Is the association between sexual minority status and suicide-related behaviours modified by rurality? A discrete-time survival analysis using longitudinal health administrative data

Abstract

While self-reported data shows that lesbian, gay, and bisexual individuals have a greater risk of suicide-related behaviours (SRB), little is known about how rurality may amplify the risk of SRB associated with sexual minority status. Sexual minority individuals in rural areas may experience unique stressors due to stigma and a lack of LGB-specific social and mental health services. This is the first study to use a population-representative sample to investigate the contribution of sexual minority status and rurality on clinical SRB outcomes, and whether rurality modifies the association between sexual minority status and SRB risk. A nationally representative survey linked to administrative health data was used to construct a cohort of individuals (unweighted n=169,091; weighted n=8,778,115) in Ontario, Canada, and captured all SRB-related emergency department visits, hospitalizations, and deaths between 2007-2017. Rural status was captured using three measures which reflect different dimensions of rurality: the Rurality Index of Ontario, the Metropolitan Influenced Zones classification, and the Index of Remoteness. Sex-stratified discrete-time survival analyses were used to examine the interaction between rurality and sexual minority status on SRB risk while controlling for potential confounders. Sexual minority men had 2.18 times higher odds of SRB compared to their heterosexual counterparts (95%CI 1.21 to 3.91), while sexual minority women had 2.07 times higher odds (95%CI 1.48 to 2.89). The Rurality Index of Ontario and the Index of Remoteness were associated with the odds of SRB in a dose-response manner. No significant interactions were observed between rural status and sexual minority status. Rural status and sexual minority status both independently contribute to an elevated likelihood of SRB. Differences in access to healthcare between urban and rural areas appears to be strongly associated with SRB in both sexual minority and heterosexual populations. Future studies should consider incorporating measures of urban-rural status that capture access to healthcare, such as the Rurality Index of Ontario, to predict rural health disparities. This study highlights the need to evaluate the effectiveness of interventions and policies to reduce SRB in both rural and sexual minority populations.