Applied Science, Faculty of
Nursing, School of
DSpace
UBCV
Dhari, Shivinder
Master of Science in Nursing - MSN
University of British Columbia
Suicidality, including ideation, plans, and attempts remains a significant public health issue in Canada for individuals who self-identify as a sexual and/or gender minority; particularly sexual and/or gender minority women (SGMW) who self-identify as lesbian, bisexual, trans, and queer, are often at an increased risk for suicide ideation and attempts compared to other sexual and/or gender minority groups. Despite this increase in risk, there remains a paucity of qualitative research examining the lived experiences of SGMW who have attempted suicide. In this study, photovoice methods, underpinned by the minority strengths model, were used to understand the lived experiences of SGMW who have attempted suicide and ways they continue to embody the strength and resiliency to continue living post-attempt. Drawing on 11 interviews, three themes were generated using reflexive thematic analysis: (ⅰ) “I can just be”: finding comfort in their own skin; (ⅱ) “Anchoring to life”: the role of connection and belonging: and (ⅲ) “Staying alive”: the journey continues. Finding comfort in their own skin was characterized by the acceptance of the participants sexual orientation and gender identity – both by themselves and by others – which enhanced their resiliencies in continuing to live post-attempt. Participants feeling of anchoring to life came from having a sense of connection and belonging gained via social support networks in survival post-attempt. Staying alive post-attempt was a journey for participants which required consistent effort involving seeking professional mental health services and effective self-management. The findings of this study offer insights for healthcare practitioners, both in the acute and outpatient clinical settings, including creation of safe spaces for SGMW and a strengths-based approach to care to further bolster individual and family resilience.
A STRENGTHS-BASED EXPOLORATION OF THE LIVED EXPERIENCES OF SEXUAL AND/OR GENDER MINORITY WOMEN WITH PAST SUICIDE ATTEMPTS by Shivinder Dhari BScN, RN, The University of British Columbia, 2016 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) August 2021 © Shivinder Dhari, 2021 ii The following individuals certify that they have read, and recommend to the Faculty of Graduate and Postdoctoral Studies for acceptance, the dissertation entitled: A strengths-based exploration of the lived experiences of sexual and/or gender minority women with past suicide attempts submitted by Shivinder Dhari in partial fulfillment of the requirements for the degree of Master of Science in Nursing Examining Committee: Dr. Emily Jenkins, Associate Professor, Nursing, UBC Co-supervisor Dr. John Oliffe, Professor, Nursing, UBC Co-supervisor Dr. Corey McAuliffe, Postdoctoral Research Fellow, Nursing, UBC Supervisory Committee Member iii Abstract Suicidality, including ideation, plans, and attempts remains a significant public health issue in Canada for individuals who self-identify as a sexual and/or gender minority; particularly sexual and/or gender minority women (SGMW) who self-identify as lesbian, bisexual, trans, and queer, are often at an increased risk for suicide ideation and attempts compared to other sexual and/or gender minority groups. Despite this increase in risk, there remains a paucity of qualitative research examining the lived experiences of SGMW who have attempted suicide. In this study, photovoice methods, underpinned by the minority strengths model, were used to understand the lived experiences of SGMW who have attempted suicide and ways they continue to embody the strength and resiliency to continue living post-attempt. Drawing on 11 interviews, three themes were generated using reflexive thematic analysis: (ⅰ) “I can just be”: finding comfort in their own skin; (ⅱ) “Anchoring to life”: the role of connection and belonging: and (ⅲ) “Staying alive”: the journey continues. Finding comfort in their own skin was characterized by the acceptance of the participants sexual orientation and gender identity – both by themselves and by others – which enhanced their resiliencies in continuing to live post-attempt. Participants feeling of anchoring to life came from having a sense of connection and belonging gained via social support networks in survival post-attempt. Staying alive post-attempt was a journey for participants which required consistent effort involving seeking professional mental health services and effective self-management. The findings of this study offer insights for healthcare practitioners, both in the acute and outpatient clinical settings, including creation of safe spaces for SGMW and a strengths-based approach to care to further bolster individual and family resilience. iv Lay Summary Though suicide remains a significant concern for sexual and/or gender minority women, known to have higher rates of suicidal thoughts and attempts, there is a lack of understanding of the experiences of those who have attempted suicide and continue to live. This study aimed to better understand the ways in which sexual and/or gender minority women who have attempted suicide, find the strength and resiliency to continue living post-attempt. Stories from 11 participants were included in this study. The participants spoke to the importance of acceptance of their sexual orientation and gender identity (by themselves and others), feeling a sense of connection and belonging, and using mental health services to self-manage as giving them the strength and resiliency to continue to live post suicide attempt. Healthcare professionals working with sexual and/or gender minority women after suicide attempt need to provide a safe, affirming environment allowing for vulnerability. v Preface This thesis is a secondary analysis of a subsample taken from a larger study and includes original, unpublished work. The conceptualization, analysis, and writing of this thesis was completed by the author with support from the supervisors including Dr. Emily Jenkins who provided guidance and support throughout the process and Dr. John Oliffe who in addition to providing guidance also provided access to the data from the original research. Ethics approval for the original research was sought and received from the University of British Columbia’s Behavioral Research Ethics Board (UBC BREB Number: H13-02592). vi Table of Contents Abstract ......................................................................................................................................... iii Lay Summary ............................................................................................................................... iv Preface .............................................................................................................................................v Table of Contents ......................................................................................................................... vi List of Figures ............................................................................................................................. viii Acknowledgements ...................................................................................................................... ix Dedication .......................................................................................................................................x Chapter 1: Introduction ................................................................................................................1 1.1 Background ..................................................................................................................... 1 1.2 Purpose ............................................................................................................................ 4 1.3 Significance..................................................................................................................... 5 1.4 Research questions .......................................................................................................... 5 1.5 Summary ......................................................................................................................... 5 1.6 Thesis overview .............................................................................................................. 6 Chapter 2: Literature Review .......................................................................................................7 2.1 Risk factors for SGMW .................................................................................................. 7 2.1.1 Multiple minority status .............................................................................................. 7 2.1.2 External factors ........................................................................................................... 8 2.1.3 Internal factors ............................................................................................................ 8 2.2 Protective factors for SGMW ......................................................................................... 9 2.2.1 Social environment ..................................................................................................... 9 vii 2.2.2 Individual-level factors ............................................................................................. 10 2.3 Current study ................................................................................................................. 11 Chapter 3: Methodology..............................................................................................................13 3.1 Theoretical framing ....................................................................................................... 13 3.2 Data collection .............................................................................................................. 15 3.3 Data analysis ................................................................................................................. 16 Chapter 4: Findings .....................................................................................................................18 4.1 “I can just be”: finding comfort in their own skin ........................................................ 18 4.2 “Anchoring to life”: the role of connection and belonging........................................... 24 4.3 “Staying alive”: the journey continues ......................................................................... 30 Chapter 5: Discussion and Implications ....................................................................................37 5.1 Discussion ..................................................................................................................... 37 5.2 Implications for practice ............................................................................................... 41 5.3 Limitations and future research recommendations ....................................................... 44 References .....................................................................................................................................46 viii List of Figures Figure 3.1 Minority strengths model ............................................................................................. 3ix Acknowledgements This work would not have been possible without the consistent support and guidance of Dr. Emily Jenkins, my advisor and supervisor. Thank you for finding the balance between supporting and challenging me and constantly advocating for me through all the unexpected changes. Thank you to Dr. John Oliffe for trusting me with the stories of the participants and for pushing my thinking further. Thank you to my partner Sanjeet Dhari for your forever support and cheerleading. Thank you to all my parents who have instilled values that continue to shape my work. I would like to acknowledge my privilege in pursuing a graduate degree and recognize my responsibility accompanied by this privilege. I would like to acknowledge that this research took place on the unceded territories of the xʷmәθkʷәy̓әm (Musqueam), Skwxwú7mesh Úxwumixw (Squamish), and sәl̓ilwәtaɁɬ (Tsleil Waututh) First Nations. x Dedication I would like to dedicate this to all the women who have struggled with suicide and have had the courage to share their stories. 1 Chapter 1: Introduction 1.1 Background People who self-identify as a sexual minority (i.e., lesbian, gay, bisexual, trans, queer, or questioning and two-spirit (LGBTQ2+))1, experience significant mental health disparities compared to their heterosexual counterparts. Specifically, depression, anxiety, substance use, and suicidal behavior are some of the mental health concerns that are more prevalent among LGBTQ2+ populations (Haas et al., 2011). The high risk for suicidality, including thoughts, plans, and attempts amongst LGBTQ2+ people is well-documented in the scientific literature and linked to the mental health concerns identified above (Haas et al., 2011; Hottes et al., 2016; King et al., 2008; Plöderl et al., 2013). With respect to suicide attempts, empirical evidence shows that people who identify as LGBTQ2+ report higher rates of suicide attempts across their lifespan than their heterosexual peers (Haas et al., 2011). Additionally, a meta-analysis of 30 studies that included population and community-based surveys found that they have a 17% higher prevalence of suicide attempts compared to their non- LGBTQ2+ counterparts (Hottes et al., 2016). To explain this disparity, the minority stress model has been useful in understanding the role of chronic social stressors including stigma, prejudice, discrimination, and violence on the physical and psychological well-being of minority groups (Meyer, 2013). These stressors, which are social and structural in nature, operate to create conditions that produce harm, including 1 There are different acronyms that are used to refer to individuals who self-identify as lesbian, gay, bisexual, trans, queer, two-spirit, questioning. For the purposes of this thesis, the umbrella acronym of LGBTQ2+ is used for consistency and being a commonly used term by the Canadian community. However, it is important to acknowledge that there are many other possible identities that fall within the sexual and gender identity spectrum and may not all be represented under the LGBTQ2+ acronym. 2 alienation, social isolation, lack of self-acceptance, discrimination, rejection, victimization, and internalized stigma (Meyer, 2013). While these stressors affect the mental health of LGBTQ2+ people broadly, there are also psychological health disparities within sexual minority populations. Specifically, sexual and/or gender minority women (SMGW) who self-identify as lesbian, bisexual, trans, and queer experience increased risk for various mental health concerns, including suicidality (Haas et al., 2011). For example, research shows that women who self-identify as lesbian/bisexual have higher rates of suicidal ideation compared to gay/bisexual men, who tend to report higher rates of suicide attempts (Haas et al., 2011; King et al., 2008). In addition, bisexual women have been found to be at increased risk of suicidality, including suicide attempts, compared to other sexual minority groups (Hottes et al., 2016; Kerr et al., 2013; Salway et al., 2019). A recent meta-analysis that sought to explain the influence of gender and sexual minority status on suicidality, found that bisexual women are at greater risk for suicide attempts compared to bisexual men and individuals who self-identify as lesbian or gay (Salway et al., 2019). Another meta-synthesis, specifically looking at individuals who self-identify as transgender, found that trans women report greater levels of suicidal ideation than trans men. Further, the rates of suicide attempts are similar in both groups and higher than individuals who self-identified as gender non-conforming (Adams et al., 2017). One explanation for these observed disparities is that SMGW may experience multiple forms of stigma and discrimination due to the both their gender and sexual orientation (Meyer, 2013; Salway et al., 2019). Recognizing the role of gender norms and expectations in understanding suicidality has been identified as a priority in the literature. The gender paradox, wherein there is a higher prevalence of suicide attempts among women while men have higher rates of suicide mortality, 3 is well-documented in research on suicide (Schrijvers et al., 2011). With respect to sexual minorities, the differences based on gender in suicidality are less established despite sexual orientation being associated with suicidality (Haas et al., 2011). Overall, it appears that SMGW experience more suicidal ideation whereas as gay/bisexual men report higher rates of suicide attempts and higher rates of suicide (Haas et al., 2011). While the gender paradox is seen in the general population, it may not fully explain the disparities in suicidality within-sexual minority groups. However, the socially and culturally constructed gender norms and expectations continue to influence the experiences of suicidality for SMGW regardless of sexual orientation (Canetto, 2008; Salway et al., 2019). Understanding the role of gender norms and expectations on the ways SGMW experience suicidality, specifically ways SMGW continue to live beyond a suicide attempt, can help inform the design of suicide prevention programs that take a gendered approach to supporting this subgroup (Fullagar & O'Brien, 2015) As mentioned, the minority stress model has been helpful in understanding the role of social stressors on the mental health of sexual minority groups. Most of the research conducted to date has utilized cross-sectional survey data from population-based studies to understand the risk factors that contribute to suicidality among LGBTQ2+ populations (Gahagan & Colpitts, 2017; Haas et al., 2011; Hjelmland, 2016). While this approach is important to identify risks and understand the reasons for observed health disparities, it fails to nuance the heterogeneity within LGBTQ2+ populations and continues to reinforce a deficit-based lens to understanding sexual minority health (Gahagan & Colpitts, 2017; Perrin et al., 2020). Alternatively, utilizing a strengths-based approach that focuses on protective factors can help highlight strength and resiliency among LGBTQ2+ populations. Further, utilizing approaches such as qualitative inquiry, to nuance the diversity of experiences within sexual minority subgroups, such as 4 SMGW, is critical (Gahagan & Colpitts, 2017; Haas et al., 2011; Meyer, 2013; Perrin et al., 2020). This type of research is needed to support a more comprehensive understanding of the mental health of SMGW, who are identified as a priority population for suicide prevention efforts (Haas et al., 2011) Moreover, such research will provide the evidence to support mental health promotion interventions that build on strengths and resilience and have shown promise in terms of effectiveness and sustainability (Gahagan & Colpitts, 2017; Haas et al., 2011). In addition to a paradigm shift towards strength-based health research, qualitative studies that center the lived experiences of SMGW who experience suicidality can provide a comprehensive and nuanced understanding of the ways that SMGW embody strength to continue living following a suicide attempt (Haas et al., 2011; Hjelmland, 2016). Furthermore, qualitative research is positioned to allow for rich and nuanced explorations to enhance understandings of experiences of suicidality, including the complexity of social, cultural, historical, and contextual factors that influence suicidality (Hjelmland, 2016). Understanding the diversity within-sexual minority groups rather than studying sexual minority populations as homogenous can help inform tailored mental health interventions for specific subgroups (Haas et al., 2011; Salway et al., 2019). 1.2 Purpose Despite the well-documented risks for suicide among SMGW, the majority of data is derived through population-based surveys that aim to identify the risk factors that contribute to suicidality. Few qualitative studies have been conducted and those that have fail to focus on the strengths that are supportive to SMGW following a suicide attempt. Given these identified gaps, the purpose of this secondary analysis is to provide an in-depth description of the experiences of 5 SMGW who have attempted suicide and illuminate the ways they continue to demonstrate strength and resilience in staying alive. 1.3 Significance A rich and nuanced understanding of the ways that SGMW demonstrate strength and resiliency in the aftermath of a suicide attempt can inform the design of effective, tailored suicide prevention and mental health promotion interventions for this priority population (Haas et al., 2011). Additionally, the insights into the perspectives of SGMW and suicidality can help mental health practitioners, including nurses, to effectively support clients who may be struggling with suicidality (Haas et al., 2011). Furthermore, by focusing on strengths and resiliency among SGMW, mental health practitioners can work to shift the discourse from a risk to a strength-based approach, thereby reducing stigma. 1.4 Research questions The research questions guiding the secondary analysis are: 1) What are the experiences of sexual and/or gender minority women who have attempted suicide? 2) How do sexual and/or gender minority women embody strength and resiliency to live beyond a suicide attempt? 1.5 Summary People who identify as LGBTQ2+ experience significant mental health disparities compared to their heterosexual counterparts. While the elevated risk of suicidality is well-documented in the literature, most of the available data is derived through population-based surveys that focus on risk and examine the LGBTQ2+ population as a homogenous group. Research that highlights lived experiences of SGMW who have attempted suicide with a focus of 6 strength and resilience can help shift the discourse from risk to strengths and inform the development of targeted mental health promotion and suicide prevention interventions that are grounded in and responsive to the lived experiences of SGMW, thereby enhancing effectiveness. 1.6 Thesis overview This chapter provides a brief background for this study, including the significance of examining the experiences of SMGW who have attempted suicide. Chapter Two provides a literature review of the risk and protective factors associated with suicidality in SGMW. In Chapter Three, the theoretical framework and methodology for this study is presented. Chapter Four, reports the findings from this research in three main themes. In Chapter Five, a detailed discussion of the findings linking them to the current literature is provided, including implications for clinical practice. 7 Chapter 2: Literature Review The following review of the literature aims to provide a description of the risk factors associated with suicidality for SGMW as well as protective factors for SGMW who have experienced suicidality. 2.1 Risk factors for SGMW Understanding the factors influencing the increased risk for suicidality among SGMW is central to understanding the specific needs of this priority population. For SGMW, risk factors related to suicidality include their multiple minority status as well as external and internal risk factors. 2.1.1 Multiple minority status Belonging to multiple minority groups has been associated with increased risk for suicide attempts in SGMW who identify as lesbian, bisexual, or queer (Haas et al., 2011; Manalastas, 2016; Plöderl et al., 2013; Williams et al., 2018). In a recent qualitative study that aimed to understand suicide attempts among people who self-identify as belonging to a sexual and/or gender minority, found that participants’ sexual identity was strongly connected to their experiences of suicidality (Williams et al., 2018). Specifically, feelings of isolation and distress stemming from a lack of self-acceptance as well as stigma related to their sexual orientation, acted as stressors that contributed to participants’ suicide attempts (Williams et al., 2018).This is aligned with other research utilizing intersectional perspectives, which identify that belonging to multiple minority groups based on gender and sexual orientation can often lead SGMW to experience more than one form stigma, discrimination, and prejudice (Borgogna et al., 2019; Meyer, 2003; Salway et al., 2019). 8 2.1.2 External factors In addition to multiple minority identities being a stressor for suicidality in SGMW, external factors such as lack of family support and victimization have also been shown to influence suicidality among SGMW. Indeed, a lack of support and rejection from family is a common experience among SGMW and often contributes to increased suicidality due to conflict, estrangement, and perceived stigma (Williams et al., 2018). In a national online survey examining the role of social support from family, friends, and significant others on suicidal ideation and lifetime suicide attempts in SGMW, lack of support from family was found to have a strong influence on suicide risk (Tabaac et al., 2015). Additionally, among SGMW, religious beliefs were linked to both suicidal ideation and attempts. Specifically, identity conflict based on faith was related to higher levels of suicide attempts among SGMW (Rabinovitch et al., 2015). In addition to gender and sexual identities, identifying as a suicide attempt survivor has been identified as further adding to the stigma and discrimination that SGMW face, with implications for well-being post-attempt (Williams et al., 2018). 2.1.3 Internal factors In addition to external influences, internal factors such as self-hate, perceived burdensomeness, failed belongingness, stigma, and internalized homophobia have been found to negatively impact mental health of SGMW and predict suicide risk. For example, for some SGMW, negative beliefs and internalized shame linked to sexual orientation has been described as more pronounced leading up to a suicide attempt (Williams et al., 2018). Perceived burdensomeness and failed belongingness have also been identified as prominent feelings related to suicidal ideation among sexual minorities (Plöderl et al., 2013). Indeed, findings from a survey of SGMW identified that perceived burdensomeness, stemming from discomfort related to 9 sexual orientation, as well as failed belongingness, predicted an increase in suicide attempts (Velkoff et al., 2016). Additionally, SGMW with higher levels of internalized homophobia have been found to experience elevated psychological distress and are less likely to engage in LGBTQ2+-specific coping strategies, including confronting homophobia, as well as practicing self-acceptance, engaging in spiritual practices, and seeking help (Kaysen et al., 2014). Further, the research literature identifies that SGMW who use venting as a form of coping, are more likely to report suicide attempts (Rabinovitch et al., 2015). 2.2 Protective factors for SGMW While the literature provides detailed findings on the risk factors for suicidality amongst SGMW, there is more limited literature identifying protective factors that decrease the risk of suicidal ideation and attempts among SGMW. Protective factors relating to the social environment as well as individual-level factors have been found to promote resiliency and decrease suicide risk among SGMW. 2.2.1 Social environment Social supports, community connectedness, and higher socio-economic status have all been found to have a protective effect on SGMW who have attempted suicide. Social support, specifically support from chosen family and peers, has been found to contribute substantially to decreasing internalized stigma among a group of SGMW post-suicide attempt (Williams et al., 2018). The nature of support from family was also found to influence suicidality, with consistent support identified as protective and associated with decreased lifetime suicide attempts among SGMW (Tabaac et al., 2015). Having supportive partners as well as being involved in LGBTQ2+ communities have also been described as fostering strength among SGMW who experience suicidality (Drabble et al., 2018). Having strong social networks to support during 10 crisis can also act as a buffer and provide a safe outlet for SGMW to process their experiences of discrimination and stigma (Tabaac et al., 2015). Further, SGMW who did not receive peer support post-attempt, have recognized its absence and described a desire to have been able to access it (Williams et al., 2018). Additionally, socioeconomic status has been identified as a protective factor, with SGMW with a higher socio-economic status reporting fewer lifetime suicide attempts (Tabaac et al., 2015). 2.2.2 Individual-level factors In addition to protective factors at the social level, individual-level factors such as self-acceptance of sexual minority identity as well as being a suicide attempt survivor have been found to be associated with well-being among SGMW. SGMW who have disclosed their sexual minority identity to individuals in their lives, have been found to be more accepting of their identity and report fewer feelings of perceived burdensomeness (Velkoff et al., 2016). Further, SGMW who protect themselves from hurtful experiences by distancing themselves from family members who are unaccepting of their sexual identity reported increased feelings of self-worth (Drabble et al., 2018). In addition, SGMW who report lower levels of internalized homophobia are more likely to engage in LGBTQ2+ specific coping strategies such as self-acceptance of their sexual minority identity, which in turn, contributes to greater resilience, thus mitigating experiences of minority stress (Kaysen et al., 2014). While self-acceptance and worth help to protect against minority stress, finding meaning and purpose in one’s sexual identity and experiences with suicidality have also been identified as protective for the mental health of SGMW. For example, in research examining SGMW who had engaged in suicidal behaviors, acceptance of these behaviors and integration of this experience into one’s identity contributed to finding meaning and purpose post-attempt (Williams et al., 11 2018). Further, some SGMW have indicated that finding meaning in their sexual minority identity by engaging in collective action, including LGBTQ2+ rights activism, supports their positive mental health and resiliency (Drabble et al., 2018). While there is limited literature on the protective factors that mitigate the risk of suicidality in SGMW, to date, little is known about the lived experiences of SGMW who have attempted suicide and the ways they embody strength and resiliency to continue living post-attempt. For example, in a recent systematic review examining suicidal behavior in LGBTQ2+ populations, the authors concluded that the majority of research to date focuses on sexual minority men or studies lesbian, gay, and bisexual men and women as a homogenous group. Indeed, only 14% of the studies in the review focused on SGMW (Yıldız, 2018). Moreover, only one study was identified that explores the lived experiences of LGBTQ2+ individuals’ post-suicide attempt, including SGMW (Williams et al., 2018). To my knowledge, no research studies have been conducted to understand the strengths that SGMW utilize to continue living following a suicide attempt – limiting the evidence-base informing interventions to support mental health and prevent suicide for this priority population. 2.3 Current study While the increased risk for suicidality in LGBTQ2+ populations and factors that contribute have been well-documented in the scientific literature, there is a paucity of research focusing on various subgroups within the LGBTQ2+ population. Specifically, there is a dearth of evidence distilling the experiences of SGMW, despite being a subgroup that has been identified as experiencing increased risk to due to their multiple minority identities (Haas et al., 2011; Plöderl et al., 2013; Yıldız, 2018). While the minority stress model has been fundamental in understanding the role of social stressors, including stigma, prejudice, discrimination and 12 violence on physical and psychological well-being of minority groups, it continues to perpetuate negative perceptions and maintains a deficit lens on minority health (Colpitts & Gahagan, 2016). Although an understanding of risks and stressors is imperative to suicide prevention, a strengths-based approach that focuses on protective factors can help to bring a strengths and resiliency orientation to the practices and interventions aimed at reducing mental health and suicidality disparities among SGMW (Gahagan & Colpitts, 2017). Thus, the purpose of this study is to provide a nuanced description of the experiences of SGMW who have attempted suicide, with a focus on the embodiment of strength and resiliency in staying alive post-attempt. 13 Chapter 3: Methodology This analysis draws on data derived from a larger qualitative study exploring the experiences of suicidality among queer women using photovoice methods, including individual semi-structured interviews (Creighton et al., 2019). Photovoice methods have been widely used in mental health research to provide a nuanced and rich understanding of the lived experiences of individuals living with chronic mental health challenges (Han & Oliffe, 2015). Drawing from a larger sample of 24 interviews, this thesis includes data from the 11 in which participants self-reported previous suicide attempt(s), which was operationalized as according to the Public Health Agency of Canada definition of a “a suicide attempt is when someone tries to end their life” (Canada, Public Health Agency of, 2016; Klonsky et al., 2016). Interviews in which participants shared engaging in risky behaviors with apathy towards the outcome of the behavior, but without an intent to end their life, were not included in this analysis. 3.1 Theoretical framing This exploration of the lived experiences of SGMW who have attempted suicide – including the ways they continue to embody the strength and resiliency to continue living post-attempt – is informed by the minority strengths model (Perrin et al., 2020). Aiming to highlight the personal and collective strengths inherent in LGBTQ2+ individuals and communities, this model outlines a theoretical chain in which empirically validated strengths-based variables such as social support, community consciousness, identity pride, self-esteem, and resilience interact to positively influence mental health and positive health behaviours (Figure 1). The minority strengths model postulates that community and relational factors, such as social support and community consciousness, influence individual level factors, such as identity pride (self-acceptance of one’s identity), self-esteem, and resilience, ultimately shaping positive mental 14 health and health promoting behaviours among LGBTQ2+ individuals (Perrin et al., 2020). Specifically, social support, including the nature, strength, and availability of this support is conceptualized to indirectly effect positive mental health through identity pride, self-esteem, and resilience. Likewise, community consciousness, which centers a sense of connection and belonging to the LGBTQ2+ community, positively influences mental health through this same pathway. This model has been empirically tested and validated, with the strongest direct association being between self-esteem and resilience, leading to mental health. Figure 3.1 Minority Strengths Model2 The minority strengths model provides a strengths-based orientation that is responsive to limitations of the widely utilized minority stress model – one of the leading frameworks for explaining the mental health disparities that exist among SGM groups (Brooks, 1981; Meyer, 2003; Rich et al., 2020). Specifically, it seeks to center the strengths and resilience of minority populations (Gahagan & Colpitts, 2017; Perrin et al., 2020), thereby re-orienting away from a deficit-based focus. In the context of study, the minority strengths model is used as a framework 2 This model represents the final version of the minority strengths model with all pathways being statistically significant and standardized β weights shown for each pathway. Reprinted with permission from “The minority strengths model: Development and initial path analytic validation in racially/ethnically diverse LGBTQ individuals” by P.B. Perrin, M. E. Sutter, M.A. Trujillo, R.S. Henry, & M. Pugh, 2020, Journal of Clinical Psychology, 76(1), p.128. 15 informing the research questions and analysis to broaden understandings about SGMW’s experiences with suicidality. Indeed, a minority strengths lens emphasizes the importance of contextual factors such as social support and a sense of belonging to the LGBTQ2+ community in fostering strength and resiliency that may promote positive mental health in this group of SGMW who have attempted suicide. An understanding of the various pathways that lead to resiliency and positive mental health in SGMW post suicide attempt can help inform the design of future suicide prevention and mental health promotion programs for this sub-group (Haas et al., 2011). 3.2 Data collection Ethics approval for the larger study was obtained from the University of British Columbia’s Behavioral Research Ethics board. Post ethics approval, social media ads were placed on Twitter and Facebook, flyers were posted in community settings focused on SGMs, and a news article was placed in the LGBT column of a local online entertainment magazine to recruit participants. After ensuring eligibility by the project coordinator, the potential participants were invited to an initial meeting where written informed consent along with demographic information and history of suicidality were obtained. Participants were made aware of the voluntary nature of the study and their ability to withdraw consent at any point. Participants were also provided with a comprehensive list of mental health resources in the event that they experienced distress. To facilitate the photovoice assignment, participants were offered a new digital camera or a cash honorarium ($100), if they preferred to use their own camera. During the course of 2-3 weeks, participants were asked to take photographs that described their experiences with suicidality and caption the images. After completion of the photo assignment, participants were 16 involved in a semi-structured interview that elicited further explanation of the photographs and sought clarity on viewpoints and experiences relating to suicidality as described by the participants via their photos. These semi-structured interviews allowed for flexibility in developing participants personal narratives and experiences (Polit & Beck, 2017). Participants were provided with another $100 honorarium following the interview to acknowledge their time and contributions. All interviews were audio-recorded, transcribed verbatim and checked for accuracy. 3.3 Data analysis In this study, reflexive thematic analysis (TA), as described by Braun et al. (2019) was used to examine the ways SGMW who have attempted suicide continue to embody strength and resiliency to continue living post-attempt. Reflexive TA was used as it is well suited to exploring the lived experiences of participants and provides a rich, nuanced description of these lived experiences while acknowledging the researcher’s role in knowledge production (Braun & Clarke, 2019; Braun & Clarke, 2020). As there is limited knowledge of the phenomenon under study, reflexive TA allowed a theoretically informed – by the minority strengths model – but inductive process to identify patterns in the data that tell the story of a phenomenon (Braun & Clarke, 2020). The six phases of reflexive TA were employed in the process of conducting this analysis: familiarizing with the data, generating codes inductively, actively constructing initial themes, revising and defining themes, and producing the report (Braun & Clarke, 2006; Braun & Clarke, 2019; Braun & Clarke, 2020). Measures to establish trustworthiness were undertaken throughout the analysis process (Nowell et al., 2017). For example, due to the secondary nature of this analysis, the first author actively read the transcripts multiple times (Nowell et al., 2017) and 17 completed familiarization notes, including initial reflections of the data and overarching concepts and patterns (Braun & Clarke, 2020). The purpose of these notes was to inform coding decisions, identify patterns, and keep an audit trail to enhance trustworthiness (Braun & Clarke, 2020; Nowell et al., 2017). Initial broad codes where then generated from the data. Once the codes were collectively agreed upon within the research team, Microsoft Word was used to organize the data and facilitate analysis and the generation of themes based on a central organizing concept. These themes were then reviewed for coherency and validity with respect to the data set. This was a recursive process accomplished by repeatedly comparing potential themes with the original data and identifying the meaningful pattern across the data (Braun & Clarke, 2020). Further, to facilitate dependability and confirmability, an audit trail in the form of a research journal detailing theoretical and analytical choices was kept (Nowell et al., 2017). Lastly, the themes were defined, finalized, and reported in relation to the research questions. Throughout this process, themes were revised as needed to ensure that the final themes capture the meaning of the data in relation to the research question (Braun & Clarke, 2020). During the presentation of findings, raw data, including quotes from the participants, are used to convey the essence of the findings and to privilege the voices of the participants (Nowell et al., 2017). 18 Chapter 4: Findings Drawing on the experiences of SGMW who previously attempted suicide, three themes utilizing reflexive thematic analysis were generated: (ⅰ) “I can just be”: finding comfort in their own skin; (ⅱ) “Anchoring to life”: the role of connection and belonging: and (ⅲ) “Staying alive”: the journey continues. The first theme describes the link between acceptance of SGMW’s sexual orientation and gender identity – both by themselves and by others – in finding comfort in their own skin and increasing their resiliencies to continue to live post-attempt. The second theme underscores the role of connection and belonging gained through social support networks in survival post-attempt. The third theme, speaks to staying alive post-attempt as a journey which required consistent effort in the form of accessing professional mental health services and self-management. Though the three themes are presented separately, they interconnect within the lives and resiliencies of the participants post-attempt 4.1 “I can just be”: finding comfort in their own skin For most participants, their suicide attempts and finding comfort in their own skin were both tied to their sexual orientation and/or gender identities. Self-acceptance of their sexual orientation and/or gender identity and being able to live in congruence with their identity influenced participants’ desire to live. In sharing their stories, participants referenced times when they accepted their sexual orientation and/or gender identity, which gave them hope and helped them stay alive post-attempt. Participant D, a 35-year-old trans woman, described her decision to start her transition journey as being protective in keeping her alive. 19 Photograph 1: Plan B “Yeah, I shot that [photograph] I think after one of my attempts and I was like, ‘Okay, that’s kind of funny.’ Because it was also the time I was coming out to myself, and starting to seriously consider transition, which I was afraid of it because of the social consequences, and the usual stuff I guess, for trans people. So, I found Plan B in the parking lot and I was like, “Yeah, that was better than Plan A,” which was just drinking, or being reckless, or openly suicidal ... I think I was 26-27. One of the things I always said was, ‘I’m never going to make it to 30,’ and I’d joke around like that, but that was completely serious. I thought there’s no chance I’d be here by the time I’m 30, and yeah, this helped, I guess.” This participant shared her surprise for continuing to live through the age of 30. She shared, how plan b – acceptance of her identity and the courageous decision to transition – overshadowed her suicide attempt and buoyed her resiliencies in finding comfort in her own skin. For other participants who had a strong sense of their sexual orientation and/or gender identity, being able to live authentically within this minority identity influenced their ability in finding comfort in their own skin. Many participants described the impact on their mental health in concealing their identity, particularly feeling trapped, hopeless, and suicidal. Participant G, a 33-year-old gender non-binary, bisexual individual, explained the pain that has been linked to secreting her identity: 20 “I’ll never be able to put into words the pain that it feels to not be able to be yourself, and at every turn when you try to be yourself, even just a little bit, and you get hatred or disgust. That is what made me want to kill myself, for sure….” For G, moving from Ireland to Canada where she could live in congruence with her identity influenced provided her comfort. She goes on to explain: “Whereas the identity stuff requires nothing. All I needed was to be myself – that’s it. That pain goes immediately. Here I have none of that pain whatsoever, because I can just be….” For G, while recovery from the trauma in other aspects of her life, including sexual abuse, was something that she would have to continue to heal from in the coming years, the pain stemming from not being able be herself dissipated as soon as she was able to find acceptance by living in an environment inclusive of such diversities. Similarly, participant I, a 29-year-old queer woman, described being able to live amongst family and friends in congruence with her identity as “freeing”, resulting in improved mental health post suicide attempt. Being able to live in accordance with their sexual orientation and/or gender identity – by accepting themselves and being accepted by others – was protective in helping participants to feel more at ease in their own skin. In addition to self-acceptance of their sexual orientation and/or gender identity and being able to live in congruence with this identity, participants described an increase in self-esteem as being protective. Many participants detailed experiences of trauma and abuse in their lives and managing to survive despite those adverse circumstances. Such lived resiliencies proved to be a source of strength for many participants in the context of their suicide attempt. For example, Participant G, shared her story of advocating for help and walking away from her abusive family at the age of 14. For this participant, her feet acted a reminder of the inherent strength that she has: 21 Photograph 2: My Bare Feet “Pretty much every day when I look at my feet…it reminds me of the strength that I have, and how important every day is, because I’m still here.” For this participant, her feet symbolized self-presence and capacity for walking away from trauma and healing. Similarly, participant A, a 19-year-old lesbian woman, explained that experiences of trauma and abuse in her childhood influenced her sense of strength and ability to survive despite adversity; fueling her desire to live beyond multiple suicide attempts. In describing her traumatic childhood and parents’ divorce, she stated, “I got a lot of my strength from that. I really learned a lot about myself and what I could put myself through.” While participants were vulnerable to the effects of trauma, they were also able to reflect on those past experiences and recognize their inherent strength and utilize it to move forward in meeting an array of everyday challenges. Indeed, acceptance of their identity, in themselves and by others, enabled participants to manifest a stronger sense of self and find comfort in their own skin which influenced their resiliencies in continuing to live post-attempt. Further to finding this sense of self and confidence for surviving, most participants articulated rediscovering themselves through self-compassion. For some participants, increased self-awareness, including recognizing their own thoughts and feelings towards their mental health 22 challenges, was a starting point in their ability to stay alive post-attempt. As participant C, a 31-year-old bisexual woman, described, awareness of her harsh self-judgements was key in managing her suicidality: “Being more aware of the judgement I put upon myself, and like I said earlier, kind of going easier on myself. It’s a slow process but it gets better over time, and slowly changes the mental landscape.” By increasing awareness of her negative thoughts and feelings, C was able to be more compassionate towards herself, which eventually helped in managing her suicidal thoughts. Similarly, participant E, a 32-year-old trans woman, explained that viewing her suicidality with less stigma and more compassion for the complex contexts was important to her everyday comfort and self-acceptance: “I think that the shift in my mindset of “I’m a failure”, to “I’m just sick”, is probably the most important. I’m not suggesting that someone can just decide to change the way they think, that is definitely a process…. But that specifically, that shift in mind set, I think has been the biggest thing that lets me manage it when it happens, that sort of keeps me alive you know.” A change in perspective in how participants viewed their mental health helped to decrease the internalized stigma attached to their suicidality. This was protective in keeping them alive post-attempt. Additionally, participants articulated strengthening feelings of self-compassion and self-love to their younger self. This included apologizing to their younger self or reflecting on the past and wanting to support themselves in new ways. For example, participant I, a 29-year-old queer woman, illustrated her feelings of love and compassion to her younger self through the photograph below: 23 Photograph 3: I’m sorry “So, it just says, “I’m sorry,” which, when I attempted suicide, I left a note and that’s all it said. It was just a Post-It note, so it’s kind of going back to that, but mostly this picture was just me kind of, I guess, apologizing to myself that I attempted suicide and that it’s okay and we’re going to get through it.” In apologizing to her younger self, this participant illustrated self-compassion, alongside a comfort in who she was. This was also accompanied by a sense of growth and discovery. For some participants, this growth was measured in concrete ways, including discovering new hobbies, while for others it was more abstract. For example, participant A, a 19-year-old lesbian woman, explained: Photograph 4: The bench 24 “I feel like now I’m - I’ve painted the bench over and I am writing a new story to it. I am writing my own graffiti on the bench. I am making my own…pathways, and I am trying not to walk the plank, like right there, I am trying to re-amp [sic] myself to be better, and you know, I’m not suicidal anymore. I don’t think about self-harm, I don’t think about drinking to escape my problems. I don’t - I’ve changed a lot, and I’ve grown a lot, and I like that idea of repainting my own picture.” For this participant and many others, having the freedom to grow and discover themselves empowered them to write a new story – one with the promise of a distinctly different journey and ending from their past. In summary, being able to live in congruence with their sexual orientation and gender identity as well as an increase in self-esteem facilitated the recognition of their internal resilience and being comfortable in their own skin helped participants in continuing to live post-attempt. 4.2 “Anchoring to life”: the role of connection and belonging Most participants provided detailed descriptions of the role of connection and belonging in increasing their internal resiliencies post-attempt and anchoring them to live. This feeling of connection and belonging was achieved with a variety of social factors; including a strong social support network and engaging in meaningful work or volunteer activities. Participants shared the importance of their strong social support network which included friends, members of the queer community and intimate partner relationships in anchoring them to life. This social network provided participants with a sense of meaningful connection and belonging, which influenced their overall wellbeing. For most participants, being able to share their struggles with suicidality and mental health openly, having reliable individuals whom they could reach out to during challenging times, as well as face-to-face social connections made them feel understood and 25 connected. For example, participant H, a 29-year-old queer woman, illustrated the importance of having friends to reach out to in the photo below: Photograph 5: Reaching out saved me For H, sharing her struggles with suicidality and reaching out to her friends was key. She goes on explain that having supports, such as this text friend who stayed up with her through the night via video chat to ensure that she was safe, was lifesaving. Similarly, for participant F, 37-year-old queer woman, having people that she could call when needing support for her suicidal thoughts was part of her safety plan. She goes on to share: “I guess, up until very recently, I’ve had, in my wallet – I’ve just downsized my wallet, so – I’ve had a card in my wallet that I have written with – this is a recovery thing too, of having the numbers and the names […] of three people I could call if I felt like using or if I was not in a good place. And I have so many people in my life right now who would answer the phone no matter what time of day I phoned them, so I feel like I’m really lucky to have that.” 26 For this participant, knowing that she had reliable people in her social circle that she could lean on and who would support her unconditionally, made her feel safe and anchored – which served as a strength in promoting her survival. Indeed, the strength gained from feeling connected to a secure and available social support network made participants feel anchored to life and influenced their resiliencies in continuing to live. For other participants, being connected to the queer women’s community and being involved in community activism offered them a meaningful connection and a sense of belonging. Likewise, participant I, a 29-year-old queer woman, described feeling “immediately connected” to the queer community. This sense of connection and belonging stemmed from her feeling understood at a deeper level and not having to explain her sexual orientation or gender identity: “Oh yeah, we’ve got this thing in common so it connects you […] you can just talk about real shit. Yeah, no stupid small talk, it’s just like hanging out with friends all the time, even if they’re strangers, kind of.” For this participant, being able to spend time with people who had similar experiences to her with respect to their sexuality and gender provided her with a sense of deep and meaningful connection. Similarly, for participant G, a 33-year-old non-binary, bisexual woman, being connected to people involved in community activism was what made her feel “normal” and gave her a sense of belonging as they all shared the “same kind of background”. Further, while the importance of being connected to the queer community was instrumental, the role of peer support groups was also key. As participant G, a 33-year-old genderqueer, bisexual woman explained: “I’ve also found that in terms of my healing, I’ve done a lot of individual work, either with therapists or myself, and there comes a point where you really need that group 27 aspect to it, and it’s hard to counter the feeling abnormal if you’re not with a group of people who have been through the same things. Therapists can teach you some kinds of things, but other people who’ve been through the same thing can teach you other different kinds of things that you need as well.” As G illustrates, support from members of the queer community was instrumental in validating their feelings and serving as a source of strength for survival post-attempt. Indeed, the role of connection and affiliation with the queer community, either through community activism or peer support groups, in enhancing the resiliencies of participants in feeling anchored to life post-attempt were key. Further, the majority of the participants spoke to the importance of being in an intimate partner relationship with someone who is supportive and understands their struggle with suicidality. Participants articulated their feelings of safety, connection, and belonging that stemmed from being in a relationship with such a partner. For instance, participant C, a 31-year-old bisexual woman, described the impact of being in a supportive relationship on quelling her suicidality: “In some ways I’m afraid that it’s the fix, like having a partner. Yeah. Just I guess the physical contact of hugging, and getting a hug and a kiss, and the unconditional love. So that is what he does, and I don’t know, he’ll cook dinner, he’ll clean, those are all super important awesome things that help.” For her being in a relationship that made her feel loved unconditionally and where the partner was able to support with daily activities of living, such as cooking and cleaning, was instrumental in her survival. Similarly, for participant B, a 34-year-old queer woman, support from their partner in navigating the “extra layers of bureaucracy” was instrumental in her 28 accessing health benefits which included seeing a counsellor. For B, the process of paying bills, requesting reimbursement, and completing the claim forms was “crushing” her until, with support from her partner, who was able to “do all the executive functioning”, was able to utilize her benefits for professional mental health services. Supportive intimate relationships in which partners took responsibility for the routine activities of day to day life played a significant role in the ability of participants continue feel safe and anchored to life. Additionally, being in a relationship gave participants a sense of accountability by influencing their sense of wanting to live for their partner. For example, participant A, a 19-year-old lesbian woman, describes her thinking about the impact that her suicidality would have on her partner: “If I did take my life, it would have had a big impact on her, too. It would have – it wasn’t like I was thinking about that at the time, but what – I guess it was a thought in the back of my head – it was – it was to try to stay strong, and try to make it through another day than want to end it in that moment, or want to take that extra – extra time or extra cut – extra whatever. It was really trying to stay strong for somebody else, I guess it was alright at the time to want to have that – to have that in your head.” This sentiment of wanting to continue to live for their partner’s sake – and the protective role of this close connection – was also shared by participant I, a 29-year-old queer woman, who stated that she would “never do that” to her partner in reference to attempting suicide again. Many participants described the role of their partners as ‘anchors’. For example, participant C, a bisexual cisgender woman, explains the role of her partner in keeping her alive: 29 “And I feel like being in a relationship with somebody that you love unconditionally is such an (sic) anchoring to life, it’s so much harder to, if you are suicidal, to conceive of a plan, and to go through with it when you have something that tethers you to the life.” This feeling of being anchored to life by a partner was also described by participant H, a queer woman in her late 20s, who was in a long-term relationship. She illustrates in the photograph 6, titled Anchor, the role of her partner in keeping her connected and alive: Photograph 6: Anchor “The caption I have on this is just “Anchor”, because I really feel like that about [name redacted], she very much anchors me, and as do all my friends in the community – like I said, I think I’m really lucky that I have a really rich community and it’s not necessarily just on her to hold me - anchor me down.” These experiences of having strong social support networks in the form of an intimate partner, friend, and/or family of choice gave participants a deep feeling of connectedness and belonging which continued to give them the strength to keep living post-attempt. Lastly, finding meaning and connection in life either through work or volunteer activities and being able to utilize their past experiences with suicidality in helping others was impactful in bolstering resiliencies. Further to providing meaning and connection, in holding roles that 30 involved caring for others, participants were able to decrease the sense of burdensomeness that had previously been tied to their suicidality. For some participants, this meant choosing careers such as nursing, youth support, and counselling, where they could draw on their experiences to directly effect change in people’s lives. For others, working closely and caring for animals was meaningful; for example, participant K, a 28-year-old pansexual cisgender woman, credited her work at animal rescue as keeping her alive: Photograph 7: Rescued is my favorite breed “Sometimes my volunteer work at the animal rescue was the only thing that I could get up for in the mornings when I was really depressed. It was the fact that the animals at the rescue depended on me to make my shift.” For K, knowing that she was needed and that animals depended on her is what kept her alive. Engaging in purposeful work that utilized past experiences with suicidality to help others or feeling needed in being responsible for caring for others, including animals, gave many participants a sense of belonging and decreased their internal sense of burdensomeness. 4.3 “Staying alive”: the journey continues Some participants described their ability for staying post suicide attempt as a journey – one that required a prolonged, persistent, and proactive effort. This effort to stay alive included 31 the recognition and operationalization of professional mental health services and effective self-management by the participants. Access to professional mental health services, which included gender affirmative counsellors, psychologists, psychiatrists, and emergency services, were significant in saving the lives of many participants. For some participants, being connected with mental health professionals, such as a psychiatrist or counsellor, immediately after a suicide attempt impacted their ability for staying alive. As participant E, a 32-year-old queer woman, reflected on their involuntary admission into the hospital after their suicide attempt, they shared their initial anger at the situation, but also recognized that being connected to the right psychiatrist helped in staying alive. “I met an amazing psychiatrist there called Dr. [name redacted], and he was experienced with gender issues, he was from [name of city], had moved here recently, he saved my life. He committed me, and I was not happy about that, so I had to stay at the hospital for a while but he saw me way longer that he was really supposed to, and helped me through a lot of the depression. Lead me on to a lot of different exercises for how to deal with anxiety and depression, how to bring yourself down if you’re really high, or really emotional. Those are tools I hold dear and have used ever since.” For this participant, even though the experience of being in hospital for an extended period of time on an involuntary basis was challenging, the connection to a psychiatrist that provided E with take-home practical tools to manage their emotions was instrumental in staying alive post-attempt. Though a few participants had negative experiences with mental health services, a majority of participants shared the positive impact of being connected to a mental health professional on their survival post-attempt. For those who had positive experiences, healthcare professionals who connected, validated, and understood the participant’s sexual orientation and 32 gender identity and equipped participants with practical tools to manage their suicidality were instrumental in their survival. For instance, for participant G, a genderqueer, bisexual woman in her early 30s, the practical strategies she learned from her psychologist to help manage her mental health, specifically her mood, were significant in getting her “this far” in staying alive. When connected to the appropriate, gender affirmative mental health professional, participants were able to use the tools gained to strengthen their efforts in self-management of their suicidality and mental health. Likewise, for participant C, a 31-year-old bisexual woman, being connected to a counsellor on a regular basis provided important tools to continue to stay alive: “And I started seeing an amazing counsellor who changed my life, helped me change my life, slowly but surely, over years and over time. Going to see her and practicing – learning about things like grounding, and breathing, just deep breathing and how that is so important. And so, she really gave me tools to use to, cope through life.” For this participant, being connected to a mental health professional in an ongoing, proactive basis and learning various self-management tools helped them change their life. For other participants, self-management also encompassed being able to manage their suicidal thoughts should they arise again. As participant G, a 33-year-old genderqueer, bisexual woman, shared being aware of the “warning signs” with respect to her suicidal ideation and having the tools to manage it herself alongside having access to ongoing professional help is part of her journey to stay alive. In addition to utilizing professional mental health services proactively and learning practical strategies that helped strengthen self-management efforts post-attempt, many participants recognized the role of a variety of coping strategies that they employed on a daily basis. These incorporated engaging in sports, listening and/or playing music, spending time in 33 nature and/or with pets, managing expectations, eating healthy, getting enough sleep, and using alcohol and marijuana. For some participants these strategies were part of their self-care toolkit and helped maintained their mental health on a daily basis. For example, participant B, a 34-year-old genderqueer woman, described an array of supports and strategies that come together to maintain their mental health: “I listening (sic) to music a lot. I can find that very therapeutic. But really the counselling has really helped a lot. Like a lot. Just having access to a great counsellor who is super not thinking I’m not gay. Having a partner and all those things. Like all the things, eating health food and drinking lots of water. All those things actually help. Quitting caffeine has been actually really good for me.” For participant B, in addition to gender affirmative mental health supports, incorporating self-care strategies alongside supportive relationships were all factors that continued to contribute to their self-management in staying alive. Similarly, for participant E, a 32-year-old genderqueer woman, using the skills learned in cognitive behavioral therapy, was central to coping on a daily basis and included an awareness of their emotional and physical needs. In the context of managing her depression and suicidal thoughts on an ongoing basis, she described being aware of when to push herself to meet day-to-day obligations and when to “cancel plans, stay at home, play video games, and just let myself treat it as if I’m sick”. For some participants, self-management incorporated use of alcohol and other substances, though most recognized the potential harms associated with this coping mechanism. For example, participant B, genderqueer woman in her mid-30s, explained her use of alcohol while journaling, which was part of her self-management toolkit: 34 Photograph 8: Bad medicine “The writing happens at the pubs, so my personal writing happens at the pubs, so it’s like they are two tigers tied by the tail as one would say. I find my personal writing very therapeutic but what fuels it is this drug which is - I would say probably if I’m not careful going to fucking kill me so… And so it’s also ambivalent.” For participant B, her therapeutic journaling was linked with her use of alcohol and both in a complex way were part of her self-management. Through this she reveals the tensions inherent in self-management strategies whereby the diligence for therapeutic value (journaling) is titrated with the risk (bad medicine) that she claims as an elixir to that therapy. This complexity brings to the light the effort that is required in staying alive, specifically in balancing living and enlivening. While the combination of utilizing professional mental health services and engaging in self-management strategies were key in helping participants stay alive post-attempt, most participants also spoke to the prolonged, persistent effort required to stay alive. For a number of participants, continuing to stay alive was a journey and was contingent on an array of supports and strategies being in place. For instance, participant H, a 29-year-old queer woman, explained 35 her worries pertaining to a return of her suicidality and her consistent effort in ensuring its prevention: “I think emotionally now there’s always that slight fear of, “What if I get back to that place?” and feeling like I need to work really hard to not get there, so that’s for sure a piece of it. […] And I think again, I have something that’s pushed me to be like, ‘You’ve got to be more physical because that will help you,’ and all these things that we know - exercise makes you feel good […] So, I go to counselling really regularly, even when nothing is wrong…., regular, regular counselling has been super important to me in the past four years.” For H, challenging as it may be, engaging in physical activity and counselling regularly regardless of the circumstances reveals the necessity of the sustained effort required to prevent a decline in their mental health. Further, engaging with professional mental health services, in this case counselling services, in an ongoing, proactive basis rather than reactive basis is part of this participants journey in staying alive. For I, a 29-year-old queer woman, part of her journey in staying alive involved fighting her suicidal thoughts as they emerged, often unexpectedly: Photograph 9: Ocean Coast 36 “Sometimes thoughts about suicide will just pop into my head. It’s not like I necessarily want to follow through with them, but sometimes it’s just like my brain just goes there…“Oh, it would be so easy to just do that [drown]” but at the same time I don’t want to do that, so it’s kind of hard to be like – your brain is telling you this thing but you’re like, “No, I don't want this!”… I mean, how easy it would be to do it again, but not wanting it, I guess.” For I, though her suicidal thoughts were always present the could be backgrounded, and actively fought when they emerged unexpectedly. This demanded work – persistent efforts to continue a journey reliant on staying alive. In summary, staying alive for participants was a journey that required persistent, prolonged effort and included proactive, regular utilization of professional mental health services and effect self-management strategies. 37 Chapter 5: Discussion and Implications 5.1 Discussion Suicidality, comprising ideation, plans, and attempts, is a significant issue for LGBTQ2+ populations (Haas et al., 2011; Hottes et al., 2016; King et al., 2008; Plöderl et al., 2013). While an understanding of the risk factors that contribute to suicidality is essential, that focus can reinforce a deficit-based view of LGBTQ2+ health (Gahagan & Colpitts, 2017). Despite recent calls to understand the strengths inherent in minority groups, literature chronicling such specificities remains scarce (Gahagan & Colpitts, 2017; Meyer, 2013); particularly among SGMW who experience increased risk of suicidality, compared to other sexual and/or gender minority groups (Haas et al., 2011; Hottes et al., 2016; Salway et al., 2019). Further, there is a paucity of research to advance understanding about the lived experiences of SGMW who have attempted suicide. Using photovoice methods, the current study examined the experiences of SGMW who had attempted suicide, and the ways in which they continue to find the strength and resiliency to stay alive post-attempt. An understanding of the strength and resiliency promoting factors for SGMW who have attempted suicide can inform the design of tailored suicide prevention and mental health promotion interventions for this population. This current study identified that coming to a place of acceptance in terms of sexual and gender identity is critical to supporting SGMW who have attempted suicide. Participants described the linkages between their sexual and/or gender minority identities and their experiences of suicidality as well as the role that acceptance plays in their survival. Further, being able to live in authenticity with their identity was protective for participants, and helped their self-esteem, further bolstering their resiliencies for staying alive. Indeed, these findings corroborate the minority strengths model, which postulates that identity pride (i.e., self-38 acceptance of one’s identity) and self-esteem are associated with increased resilience and positive mental health among sexual and gender minorities (Perrin et al., 2020). Acceptance of – and increased comfortability with – one’s identity is a known protective factor against suicidality in older sexual and/or gender minority adults (Fredriksen-Goldsen et al., 2017) and trans individuals (Moody & Smith, 2013). Additionally, other research identified self-esteem as the only significant protective factor against suicidality among a group of young adult LGBTQ university students (Peter & Taylor, 2014). While there is limited research with respect to SGMW, the broader research on sexual and/or gender minority health has found that those who have survived a suicide attempt report that concealing ones’ identity produces psychological distress that contributes to suicidality (Williams et al., 2018). Indeed, participants in the current study consistently cited the freedom that comes with being open about ones’ SGM identity and the positive effects it has on mental health and in staying alive post suicide attempt. Further, consistent with other literature (Manalastas, 2016; Velkoff et al., 2016; Williams et al., 2018), these findings highlight the linkages between suicidality and belonging to multiple minority groups, including sexual orientation and gender identity. Moreover, findings from the current study adds a strengths-based understanding to the existing literature belaboring the risk factors associated with suicidality, stemming from experiences of victimization, discrimination, and prejudice, in sexual and gender minorities (Haas et al., 2011; Meyer, 2013; Salway et al., 2019). These findings highlight the protective role of acceptance and self-esteem in feelings of strength and resiliency post attempt. Findings from the current study also underscore the role of social connection in increasing participants’ resiliencies to stay alive post-attempt. Participants detailed experiences of gaining a sense of connection nurtured via social supports and community connectedness, 39 which included intimate partner relationships, friends and family (as defined by the individual) and more broadly, the queer community. For most participants, feeling connected, especially to their families, “anchored them to life”, eradicated feelings of burdensomeness, and gave them a sense of belonging and strength to continue to live post-attempt. Indeed, the protective role of social connection against minority stressors and suicide is well-documented in the literature (Frost & Meyer, 2012; Kaniuka et al., 2019; Zimmerman et al., 2015). A sense of connectedness within the LGBTQ2+ community can provide access to environments that are affirming, accepting, and non-stigmatizing and that buffer against the unique stressors faced by minority groups (Fredriksen-Goldsen et al., 2017; Frost & Meyer, 2012; Hudson & Romanelli, 2019; Meyer, 2015; Perrin et al., 2020; Zimmerman et al., 2015). Participants in the current study shared their feelings of freedom that surfaced when they spent time within the queer community. More broadly, connectedness is theorized to play a significant protective role in the prevention of suicide attempts even in the presence of suicidal ideation stemming from pain and hopelessness (Klonsky et al., 2016). While there is a lack of research pertaining to SGMW, previous research involving sexual and gender minorities has shown the significance of connection gained via positive social supports, specifically from family as being protective against suicidality (Tabaac et al., 2015; Williams et al., 2018). These findings are consistent with previous research that highlights the role of social connection in fostering self-esteem and positive mental health for LGBTQ2+ individuals (Perrin et al., 2020) and contributes to the current limited research focused on SGMW who have attempted suicide. While acceptance and social connection were identified by participants as key contributors to their ongoing survival, professional mental health services also surfaced as bolstering participant’s resources for managing suicidality. Though negative experiences with 40 mental health practitioners were identified by some participants, many shared the positive impact of professional mental health services on their ability to stay alive post-attempt. Specifically, participants shared the importance of feeling safe, respected, and having their sexual and/or gender minority accepted by the mental health practitioner they were connected to. This finding aligns with results from a systematic review that examined the experiences of sexual minority women with health care services and reported that feeling that their sexual orientation and/or gender identity was respected is key to having a positive health care experience (Meads et al., 2019). Further, for participants in the current study, being connected to an accessible, LGBTQ2+-affirming mental health practitioner, empowered participants with practical strategies for managing challenging emotions and bolstering their resiliencies. Such services have been identified in other suicide prevention research, which also highlights the importance of accessible, affordable, and equitable LGBTQ2+-affirming services (Ferlatte, O. et al., 2020; Goldbach et al., 2019). More broadly, the findings from the current study are consistent with research reporting that health professionals who are empathetic, respectful, inclusive, and create a safe space when working with suicide attempt survivors, can positively impact the mental health (Hom et al., 2020). The findings from this current study enhance our current understanding of the role of professional mental health services in supporting SGMW who have attempted suicide, providing important clinical directions. While the role of tailored crisis mental health services in prevention of suicide in sexual and/or gender minorities is vital, participants in the current study highlight the importance of ongoing and proactive mental health services that focus on offering practical strategies for managing suicidal thoughts post-attempt. Mental health practitioners who are able to focus on resilience and highlight the strengths of an individual 41 within an experience of suicidality are pivotal to in bolstering the self-management efforts of this priority population. 5.2 Implications for practice Ultimately, the findings of this current study offer important insights for recognizing and promoting strengths and resiliency among SGMW in clinical practice, both in acute and outpatient settings. In an acute clinical setting, findings point to the importance of creating environments that ensure safety, comfort, and connectedness for sexual and/or gender minorities. De-stigmatizing spaces to demonstrate inclusivity and create a safe space for individuals post-attempt to share their stories and vulnerabilities can be vital in building a therapeutic alliance. Indeed, the role of healthcare practitioners in creating a non-stigmatizing, empathetic, validating, and collaborative environment has been found to positively impact the recovery journey for suicide attempt survivors (Hom et al., 2020). While an in-depth analysis of the participants experiences with healthcare practitioners resides outside the scope of the current study, many participants did rely on mental health services to bridge and sustain effective self-management of their suicidality. Specifically, participants shared that having their sexual orientation and/or gender identity affirmed by the healthcare professional was key to building a therapeutic relationship whereby they could learn practical tools to safely and sustainably self-manage their suicidality. Further, utilizing visual cues that demonstrate support and allyship in both acute and outpatient settings can indicate a welcoming space for all sexual and/or gender minority individuals. This is similar to the LGBT Safe Space Ally Program that has been implemented in universities and colleges and that utilizes nonverbal cues to demonstrate support and acceptance in addition to increasing awareness and training to address underlying biases pertaining to sexual and/or gender minorities (Hartal, 2017; Poynter & Tubbs, 2008). Clinical settings can work 42 towards implementing the principles of the LGBT Safe Space Ally Program to ensure that SGMW feel accepted and can begin to collaboratively work with healthcare professionals to further enhance their strengths and resiliencies for continuing to stay alive post-attempt. Further to creating safe, inclusive environments, healthcare practitioners working in clinical contexts, with SGMW who have attempted suicide can build in opportunities to surface client’s strengths, rather than deficits, even in the presence of suicidality. This can be achieved by utilizing the principles of recovery-oriented mental health practice with an underlying belief that recovery from mental illnesses and adversity is possible for all (Mental Health Commission of Canada, [MHCC], 2015; Waldemar et al., 2016). Additionally, recognizing sustained, proactive help-seeking as a sign of courage and communicating a genuine concern for the well-being and recovery of the suicidal person can help highlight the resiliencies of clients and further enhance their efforts in staying alive post-attempt (Mental Health Commission of Canada, [MHCC], 2015; Sellin et al., 2018). Further, acknowledging and working through past adverse experiences and reflecting the resilience involved in continuing to live despite adversity can be another way for healthcare practitioners to affirm the resiliencies inherent to sexual and gender minorities. This is not to say that all sexual and/or gender minorities will have experienced trauma and adversity, but for those who have attempted suicide and have continued to live, acknowledging their resilience with a genuine belief that they can recover from past adverse experiences and reconstruct themselves post-attempt highlights their work and will to effectively self-manage their ongoing suicidality. Indeed, participants in the current study recounted their experiences of having someone believe in their ability to stay alive post-attempt was instrumental for recognizing their own resilience and beginning to rewrite their story. In addition, adoption of strengths-based suicide prevention approaches such as the collaborative 43 assessment and management of suicide (CAMS) can be beneficial for healthcare practitioners both in acute and outpatient settings (Galavan & Repper, 2017). Approaches that are responsive to the complexity and fluidity of suicidality and work in collaboration with the suicidal person, focusing on empowering the individual in managing their suicidality, can support SGMW post-attempt in all clinical contexts (Galavan & Repper, 2017). Lastly, in addition to focusing on the strengths and resilience of the individual, healthcare practitioners can focus on empowering families (as defined by the client) friends and communities to help SGMW struggling with suicidality. Given the positive impact acceptance from family, friends, and communities with respect to their sexual orientation and/or gender identity plays on the mental well-being of SGMW, healthcare practitioners can focus on leveraging the strengths within the family and community. This can be achieved by tailored education, awareness, and destigmatizing approaches to sexual and gender identities and suicidality (Ferlatte et al., 2020; Ferlatte, Olivier et al., 2019). Further, leveraging the strengths within the family or social network and working to promote healthy interpersonal relationships can help empower individuals connected to the lives of sexual and/or gender minorities and bolster their resilience in continuing to live post-attempt. This can include exploration of the relationship for SGMW clients and supporting them in achieving them, either in intimate partner relationships or with families. In addition, to promotion of positive interpersonal relationships, healthcare practitioners can support sexual and/or gender minority clients in detecting relationships that are not supportive and harmful to their mental well-being, and therefore further enhancing their resiliencies in staying alive post-attempt. Moreover, with the knowledge that community connectedness is protective against suicidality for sexual and gender minorities (de Lira & de Morais, 2018; Dickinson & Adams, 2014; Ferlatte, Olivier et al., 2020; Perrin et al., 44 2020), promoting inclusivity, access, and connection to community supports and services that are LGBTQ2+-affirmative can further build spaces for living and connecting. In relation to this, healthcare practitioners can explore the level of connectedness to the LGBTQ2+ community and support clients to increase their connection to community sources to further enhance their resiliencies in staying alive. These community sources of resilience can be client-specific and include activism, volunteer, and peer support groups – all sources that have been found to be protective in previous research (de Lira & de Morais, 2018) and were shared by participants in the current study as increasing their connection, strength, and self-esteem by helping others and distracting from their own challenges. 5.3 Limitations and future research recommendations While the current study is among the first to utilize a strengths-based approach to exploring suicidality among SGMW, there are limitations that warrant discussion. For example, the current study had a small, homogenous sample, comprised of 11 participants who predominately identified as white, cisgender, queer women. Additionally, for the purposes of the current study, participants were broadly incorporated under the label of sexual and/or gender minority women (SGMW) and their stories may not fully reflect the diversity of women who identify as a sexual and/or gender minority. Future research should pay particular attention to sexual and/or gender minority individuals who tend to be underrepresented in research, including those who are Trans, Indigenous, racialized, and/or queer (Frost & Meyer, 2012; Meyer, 2015). Further, while the current study employed photovoice – a methodological tool known to support data collection on sensitive topics and to promote feelings of empowerment in the research process (Han & Oliffe, 2015) – the strengths-based lens is specific to this analysis, and did not focus the recruitment or data collection stages of the larger study. 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Thesis/Dissertation
eng
Nursing
Vancouver : University of British Columbia Library
Attribution-NonCommercial-NoDerivatives 4.0 International
Graduate
Jenkins, Emily (Emily K.), 1981-
Oliffe, John Lindsay
A strengths-based exploration of the lived experiences of sexual and/or gender minority women with past suicide attempts
Text