THE EPIDEMIOLOGY OF SUICIDE: SOCIAL SCIENCE’S FOCUS ON WOMEN
Epidemiology of Suicide: Social Science’s Focus on Women
Damaris Taylor, BA, CPhT
Concordia University
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Abstract
Suicide is a serious public health problem that affects individuals, families, friends,
and communities. While the World Health Organization (WHO, 2012) reports that
more than 800,000 people die from suicide inflicted wounds around the world each
year, the Centers for Disease Control and Prevention (SAVE, 2015) reports there
were 41,149 suicides in 2013, which pushed suicide to the 10th cause of death for all
ages. Approximately 105 people die from suicide each day, which breaks down to 1
death every 13 minutes (SAVE, 2015). Women remain as one of the vulnerable
populations that attempt suicide with greater frequency than men. The risk factors
of suicide can be linked to culture, economics, socio-economic status, age, gender,
history of mental illness, and previous suicide attempt. According to one social
science argument, “with advances in modernization, greater female labor force
participation, and greater overall gender equality, the male–female suicide
differentials will dissipate” (Kposowa and McElvain, 2006). Unfortunately, statistics
show that prevention programs are not working citing the example that female
suicide rates have remained fairly constant over a 36-year period (The College
Board, 2004, p. 16). Whether the onset of the ideation is fiscal, relational, mental
health related, imprinted from prior violence, lubricated by substance-abuse issues,
or due to societal pressures, suicide among women is still a global problem. The CDC
and the WHO have provided resources over the last several years to develop suicide
prevention methods for clinical and non-clinical personnel. Taking into
consideration the social, cultural, and gender differences, these organizations are
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using multi-pronged approaches when dealing with suicide. At the forefront of
suicide prevention research is a better understanding of mental health issues. From
an epidemiological approach to suicide, theorists and researchers are both
contributing to the detection, prevention, and treatment of people who want to
attempt suicide.
Key Words: Epidemiology, Suicide, Women, Culture, Socio-Economic Status, Social
Science, Sociology, Physician Assisted Suicide, Mental Health, Mental Illness,
Depression, Bipolar Disorder, Alcohol, Adolescents, Prevention.
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The Epidemiology of Suicide: Social Science’s Focus on Women
Culture, gender, mental health and exposure to violence all impact the
epidemiology of suicide. Questions many researchers ask is whether suicide is a
byproduct of: veterans mental health issues postwar, intimate partner violence
(IPV) or abuse, a complication of major depressive disorder (MDD) or bipolar
depression, hormones, economics, socioeconomic status, gender, age, disability,
substance abuse, or location. While focusing on data collected on women, culture
ultimately affects the morbidity and mortality rates in each society. Whatever the
trigger for suicide, the cultural implications of suicide vary according to person,
place and time. I will argue that the impact, definition, and method of suicide cannot
be removed from culture.
History
Suicide in antiquity was greatly contested. As far back as the Egyptian
empire, suicide was not taboo (Baton Rouge Crisis Intervention Center, 2011). It
was not until Greek times that some philosophers believed that there were a finite
number of souls so the departure of one would impact the future of the human race.
Other philosophers believed if a person pleaded a justifiable case in front of the
court and the testimony was convincing the person had the right to end their own
life. Suicide as a means of maintaining ones honor was culturally acceptable, yet
suicide as a means of relieving ones own suffering was seen as a crime. As culture,
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law, and religion migrated, merged, and evolved, the practice of suicide and its
perceived impact on society changed—hinging on societies definition of the body
and the soul.
Statistics
In the United States, violence became a public health issue in 1979, but not until
1983 did the Center for Disease Control and Prevention (CDC) open an
epidemiology branch on violence prevention (CDC, 2014). This branch was
earmarked to collect data, compile research on violence, and create educational
prevention programs. Meanwhile, the World Health Organization (WHO) followed
suit and tracked violence as a public health issue worldwide. The WHO cites the
following as key facts about suicide:

Over 80,000 people die due to suicide each year (2014).

For every suicide there are many more people who attempt suicide every
year. A prior suicide attempt is the single most important risk factor for
suicide in the general population (2014).

Suicide is the second leading cause of death among 15-29 year-olds (2014).
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75% of global suicides occur in low- and middle-income countries (2014).

Ingestion of pesticide, hanging and firearms are the most common methods
of suicide globally (2014).
Risk Factors
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The WHO explains, “Suicide is a serious public health problem; however,
suicides are preventable with timely, evidence based and often low-cost
interventions” (2014). These interventions vary by space, time, and place—with
each culture and society defining the rules that govern female suicide. Western
society studies the link between suicide and mental disorders (in particular,
depression and alcohol use disorders) because it “is well established in high-income
countries, many suicides happen impulsively in moments of crisis with a breakdown
in the ability to deal with life stresses, such as financial problems,
relationship break-up or chronic pain and illness” (WHO, 2014). Other risk factors
for suicide include: disaster, conflict, abuse, discrimination, violence, or loss and a
sense of isolation. Suicide rates are high among vulnerable populations who have
experienced discrimination, such as: “refugees and migrants; indigenous peoples;
lesbian, gay, bisexual, transgender, intersex (LGBTI) persons; and prisoners” (WHO,
2014).
Suicide Among Women
Despite much higher rates of attempted suicide among women in Western
society, an accumulating body of evidence suggests that rates of completed suicides
are much higher in men (Kposowa and McElvain, 2006). In the research paper,
Gender, Place, and method of suicide, the authors use descriptive statistics on method
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and place of suicide. Multivariate logistic regression models were fitted to data on
643 suicide victims, which showed:
Women were over 73% less likely to use firearms than men (OR
= 0.267, CI = 0.172, 0.413). There were no sex differentials in
hanging. Female victims were over 4 times more likely to die from
drug poisoning than male victims (OR = 4.828, CI = 3.047, 7.650).
When place of committing suicide was added to the equation, it
was found that victims killing themselves at home were over 2.5
times as likely to use firearms as those dying in outdoor settings
(OR = 2.501, CI = 1.078, 6.051). Persons committing suicide at
home were over 3 times more likely to hang themselves than
those killing themselves outdoors or on railway tracks (CI = 3.118,
CI = 1.447, 6.718). Victims committing suicide at home were also
3 times as likely to use drugs as those dying outdoors or on
railway tracks (OR = 3.118, CI = 1.242, 7.828). Hotel or motel
suicides were 4.9 times more likely to use drug poisoning than
outdoor or
railway suicides (OR=4.924, CI = 1.409, 17.206)
(Kposowa and McElvain, 2006).
Social Theories of Gender
Multiple sociological theories exist about the reason for gender differences in
suicide rates. These theories range from how culture engenders men and women—
THE EPIDEMIOLOGY OF SUICIDE: SOCIAL SCIENCE’S FOCUS ON WOMEN
dividing their responsibilities and societal pressures—to power-control theory in
psychology and sociology (Kposowa and McElvain, 2006). According to one
argument, “with advances in modernization, greater female labor force
participation, and greater overall gender equality, the male–female suicide
differentials will dissipate” (Kposowa and McElvain, 2006). But, an accumulating
body of research has suggested that the reasons for the gender differences in rates
of completed suicides lies in the means by which the person chooses to act on their
desire. The tool determines lethality, which argues validity due to its scientific
rationale.
Table 1. 10 Leading Causes of Death, United States, 1997 – 2007, All Races, Females
Note. Retrieved from WISQARS. Copyright 2007; by the CDC.
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http://webappa.cdc.gov/cgi-bin/broker.exe
Adolescent Rates—A Vulnerable Population
In a study by the Statistical Bulletin-Metropolitan Life Insurance Company,
violent deaths from suicide and homicide increased or stayed the same between
1960-1991 (1994). Nine years later, the CDC announced a new low in adolescent
homicide rates, yet homicide remains as the second leading cause of death for
persons 15-24 (CDC, 2012). Adolescents remain a vulnerable population; men
especially more than women. For females, suicide rates have remained fairly
constant over a 36-year period (The College Board, 2004, p. 16). Whether it is
hormones, family violence, or the onset of mental health issues, adolescent suicide
reflects one of the highest rates of suicide among all age groups. Table 1. will further
illustrate the point.
Table 2. Suicide Mortality in Selected Age Groups, by Age Group, United States,
2000
Age Group (yrs)
Mortality Rate (per
Percent of All Deaths
100,000)
10-14
1.5
7.2
15-19
8.2
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12.8
13.4
25-34
12.8
11.8
35-44
14.6
7.3
45-54
14.6
3.4
55-64
12.3
1.2
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Note. Retrieved from National Vital Statistics Report. Copyright 2002; 50(16): 13–14
by the CDC. http://www.cdc.gov/nchs/data/nvsr/nvsr50/nvsr50_16.pdf
The Subjective Experience
For many people who are afflicted with the urge to commit suicide, the pain
is so intense, there seems to be no other way to stop the discomfort. With the evergrowing Internet at people’s fingertips in Industrial societies, individual’s plagues
by the ever-haunting depression can seek refuge among peers in support groups
and blogs. Notable support groups include the National Alliance on Mental Illness
(NAMI) and Depression/Bipolar Support Alliance (DBSA). For those who suffer from
mental illness, these peer groups help assist people on experiences with
medications, cooping techniques, daily living, and suicidal ideation. Blogs are
another means of communicating with peers and possibly mental health
professionals. On select blogs, women were shone to be more prone to expressing
their emotions, and seeking help if needed (Clarke and van Ameron, 2008).
Women’s Socialization of Emotion and Depression
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“From the micro perspective, the construction of depression appears to differ
for men and women” (Clarke and van Ameron, 2008). Men tend to act out and
express their frustrations, depression through anger and opposition to others
(Clarke and van Ameron, 2008). Women internalize anger and depression. They
take the emotion out on themselves, so depression and anxiety are common among
women who go on to attempt or commit suicide. “Women also are more able or
likely to notice and identify feelings of sadness, and doctors are more likely to
identify the same symptoms as depression in women but not in men”(Clarke and
van Ameron, 2008).
The Gender Differences of Violence and Mental Illness
“Gender differences of at least 2:1 (female to male) in the incidence of
depression in adult men and women have been documented repeatedly beginning
approximately 30 years ago in the United States” (Clarke and van Ameron, 2008).
“Rates for injuries, both intentional (e.g., homicide and suicide) and unintentional
(e.g., motor vehicle), are 2--6 times higher among persons with a mental illness than
in the overall population” (CDC, 2011). This trend may lead to skewed statistics in
the administration of pharmaceutical medications among women. Since they will
seek help sooner and that help may diagnose her with a mental illness, medications
will typically follow suit. So one must question if the higher rates of suicide among
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men is due to under reporting or late diagnosis of depression, and not being treated
with the appropriate medications for prevention of depression.
Theoretical Models of Suicide in Economics
“Since the appearance of Durkheim’ s Le suicide in 1897, sociologists have
constructed numerous theories to explain patterns in suicide rates both within and
across societies” (Hamermesh & Soss, 1974). Their theories ranged from the impact
economics had on the hardship of a person and their internal frustrations in dealing
with the issue to correlating social status with rates of suicide. Studying the
economics of suicide has come a long way since then. However, in the fervor of a
new study conducted by David Marcotte, he found that “after people attempt suicide
and fail, their incomes increase by an average of 20.6 percent compared to peers
who seriously contemplated suicide but never made an attempt” (Duhigg, 2003).
Reports such as these could benefit from a case-controlled study, repeated in
different locations. Ultimately removed from theoretical economics, researchers
moved from these models to reviewing socioeconomic status and suicide rates.
Socioeconomic Status: Determinants, Health
The social determinants of health advance with grim recognition of the
problems associated with suicide among various socioeconomic statuses. For
women, the story may speak to mental health problems, wage inequality, maternal
responsibilities, alcohol, violence and abuse, or loss of a loved one and isolation.
Suicide is a result of a dynamic interplay of historical, personal, and contextual
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factors that result in the ultimate loss of all hope. Social support when facing grief or
depression is the glue that decreases the risk of death during these fragile times
(Denney, 2011). While higher education and socioeconomic status may buffer the
depressive symptoms when loss is experienced, those in lower socioeconomic
statuses do not have access to the resources which may ease symptoms, like health
insurance, access to doctors, medications, counselors, transportation to social
groups, or close relations to rely on (Denney, 2011).
Alcohol’s Retaliation
When many of these connections are severed, people turn to alcohol. In 1992,
detailed alcohol histories were taken from 250 consecutive suicide attempts at West
Midlands Poisons Unit, Birmingham. Merrill, et al. cites, “between 15 to 26% of
those who kill themselves are alcoholic and 15% of alcoholics take their own lives”
(1992). It would be nice to see a current study that asked the same questions
considering the population was limited to white adults.
Table 3. Characteristics of attempted suicide patients by sex and alcohol
consumption group
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Note. Retrieved from The British Journal of Addiction. Copyright 1992; 87, p. 85. by
the Merrill et al.
For all patients, the severity of alcohol consumption was directly linked to
the possibility of ingesting lethal medical doses (males 53.9%, females 41.2%, 𝑥 2
=3.92, df l, P<0.05)(Merrill et al, 1992). Treatment for individuals with alcoholic
tendencies or who subscribe to being alcoholics is a difficult path. Many alcoholics
share similar suicidal stories, and when attending support groups, loose the same
group members. For those who find recovery, support, and encouragement, they
find a peace from the obsessive thoughts of suicide.
Physician Assisted Suicide
The obsessive thoughts of wanting to end one’s own life may be do to a
complicating terminal illness. The illness grants no peace, comfort, or dignity, so
pondering over those final conclusions is the desire to end suffering and pain.
Wrapped in an enigma of ethical debates, physician assisted suicide is legal in few
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countries and states. In two studies comparing death by ingesting lethal doses of
medications, patients who chose assisted dying had “greater control of their
symptoms and that they and their families were more prepared for and accepting of
their death” (Prokopetz and Lehmann, 2012). Rigorous standards and requirements
must be meet before a patient becomes eligible for this type of treatment. Many
times they must be terminally ill with less than six months to live. As cultures and
societies learn from each other about physician assisted suicide, ethics and opinions
change in favor of the terminally ill patient and their wish to end their suffering.
Crossing oceans in favor of this sympathetic practice is Oregon. Data below shows
prescription administration and adherence.
Table 4. Oregon Death with Dignity Act prescription recipient and deaths, 19982013.
Note. Retrieved from CNN. Copyright 2015. by
http://www.cnn.com/2014/11/26/us/physician-assisted-suicide-fast-facts/
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A Cultural Perspective of Suicide
Human reaction to suicide is not cross-cultural. Whether the form takes the
shape of honor killing in Japan, mercy killings in Renaissance Europe, sacrificial
offerings to Gods in Ancient Mexico, or asphyxiation in America, understanding,
judging, and applying the proper rituals takes the guise of enculturation. Underreporting suicides is typical across the globe. “Because classifying a death as suicide
has negative emotional, religious, legal and financial implications, aggregated
statistics must always be presumed to be under-reporting true incidence” (Rudmin,
et al., 2003). The regularity of the gender effect is remarkable considering that the
84 reporting countries represent a wide variety of cultures, religions, standards of
living, education systems, mental health services, reporting criteria, economies and
other factors that might be presumed to have some effect on reported suicide
(Rudmin, et al., 2003).
Finally, the WHO data show very large differences in reported suicide
incidence between nations. For the 61 nations reporting incidence
rates, the median number of reported suicides per 100,000 population
was 20.5 for males and 6.1 for females. But the ranges of national
incidence rates were 1.1–79.1 for males and 0.2–30.5 for females.
These statistics argue that the socio-cultural characteristics of the
nations may be playing some role in causing, inhibiting, or
disinhibiting suicidal behaviors. It seems unlikely that national
differences in reporting standards alone could explain gender and age
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differences within nations or such large incidence differences between
nations (Rudmin, et al., 2003).
In a study of the tables presented in the report by Rudmin, et al., The larger
the variance measures, the greater are the differences in national reports of suicide
incidence, suggesting that national characteristics are somehow related to suicide
incidence, especially for men and for older people (2003). In every age group and
sample year selected, the variance of incidence for reporting nations is greater for
male suicides than female suicides, except in the case of China. The researchers used
four major dimensions of values to determine the operationalization of a nation’s
culture.
1. Power-Distance describes a people’s social separation due to differences in
status, finances, and organizational power. The Philip- pines and Mexico
were very high in Power-Distance, Austria and Israel very low (Rudmin, et
al., 2003).
2. Uncertainty Avoidance describes a people’s preference for stability and
predictability. Greece and Portugal were very high on Uncertainty Avoidance,
Denmark and Singapore very low (Rudmin, et al., 2003).
3. Individualism describes a people’s self-perception that they are
autonomous personalities not defined by, or merged into, collective familial
or social groups. The USA and Australia were very high on Individualism,
Colombia and Venezuela very low (Rudmin, et al., 2003).
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4. Masculinity describes a people’s differentiation of men and women into
distinct roles, with women and their social and environmental concerns
having lower status. Japan and Austria were very high on Masculinity,
Norway and Sweden very low (Rudmin, et al., 2003).
Table 5. Correlations of Hofestede’s (1980) cultural values with suicide rates for
genders and age groups combined based on samples of nations.
Note. Retrieved from Scandinavian Journal of Psychology, 44, p. 373-381. By
Rudmin, et al. Copyright 2003.
Generally speaking, Rudmin et al., states that 25% of the variance in national
suicide reports can be somehow related to these four cultural values. The median R2
for women was 0.27, compared with 0.23 for men, indicating that national suicide
reports for women are more related to these cultural measures than are suicide data
for men; A two-way analysis of variance of these R2 values, following r–Z
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transformations, showed that culture has a greater relationship to national suicide
reports for women than for men (F = 8.71, d.f. = 1, 48, p < 0.01), and that the
relationship of cultural values to suicide rates was different for the different age
groups (F = 5.27, d.f. = 5, 48, p < 0.001) (Rudmin et al, 2003). The four measures of
cultural values related mostly to women and middle-aged adults, which might
explain large variances in suicide by men and older people. “The analyses thus far
have established that national cultural values are substantial predictors of suicide
and that the impact of culture on suicide varies with age and gender” (Rutmin, et al,
2003).
Prevention and Education
Since culture plays into the severity, definition, and practice of suicide, public
health education on the prevention of suicide must also remain in the realm of
culture. Although the rates of suicide are higher among men, suicidal ideation,
intention, and non-completed suicide attempts are more frequent among women.
“Certain US populations such as American Indians/Alaska Natives and AfricanAmericans have their highest suicide rates among adolescents and young adults
whereas other groups such as Asian-Americans and Hispanics have their highest
rates among older adults” (CDC, 2011, p.12). The rates, risk factors, cultural and
gender differences make the project of prevention and education quite specialized.
In the WHO’s Preventing Suicide: A Global Imperative (2014) and Public Health Action
for the Prevention of Suicide (2012), researchers focus on prevention approaches and
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how to implement specialized education. Since epidemiologists have studied
identification of risk and protective factors, there has been an increase in knowledge
about psychological factors related to suicidal behavior, especially within culture.
“During the past 15 years the delivery of training packages on suicide prevention
has also become widespread, with specific modules for different settings such as
schools, military environments and prisons” (WHO, 2014). Training has been
established for clinical and non-clinical providers on how to deal with suicidal
patients and is supported by state, federal, or local programs, depending on the
area. The strategy for suicide prevention varies by country.
Table 6. Numbers of Responding Countries with a National Strategy on Suicide
Prevention Adopted or Under Development.
Note. Retrieved from WHO. Preventing suicide: a global imperative. Copyright 2014.
http://www.who.int/mental_health/suicide-prevention/world_report_2014/en/
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WHO begins by assessing the availability of resources, addressing the stigma,
increasing awareness, creating prevention strategies, then monitoring the effects.
The WHO cites that, “Suicide is estimated to contribute more than 2% to the global
burden of disease by the year 2020” (2012). With grim statistics such as these, the
national suicide prevention strategy needs to take action. Beginning with a thorough
investigation of the political and social structure ruling programs supporting suicide
prevention, researchers can identify gaps in policy and procedure, as well as where
the monetary support is lacking. Since many suicide prevention programs are
weaved into existing infrastructures, epidemiologists must work within these frame
works to ensure support networks are available for those suffering from suicidal
ideation. These networks include training first-responders, mental health officers
with the police, clinical personnel in hospitals and outpatient settings, as well as call
operators who receive panicked calls. Much strategy involved awareness campaigns,
advocacy, and media communications. The public must be aware of social supports
in order to decrease the occurrence of suicide. Education includes teaching people
about the risk factors associated with suicide—see below.
Table 7. Risk Factors (Non-Exhaustive List)
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Note. Retrieved from WHO. Preventing suicide: a global imperative. Copyright 2012.
http://apps.who.int/iris/bitstream/10665/75166/1/9789241503570_eng.pdf
Selective intervention focuses on sub-populations that are known to have an
elevated risk and can be employed on the basis of socio-demographic
characteristics, geographical distribution, or prevalence of mental and substance
use disorders, depending on the contribution of these various factors to the overall
burden of suicide (WHO, 2012). Prevention strategies include decreasing access to
suicide-inducing devices, ensuring proper social support, warnings about the risks
associated with drug and alcohol abuse, and localizing media support on the risk
factors and means of seeking help in the population where the individual lives.
Unfortunately, many suicide attempts end a person’s life or qualify them for a
stay in a local hospital. Hospitalization may be the first contact a person has with a
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mental health and suicide prevention team. These teams of clinical professionals
organize a plan for people to successful exit the hospital with the necessary support
systems in place. Based on gender, socio-economic factors, culture, and location,
suicide prevention teams create an individualized plan for patients. Support groups
may be available for survivors, both those who have attempted suicide and those
who were survived by suicide. These protocols and programs are specifically
designed to help reduce the incidence of suicide.
Conclusion
Throughout history, the definition and consequences of suicide have
changed. Currently, the WHO has identified suicide as a public health problem,
which is treatable. National strategies have been implemented to improve
awareness among government officials and society as a whole. The WHO defines,
“The lack of resources – human or financial – can no longer remain an acceptable
justification for not developing or implementing a national suicide prevention
strategy” (2012). Even though the rates of successful suicides are higher among men
than women, women need to be treated as a vulnerable population that experiences
cultural, social, socio-economic and individual pressures which may induce a suicide
attempt. These factors must be taken into considerations when building a successful
suicide prevention program. Age is another factor that influences the prevalence of
suicide. Rates increase in the adolescent years and then wane after 30, increasing
again in old age. Evidence-based risk factors remain determinants as to whether a
person will attempt suicide or not. Ultimately, prevention is the key. Whether this
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takes the form of outreach and prevention programs, strong social relationships,
clinical recommendations for medications, or hospital programs, suicide prevention
takes a multi-pronged approach and a global effort.
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