familial, and personal factors could all help reduce the risk of suicidality among Black youth. 27 , 28 In addition, protective factors for both Black or LGB+ youth include feelings of hopefulness, a positive self-identity, having a stable environment, and community or social support. Importantly, suicidal ideation and planning among Black LGB+ youth do not emerge in isolation but reflect the cumulative and developmentally patterned effects of social, educational, and structural stressors. Adolescence represents a sensitive developmental period marked by identity formation, heightened peer salience, and limited emotion regulation capacity, all of which may amplify vulnerability to stress-related psychopathology. Younger adolescents, in particular, may experience greater difficulty accessing coping resources or articulating distress, increasing the likelihood that stressors related to race-, sexuality-, and gender-based stigma manifest as internalized distress or suicidal ideation rather than help-seeking behaviors. Educational context further compounds this risk; school environments function as primary social ecosystems for youth, and exposure to bullying, exclusion, or curricula that erase or stigmatize Black and LGB+ identities can exacerbate feelings of invisibility, burdensomeness, and thwarted belonging. It is important to note racial/ethnic differences in the “coming out” process. Compared to White adolescents, Black youth may "come out" expressively sooner than their white counterparts and be subjected to harassment at home and school; therefore, to cover their true identities, many LGB+ youth will deny or hide their sexuality in order survive. Prior literature has shown that among African American youth, coming out led to an initial reaction of negativity, but soon was tempered over time. 29 The socio-cognitive-behavioral model of adjustment theorizes that family members’ initial responses to a child’s disclosure are shaped by preexisting beliefs, cultural norms, and perceived social stigma, which may result in early rejection or distress. 30 Over time, however, cognitive reframing, increased knowledge, and ongoing interpersonal interactions can facilitate more adaptive coping and behavioral change, leading to greater acceptance and improved family relationships. This adjustment process may ultimately result in greater acceptance, improved communication, and enhanced family functioning, even within cultural contexts that initially discourage sexual minority identities. 31 – 33 . While suicide prevention programs exist for minority youth, studies have not been conducted to determine whether these interventions are effective for Black LGB+ youth who participate in these programs. 27 A recent systematic review and meta-analysis of psychotherapy interventions for reducing suicidal thoughts and behaviors among Black youth notes the lack of interventions and community initiatives to address this problem 28 , although several interventions call for the integration of community leaders and mental health professionals to take a multi-factorial approach for addressing suicidality among Black youth. 35 , 36 Implications for Prevention To address suicide among Black LGB+ youth, prevention strategies must move beyond one-size-fits-all approaches that overlook the interplay between race, culture, and sexual identity. Traditional school-based suicide prevention programs, while effective for general populations, often fail to engage racial and sexual minority adolescents if they lack cultural relevance or affirming representation. 36 Efforts such as Sources of Strength and Signs of Suicide have shown efficacy in general adolescent populations, but their impact among Black LGB+ youth remains limited without adaptation for intersectional identity experiences. 37 , 38 Culturally responsive and community-engaged approaches are essential for youth suicide prevention. 39 Programs co-developed with Black LGB+ youth and community leaders can enhance trust and relevance. Interventions that leverage community-based organizations, faith institutions, and peer mentoring networks may provide critical safe spaces that affirm both racial and sexual identity. 28 For example, the BEAM (Black Emotional and Mental Health Collective) and The Trevor Project’s Black & LGB+ Initiative demonstrate how partnerships between community and clinical systems can promote identity-affirming care and crisis support. 40 , 41 Clinician training in intersectional cultural competency represents another vital layer of prevention. Mental health professionals must be equipped to address racial trauma, heterosexism, and identity-related stress with cultural humility. 42 , 43 Studies show that clients report higher satisfaction, therapeutic engagement, and improved mental health outcomes when clinicians integrate affirming language and explore intersecting identities. 44 , 45 The American Psychological Association has emphasized that culturally competent, affirming care is a core component of suicide prevention among marginalized youth. 46 Moreover, inclusive school climates have measurable protective effects. Exposure to supportive teachers, gender-sexuality alliances (GSAs), and inclusive anti-bullying policies significantly reduces suicide attempts among LGB+ students, with particularly strong benefits for students of color. 47 , 48 Gender–Sexuality Alliances (GSAs) are uniquely positioned to function as protective spaces but must move beyond symbolic inclusion to intentional engagement. GSAs can be strengthened by incorporating leadership opportunities for students of color, addressing racism within LGBTQ+ spaces, partnering with Black community organizations, and providing structured peer-support or mentorship components. GSAs that explicitly affirm racial identity alongside sexual identity may enhance belonging, reduce isolation, and foster collective efficacy—key buffers against suicidality during adolescence. Consistent actions such as using correct pronouns, displaying affirming symbols, or integrating diverse role models into curricula, can foster belonging and resilience. 49 Moreover, teachers and school staff also play a measurable role in prevention. Training educators to integrate inclusive and affirming content into curricula, particularly in history, literature, and health education, can reduce identity-based stigma and promote visibility. Simple but consistent practices, such as using correct pronouns, intervening in bias-based bullying, and acknowledging diverse family structures, have been shown to improve school climate and mental health outcomes for LGB+ students, with particularly strong effects for students of color.⁴⁷-⁴⁹ These practices are especially important during early adolescence, when peer validation and adult support are critical to psychological well-being. At the structural level, funding and policy mechanisms must explicitly prioritize intersectional populations. Programs such as the Minority Fellowship Program and Project AWARE should be leveraged to expand culturally competent mental health training and research focused on Black LGB+ youth, thereby expanding critical resources for health promotion. 50 , 51 Federal and state policies aimed at improving insurance coverage, expanding school-based behavioral health services, and enforcing anti-discrimination protections can function as upstream suicide prevention strategies. 52 Addressing systemic inequities, such as underrepresentation of Black clinicians and barriers to affirming care, is critical to closing the mental health gap. 53 Finally, informal support systems play a critical protective role for Black LGB+ youth, particularly in the context of suicide risk, by offering affirmation, belonging, and culturally responsive coping resources that may be absent in families, schools, or formal institutions. House and ballroom communities—historically rooted in Black and Latinx LGB+ culture—function as chosen families that provide mentorship, emotional support, identity validation, and opportunities for leadership through roles such as “house mothers” and “house fathers,” which have been associated with resilience and reduced social isolation among sexual and gender minority youth of color. 54 , 55 Similarly, fictive kin networks, including gay mothers, gay fathers, and peer-based family structures, serve as alternative caregiving systems that buffer the effects of rejection, homelessness, and stigma, all of which are well-established risk factors for suicidal ideation and attempts. 56 Online spaces further extend these informal supports by enabling Black LGB+ youth to access community, information, and peer validation beyond geographically constrained or unsafe environments, though the quality and safety of these spaces remain variable. 57 Finally, engagement in visual and performing arts including dance, music, poetry, and performance traditions embedded within ballroom culture provides expressive outlets that facilitate emotion regulation, identity exploration, and meaning-making, processes that are increasingly recognized as protective against depression and suicidality among marginalized youth. 58 Collectively, these informal support systems operate as vital, community-generated mechanisms of survival and resilience for Black LGB+ youth facing intersecting forms of racism, heterosexism, and cisnormativity. Implications for Intersectionality Research and Future Directions Advancing suicide prevention science requires research frameworks that move beyond single-axis analyses of race or sexual identity and instead center intersectionality as a guiding paradigm. Rooted in Black feminist scholarship, intersectionality emphasizes that systems of racism, heterosexism, and other forms of structural oppression are mutually constitutive and shape health in synergistic ways rather than as independent risk factors. 13 Traditional epidemiologic models that treat race and sexual orientation as separate covariates risk obscuring these dynamics and may underestimate disparities among multiply marginalized youth. 59 Future studies should explicitly test intersectional effects and theorize identity as relational and structural, rather than additive. 60 Methodologically, researchers should expand the use of analytic approaches capable of modeling intersectional inequities. Multilevel frameworks that incorporate structural stigma indicators (e.g., state-level policy climates, school anti-bullying protections) can better capture contextual influences on suicidal behaviors. 61 Intersectionality-informed quantitative methods—including interaction modeling, stratified analyses, multilevel intersectional models (e.g., MAIHDA), and person-centered approaches such as latent class or profile analysis—allow for the examination of heterogeneous risk configurations across identity groups. 62 , 63 These approaches help disentangle whether disparities reflect compositional differences or structural processes embedded in social systems. Longitudinal research is particularly critical. Most existing studies rely on cross-sectional data, limiting causal inference and developmental insight. 64 Life-course frameworks suggest that exposure to discrimination, identity-based victimization, and structural inequities accumulates over time, shaping trajectories of mental health and suicidality. 65 Prospective cohort studies beginning in early adolescence—and ideally incorporating biomarkers of stress or neurodevelopmental indicators—could clarify sensitive periods and mechanisms linking intersectional stressors to suicidal ideation and attempts. 66 Measurement refinement is also needed. Many large datasets lack nuanced assessments of sexual identity, gender identity, racialized experiences, and cultural context. 67 Expanding survey items to include multidimensional measures of identity affirmation, racial discrimination, internalized stigma, and community connectedness would strengthen explanatory models. 68 Additionally, incorporating qualitative and mixed-methods research can illuminate protective cultural processes—such as chosen family networks or community-based resilience—that may not be captured in standardized instruments. 69 Community-based participatory research (CBPR) models are especially valuable, as they center youth voices and enhance ecological validity. 70 Future research must also interrogate protective factors alongside risk. While minority stress theory has been instrumental in identifying mechanisms of vulnerability, emerging resilience frameworks highlight the importance of identity pride, collective efficacy, and culturally grounded coping. 71 Examining how protective school climates, affirming clinicians, and community-based organizations buffer intersectional stress can also inform multilevel intervention design. At the structural level, policy-focused research is essential. Evaluations of anti-discrimination laws, inclusive school policies, Medicaid expansion, and culturally responsive workforce initiatives can clarify upstream determinants of suicide risk among multiply marginalized youth. 72 Structural stigma has been linked to adverse mental health outcomes among sexual minority populations, underscoring the need for natural experiments and quasi-experimental designs that assess policy change over time. 73 Integrating administrative data, geospatial indicators, and policy surveillance tools will strengthen causal inference and translational relevance. Finally, intersectionality research must prioritize workforce diversification and research equity. Underrepresentation of Black investigators and scholars with lived experience in LGBTQ+ communities limits innovation and trust. 74 Federal initiatives that fund early-career scholars, community partnerships, and culturally grounded intervention trials are essential to sustaining progress. 75 By embedding intersectionality across theory, measurement, design, and policy translation, future research can more precisely identify mechanisms of risk and resilience—and ultimately inform suicide prevention strategies that reflect the full complexity of Black LGB+ youths’ lived experiences. Limitations Several limitations of the current study should be noted, including self-selection bias.While sexual orientation was assessed, gender identity was not; future research needs to examine gender identity, given that gender diverse individuals report high rates of suicide. 76 Moreover, the generalizability of our findings may be limited by the high prevalence of opioid and other substance use in some areas, which was not included in the NSDUH dataset. Conclusion This study highlights the heightened vulnerability of Black LGB+ youth to suicidal ideation and planning, underscoring the urgent need for targeted mental health interventions. Compared with Black non-LGB+ peers, Black LGB+ adolescents experience a disproportionate burden of suicidality and associated mental health concerns such as depression and substance use. Our findings emphasize that youth who describe their identities outside of conventional LGB+ labels are at especially high risk, signaling a critical gap in both research and clinical care. Given the persistently rising rates of suicide among Black youth and the longstanding disparities affecting LGB+ adolescents, these findings call for culturally responsive, identity-affirming prevention strategies. Expanding access to mental health care, addressing structural barriers, and ensuring culturally competent providers are essential steps toward reducing these inequities. Moreover, future research should prioritize identifying and strengthening protective factors—such as social support, positive identity development, and community resources—that can buffer against suicide risk in this population. Declarations Ethics approval and consent to participate A University Institutional Review Board approved this study. Consent for publication Not Applicable Funding Not Applicable Author Contribution All authors contributed to analyses and the overall draft of the manuscript. Acknowledgements Not Applicable Availability of data and materials Data are available on SAMHSA website Competing interests Not Applicable References Centers for Disease Control and Prevention. CDC WONDER: About Multiple Causes of Death, 2018–2022 . US Department of Health and Human Services, National Center for Health Statistics; 2025. https://wonder.cdc.gov/ Centers for Disease Control and Prevention. Youth Risk Behavior Survey Data Summary and Trends Report: 2013–2023. US Department of Health and Human Services; 2024. https://www.cdc.gov/healthyyouth/data/yrbs/ Plemmons G, Hall M, Doupnik S, et al. Hospitalization for suicide ideation or attempt: 2008–2015. Pediatrics .2018;141(6):e20172426. US Department of Health and Human Services, Office of Disease Prevention and Health Promotion. 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J Racial Ethn Health Disparities. 2025;12(1):1–7. doi: 10.1007/s40615-024-02226-3 . Epub 2024 Oct 25. PMID: 39455520. Horwitz AG, Berona J, Busby DR, Eisenberg D, Zheng K, Pistorello J, Albucher R, Coryell W, Favorite T, Walloch JC, King CA. Variation in Suicide Risk among Subgroups of Sexual and Gender Minority College Students. Suicide Life Threat Behav. 2020;50(5):1041–1053. doi: 10.1111/sltb.12637. Epub 2020 Apr 15. PMID: 32291833; PMCID: PMC7981781. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 18 May, 2026 Reviewers agreed at journal 14 May, 2026 Reviewers invited by journal 05 May, 2026 Submission checks completed at journal 27 Apr, 2026 First submitted to journal 23 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Andrew Yockey","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA50lEQVRIiWNgGAWjYNCCAww8/AzMDQwMBmCuAVFaZCQbGEnUYmNwAKSFgQgt5u1nDB/8OGPDY3y8sfHRjYI6ewb25m0S+LTInMkxNuy5kcZjduZgs3GOweHEBp5jZXi1SDDkmEkzfDjMY3YjsU06x+BAAoNEjhl+LfxvQFr+8xjPSGz/nWMAdJj8GwJaJEC23DjAYyCR2MacY8DM2CDBQ0jLs2LDnjPJPBJAv0iD/NLGk1Zsgd9hyRsf/DhmZ8/f3nzwc86fOnt+9sMbb+DTwsDAgRYLbPiVgwD7A8JqRsEoGAWjYGQDAFNvRnfcfiCiAAAAAElFTkSuQmCC","orcid":"","institution":"University of Mississippi","correspondingAuthor":true,"prefix":"","firstName":"R.","middleName":"Andrew","lastName":"Yockey","suffix":""}],"badges":[],"createdAt":"2026-03-10 19:23:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9087260/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9087260/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":109296191,"identity":"e245c86d-7b5b-4a72-865a-e18e3ab796ce","added_by":"auto","created_at":"2026-05-15 08:46:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":292985,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9087260/v1/8815aab5-73b3-45ca-932d-9f1130302f48.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"An Intersectional Approach Towards understanding Suicidality among Black LGB+ Adolescents, USA, 2023","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSuicide was the third-leading cause of death among adolescents aged 14 to 18 years in 2021, with an estimated 1,952 suicide-related deaths annually in the United States, resulting in a rate of 9.0 per 100,000 adolescents.\u0026sup1; National data from the Youth Risk Behavior Surveillance System (YRBSS) indicated that in 2023, 20% of high school students seriously considered attempting suicide, 16% made a suicide plan, and 9% attempted suicide.\u0026sup2; Moreover, significant increases in hospitalizations for suicide attempts and ideation\u0026mdash;nearly doubling from 2008 to 2015\u0026sup3;\u0026mdash;have made suicide a focus of several government initiatives (eg, Healthy People 2030). However, little progress in reducing suicidality among adolescents has been achieved.⁴\u003c/p\u003e \u003cp\u003eSignificant disparities in suicidality have been recorded among adolescents who identify as lesbian, gay, or bisexual (LGB+). Additional data from the 2023 YRBSS found that compared with non\u0026ndash;LGB+ adolescents, LGB+ adolescents were more likely to seriously consider suicide (41% vs 13%), make a plan (32% vs 11%), and attempt suicide (20% vs 6%).\u0026sup2; Further, research using National Violent Death Reporting System data indicated that from 2014 to 2019, significant increasing trends in deaths by suicide were observed among LGB+ adolescent populations.⁵\u003c/p\u003e \u003cp\u003eIn recent years, significant racial and ethnic disparities have also been noted, with suicide among Black youth rising at a notable rate. From 2003 to 2017, 1,810 Black adolescents died by suicide, an overall rate of 1.36 per 100,000. Black youth aged 15 to 17 years experienced the most significant increases during this period.⁶ Additionally, Black/African American girls experienced suicide rates more than twice those of Black boys.⁶\u003c/p\u003e \u003cp\u003eAlthough suicidality among LGB+ youth and among Black youth has been widely documented, comparatively little research has examined their intersection.⁷ This omission is notable given that more than one in five Black adolescents identify as LGB+.⁸ Intersectionality theory and Minority Stress Theory provide a critical framework for understanding why Black LGB+ youth may experience heightened suicide risk. Meyer\u0026rsquo;s Minority Stress model posits that sexual minority individuals experience chronic stressors\u0026mdash;such as discrimination, concealment, and internalized stigma\u0026mdash;that elevate mental health risk.\u0026sup1;\u0026sup2; For Black LGB+ youth, these stressors are compounded by racism, heterosexism, and age-related vulnerabilities, creating a qualitatively distinct stress experience that cannot be understood by examining race or sexual orientation in isolation.\u0026sup1;\u0026sup2;˒\u0026sup1;\u0026sup3;\u003c/p\u003e \u003cp\u003eImportantly, identity is not merely additive but relational and context dependent. For some youth, racial identity may be more salient than sexual orientation (\u0026ldquo;Black and gay\u0026rdquo;)\u003csup\u003e8,9\u003c/sup\u003e, whereas for others, sexual minority identity may be foregrounded (\u0026ldquo;gay and Black\u0026rdquo;), depending on family context, community norms, and exposure to stigma. Navigating multiple marginalized identities during adolescence\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e\u0026mdash;a developmental period characterized by identity formation and heightened sensitivity to social evaluation\u0026mdash;may intensify psychological distress, social isolation, and feelings of burdensomeness, all of which are well-established correlates of suicidal ideation and planning. These intersecting identity processes may help explain why recent increases in suicidality have been particularly pronounced among Black LGB+ youth.\u003c/p\u003e \u003cp\u003eThe inclusion of the \u0026ldquo;+\u0026rdquo; in LGB+ further reflects important heterogeneity within sexual minority identities. Adolescents who identify as bisexual, pansexual, queer, questioning, same-gender loving, or who report uncertainty about their sexual identity often report equal or greater levels of psychological distress compared with their gay and lesbian peers.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Prior research suggests that bisexual and questioning youth may experience unique stressors\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e, including identity invalidation, pressure to \u0026ldquo;choose\u0026rdquo; an identity, and marginalization within both heterosexual and LGBTQ+ spaces. Identity fluidity and uncertainty may independently contribute to suicide risk by increasing rumination, concealment, and exposure to stigma, particularly in environments where nonbinary or culturally specific identity labels are poorly understood or rejected.\u003c/p\u003e \u003cp\u003eAdditionally, barriers to mental health care remain pervasive. Black adolescents, particularly those who are LGB+, often report limited access to identity-affirming care, mistrust of health systems, and lower engagement with mental health services.\u0026sup1;⁴-\u0026sup1;⁵ Systemic inequities\u0026mdash;including underrepresentation of Black clinicians, cultural stigma about mental illness, and socioeconomic challenges\u0026mdash;compound these barriers.\u0026sup1;⁶-\u0026sup1;⁷ Consequently, Black LGB+ youth may experience the highest unmet mental health need of any adolescent group in the United States.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAlthough elevated suicide risk among sexual minority youth is well documented, major gaps remain in understanding within-group heterogeneity among Black youth and why these disparities exist. Most nationally representative studies either aggregate all LGB+ youth\u003csup\u003e12\u003c/sup\u003e\u0026mdash;masking meaningful differences between gay/lesbian, bisexual, and questioning identities\u0026mdash;or lack sufficient power to examine Black sexual minority youth separately. As a result, it is unclear whether disparities in suicidal ideation and planning are uniform across sexual orientations or whether certain subgroups (e.g., bisexual or questioning Black youth) experience disproportionately higher risk. Further, existing research often treats sexual identity as fixed and clearly defined, overlooking youth who use alternative terms (e.g., queer, same-gender loving) or who report being unsure, despite evidence that identity uncertainty and identity-related stress may independently contribute to psychological distress. This gap limits theory development and the targeting of prevention efforts, as risk mechanisms and support needs may differ by specific sexual identity labels and levels of identity clarity within Black youth populations. The purpose of this study was to examine suicidal ideation and planning among a large sample of Black youth and investigate disparities by sexual identity using a nationally representative dataset. We hypothesized that compared with non\u0026ndash;LGB+ youth, Black LGB+ youth would be more likely to report suicidal ideation and planning.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eWe conducted a secondary analysis of data from the 2023 National Survey on Drug Use and Health (NSDUH), a nationally representative, cross-sectional survey designed to assess substance use and mental health among the U.S. civilian, non-institutionalized population aged 12 years and older. The NSDUH employs a complex, multistage area probability sampling design to produce reliable estimates at national, regional, and state levels. In the first stage, primary sampling units (PSUs), typically consisting of counties or groups of contiguous counties, are selected across all 50 states and the District of Columbia. Within PSUs, smaller geographic units are sampled sequentially, including census tracts, census block groups, and individual housing units. Within selected dwelling units, one or two individuals are randomly chosen using an automated selection procedure to ensure equal probability of selection within households.\u003c/p\u003e \u003cp\u003eTo improve the precision of estimates for key demographic groups, the NSDUH incorporates differential sampling and oversampling strategies, particularly for adolescents (ages 12\u0026ndash;17), young adults (ages 18\u0026ndash;25), and racial and ethnic minority populations. These procedures allow for more stable subgroup estimates while maintaining overall representativeness through the application of sampling weights. Data collection is conducted through in-person interviews administered by trained field staff using a combination of computer-assisted personal interviewing (CAPI) for less sensitive items and audio computer-assisted self-interviewing (ACASI) for sensitive questions, such as substance use and mental health symptoms. The ACASI method allows respondents to privately read and/or listen to questions and enter responses directly into a computer, thereby enhancing confidentiality and reducing social desirability and reporting biases. The NSDUH also implements rigorous quality control procedures, including interviewer training, field monitoring, and data validation protocols. Final survey weights account for the complex sampling design, nonresponse, and post-stratification adjustments to align the sample with U.S. population benchmarks. Additional methodological details, including response rates, weighting procedures, and variance estimation techniques, are documented in publicly available NSDUH methodological reports.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eMeasures\u003c/h2\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003eSuicide Planning and Ideation\u003c/h2\u003e \u003cp\u003eTwo self-report items assessed suicidal thoughts and planning within the past 12 months: \u0026ldquo;At any time in the past 12 months, did you seriously think about trying to kill yourself?\u0026rdquo;; \u0026ldquo;During the past 12 months, did you make any plans to kill yourself?\u0026rdquo; Responses were coded dichotomously (Yes/No).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eSexual Orientation\u003c/h3\u003e\n\u003cp\u003eParticipants were asked which of the following best described their sexual orientation: heterosexual (straight), gay/lesbian, bisexual, not sure, or \u0026ldquo;use a different term.\u0026rdquo; Responses were categorized into five groups: heterosexual (reference), gay/lesbian, bisexual, unsure, and other term.\u003c/p\u003e\n\u003ch3\u003eMental Health and Substance Use\u003c/h3\u003e\n\u003cp\u003eThe presence of a major depressive episode (MDE) in the past year was measured using DSM-5 criteria derived from self-reported symptoms.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e Past-year alcohol use, past-year marijuana use, and past-year opioid misuse were included as covariates due to their known associations with suicide risk.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003ch3\u003eDemographics\u003c/h3\u003e\n\u003cp\u003eDemographic variables included age (years), sex at birth (male/female), race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, other), sexual orientation (heterosexual, gay/lesbian, bisexual, unsure, use a different term), and county status (large metropolitan, small metropolitan, nonmetropolitan).\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eAnalysis Plan\u003c/h2\u003e \u003cp\u003eFor all analyses, when available, we used multiple-imputed variables provided by NSDUH to limit the amount of missing data. The NSDUH employs a fully integrated imputation strategy, most commonly based on predictive mean matching and logistic regression frameworks, to address item-level missingness for sensitive measures (e.g., income, substance use, and mental health indicators). Multiple imputed datasets are released as part of the public-use files, and analyses incorporated these imputations following recommended guidelines to preserve variance and reduce bias associated with missing data. When applicable, imputed variables were used in place of raw variables, and estimates were combined using Rubin\u0026rsquo;s rules to account for between- and within-imputation variability. Frequencies were estimated to describe participant characteristics. Bivariate comparisons were estimated with Rao-Scott Chi-square tests. Multivariate logistic regression analyses were built to determine conditional associations to past-year suicidal ideation and planning. To operationalize intersectionality, interaction terms between sex at birth and sexual identity were included in regression models. All analyses accounted for the NSDUH\u0026rsquo;s complex survey design, including stratification, clustering, and unequal probabilities of selection. Sampling weights provided by NSDUH were applied to generate nationally representative estimates of Black/African American youth in the United States. These weights incorporate adjustments for differential selection probabilities, nonresponse, and post-stratification to U.S. Census population controls. Variance estimation was conducted using Taylor series linearization to produce appropriate standard errors and confidence intervals under the complex design. To operationalize an intersectional framework, interaction terms between sex at birth and sexual identity were included in regression models to assess whether associations with suicidal ideation and planning differed across intersecting identities (with white LBG+ youth as a reference). Where statistically significant interactions were observed, stratified estimates or predicted probabilities were examined to aid interpretation. All analyses were conducted in R (version 4.5.1), primarily using the dplyr package for data management and the survey package for design-based estimation, ensuring that all point estimates and inferential statistics appropriately reflected the NSDUH\u0026rsquo;s sampling design and weighting structure.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe sample consisted of 1,146 Black youths (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) were distributed almost evenly by sex at birth (53.5% male and 46.4% female). Large metropolitan regions accounted for the majority (60.9%), small metro counties (30.3%), and nonmetro counties (8.76%). An estimated 12.0% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;137) thought about suicide in the past year and 5.76% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;66) of youth planned suicide in the past year.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSample Demographics (N\u0026thinsp;=\u0026thinsp;1,146)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWeighted % [95% CI\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex at birth\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e53.5 [49.4,57.6]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e46.4 [42.3, 50.6]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12-13-Year Olds\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e33.2 [29.3, 37.3]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14-15-Year Olds\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e34.5 [30.7, 38.4]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16\u0026ndash;17 Year Olds\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32.3 [28.6, 36.3]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSexual Identity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeterosexual, that is, Straight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e83.9 [80.8, 86.5]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGay/Lesbian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.23 [1.41, 3.51]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBisexual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7.90 [6.09, 10.2]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI use a different term\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.43 [0.80, 2.55]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI am not sure about my sexual identity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.58 [3.17, 6.58]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCounty Level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLarge Metro\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e60.9 [56.9, 64.8]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmall Metro\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30.3 [26.7, 34.1]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-Metro\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8.76 [6.86, 11.1]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMajor Depressive Episode (Past-Year)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10.9 [8.66, 13.7]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e89.1 [86.3, 91.3]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePast Year Alcohol Use\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10.2 [7.94, 13.1]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e89.8 [86.9, 92.1]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePast Year Marijuana Use\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11.5 [9.15, 14.5]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e88.5 [85.5, 90.8]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePast-Year Non-Medical Opioid Use\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.74 [1.75, 4.28]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e97.2 [95.7, 98.2]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAfter adjusting for biological sex, county type, past-year use of alcohol/opioids/marijuana, grade level, and family income, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the adjusted odds ratios (AORs) for suicide ideation and suicide planning across various sexual identity categories. Compared to adolescents who identified as heterosexual, adolescents who reported describing their sexual identity with a different term had the highest chances of suicidal thoughts (AOR\u0026thinsp;=\u0026thinsp;7.69, 95% CI 2.83, 20.9) and planning (AOR\u0026thinsp;=\u0026thinsp;4.74, 95% CI 1.19, 18.9). Additionally, those who identified as gay or lesbian had higher risks of suicidal thoughts (AOR\u0026thinsp;=\u0026thinsp;5.81, 95% CI 1.10, 30.6), but no differences on planning. Adolescents who identify as bisexual had higher odds of suicidal thoughts (AOR\u0026thinsp;=\u0026thinsp;4.15), but not planning. Adolescents who were unclear of their sexual orientation had significantly reduced risks of suicidal thoughts (AOR\u0026thinsp;=\u0026thinsp;3.32) and planning (AOR\u0026thinsp;=\u0026thinsp;4.81). The interactions between sex at birth and sexual identity and their associations with suicide ideation and planning were not significant.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAdjusted Odds Ratios towards Suicide Ideation and Planning among Black/African American Youth\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSexual Identity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSuicide Ideation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSuicide Planning\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eHeterosexual, that is straight\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eReference\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eReference\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eGay or lesbian\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e5.81 [1.10, 30.6]\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.27 [0.81, 34.2]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eBisexual\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e4.15 [1.41, 12.2]\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.27 [0.41, 3.86]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eI use a different term\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e7.69 [2.83, 20.9]\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e4.74 [1.19, 18.9]\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eI am not sure about my sexual identity\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.49 [0.52, 4.21]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.88 [0.69, 5.13]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSex at Birth * Sexual Identity\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.23 [0.04, 1.38]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.45 [0.04, 4.83]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eWhite LGB+ Youth (reference) vs. Black LGB Youth\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.09 [0.34, 11.5]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.35 [0.49, 23.1]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e*Models controlled for biological sex, past year use of alcohol//marijuana/opioids, major depressive episode, income, county status, and grade-level. Bolded ORs indicate \u003cem\u003ep\u003c/em\u003e\u0026lt;.05.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eMain Findings\u003c/h2\u003e \u003cp\u003eThis study sought to examine suicidal behavior among Black LGB+ youth in relation to adverse mental health outcomes such as depression and substance use. Compared to Black non-LGB+ adolescents, Black LGB+ adolescents were at increased risk for suicidal ideation and planning. Moreover, youth who used a different term to describe their identity were at the highest risk for both outcomes, highlighting the need for further research into specific identities and intersectional components and their relationship to poor mental health.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eFindings in Context\u003c/h2\u003e \u003cp\u003eAdolescent suicide remains a critical public health issue in the United States and globally.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e Moreover, from 2011 to 2020, the number of emergency department visits in the US associated with suicide attempts and self-harm increased nearly 20%.\u003csup\u003e24\u003c/sup\u003e These rates are of concern, given the low providerment of health services and screening opportunities to address suicide among youth.\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e Adolescence represents a sensitive developmental period characterized by identity formation, heightened peer influence, and ongoing neurocognitive maturation, which together may amplify vulnerability to social stressors and limit youths\u0026rsquo; capacity to regulate distress or seek support. As a result, suicidal ideation and planning during this life stage often reflect cumulative exposure to interpersonal, institutional, and structural adversity rather than isolated events.\u003c/p\u003e \u003cp\u003eDisparities in suicidality are especially pronounced among adolescents who identify as lesbian, gay, or bisexual (LGB+), substantiating our findings. According to the 2023 YRBSS, LGBT+ adolescents were significantly more likely than their non-LGB+ peers to report seriously considering suicide (41% vs. 13%), planning a suicide attempt (32% vs. 11%), or attempting suicide (20% vs. 6%).\u0026sup2; Minority stress theory provides a useful framework for understanding these disparities, as LGB+ youth are disproportionately exposed to stigma, victimization, and identity concealment, all of which increase psychological distress and reduce access to affirming support systems.\u003c/p\u003e \u003cp\u003eIn addition, the observed increase in suicide rates for Black youth highlight a lack of progress for this growing disparity. Previous research has shown that Black youth ages 15\u0026ndash;17 experienced the largest increase in suicide, and Black females were twice as likely to attempt suicide compared to Black males.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e These patterns suggest that suicidality among Black adolescents may be shaped by intersecting stressors\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e related to racism, gendered expectations, and reduced access to culturally responsive mental health care. Educational context may play a particularly important role, as Black youth are more likely to experience school-based discrimination and reduced school connectedness\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e, which have been identified as factors that have been independently linked to depression and suicidality.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e Additionally, the findings in our study contribute to the growing but low amount of research that has been conducted on Black LGB+ youth. An estimated 12.8% of Black youth in the NSDUH study sample reported experiencing a major depressive episode (MDE), a known risk factor for suicidality. Data from the 2024 Human Rights Campaign 2024 Black LGBTQ+ Youth Report\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e revealed that 53.3% of Black LGB+ youth screened positive for depression, but less than half (46.5%) of youth wanted therapy but could not receive it, highlighting the ongoing awareness of increasing mental health resources for underserved youth.\u003c/p\u003e \u003cp\u003eAs research focusing on risk factors for Black and LGB+ youth continues, evidence-based protective factors remain significantly less studied, and research barely intersects the two.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e Prior reviews have found that religious, social, familial, and personal factors could all help reduce the risk of suicidality among Black youth.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e,\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e In addition, protective factors for both Black or LGB+ youth include feelings of hopefulness, a positive self-identity, having a stable environment, and community or social support.\u003c/p\u003e \u003cp\u003eImportantly, suicidal ideation and planning among Black LGB+ youth do not emerge in isolation but reflect the cumulative and developmentally patterned effects of social, educational, and structural stressors. Adolescence represents a sensitive developmental period marked by identity formation, heightened peer salience, and limited emotion regulation capacity, all of which may amplify vulnerability to stress-related psychopathology. Younger adolescents, in particular, may experience greater difficulty accessing coping resources or articulating distress, increasing the likelihood that stressors related to race-, sexuality-, and gender-based stigma manifest as internalized distress or suicidal ideation rather than help-seeking behaviors. Educational context further compounds this risk; school environments function as primary social ecosystems for youth, and exposure to bullying, exclusion, or curricula that erase or stigmatize Black and LGB+ identities can exacerbate feelings of invisibility, burdensomeness, and thwarted belonging.\u003c/p\u003e \u003cp\u003eIt is important to note racial/ethnic differences in the \u0026ldquo;coming out\u0026rdquo; process. Compared to White adolescents, Black youth may \"come out\" expressively sooner than their white counterparts and be subjected to harassment at home and school; therefore, to cover their true identities, many LGB+ youth will deny or hide their sexuality in order survive. Prior literature has shown that among African American youth, coming out led to an initial reaction of negativity, but soon was tempered over time.\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e The socio-cognitive-behavioral model of adjustment theorizes that family members\u0026rsquo; initial responses to a child\u0026rsquo;s disclosure are shaped by preexisting beliefs, cultural norms, and perceived social stigma, which may result in early rejection or distress.\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e Over time, however, cognitive reframing, increased knowledge, and ongoing interpersonal interactions can facilitate more adaptive coping and behavioral change, leading to greater acceptance and improved family relationships. This adjustment process may ultimately result in greater acceptance, improved communication, and enhanced family functioning, even within cultural contexts that initially discourage sexual minority identities.\u003csup\u003e\u003cspan additionalcitationids=\"CR32\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eWhile suicide prevention programs exist for minority youth, studies have not been conducted to determine whether these interventions are effective for Black LGB+ youth who participate in these programs.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e A recent systematic review and meta-analysis of psychotherapy interventions for reducing suicidal thoughts and behaviors among Black youth notes the lack of interventions and community initiatives to address this problem\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e, although several interventions call for the integration of community leaders and mental health professionals to take a multi-factorial approach for addressing suicidality among Black youth.\u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e,\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eImplications for Prevention\u003c/h2\u003e \u003cp\u003eTo address suicide among Black LGB+ youth, prevention strategies must move beyond one-size-fits-all approaches that overlook the interplay between race, culture, and sexual identity. Traditional school-based suicide prevention programs, while effective for general populations, often fail to engage racial and sexual minority adolescents if they lack cultural relevance or affirming representation.\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e Efforts such as Sources of Strength and Signs of Suicide have shown efficacy in general adolescent populations, but their impact among Black LGB+ youth remains limited without adaptation for intersectional identity experiences.\u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e,\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eCulturally responsive and community-engaged approaches are essential for youth suicide prevention.\u003csup\u003e\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e Programs co-developed with Black LGB+ youth and community leaders can enhance trust and relevance. Interventions that leverage community-based organizations, faith institutions, and peer mentoring networks may provide critical safe spaces that affirm both racial and sexual identity.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e For example, the BEAM (Black Emotional and Mental Health Collective) and The Trevor Project\u0026rsquo;s Black \u0026amp; LGB+ Initiative demonstrate how partnerships between community and clinical systems can promote identity-affirming care and crisis support.\u003csup\u003e\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e,\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eClinician training in intersectional cultural competency represents another vital layer of prevention. Mental health professionals must be equipped to address racial trauma, heterosexism, and identity-related stress with cultural humility.\u003csup\u003e\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e,\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u003c/sup\u003e Studies show that clients report higher satisfaction, therapeutic engagement, and improved mental health outcomes when clinicians integrate affirming language and explore intersecting identities.\u003csup\u003e\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e,\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u003c/sup\u003e The American Psychological Association has emphasized that culturally competent, affirming care is a core component of suicide prevention among marginalized youth.\u003csup\u003e\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eMoreover, inclusive school climates have measurable protective effects. Exposure to supportive teachers, gender-sexuality alliances (GSAs), and inclusive anti-bullying policies significantly reduces suicide attempts among LGB+ students, with particularly strong benefits for students of color.\u003csup\u003e\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e,\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/sup\u003e Gender\u0026ndash;Sexuality Alliances (GSAs) are uniquely positioned to function as protective spaces but must move beyond symbolic inclusion to intentional engagement. GSAs can be strengthened by incorporating leadership opportunities for students of color, addressing racism within LGBTQ+ spaces, partnering with Black community organizations, and providing structured peer-support or mentorship components. GSAs that explicitly affirm racial identity alongside sexual identity may enhance belonging, reduce isolation, and foster collective efficacy\u0026mdash;key buffers against suicidality during adolescence. Consistent actions such as using correct pronouns, displaying affirming symbols, or integrating diverse role models into curricula, can foster belonging and resilience.\u003csup\u003e\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u003c/sup\u003e Moreover, teachers and school staff also play a measurable role in prevention. Training educators to integrate inclusive and affirming content into curricula, particularly in history, literature, and health education, can reduce identity-based stigma and promote visibility. Simple but consistent practices, such as using correct pronouns, intervening in bias-based bullying, and acknowledging diverse family structures, have been shown to improve school climate and mental health outcomes for LGB+ students, with particularly strong effects for students of color.⁴⁷-⁴⁹ These practices are especially important during early adolescence, when peer validation and adult support are critical to psychological well-being.\u003c/p\u003e \u003cp\u003eAt the structural level, funding and policy mechanisms must explicitly prioritize intersectional populations. Programs such as the Minority Fellowship Program and Project AWARE should be leveraged to expand culturally competent mental health training and research focused on Black LGB+ youth, thereby expanding critical resources for health promotion.\u003csup\u003e\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e,\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e\u003c/sup\u003e Federal and state policies aimed at improving insurance coverage, expanding school-based behavioral health services, and enforcing anti-discrimination protections can function as upstream suicide prevention strategies.\u003csup\u003e\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e\u003c/sup\u003e Addressing systemic inequities, such as underrepresentation of Black clinicians and barriers to affirming care, is critical to closing the mental health gap.\u003csup\u003e\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eFinally, informal support systems play a critical protective role for Black LGB+ youth, particularly in the context of suicide risk, by offering affirmation, belonging, and culturally responsive coping resources that may be absent in families, schools, or formal institutions. House and ballroom communities\u0026mdash;historically rooted in Black and Latinx LGB+ culture\u0026mdash;function as chosen families that provide mentorship, emotional support, identity validation, and opportunities for leadership through roles such as \u0026ldquo;house mothers\u0026rdquo; and \u0026ldquo;house fathers,\u0026rdquo; which have been associated with resilience and reduced social isolation among sexual and gender minority youth of color.\u003csup\u003e\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e,\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e\u003c/sup\u003e Similarly, fictive kin networks, including gay mothers, gay fathers, and peer-based family structures, serve as alternative caregiving systems that buffer the effects of rejection, homelessness, and stigma, all of which are well-established risk factors for suicidal ideation and attempts.\u003csup\u003e\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e\u003c/sup\u003e Online spaces further extend these informal supports by enabling Black LGB+ youth to access community, information, and peer validation beyond geographically constrained or unsafe environments, though the quality and safety of these spaces remain variable.\u003csup\u003e\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e\u003c/sup\u003e Finally, engagement in visual and performing arts including dance, music, poetry, and performance traditions embedded within ballroom culture provides expressive outlets that facilitate emotion regulation, identity exploration, and meaning-making, processes that are increasingly recognized as protective against depression and suicidality among marginalized youth.\u003csup\u003e\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e\u003c/sup\u003e Collectively, these informal support systems operate as vital, community-generated mechanisms of survival and resilience for Black LGB+ youth facing intersecting forms of racism, heterosexism, and cisnormativity.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eImplications for Intersectionality Research and Future Directions\u003c/h2\u003e \u003cp\u003eAdvancing suicide prevention science requires research frameworks that move beyond single-axis analyses of race or sexual identity and instead center intersectionality as a guiding paradigm. Rooted in Black feminist scholarship, intersectionality emphasizes that systems of racism, heterosexism, and other forms of structural oppression are mutually constitutive and shape health in synergistic ways rather than as independent risk factors.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Traditional epidemiologic models that treat race and sexual orientation as separate covariates risk obscuring these dynamics and may underestimate disparities among multiply marginalized youth.\u003csup\u003e\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e\u003c/sup\u003e Future studies should explicitly test intersectional effects and theorize identity as relational and structural, rather than additive.\u003csup\u003e\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eMethodologically, researchers should expand the use of analytic approaches capable of modeling intersectional inequities. Multilevel frameworks that incorporate structural stigma indicators (e.g., state-level policy climates, school anti-bullying protections) can better capture contextual influences on suicidal behaviors.\u003csup\u003e\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e\u003c/sup\u003e Intersectionality-informed quantitative methods\u0026mdash;including interaction modeling, stratified analyses, multilevel intersectional models (e.g., MAIHDA), and person-centered approaches such as latent class or profile analysis\u0026mdash;allow for the examination of heterogeneous risk configurations across identity groups.\u003csup\u003e\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e,\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e\u003c/sup\u003e These approaches help disentangle whether disparities reflect compositional differences or structural processes embedded in social systems.\u003c/p\u003e \u003cp\u003eLongitudinal research is particularly critical. Most existing studies rely on cross-sectional data, limiting causal inference and developmental insight.\u003csup\u003e\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e\u003c/sup\u003e Life-course frameworks suggest that exposure to discrimination, identity-based victimization, and structural inequities accumulates over time, shaping trajectories of mental health and suicidality.\u003csup\u003e\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e\u003c/sup\u003e Prospective cohort studies beginning in early adolescence\u0026mdash;and ideally incorporating biomarkers of stress or neurodevelopmental indicators\u0026mdash;could clarify sensitive periods and mechanisms linking intersectional stressors to suicidal ideation and attempts.\u003csup\u003e\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eMeasurement refinement is also needed. Many large datasets lack nuanced assessments of sexual identity, gender identity, racialized experiences, and cultural context.\u003csup\u003e\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e\u003c/sup\u003e Expanding survey items to include multidimensional measures of identity affirmation, racial discrimination, internalized stigma, and community connectedness would strengthen explanatory models.\u003csup\u003e\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e\u003c/sup\u003e Additionally, incorporating qualitative and mixed-methods research can illuminate protective cultural processes\u0026mdash;such as chosen family networks or community-based resilience\u0026mdash;that may not be captured in standardized instruments.\u003csup\u003e\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e\u003c/sup\u003e Community-based participatory research (CBPR) models are especially valuable, as they center youth voices and enhance ecological validity.\u003csup\u003e\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e\u003c/sup\u003e Future research must also interrogate protective factors alongside risk. While minority stress theory has been instrumental in identifying mechanisms of vulnerability, emerging resilience frameworks highlight the importance of identity pride, collective efficacy, and culturally grounded coping.\u003csup\u003e\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e\u003c/sup\u003e Examining how protective school climates, affirming clinicians, and community-based organizations buffer intersectional stress can also inform multilevel intervention design.\u003c/p\u003e \u003cp\u003eAt the structural level, policy-focused research is essential. Evaluations of anti-discrimination laws, inclusive school policies, Medicaid expansion, and culturally responsive workforce initiatives can clarify upstream determinants of suicide risk among multiply marginalized youth.\u003csup\u003e\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e\u003c/sup\u003e Structural stigma has been linked to adverse mental health outcomes among sexual minority populations, underscoring the need for natural experiments and quasi-experimental designs that assess policy change over time.\u003csup\u003e\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e\u003c/sup\u003e Integrating administrative data, geospatial indicators, and policy surveillance tools will strengthen causal inference and translational relevance.\u003c/p\u003e \u003cp\u003eFinally, intersectionality research must prioritize workforce diversification and research equity. Underrepresentation of Black investigators and scholars with lived experience in LGBTQ+ communities limits innovation and trust.\u003csup\u003e\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e\u003c/sup\u003e Federal initiatives that fund early-career scholars, community partnerships, and culturally grounded intervention trials are essential to sustaining progress.\u003csup\u003e\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e\u003c/sup\u003e By embedding intersectionality across theory, measurement, design, and policy translation, future research can more precisely identify mechanisms of risk and resilience\u0026mdash;and ultimately inform suicide prevention strategies that reflect the full complexity of Black LGB+ youths\u0026rsquo; lived experiences.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eSeveral limitations of the current study should be noted, including self-selection bias.While sexual orientation was assessed, gender identity was not; future research needs to examine gender identity, given that gender diverse individuals report high rates of suicide.\u003csup\u003e\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e\u003c/sup\u003e Moreover, the generalizability of our findings may be limited by the high prevalence of opioid and other substance use in some areas, which was not included in the NSDUH dataset.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study highlights the heightened vulnerability of Black LGB+ youth to suicidal ideation and planning, underscoring the urgent need for targeted mental health interventions. Compared with Black non-LGB+ peers, Black LGB+ adolescents experience a disproportionate burden of suicidality and associated mental health concerns such as depression and substance use. Our findings emphasize that youth who describe their identities outside of conventional LGB+ labels are at especially high risk, signaling a critical gap in both research and clinical care.\u003c/p\u003e \u003cp\u003eGiven the persistently rising rates of suicide among Black youth and the longstanding disparities affecting LGB+ adolescents, these findings call for culturally responsive, identity-affirming prevention strategies. Expanding access to mental health care, addressing structural barriers, and ensuring culturally competent providers are essential steps toward reducing these inequities. Moreover, future research should prioritize identifying and strengthening protective factors\u0026mdash;such as social support, positive identity development, and community resources\u0026mdash;that can buffer against suicide risk in this population.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003eA University Institutional Review Board approved this study.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot Applicable\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eNot Applicable\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors contributed to analyses and the overall draft of the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eNot Applicable\u003c/p\u003e\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e \u003cp\u003eData are available on SAMHSA website\u003c/p\u003e \u003cp\u003eCompeting interests\u003c/p\u003e \u003cp\u003eNot Applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCenters for Disease Control and Prevention. \u003cem\u003eCDC WONDER: About Multiple Causes of Death, 2018\u0026ndash;2022\u003c/em\u003e. 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PMID: 39455520.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHorwitz AG, Berona J, Busby DR, Eisenberg D, Zheng K, Pistorello J, Albucher R, Coryell W, Favorite T, Walloch JC, King CA. Variation in Suicide Risk among Subgroups of Sexual and Gender Minority College Students. Suicide Life Threat Behav. 2020;50(5):1041\u0026ndash;1053. doi: 10.1111/sltb.12637. Epub 2020 Apr 15. PMID: 32291833; PMCID: PMC7981781.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"global-lgbtq-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Global LGBTQ+ Health](https://link.springer.com/journal/44506)","snPcode":"44506","submissionUrl":"https://submission.springernature.com/new-submission/44506/3","title":"Global LGBTQ+ Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Epidemiology, prevention, suicidality","lastPublishedDoi":"10.21203/rs.3.rs-9087260/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9087260/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSuicide remains a leading cause of death among U.S. adolescents, with notable disparities based on race/ethnicity and sexual orientation. Black adolescents and those identifying as lesbian, gay, bisexual, or using alternative sexual identity labels (LGB+) face higher risks for suicidal thoughts and behaviors, yet research on the intersection of these identities is limited. The aim was to assess the prevalence of suicidal thoughts and planning among Black youth in the U.S. and examine disparities by sexual identity using a nationally representative dataset.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe performed a secondary analysis of 1,146 Black adolescents from the 2023 National Survey on Drug Use and Health (NSDUH). Suicidal ideation and planning were measured through self-reports of thoughts or plans in the past 12 months. Covariates included demographics, sexual orientation, mental health, and substance use. Analyses involved weighted frequencies, Rao-Scott Chi-square tests, and multivariate logistic regression to explore associations.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAmong Black adolescents, 12.0% reported suicidal ideation in the past year, and 5.76% reported planning suicide. Compared with heterosexual peers, adolescents identifying as gay/lesbian, bisexual, or using alternative identity labels had significantly higher adjusted odds of suicidal ideation (AOR\u0026thinsp;=\u0026thinsp;4.19\u0026ndash;7.69) and planning, with the highest risk seen among those using different terminology (AOR: 4.74). The interaction between sex at birth and sexual identity was not significant. Youth using alternative identity labels showed the greatest risk for both outcomes.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eBlack LGB+ youth, especially those with nonconventional sexual identities, experience disproportionately high rates of suicidal thoughts and planning. These findings highlight the urgent need for culturally responsive, identity-affirming prevention strategies, better access to mental health care, and tailored interventions for this underserved population. Future research should investigate protective factors and mechanisms that can buffer suicide risk among Black LGB+ adolescents.\u003c/p\u003e","manuscriptTitle":"An Intersectional Approach Towards understanding Suicidality among Black LGB+ Adolescents, USA, 2023","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-14 09:50:32","doi":"10.21203/rs.3.rs-9087260/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"2002223698058820307031528976487378866","date":"2026-05-18T09:07:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"75546774914974771805040033148004101478","date":"2026-05-14T13:24:35+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-05-05T07:27:40+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-27T13:21:40+00:00","index":"","fulltext":""},{"type":"submitted","content":"Global LGBTQ+ Health","date":"2026-04-23T17:40:05+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"global-lgbtq-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Global LGBTQ+ Health](https://link.springer.com/journal/44506)","snPcode":"44506","submissionUrl":"https://submission.springernature.com/new-submission/44506/3","title":"Global LGBTQ+ Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"becbac88-396e-4a47-adc3-00ea3ebf5c4f","owner":[],"postedDate":"May 14th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"2002223698058820307031528976487378866","date":"2026-05-18T09:07:23+00:00","index":35,"fulltext":""},{"type":"reviewerAgreed","content":"75546774914974771805040033148004101478","date":"2026-05-14T13:24:35+00:00","index":33,"fulltext":""},{"type":"reviewersInvited","content":"16","date":"2026-05-05T07:27:40+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-14T09:50:32+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-14 09:50:32","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9087260","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9087260","identity":"rs-9087260","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}