The need for a comprehensive exploration of self-harm and suicide among all categories of LGBT populations in Bangladesh has long been felt. A few articles addressed self-harm and suicide among the gay population. However, there was a major gap in published data on self-harm and suicide among the other sexual minority groups in Bangladesh, namely lesbian, bisexual, and transgender. The present study, therefore, incorporated a cross-sectional survey of self-harm and suicidal behaviour of the four groups of sexual minorities and the cisgender population. Self-reported histories of self-harm and suicidal behaviour were recorded with two different time spans, lifetime (ever) and recent (last 3-month). Determining an experience to be exactly within the last 3-month is understandably difficult, a fact that has been reflected in the appearance of multiple missing values in data under this category across all the groups.
Self-harm is often considered a precursor of suicidal behaviour [22] but due to the perception of low immediate risk, indirect self-harm i.e., engaging in risky behaviour with the intention to facilitate early death, usually goes unnoticed and unexplored. Higher rates of direct and indirect self-harm were observed among the LGBT groups. However, the lesbian participants demonstrated a distinctively high lifetime (OR = 12.35) as well as recent (OR = 13.17) engagement in direct self-harm in contrast to the other sexual minority groups (all OR < 4). Non-suicidal self-injurious behaviours have been generally known to be more prevalent among biological females [23, 24], which might also have contributed to its higher prevalence among lesbian participants.
Higher odds found on all five indicators of self-defeating behaviours among the LGBT population raised a major concern regarding their suicidality in clear contrast to that of the cisgender population in Bangladesh. Concerns around high rates of self-harm and suicidal behaviour among the gay community of the country are already known [15]. The present study findings provided further support to that and raised similar concerns about other sexual minority groups, especially lesbians and transgenders. About five to six times higher probability of suicide attempts among the lesbian, transgender, and gay population is alarming. The high rates of self-harm and suicidal behaviour reported in this study resonate with similar studies conducted across the globe [5, 25].
Lesbians were found to be the most vulnerable groups among the sexual minorities in terms of self-harm and suicidal behaviour. Previous reports suggested a link between their extreme vulnerability and the existing marginalisation of women in the socio-cultural framework of the country [26]. Although some services are available for the gay and transgender population through community-based organisations, comprehensive customised services for lesbians are yet to be developed at an organisational level. In contrast to many studies across the globe [2, 5], the present study indicated lower rates of suicidal behaviour among bisexuals compared to other sexual minority communities. It might be noted here that the bisexuals, having interests towards the opposite gender, are apparently blended within the cisgender population in Bangladesh. Differences in sociocultural contexts of the bisexuals in Bangladesh might also be the possible reason behind this lower rate.
Suicide is thought to be preventable at an individual level with psychological support and intervention. Sadly, for the LGBT population in Bangladesh, service accessibility concerns are understandably high due to widespread stigma, discrimination, and legal provisions. It may be noted here that attempted suicide is a cognisable offence as per the penal code in Bangladesh [section 309; 14] and anyone knowing about it (including the psychosocial service providers) is mandated to report such behaviour to law enforcing authorities. The same also applies to anyone engaged in sodomy [section 377; 14]. These legal provisions further intensify the existing burden due to scarcity of service, feared discrimination, or lack of agency, and further prevent individuals from seeking service or disclosing such history needed to get appropriate service. Thus, sexual practices and suicidality become a double burden for anyone from the LGBT community seeking support.
Combating suicidality among the sexual minority population would require the involvement of multiple stakeholders (including government agencies, non-government organisations, and community-based organisations) engaged in an intensive, coordinated, and carefully planned effort. Tackling the problem may require affirmative actions targeted towards increased social acceptance of the sexual minority population. Legal acceptance and protection may also be useful. However, any such attempt, from the government or other key stakeholders to ease the burden of these communities, needs to take into consideration the socio-cultural and political context as well as the sensitivity and sentiments of the larger cisgender population. Hasty, insensitive attempts towards awareness may not only be ineffective but also run the risk of igniting further reactivity towards sexual minority groups. The recent anti-LGBT backlash [27] in Bangladesh that erupted over the nation after the inclusion of a transgender story in the secondary school textbook can be considered as a classic example of an affirmative action that backfired. It may be noted here that, to avoid further complications from this backlash, the LGBT community-based organisation that aided in collecting data from the LGBT participants expressed preference for not to be named in this research or in the acknowledgement section.
The World Health Organization has declared a global target to reduce the suicide rate by one-third by 2030 [28]. In line with that, the government of Bangladesh aspires to reduce suicide mortality by 5% by 2025. However, recognising the gap in the knowledge of mental health and well-being of the LGBT population, no discussion has been made concerning suicide prevention among these sexual minority groups in the national mental health strategic plan [see 11]. Due to the secretive nature of the LGBT community and a lack of proper estimates of population size, it is difficult, if not impossible, to conduct a methodologically perfect prevalence study on them in Bangladesh. Data from small, non-random samples can best be described as pilot estimates and are understandably far from being generalisable toward actual rates. However, with the inclusion of countrywide sampling in the present study, the findings can be considered representative of the LGBT community in Bangladesh. Therefore, these can be useful for policymakers as well as program implementers and may serve as an impetus to act toward intervention in curbing the self-harm and suicidal behaviour among the sexual minority communities in Bangladesh. Although some risk factors for suicidal behaviour have been reported in an international context, those findings may not be useful for Bangladesh considering the contextual difference. An in-depth analysis of putative causes or risk factors behind such high rates of self-defeating behaviour among the LGBT population in Bangladesh may need to be carried out before designing contextually sensitive interventions.