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Monday, January 27, 2014

Gender differences in suicide

A Gendered Analysis of Sex Differences in Suicide-Related Behaviors:
A National (U.S.) and International Perspective
Jennifer Langhinrichsen-Rohling, Ph.D.
University of South Alabama

Evidence was reviewed for national (U.S.) and international sex differences in suicidal behavior.
Suicidal behavior included suicide ideation, suicide attempts, and suicide completions, as well as
suicide-prone behaviors. Across most countries, females have higher rates of suicide ideation and
more frequent suicide attempts than males; females also score higher than males on measures of
suicidality that overlap with depression assessments. However, males generally have higher rates
of suicide completions. Therefore, identification of at-risk males remains an important task. Yet,
common suicide prediction self-report measures identify more females than males. Using a
measure of suicide proneness that assessed engagement in traditionally defined suicidal behavior,
as well as engagement in risky and/or illness producing behaviors, United States males were
found to be more suicide-prone than females. This measure has not yet been used internationally.
These results were used to argue that the ability to detect male and female suicidal individuals is
enhanced by utilizing both traditional and non-traditional suicide proneness measures. Reviewed
research revealed similar suicidal risk factors for males and females. However, the prevalence
and strength of prediction of certain risk factors were found to vary gender-specifically. These
findings support the utility of gender-sensitive suicide assessment, prevention and intervention

A Gendered Analysis of Sex Differences in Suicide-Related Behaviors:
A National (U.S.) and International Perspective
Introduction- Sex Differences in Suicide
The purpose of this paper is to conduct a gendered analysis of sex differences in the
frequency, risk factors, and outcome of a broad range of suicidal behavior occurring within the
United States and around the world. According to official statistics (e.g., World Health Statistics
Annual, 1998), in many countries, there are differences in the rate and expression of men and
women’s suicidal behavior. For example, in the United States, across most age groups, men
complete suicide more often than women, yet women attempt suicide more often than men
(McIntosh, 1993; National Center for Health Statistics, 1994). The trend for males to complete
suicide more than females was also found in all but one of the 56 countries catalogued by Lester
(1997). Furthermore, Lester (1997) concluded, “While male suicide rates seem to be rising
worldwide, females rates do not." Lester (1998) reviewed the international statistics on youth
suicide and came to the same conclusion; male youth were more likely to experience an increase
in their suicide rates than female youth. These findings suggest that sex differences in rates of
suicide completion’s are becoming more pronounced over time (males greater than females).
Taken as a whole, these data have been used to contend that there are inherent sex differences in
the extent and expression of suicidality, which need to be understood with a gender-sensitive
analysis. A gender-sensitive approach considers how the social, cultural, and power roles of men
and women, rather than inherent biological differences, can be used to better understand any
obtained sex differences in suicidal behavior (Gender and Health: Technical Paper, World Health
Organization, 1998).4
Based on suicide completion rate differences, it has typiBased on suicide completion rate differences, it has typically been argued that the more
lethal suicidal behavior of men is what mainly needs to be understood for suicide prevention and
intervention purposes. However, some researchers have debated the extent, nature, and
interpretation of the suicide rate differences between males and females. For example, the
method hypothesis asserts that men and women are equally prone to self-destruction, but merely
chose different methods of suicide expression, because of their gender, that results in a different
levels of fatality (Garland and Zigler, 1993). They argue that gender roles dictate that men not
“fail” at suicide, which leads them to choose highly lethal methods of self-destruction.
Conversely, gender roles for women encourage delicacy and attention to appearance, even in
death. As a result, women may be more likely to choose a method that will not result in blood or
disfigurement (e.g., pills rather than guns). These methods tend to be less likely to result in
fatality, even if the intention to die was equally high for the woman. Certainly, since suicide
completion rates rely solely on outcome, they fail to account for intent (Kushner, 1985;
Langhinrichsen-Rohling, Sanders, Crane, & Monson, 1998). Individuals who unexpectedly
survive an intentional and lethal suicidal act are not counted in the completed suicide rates. Since
women appear to be more likely than men to select suicide methods that allow time for discovery
and intervention (e.g., overdose), women might be more likely than men to survive what could be
a completed suicide. Not counting these occurrences would result in an underreporting of
females’ potentially lethal suicidal behavior.
In fact, many researchers have suggested the reported magnitude of the suicide mortality
sex differential is not accurate, because of the difficulties inherent in collecting valid data about
completed suicides (Madge & Harvey, 1999). Less valid official data is thought to occur because
of the classification biases of individual coroners and physicians, and as well as differences in5
state and national laws regarding suicide determination. For example, at times, in some areas
within the United States, it has only been possible to consider a death by suicide if the deceased
left a suicide note. There may be gender differences in the likelihood of this documentation.
State, regional, and national differences in suicide classification rules can result in generalized
underreporting and can also lead to age, sex, and racial group rate biases (Holinger, Offer, Barter,
& Bell, 1994). Even without excessively stringent decision rules such as noted above, it is
possible that a number of suicides are labeled “accidents” because there is not enough evidence
to conclude conclusively that they are suicides. It has been estimated that the actual incidence of
suicide in groups with a high rate of accidental death might be up to three times the official
recorded level (Madge & Harvey, 1999). Since these types of suicides may be more utilized by
women than men, female suicides may be more likely to be underreported. In fact, in a study of
the adequacy of official suicide statistics, Phillips and Ruth (1993) conclude that suicides can be
misclassified into at least five other causes of death. They state that suicides are most likely to be
underreported for groups with low official suicide rates, namely females and African-Americans.
Furthermore, there may be other reasons to underreport suicide that change the validity of
the reported rates. For example, Kushner (1985) has argued that cultural notions of femininity, in
conjunction with societal beliefs that women’s suicidal behaviors are a direct reflection of
relationship failures may provide subtle incentives for family members, physicians, and public
health officials to underreport female suicide completions. In the United States, the construct of
femininity does not typically include completed suicide. Instead, women are thought to “attempt”
suicide and commit suicidal gestures as a “cry for help” (Canetto, 1992-93). Furthermore,
motherhood in many cultures is considered a sacred gender role. Many cultures hold the value
that mothers are not supposed to abandon their children, so there may be additional reasons to6
underreport female suicides in which children are left. However, this stands in contrast to some
data revealing that single mothers in some countries might be at particular risk for suicidality
(Weitoft, Haglund, & Rosen, 2000).
As a contrast, male suicide has been viewed in some cultures as a legitimate answer to
economic difficulties and other potential humiliations. Explanations of men’s suicides have often
focused on issues of performance and achievement (Canetto, 1992-93), rather than love, which is
evoked for women’s suicides. Male suicide has also, at times, been socially sanctioned as a
patriarchic duty (i.e., Kamikaze). Certainly, these gender and culture values can effect how a
death is classified. Generally, because of these gender roles, it has been thought that women’s
suicides are underreported.
Some biases, however, might also differentially lower the official rate of male suicide.
For example, Rockett and Thomas (1999) reported that over half of both the official
unintentional firearm deaths and those of undetermined intent among males aged 18 to 21 years
of age in Israel were ultimately determined to be misclassified suicides. Overall, because
gendered and cultured biases can alter the reported rates of both female and male completed
suicide, it is difficult to know the true gender differential when comparing completed suicide
rates from different states, regions, and countries.
Consequently, Kushner and others have argued that it is more appropriate to combine the
rates of fatal and nonfatal suicidal behavior when comparing the suicidal behavior of men and
women (Kushner, 1985; Langhinrichsen et al., 1998). When this data comparison strategy is
employed, women are found to be at greater risk than men for suicidal behavior. In fact, using
this logic, Canetto and Lester (1995b) conclude that while suicidologists have tended to focus
almost exclusively on suicide mortality, which is typically male and quite infrequent, from an7
epidemiological standpoint, the nonfatal suicidal behavior engaged in by women is more
normative and certainly equally worthy of attention. Considering the potential biases and their
possibly conflicting impact on male and female completed suicide rates, in the current paper, it is
argued that a complete understanding of both the fatal and nonfatal suicidal behavior of men and
women is necessary to inform suicide prevention and intervention efforts

The Gender Inequality Of Suicide: Why Are Men At Such High Risk?

Though mental health issues are less taboo than they were in the past, and certainly more people are getting treated for them (at least pharmaceutically), the suicide rate is still high – especially for men. The World Health Organization estimates that about one million people take their own lives each year, and this is not counting those who attempt it but are not “successful.” In just about every country, men commit suicide more frequently than women, which is intriguing since women typically have higher (at least, reported) rates of mental health disorders like depression. A new study looked at the factors that might explain why certain groups of men are so much more likely than women to take their own lives.
Certainly suicide is linked to mental health problems like depression and anxiety – it almost has to occur in their presence – but there are other factors involved. And it is these external factors that, according to the researchers, need some attention. The new study was commissioned by the organization Samaritans, and carried out by a team of researchers in Great Britain.
One of the risk factors for suicide in men seems to be middle age. Historically, younger men were at greater risk than older ones, but this has changed in recent decades. Now, middle-aged men experience the lowest levels of well-being and the highest suicide rates (especially if they are of lower socioeconomic class; more on this later). In fact, well-being for both sexes follows a U-shaped curve, with well-being bottoming out in the middle years.
For middle-aged men today, being in between two very different generations (“the prewar ‘silent’ and the post-war ‘me’ generation”) may make them feel more stuck. “Men currently in their mid-years are the ‘buffer’ generation – caught between the traditional silent, strong, austere masculinity of their fathers and the more progressive, open and individualistic generation of their sons. They do not know which of these ways of life and masculine cultures to follow.”
Middle age is also the time when the importance of long-term life decisions is clear: Making changes can come with a big cost, both financially and personally/socially, since doing so could lead to job loss, financial uncertainty, or on the personal front, a breakdown in marriage. Feeling boxed in could seriously compromise well-being.
The study found that the suicide rate was ten times higher in men of lower socioeconomic status than in affluent men. The link between suicide and unemployment has been known for some time, but the authors discuss the reasons why, beyond losing a job, socioeconomic class might affect suicide risk. One factor is the increasing “‘feminisation’ of employment (shift towards a more service-oriented economy),” which may cause men to feel like they have less room in the professional world. The authors write that “men in lower socioeconomic groups now have less access to jobs that allow for the expression of working-class masculinity, and have thus lost a source of masculine identity and ‘pride.’” Yet losing a job may still make men feel like a “double failure, since they are unable to meet two central demands of the masculine role: being employed; and ‘providing’ for the family.”
Another interesting finding is that while divorce and separation are linked to suicide risk in both sexes, divorced/separated men seem particularly vulnerable to suicidal “ideation” (thoughts and planning) and to suicide itself. This may make sense, since it’s been shown that men derive more mental and physical health benefits from marriage than do women (although it’s good for both sexes) – so the breakdown of a marriage could lead to more detrimental outcomes for men. That said, there’s still a lot of pressure on men to fill out the masculine husband role, whatever socioeconomic class one is in, and the reality is that today this classic role may be somewhat unrealistic. “There is a large and unbridgeable gap between the culturally authorised idea of ‘hegemonic masculinity’ and the reality of everyday survival for men in crisis,” write the authors. One way of taking back one’s own masculinity, they suggest, is to take one’s own life.
The reality is that there is a constellation of variables that all interplay, and can compound one another. Men of lower socioeconomic status may, for example, feel the breakdown of a relationship more, and conversely, financial problems can contribute to marital problems and pressures. When things break down for men, they really break down. The authors point out that there is too little known about the actual “psychological routes” to suicide for men – that is, once men are feeling the fallout of financial, professional, or personal problems, why do these problems end in suicide more frequently than women?
Part of it may be that men actually have a higher threshold for pain, which could, counterintuitively, lead to a greater risk for suicide, in volcano-like fashion. They may also may poorer decisions when under stress – and men who are unemployed may not come up with effective solutions to personal problems as well as their employed counterparts.
How to reduce the risk of suicides in middle-aged men (or any other demographic) is a question to which there aren’t many answers. The authors of the new study suggest one way may be to develop effective interventions for young men and boys at risk, since many of the patterns leading to suicide in middle age may begin during youth.
“It’s not acceptable for people in lower socioeconomic positions to be at so much higher risk than men in higher socioeconomic positions,” study author Stephen Platt told the Telegraph. “And we need that understanding to be very much a part of suicide prevention strategies and action and local and national level – and up to now, it’s not been.”

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