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Lesbian, gay, bisexual, and transgender (LGBT) youth are a vulnerable population at high risk of suicide and, as such, benefit from an informed psychotherapeutic approach to treatment. While it is clear that sexual orientation and gender identity are independent dimensions from psychopathology, LGBT youth are frequently marginalized and may face unique challenges with self-acceptance and identification with peers, family, and society, increasing risk of social isolation, which in turn increases vulnerability to anxiety, mood disorders, substance use, and suicide. We elaborate on the common phenomenon of ambivalent repression of the sexual self in adolescents associated with intertwined themes frequently expressed in suicidal lesbian, gay, transgender, bisexual, and queer patients on the inpatient adolescent unit: anger directed toward internal and external objects; desire for self-punishment, atonement, and possibly rebirth; and desperation and desire to escape psychic pain. We enhance our discussion with case examples and practical therapeutic considerations that emerge from these themes that can be harnessed across treatment settings.