An Integrated Conceptual Model to Understand Suicidality among Queer Youth to Inform Suicide Prevention

Round 1

Reviewer 1 Report (New Reviewer)

This is a timely topic for consideration and this work can be a great contribution. In particular, there is a need for more conceptual models in mental health to consider the impact of social and environmental influences such as discrimination. All of the materials needed for a solid presentation of an integrated conceptual model are included. However, the work would benefit from re-organization.

While it was useful to describe the different conceptual frameworks at the outset, it would be easier to follow the description of the PRYSM model if it was organized around major concepts instead of organized around the models. As it stands, there are many points that are duplicative because the ideas are common across models (e.g., the importance of family acceptance/rejection). In deciding on the order for presenting frameworks that contribute to PRYSM, consider putting the MST up front given its status as "the leading theory in research that seeks to understand mental health problems among queer people." (lines 165-166). Contributions from other models would then augment the prevailing framework, with the end result being the PRYSM model.

Additionally, dense blocks such as the paragraph in Minority Stress (lines 275-312) would be easier for the reader to digest if separated into thematic segments. For example, one paragraph about family or guardian experience, one paragraph about internalizing stress, etc.

The figure is thoughtfully constructed, but there are a few things that can be improved. Using colors to reinforce concepts such as intersectionality is novel, but needs to be balanced against the needs of individuals who have color blindness or other visual impairments. The authors are also encouraged to reconsider whether concepts like thwarted belonging would act as moderators (as currently depicted) rather than as mediators. It might also be worth considering whether peer factors (dyad or social circle interactions) should be boxed with school (institution) factors.

As noted, the IPTS model has some limitations. While it is, perhaps, less well known, the authors are encouraged to review the Integrated Motivational Volitional (IVM) model (https://suicideresearch.info/the-imv). That model builds on the IPTS and in particular, their focus on the importance of experiences of defeat, humiliation, and entrapment seems like a beneficial fit for the PRYSM model.

There are terms used in the paper that may be accurate, but some groups have described them as objectionable. The term "suicide contagion" which calls to mind infectious disease, can be replaced with "suicide clusters" when referring to the outcome or "suicide suggestion" when referring to the process. The note about "extant and new policies that fail to protect queer youth or are explicitly hostile to queer youth" (lines 620-621) can stand on its own. Specific examples that risk political reactions are unnecessary distractions.

Author Response

Please see the attachment for our cover letter and response to all reviewer's comments.

Author Response File: Author Response.pdf

Reviewer 2 Report (New Reviewer)

See the attachment below.

Comments for author File: Comments.pdf

Author Response

Please see the attachment for our cover letter and response to all reviewer's comments.

Author Response File: Author Response.pdf

Reviewer 3 Report (New Reviewer)

Dear Authors, 

First of all, congratulations on your work, it is a relevant topic and in general presents, a good level of academic-sounding, expertise and is well written. For this reason, I am going to advise the editor to publish it, subject to possible modifications which I will advise below:

- Firstly, there is a high number of self-citations, although this signifies extensive expertise in the field, please review this aspect and corroborate the need to include each of these references. 

- It is also recommended that the objective of the article does not appear only in the abstract, and is also included from the introduction. 

- Please check the references that accompany the examples (in parentheses), sometimes it is difficult to know if the proposed references correspond to all the examples included. 

- Finally, it is recommended to reinforce the discussion, which is extremely brief, by discussing the proposed models. And include a brief final conclusion to the manuscript. 

Best wishes, 

Reviewer

Author Response

Please see the attachment for our cover letter and response to all reviewer's comments.

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report (New Reviewer)

The coherence and flow in the revision work well and will benefit the audience. The changes from "suicide contagion" to "suicide exposure" and "suicide diffusion" are appreciated.

Author Response

We extend our thanks to you for your thoughtful input to improve the manuscript. 

Reviewer 2 Report (New Reviewer)

“An Integrated Conceptual Model to Understand Suicidality Among Queer Youth to Inform Suicide Prevention”

This paper presents a new framework through which to analyze the root causes of queer adolescent suicidality, the “Queer prevention of Youth Suicidality Model (Queer-PRYSM).” While I appreciate the additions made, several aspects should be improved. 

● In the abstract, only one sentence about the need for the study would be sufficient. It should be followed by four short sentences about what the four theories contribute to our understanding of suicidality among queer youth. Currently, every sentence in the abstract describes the gap in the literature rather than the constructs embedded in the model. 

● I appreciate the authors appropriately added the YRBS definition of “queer” youth.

● When talking about multiple marginalized intersectional identities, it is important to note that the sample sizes get smaller when looking at people with multiple minoritized, not just that SOGI measures have been absent. This is a problem even in large, nationally- representative survey studies. 

● The authors did not make any edits in relation to the reviewer’s suggestion to further

explain why the specific theories and frameworks were chosen for this work

(“psychology, social work, sociology, public health, and related fields”). 

● The authors define “queer” to be inclusive of trans people, but than discuss trans populations as separate identities from queer in the intersectionality section and in discussing the lack of research concerning trans people and suicidality (although the existing research, such as the work of Toomey, isn’t cited). The authors should use queer consistently to include trans people, as defined, or be specific when referring to queer (i.e., non-straight sexual orientation) versus trans (i.e., non-cisgender) populations. 

● The authors responded appropriately to this reviewer’s feedback of defining what a

“supportive school staff and policies” may look like by adding in a reference to the Gay,

Lesbian & Straight Education Network’s Safe Space Kit.

●8.3. School and Peer Factors -> Should be 8.2.

● There’s a clear argument that supportive communities reduce suicidality, while less

supportive ones are a risk factor for queer adolescent suiciadiliy. However, there are so

many complex components of a community. I am concerned that the authors argument

here is, again, too broad

●8.4. Suicide Contagion and Acquired Capability for Suicide -> Should be 8.4.

● What did COVID add to our understanding of suicidality among queer youth and developing this conceptual framework? Did rates rise or decrease for queer youth? This was such a massive disruption it could exemplify core aspects of your model. 

●  I’d agree with reviewer three who pointed out the overuse of self-cites. The authors self-cite and use their own citation as one of the main citations for a broad concept in almost every section of the paper, even when there are a number of scholars that could support the point made like MST. It is rare to read a manuscript with this level of self-citations even among the most established scholars. The extensiveness of the self-citations (55 times in an 8,000 word manuscript) undermines the credibility of the claims made and demonstrating knowledge of the field. 

● Several sections lack the appropriate citations. The following claims need citations on page 8:

The experience of minority stressors manifests differently among queer youth de-pending on their various intersectional identities. For example, a transgender, bisexual youth in foster care who may otherwise have higher levels of minority stress due to their queer identity may be protected by a combination of caring, affirming foster parents, in-clusive, supportive school staff and policies, and peer support groups, subsequently less-ening their mental health issues and suicide risk. Supportive school climates foster affirm-ing, nonjudgmental spaces, such as those outlined by the Gay, Lesbian & Straight Educa-tion Network GLSEN’s_ _Safe Space Kit (2016) can mitigate risk for mental health issues and suicide. Conversely, a youth with the same background in an environment that is rejecting and hostile toward their queer identity may exacerbate mental health issues and suicide risk through victimization, discrimination, and internalized stigma. The queer youth may experience rejection from both the queer community and heterosexual, cis-gender communities as someone who identifies as bisexual. and transgender. Negative interactions and continued rejections may lead to an expectation of negative interactions with other, causing them to hide their queer identity (e.g., identity management). If they are unable to feel acceptance and live life as their true, authentic self and experience joy (e.g., gender euphoria), this may decrease the likelihood that they will be able to find sup-portive individuals in their lives. Such experiences can lead to feelings of thwarted be-longing and perceived burdensomeness, as explored more in-depth below.

… and on page 9:

Queer youth who feel ostracized by others because of their sexual orientation and gender identities may feel hopeless and experience alienation by their families, schools, and communities, subsequently increasing their risk for suicide. For example, if queer youth may disclose their queer identity to their family, and if their parent(s) but they do not have a positive reaction, without adequate friend support or supportive social net-works to serve as protective factors, theythe youth may become suicidal. YouthHowever, youth who feel supported in these areas may experience feelings of hope and acceptance, lessening the likelihood that they will experience suicidal ideation or behaviors.

And page 12:

Queer youth who have positive interactions with other youth and adults in their communities in terms of affirmation, acceptance, or even respectful tolerance regarding their queer identities would be beneficial to mental health, whereas negative or hostile interactions in community spaces may be harmful. Some communities, such as more pro-gressive urban areas, typically have more queer-specific and queer-affirming mental health treatment and service options. Communities may also vary in opportunities for psychosocial engagement around queer issues, such as queer youth social organizations, support groups for parents and family members of queer youth, and queer youth advo-cacy organizations that interface with schools.

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Reviewer 3 Report (New Reviewer)

All my concerns have been taken into account

Author Response

We extend our thanks to you for your thoughtful input to improve the manuscript. 

This manuscript is a resubmission of an earlier submission. The following is a list of the peer review reports and author responses from that submission.

Round 1

Reviewer 1 Report

The manuscript try to construct a theoretical framework to explain the problems of queer youth suicide in the United States. 

The topic is interesting and it is certainly important since suicide it's a growing problem that affects society, not only in the States, but in the world. Regarding this, I believe that this theoretical framework shouldn't be focused just in the United States, but in the world, especially considering that the selected journal to publish is international.

The article is similar to a meta-analysis, which goes a step further to build a theoretical model that integrates the components of suicide detected by other studies. In this way, I do not think it provides new data, since all the information presented in it can be found by reading the literature related to the subject. Thus, I think the paper could make a good chapter for a book on suicide and related factors, but I don't think it would be suitable for publication as an article.

Finally, I would like to point out that this work would be a good starting point to carry out deeper analyses, testing the constructed theoretical framework and exploring the way in which the components are related to each other (for example, which are mediating factors, and which ones are moderators).

Reviewer 2 Report

Thank you for the opportunity to review this important and thoughtful manuscript on the serious issue of LGBTQ youth suicide! The authors take a broad view of this challenging phenomenon and propose a comprehensive conceptual model, the Queer Prevention of Youth Suicidality Model (Q-PRYSM). A strength of this manuscript is its’ extensive review of the literature on LGBTQ youth suicide. However, due to several methodological and organizational issues, I recommend that the editors reconsider the manuscript after major revisions. I will give an overview of these broad challenges below and then move into a more detailed discussion of the manuscript text by section.

The first methodological issue is the authors’ choice to use “queer” to describe all LGBTQ youth. The authors state that they are using “queer” in a manner that includes transgender people. However, in several places throughout the manuscript, the use of “queer youth” as an umbrella term obfuscates the unique experiences of transgender and gender diverse (TGD) youth and the effects of transphobia in the model. For example, there are several places in the manuscript where “heterosexual youth” are posited as the comparison group for “queer youth” (e.g. line 43, page 1). However, using the authors’ own inclusive definition of “queer”, this is inaccurate because it conflates sexual orientation and gender identity. The correct comparison group for “queer youth” is “heterosexual and cisgender youth”.  While I do not think the authors need to completely separate queer and trans youth in the model, they should pay more attention to differences in experience and risk both in the research literature and the proposed model, due to the fact that sexual orientation and gender identity are two different aspects of a youth’s identity. 

The of “queer youth” as an umbrella term becomes a more serious methodological issue when it is used to refer to research findings throughout the manuscript. Because TGD youth have been historically excluded from public health data and research studies on LGBTQ youth suicide, the authors must specify when findings from the literature have included TGD youth and when they have not. For example, in lines 40-43 on page 1, the authors claim that the 2019 YRBS found 46.8% of “queer youth” reported seriously considering suicide in the past year. This is inaccurate because the 2019 YRBS only included transgender-inclusive questions about gender identity in 15 states and 15 additional municipalities. Because TGD youth were not included in the full sample, it is more accurate to conclude that 46.8% of LGB youth reported seriously considering suicide in the past year. A similar approach must be applied to every other research finding shared in the manuscript- the authors must clarify if the finding is truly relevant to all youth in the LGBTQ community or only for LGB youth. This is frequently accomplished by using “LGBT” to describe research findings why apply to all youth and “LGB” for findings that only apply to youth who are sexual minorities. 

The second methodological issue is with the description and scope of the Q-PRYSM model. The authors have done an excellent job applying the four named frameworks to the phenomenon of LGBTQ youth suicide. However, the manuscript reads more like a literature review than a description of a conceptual model. There is little discussion of how the model functions and how its components interact with one another. For example, it is unclear how Minority Stress is related to Mental Health. Why did the authors choose to use a one-directional arrow between these two boxes in Figure 1? Could there be a bidirectional relationship between Minority Stress and Mental Health? I encourage the authors to spend less time reporting findings in the literature and more time discussing components of the model, how they differ or overlap with one another, and how they interact to contribute to suicide risk among LGBTQ youth.

Refining the model and providing more description of how its components interact will also increase the research and practical implications of the Q-PRSYM model, as it will give researchers and practitioners more detailed hypotheses to test or more targeted interventions to develop. The authors may consider scaling down the model in order to focus on one or two key pathways or relationships. For example, it is redundant to both list a number of identities which youth may hold on the left side of the model and a corresponding list of systems of oppression that impact those identities on the right side- especially since there is no detailed description of either those identities or the systems of oppression in the manuscript text. 

The following comments are organized by the order in which they appear in the manuscript. 

More discussion is needed of the racial disparities noted on lines 50-53 on page 2. The authors’ mention using the Intersectionality framework in the model, but there is little discussion of the intersections of LGBTQ identity with race, ability, class, or other identities throughout the text. The authors should augment this discussion or remove Intersectionality from the included frameworks and instead encourage those using the Q-PRYSM model to apply it in conjunction with Intersectionality.

The section on the Need for a Conceptual Model on Suicidality Among Queer Youth starting on page 2 should be shortened and that additional space should be used for increased discussion of the Q-PRYSM model. 

Overall, the discussion of the four frameworks used in the Q-PRYSM is very well done. The authors have done a great job describing each framework, its strengths and weaknesses, and its implications for LGBTQ youth suicide. It is confusing that the authors chose to present Person-In-Environment and Risk and Resilience as one framework when most scholars and practitioners think of them as two separate frameworks. While one of the citations shared on the PIE-R&R section on page 3 does appear to use both frameworks (Hall et al., 2022), most use one framework or the other and none of them appear to use to refer to a “PIE-R&R” framework the way it is used in this manuscript. I agree that the frameworks complement one another, but I recommend that the authors either 1) very explicitly explain that they are combining these frameworks into one and explain the purpose for that choice and how it serves Q-PRYSM, 2) separate the discussion and edit the paper to reflect the five frameworks which inform Q-PRYSM, or 3) focus only on PIE since it is directly referenced in the discussion of the Q-PRYSM model. Currently there is very little discussion of resilience in the manuscript and the model, so the use of Risk and Resilience feels underdeveloped. The Minority Stress framework could be used to conceptualize risk as it is currently presented in the model. 

The discussion of the Intersectionality Framework is well done on pages 4 and 5 but is undercut by the lack of corresponding discussion in the description of the Q-PRYSM model. As mentioned earlier, the authors should add more discussion of how LGBTQ youths’ intersecting identities impact LGBTQ youth suicide and the Q-PRYSM model or they should remove this framework. 

As mentioned earlier, more discussion of the model as it is represented in Figure 1 is needed. The authors may consider explicitly telling the reader the order in which they are going to describe the components of the model and its rationale (e.g., “We will start in the top left corner and move toward the outcome variables on the right-hand side.”). The authors should add more discussion of the arrows connecting the box- what kinds of relationships do they indicate? 

Resilience is conspicuously missing from the model. How do the authors believe that Resilience may buffer or complicate LGBTQ youths’ risk of suicide? What is Resilience’s relationship to other components of the model?

The use of “Consequentially” on line 249 on page 6 is confusing. “Consequentially” implies a causal relationship but it is unclear how the outcomes in the first sentence of the paragraph are related to the outcomes in the second sentence. 

On line 312 of page 7 the authors note that “gender identity is significantly associated with…”. More detail is needed here- which gender identities are associated with elevated risk? How do sexism and transphobia contribute to that risk? 

Sections 4.3.1 and 4.3.2 are both too long and need to be edited for narrative flow. Findings from the literature should be consolidated and connected to the themes previously discussed in the model. Currently, some topics which naturally go together are discussed in separate paragraphs. For example, family rejection is discussed in the middle of the second paragraph but the parental anti-LGBTQ attitudes (which can contribute to family rejection) are not mentioned until the top of the third paragraph. Parent connectedness and parent-child relationships are also currently in separate paragraphs when they could be grouped together. 

There are several places on page 8 where language is used that is not inclusive of TGD youth. Youth are referred to as “sexual minority” on line 242 and “homophobic” attitudes are referenced on line 356. Since the authors are including all LGBTQ youth in “queer youth” this language to be edited include gender minorities and transphobic attitudes. 

On line 373 of page 8 there is an apostrophe missing after queer youth. 

The section on peer support and chosen family on the bottom of page 8 and top of page 9 is underdeveloped. The author may consider moving it to the following section on “Peer Factors”.  This may be a good place to discuss Resilience. 

“Sexual minority” on line 383 on page 9 should be changed to “sexual and gender minority” unless the findings in the citations are exclusive to LGB youth. 

The School and Peer Factors section has similar organizational issues to the Family section. Bullying and peer victimization are mentioned briefly in the first three paragraphs, which feels repetitive. Parents and teachers are mentioned at the end of the paragraph about GSAs without any discussion of if or how parents and teachers can support GSA’s. 

The Community Factors section is much shorter than the sections on Family and School / Peer and should be developed more or removed. It is also vague. In lines 438-439 on page 10, the authors refer to “Policies that enhance and foster such accessible and supportive climate”. More detail is needed- what exact policies could do this? 

It is unclear why Suicide Contagion and Acquired Capability for Suicide are grouped together, especially since they are separate boxes in the Q-PRYSM model. The Acquired Capability paragraph is undeveloped and should be augmented. There should be less reporting on the literature and more discussion of how these concepts interact with each other and the previously discussed parts of the model (Family, School, Minority Stress, etc.). 

I recommend moving the first sentence of the second paragraph to the beginning of the Suicide Contagion section, since it explains the concept of suicide contagion among youth in general. Then you can go into the research on suicide contagion among LGBTQ youth in particular. 

It is implied but never explicitly stated that Section 4.4 is the section which corresponds with the Intersectionality Framework. This section is also underdeveloped and needs more explicit connection to the Q-PRYSM model. In line 512-515 on page 11 the authors state that “Q-PRYSM can be used to explore unique manifestations of risk factors… for queer youths’ intersecting identities…” but they never explain how the model accounts for youths’ intersecting identities. 

More detail is needed in the Implications for both researchers and practitioners. How does the Q-PRYSM model allow researchers to discern and test more nuanced hypothesis about LGBTQ youth suicide? What specific risks can practitioners intervene on and how does the Q-PRYSM model make their interventions more inclusive or effective? In lines 562-564 on page 12 the authors state that “Q-PRYSM suggest several avenues for prevention and intervention regarding queer youth suicidality…” but the next sentence is about the benefits of “universal prevention” via staffed up mental health services in schools. While I certainly agree that having accessible school-based mental health services could be effective in mitigating LGBTQ youth suicide, it is strange to see a broad, non-LGBTQ-specific solution proposed after reading about a model that claims to provide a more detailed conceptualization of LGBTQ youth suicide. 

The Discussion is currently lacking a Limitations section. The authors should discuss any weaknesses or gaps that the Q-PRYSM model does not address. 

In line 582 on page 12 it is unnecessary to define suicidality as suicidal ideation and behavior, this should be done earlier in the manuscript and does not need to be repeated.

Reviewer 3 Report

The authors refer to "the developmental contexts of queer youth," but do not explain what this means or how they may be different from those of non-queer-identified youth.

The use of minority stress theory in this context seems out of place. While I agree it is used for the identified purpose in some literature, a structural stress framework would be more relevant and effective, given that the authors also invoke intersectionality. Such a framework could begin to remedy the issues that the authors identify with MST.

The model diagram seems unnecessarily complicated and I think it could be both simplifed and made more clear.

I am a little surprised that the link between social and/or familial rejection and mental health is not delineated. This is a significant issue, especially since many queer youth experience homelessness at some point, and with it worsening mental health.