Trigger warning: This article talks about suicide.
There has been a simmering crisis in youth mental health over the past decade and a half, exacerbated by the isolation of COVID-19, according to Dr. Cornelio “Cornie” Banaag, considered as the Father of Child and Adolescent Psychiatry in the country.
Pushing 89, Cornie remains as energetic and dedicated as ever; we work together on the Board of an NGO, Community and Family Services International (CFSI). He still maintains a clinic from 9 to 5 six days a week, and after hours, is often interrupted by calls of distress from young people or their parents. My psychiatrist friends here in Iloilo city sometimes feel overwhelmed, despite the fact that there are now about 30 of them practicing in the city, compared to just three in the late 80s.
Local researchers, analyzing data from extensive national surveys such as the Young Adult Fertility Survey (YAFS) and World Health Organization (WHO) Global School Health Surveys, reported rising rates of suicide attempts in young people in the Philippines back in 2016; Manalastas et al found that young Filipino gay and bisexual men had disproportionately higher rates of suicidal ideation (thoughts of killing oneself) than their heterosexual peers.
These thoughts were associated with depression, recent suicide attempts of a friend, and experiences of threat and victimization. In 2021 the University of the Philippines Population Institute (UPPI) 2021 Young Adult Fertility and Sexuality Study (YAFS5) found that close to almost 1.5 million youth had tried ending their life in 2021 — that is 7.5% of youth. That is a 150% increase over the 3% recorded in 2013.
Dire numbers
Successful suicides, sadly are just the tip of the iceberg — for every successful attempt (often a celebrity) that makes it to the headlines, there are a dozen more cases of attempts, suicidal thoughts, self-harm, depression, anxiety, and other conditions that have a major mental health component — such as alcoholism, substance abuse, many types of violence, experience of being bullied. A well-established fact is that some young people are more vulnerable than others — because of their being Lesbian, Gay, Bisexual, Transgender or Queer (LGBTQ+). Rates of suicide and mental health problems are higher compared to non- LGBTQ+ peers.
The Department of Education reported 404 suicides, and 2147 attempts, during the school year 2021-2022. That’s 40 a month, or 9 to 10 suicides a week on average, among students. Other cases may be unreported, or unrecognized, given the stigma, including church admonitions against suicides. WHO notes that suicide is the fourth leading cause of death in those aged 15-29 worldwide; suicide reduction is a target of the 2030 Sustainable Development Goals.
RA 11036, or the National Mental Health Act (2018), mandates the education and promotion of mental health in educational institutions and the workplace, with schools supposed to set up mental health programs, but these remain greatly understaffed and under-resourced. Last year, DepEd ASEC Galban informed a senate panel that the recommended ratio for guidance counselors is 1:250 students; but in actuality, there is one guidance counselor for every 13,394 learners in the public school system.
Trevor Project in the Philippines
Therefore, when I saw that the Trevor Project, a US-based organization that is the world’s leading organization working to end suicides in LGBTQ+, released the results of the first survey on mental health of young LGBTQ+ people in the Philippines, I immediately downloaded it. It has both English and Filipino versions.
The online survey had 5,515 respondents between the ages of 15-24. It was authored by the Psychology Association of the Philippines (PAP) LGBT Psychology Special Interest Group — Marc Eric Reyes, Beatriz Torre, Angelie Bautista, Junix de los Santos, Moniq Muyargas, Jan Castañeda, and supported by a Trevor project team.
What the survey found, is shocking, to say the least. The numbers are so high, that rates are two to three times higher than reported pre-pandemic; they are almost numbing. The survey found that 3 in 4 of LGBTQ+ young people have ever seriously considered suicide, nearly half have ever attempted suicide, with more than one in three (34%) attempting suicide in the past 12 months. (Note that this is four to five times higher than all Filipino youth in general).
62% reported symptoms of depression, and 62% reported symptoms of anxiety; 59% engaged in self-harm in the past year. 19% (1 in 5) reported being threatened with, or subjected to conversion therapy,
which was related to higher rates of mental health concerns, and nearly two-thirds (63%) saw their LGBTQ identity as a burden and more than half (58%) did not feel comfortable interacting with others as their true selves. Both were related to higher rates of anxiety, depression and self-harm
At the beginning, I was a bit skeptical of the disturbingly high rates reported. I consider myself relatively better informed, having done consulting work in the field of LGBTQ+ health and rights, including with the Trevor project in 2022; I lecture on Gender, SOGIE-SC (Sexual Orientation, Gender Identity, Expression, and Sex Characteristics) and Health at a state-run medical school in Iloilo. So I took a closer look at the methodology and statistical tests that Trevor used.
Pros and cons of the survey methodology
The Trevor Project has done several such annual online surveys in the past six years; five have been done in the US. In 2023, Peru, Mexico, the UK, and the Philippines were added.
The survey questionnaire underwent review by institutional review boards in both the US and in the Philippines (Philippine Social Science Council-Social Science Ethics Review Board).
Trevor used targeted ads on social media platforms to recruit, not via their website or social media accounts. A quantitative cross-sectional design was used. Individuals aged 15 to 24 residing in the Philippines were eligible, and responses collected over a three-week period in June 2023. The secure online questionnaire had up to 70 questions.
For the Philippines, the survey was offered in four languages — English, Filipino (Tagalog), Cebuano and Hiligaynon. All three major geographic divisions (Luzon, Visayas, Mindanao) were covered, and 17 regions coded.
The methodology further describes how unique responders (meaning, different individuals) were identified, involving the use of safeguards to avoid duplications and possible spamming. They also detail the numbers excluded from the final list because of incomplete demographic information, not reaching or answering validity questions, multiple attempts to answer, and “non-honest” responses. 12,872 unique individuals consented, and 5,515 LGBTQ+ aged 15-24 residing in the Philippines made up the final sample.
Respondents were defined as being LGBTQ+ if they identified with a sexual orientation other than heterosexual, a gender identity other than cisgender, or both. Recruitment was monitored to ensure adequate sample sizes with respect to age, region, gender identity and sexual orientation. The questions themselves are validated and used internationally, identical to those used by the US Centers for Disease Control and Prevention’s Youth Risk Behavior Surveys, the Generalized Anxiety Disorder Scale 2 (GAD-2), the Patient Health Questionnaire 2 (PHQ-2), the WHO Five Well Being Index (WHO-5) and the 2017 Philippine Demographic and Health Survey (DHS).
Chi-square tests were used to examine differences between groups; comparisons are statistically significant at p
The survey covered the following topics:
Risk Factors (those associated with higher rates of suicide, self-harm, and mental health problems):
- Respondent experiences of Conversion Therapy
- Homelessness,
- Anti-LGBTQ+ Discrimination and Victimization,
- Self-Stigmatization, and
- Access to Care
Protective Factors: (associated with decreasing rates of suicide, self-harm and mental health problems):
- Community Acceptance,
- LGBTQ+ Affirmation
Support Factors:
- Having family support was associated with the lowest suicide risk; Specifically, rates of considering suicide in the past year (51%) and attempting suicide (26%) were lowest among those who identified family support as an important factor in managing life difficulties.
- Religion – categories include Roman Catholic, Protestant, other Christian, Iglesia Ni Cristo, Others not listed (includes Aglipay and Islam). Catholics constituted 63%, the rest from between 2-9%. Notably, 16% of the respondents indicated “No religion” and were the second biggest category after Catholics. This indicates that almost one in six young LGBTQ+ Filipinos do not follow any religion.
Generally, the above “protective factors” were associated with lower rates of suicide thoughts and attempts. There is a huge gap in need for mental health counseling; only a small proportion of respondents had this type of support from professionals. Even if services are available, other factors can serve as barriers to these services. Medical anthropologist Gideon Lasco, writing about students and suicide, noted: “mental health remains stigmatized, people are too embarrassed to talk about it, and seeking help from counselors and psychiatrists is associated with shame and embarrassment”.
Seeking care is not always acceptable — and here gender factors come into play, since boys are less likely to seek care in general.
The report has up to nine different ethnicity categories: Ilocano, Waray, Ilonggo, Bisaya, Cebuano, Bicolano, Kapampangan, Tagalog and the “others not mentioned above” category (includes Maranao and Tausog). Almost half (49%) of the respondents said they were Tagalog, and the rest varied from 2% to 14%. The smallest category with 2% has over 100 respondents.
Outstanding features of the report are its attractive lay-out, readability and relative brevity. Language is clear and straightforward. English terms used for Sexual Orientation and Gender Identity are identical in the English and Filipino reports, such as “Bisexual”,” Queer”, “Pansexual”, “Sexually Fluid” and “Questioning”; or “Non-Binary”, “Cisgender”, “Transgender man” and “Transgender woman”. “Survey” is filipinized into “sarbey”; “Sample” into “sampol”. “Gay” and “Lesbian” are translated as “Bakla” and “Tomboy” respectively.
There is no universal agreement on whether these terms are directly translatable, since they may mean slightly different things to LGBTQ+ people themselves. For example, “Lesbian” is understood to refer to a sexual attraction, while “tomboy” is also understood to refer to a manner of expression – like that of a male, but not necessarily indicating same-sex sexual attraction, while “Gay” may not be wholly equivalent to “Bakla” (Tagalog), “Bayot” (Cebuano/Bisaya), or “Agi” (Ilonggo).
These terms — and their meanings, continue to evolve. I assume though that with a team of Pinoy psychologists as authors — including an Ilongga, the terms used would have been sufficiently pre-tested and validated.
Points of improvement
Completing this type of survey requires good literacy levels, comprehension, and understanding of terminologies of Western/US origin, a good internet connection, and smart devices — thus it is likely that young, more affluent urbanites are probably “over-represented”.
Given the anonymity afforded by an online survey, sans interviewers, responses to sensitive topics are likely to be more reliable than in a personal interview. Face to face methods are costlier, take longer, and are more difficult to organize. Respondents may give evasive answers to sensitive questions, or give responses that they think are acceptable to, or expected by the interviewer. I wonder how an average student in senior high would be able to complete the questionnaire, given dismal PISA scores in comprehension!
It would be good to have details reported about social and economic status (income levels, if any), as well as whether participants were in school or not, their schooling levels, and if they were working, as these demographics are only fleetingly noted and not analyzed. Without the full questionnaire and its algorithms, it is not known if these questions were asked, and how.
One of the authors told me that they hope to have access to the full data sets. With this, further analyses can be done, uncovering information that might be useful for practical work and policy design, and specific for the regions. A section on definitions of terms, or a glossary, would also be helpful, even as many of the terms used are defined or clarified in the text itself.
“Food insecurity” in the past 12 months is also measured, cited as a proxy for socio-economic status, and is related to higher rates of suicidal ideations and attempts compared to those who did not experience this.
The report strongly emphasizes the urgency of prioritizing the mental health of young LGBTQ+ Filipinos. Recommendations include fostering supportive and accepting environments from family and friends, LGBTQ+ affirming health care and community services, independent access to mental health care, and complete eradication of dangerous and discredited conversion practices. It highlights the necessity for access to gender-affirming care, underscoring its lifesaving potential; an intersectional, systemic approach to addressing mental health needs, and increased awareness and policy development for protecting marginalized subgroups within the LGBTQ+ community.
Young LGBTQ+ pinoys cannot wait. – Rappler.com
Are you experiencing distress, suicidal thoughts, or thinking of harming yourself? The Department of Health, through the National Center for Mental Health, has a national crisis hotline. Call 1553, which is a Luzon-wide, toll-free landline number; 0917-899- 8727 and 0966-351-4518 (Globe and TM); and 0908-639-2672 (Smart and Sun).
Author’s note: Other institutions and groups use slightly different acronyms, i.e., LGBTIQ+. “I” refers to Intersex individuals. For consistency with the survey report, I opted to use LGBTQ+; if there are known intersex individuals participating, it is their gender identity and sexual orientation that is asked for in the survey rather than one’s genetic, chromosomal, or phenotypical characteristics.
Disclosure: I had a consultancy assignment with the Trevor Project in mid-2022 — an analysis and scoping of the situation in the Philippines, in preparation for Trevor’s planned expansion. Trevor eventually decided to defer start-up work in the Philippines, citing internal issues within the organization. Nevertheless, the survey is an essential first step; the magnitude of the findings emphasizes the urgency of the mental health crisis in young LGBTQ+; this should spur efforts to address this emergency, whether or not Trevor decides to start a Philippine project.
