dren from New Zealand (birth to age 21) found that gay, lesbian, and bisexual youth had higher risk not only of suicidal behavior, but also of depression, anxiety, substance abuse. The increased risk was greatest (a 6-fold increase) for suicide behavior and having multiple mental disorders (Fergusson et al., 1999). Harrell et al. (1999) used a co-twin control method to assess suicidality in relation to sexual orientation. They found that middle-aged male twins reporting same-gender sexual orientation were at higher risk for several lifetime measures of suicidality. The strong association could not be explained by abuse of alcohol and other substances, by depressive symptoms, or by unmeasured genetic and familial factors. The contribution of unique risk factors such as disclosure of sexual orientation to friends and family (McDaniel et al., 2001) remains to be fully assessed.

LIMITATIONS OF DATA

Official suicide rates capture completed suicides only. They have been used to chart trends in suicide, monitor the impact of change in legislation, treatment policies, and social change, and to compare suicides across regions, both within and across countries. In addition, suicide rates have offered a way to assess risk and protective factors for geographical areas (counties, states, and countries). However, official suicide statistics are fraught with inaccuracies. Undetermined cases and open verdicts and under-reporting limit their strength. The methodological weaknesses and promising approaches to resolve them are discussed more fully in Chapter 10. In brief, there are four primary sources of variability in suicide statistics (Jobes et al., 1987; O’Carroll, 1989). First, there are regional differences in the definition of suicide and in how ambiguous cases are classified. Legally a classification of suicide requires that it be beyond a reasonable doubt (O’Donnell and Farmer, 1995). Second, there are regional differences in the training and background of the coroner or medical examiner. Third, there are differences in terms of the extent to which cases are investigated. Fourth, there are sources of variability that have to do with the quality of data management involved in preparing official statistics. In fact, in many developing countries, suicide statistics are imputed, rather than based on actual death registries (Kleinman, 2001). This is discussed further in Chapter 6.

COST TO SOCIETY

The emotional cost of suicide is severe, and for family and friends of suicide victims, the personal loss is paramount. There is an additional economic cost that society incurs with these untimely deaths. The eco-



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