Understanding Suicide: Why Gender and other Protected Characteristics are Important to Consider - Part Two

Hello and welcome back to this, the second part of the exploration into understanding suicide, and specifically why considerations of protected characteristics (e.g., sex, age, race, sexuality, etc) are important when trying to understand why a person might choose to end their own life.

Before we begin it is worth noting two things. Firstly, I must admit an error. In the first newsletter of this series I made reference to gender being a protected characteristic, which is factually incorrect. There are nine protected characteristics, which are social identity characteristics protected under law to prevent a person from being discriminated against on the basis of these. While gender reassignment is one of them, gender (i.e., identifying as a man or a woman) is not. Rather, when thinking about the differences between biological males and biological females sex is the protected characteristic of focus. So, technically, I should be speaking about sex differences, rather than gender differences - which I will do from here on out. Although, not all articles I use differentiate by sex. Rather gender and sex are often used interchangeably. Therefore, when talking about sex differences I will refer to males and females, while men and women will be used when sources refer to differences in gender.

Secondly throughout this newsletter I talk about rates of suicide in terms of number of deaths per 100,000. This is the recommended way of reporting on suicide numbers as it standardises the rates of suicide across different populations or groups and allows for comparison.

Last time we looked at the processes that needed to converge for someone to arrive at the decision to engage in a lethal suicidal act. This was broken down in three conditions: thwarted belongingness, perceived burdensomeness, and acquired capability. These three conditions are the basis of the Interpersonal Theory of Suicide. If you have not read the previous newsletter yet I would suggest doing so as it offers context to the rest of this newsletter (also, it’s not long – apparently only a seven-minute read!)

Why then are statistics or trends in data about specific population groups helpful?

Well, simply put the factors related to a person’s decision to take their own life are numerous, varied and person specific: the trajectory as to why people choose to take their own life are unique to each person. At the same time, it is worth being aware of the different types of risk factors that exist that might influence that trajectory. At this point it might be worth differentiating between risk factors and causal factors.

Risk factors are what increase the likelihood of something like suicide occurring, however, they are not necessary causal. For example, having major depression increases the likelihood that someone may engage in suicidal behaviours, but it is not an absolute guarantee. Causal factors are those factors that can explain why someone engaged in suicidal behaviours. At the same time, it is possible that if some risk factors immediately preceded a suicidal act, those may then also be considered causal.

In researching the Interpersonal Theory of Suicide, Van Orden et al. (2010) reviewed a significant body of literature to determine the most common risk factors related to suicidal acts. These risk factors include: mental illnesses, previous suicide attempts, social isolation, physical illness, unemployment, family conflict, family history of suicide, impulsivity, incarceration, hopelessness, seasonal variation, serotonergic dysfunction (i.e. issues with serotonin release and absorption), difficulties with sleep, child abuse, exposure to suicide, homelessness, combat exposure, and issues with self-esteem and shame. These risk factors then are what may over time contribute to someone’s feelings of thwarted belongingness and perceived burdensomeness, creating suicidal desire. But what is less understood is how these risk factors might map onto and be further explained by or influenced by population protected characteristics, and if or how they further contribute to thwarted belongingness and perceived burdensomeness.

For example, in a 2022 survey The Trevor Project found that within the LGBTQ community suicide is the second leading cause of death among young people aged 10 to 24, with LGBTQ youth being more than four times as likely to attempt suicide than their peers. Additionally, transgender and non-binary youth “face elevated risk for depression, thoughts of suicide, and attempting suicide compared to youth who are cisgender and straight, including cisgender members of the LGBTQ community”. It was also noted that Black transgender and non-binary youth reported “disproportionate rates of suicide risk with 59% seriously considering suicide and more than 1 in 4 (26%) attempting suicide in the past year.”

Within the above example of the LGBTQ community, there is evidence of three protected characteristics potentially having some kind of impact on suicidal behaviour: race, sexuality, and (potentially) gender reassignment (this would include both transgender and non-binary individuals).  More specifically, the impact of homophobia, transphobia, and racism are likely the contributors to increased suicidal behaviours. Furthermore, there is evidence that when different protected characteristics overlap - for example gender reassignment and race - there is a higher rate of suicide risk and this likely involves the compound effect of multiple forms of discrimination, i.e., racism and transphobia. This overlapping of different forms of discrimination is known as intersectionality, first coined by Kimberlé Crenshaw in 1989. When we think about experiences racism and homophobia and transphobia, it is not difficult to think about how these experiences might lead to feelings of loneliness, isolation, and feelings of burdensomeness. Therefore, this combination of intersectional factors could be what contributes to feelings of thwarted belongingness and perceived burdensomeness within the Interpersonal Theory of Suicide.

When it comes to discussions of suicide rates between males and females, I am always curious about what contribution intersectionality has to play. For example, males are three times more likely than females to die by suicide. The latest suicide statistics note that the overall suicide rate for England is 10.5 deaths per 100,00, with the rate for male suicide being 15.8 deaths per 100,000 compared to the female rate of 5.5 deaths per 100,000. This had been the trend for since about the 1990s. Discussions around male suicide often relate to issues of masculinity (i.e. suppressing of emotions or difficulties with help-seeking due to masculine scripts of not wanting to seem weak) and the selection of more definitive methods of suicidal acts (e.g. in 2018, the most common method of suicide was hanging/strangulation, with males accounting for 59.4% and females 45% of deaths by this method. Note, this is not the most recent data, however, the 2021 data for methods of suicide do not appear to be aggregated by sex).

The only protected characteristic that seems to be frequently highlighted when talking about male suicide is that of age as it is often cited that males in their 50s are at the highest risk of suicide (22.5 deaths per 100,000).

As we have seen though, suicide rates in the LGBTQ community are higher than the general population, but the prevalence rates of suicides of gay men do not seem to exist (or at least I can’t find any within the UK Office of National Statistics data or by looking online). There is, however, more recent research that has started to examine the suicide amongst gay men. For example, a research paper in the American Journal of Preventative Medicine examined the reasons for suicide among 123,289 LGBTQ individuals who had died by suicide, which included 335 gay men. Some of the finding highlighted that while gay and non-gay men shared many similar difficulties prior to suicide, gay males were more likely to have had a current mental health diagnosis than non-gay males (47.8 vs 37.4%), or current depressed mood (51.3% vs 35.7%,), more likely to be in treatment for either mental health of substance use problems (37.6% vs 24.5%), and more likely to have has a history of suicidal thoughts or plans (20.5% vs 27.2%).

Similarly, there is very little consideration of what the racial or ethnic composition is of the males who make up the higher rates of death by suicide. It is not that suicide is not considered within racial and ethnic minority population, nor that there isn’t any research on the topic, but that rather that this is not necessarily considered when discussing the wider topic of male suicide. For example, a recent meta-analysis which looked at 42 studies on the rates of suicide among ethnic minorities found that the pooled suicide rate amongst ethnic minorities is 12.1 deaths per 100,000 (which is slightly higher when compared to the overall UK population rate mentioned above); however, prevalence rates ranged from 1.2–139.7 per deaths 100,000 (which is a huge range!!!). And when looking at the rates for ethnic minority males, the average prevalence rate jumps to 22.6 deaths per 100,000 (compared to 15.8 deaths per 100,000 males in the UK, and which is on par with the prevalence rate of men in their 50s, the often considered “most at-risk” category).

Based on this, there is an argument to consider ethnicity and race when thinking about suicide. Only as recently as 2021, in a report on mortality rates according to Census data in the UK gathered between 2014 and 2019, were deaths by suicide broken down by ethnicity. In an article commenting in this, Emily Yue notes that “in light of the UK’s recent and historic immigration practice and policy which produces Britishness as synonymous with whiteness…the paucity of ethnicity in suicide reporting and thus the prevention campaigns such statistics generate, translates to the male suicide crisis being a crisis for white men.” And yet, the data highlights that the highest rates of suicide are within the White population (14.9 per 100,000) and men of Mixed Ethnicity (14.7 per 100,000), with Yue noting that these equivalent rates or suicide mean that there should be suicide prevention campaigns that focus on non-white males, too, and that “race and racism can no longer be absent from [campaigns].”

Another area that I don’t think receives as much attention is that of class. Although not a protected characteristic afforded protection under law, it still appears to be an area of marginalisation that has a significant impact on suicide risk. In an Australian report examining the relationship between socioeconomic status and mortality, it was noted that in 2020, the overall suicide rate for those living in the most disadvantaged areas were twice that of those living in the highest socioeconomic areas (18.1 vs 8.6 deaths per 100,000 respectively). Similarly, a 2017 report commissioned by the Samaritans, a UK suicide prevention charity, summarised that “people who are socioeconomically disadvantaged or who live in areas of socioeconomic deprivation have an increased risk of suicidal behaviour.” When exploring gender, the report noted that “men are more vulnerable to the adverse effects of economic recession, including suicide risk, than women.” Further noting that “men in the lowest social class, living in the most deprived areas, are up to ten times more at risk of suicide than those in the highest social class, living in the most affluent areas.”

So, what am I trying to say? Well, as we have seen there is a big focus on male suicide awareness, and rightly so given that the rate of male suicide rate is three times that the female suicide rate. Also, in the focus on suicide prevention strategies there is a very helpful discussion about masculinity and how that impacts on men’s help seeking, which may lead some difficulties in accessing support before they engage in suicidal acts. However, there seems to be a distinct lack of focus on certain aspects of society that engender discrimination and marginalisation – the intersections – that are absent from these suicide prevention strategies and conversations. And I will admit that I sometimes forget these intersections, too. But as has hopefully been demonstrated, there are other factors, wider systemic factors, that are not as individualistic and may bare more focus and attention, whilst also, at the same time, considering the impact of traditional masculinity and masculine scripts within each of level of intersection.

Another distinctive absence within the conversation of suicide is that of suicide within the female population. The common narrative (that I have picked up on at least) is that males commit suicide at a rate 3 times that of females, but that women engage in greater numbers of self-harm and have higher rates of suicidal thoughts… and then there is nothing much more said about that.

However, there is evidence from the US to suggest that since 2007 there has been a steady decrease in the gap between male and female suicide rates in the youth. What is concerning though, is not that the rate of male suicide is decreasing, but rather that the rate of female suicide is increasing. More locally, a 2020 article in the Telegraph notes that according to data from the Office of National Statistics, “suicides among girls and young women have hit a record high” with the rate “increasing significantly” since 2012. This increase was present across most age ranges, except for women aged 75 and older where the rate of suicide actually decreased. The highest increase was noted in girls and women between the ages of 10 and 24, which rose 93.8% between 2012 and 2019 (1.6 deaths per 100,000 vs 3.1 deaths per 100,000). More recently in 2022, the Telegraph published a further article noting that the rate of death by suicide in the same population group had once more risen to 3.6 deaths per 100,000.

When looking at the factors that may have contributed to this, it is noted that hanging and suffocation amongst female suicides has increased as a cause of death, which suggests that females are using more lethal and definitive means of suicide (as noted earlier, this is a notable theorization as to why the number of male suicides is so high). Another factor potentially related to this is social media, with two separate sources noting that a) young females spend more time on social media than young males and therefore may experience more cyber bullying, and b) that social media “can also negatively affect young people’s mental health and self-esteem, as users may be encouraged to scroll through others’ unrealistic images, which often portray their lives in the best possible light” (this was not directly related to young girls’ suicide specifically, but it was offered as one possible explanation in an article about female suicide).

When reading these factors, I was continually thinking about “why”? Why are these factors more related to young females dying by suicide? What is it about females and the gender identity of being a young girl or women that makes it more likely for them to be impacted by cyberbullying or social media? Why are females using more lethal methods? Also, what about other intersections, for example those of race, sexuality and class as mentioned would contribute to this (all those references mentioned in the section about male suicide also have very interesting prevalence rates and risk factors identified for lesbian and Black women - less so about class it seems, though).

As an example, when thinking about cyberbullying it can’t just be that young females spending more time online means they are more likely to experience cyberbullying. More research needs to be undertaken to look at the nature of the cyberbullying. Such as examining the content of the cyberbullying and looking at who the perpetrators are? In terms of aggression, females have been known to be more relationally aggressive (i.e. more likely to use passive aggression, insults, degradation, and attempt to ruin another person’s reputation), and it is possible that this is something that can translated into the online world. Targeting relational aggression in younger women then might be a way in which to address this issue.

On the other hand, males are more likely to use physical aggression, which online could present as threats of physical and sexual violence or harassment. In fact, there is recent research to suggest that women are at a higher risk of experiencing online abuse and harassment, with many women noting that responses and support received from social media platforms when they make their abuse known are considerably inadequate. There are currently efforts under way to include special considerations for women under the UKs new Online Safety Bill; but this this is something that is still being petitioned for by women’s charities such as Refuge. However (and while I think that women experiencing more abuse online should be a good enough to include specific considerations for women), if this link between online abuse and suicide within the female population was drawn a little more clearly, this might lend greater weight to the arguments for including specific protections for women and sway government decision making (also, I don’t know if this has already been done - so, if anyone knows if it has please put it in a comment below). Similarly, trying to understand and address the nature of online misogyny, harassment and abuse perpetrated by men against women would be one way to address the rise in female suicides related to cyberbullying.

This is what I think is missing from the broader discussion of suicide. It is not to say that we should stop talking about male suicide; but rather that we need to think more specifically about what factors affect which men in society? How do the different facets of a male’s social and cultural and economic identity map onto the common risk factors noted above (i.e. mental illness, family conflict, loneliness, homelessness, unemployment, etc). And additionally, how do these different protected characteristic factors connect with the rise in female suicide rates. The same could be said of those whose gender identity or biological sex does not fall within the binaries of male and female or man and woman. How do these intersectional characteristics create the feelings of thwarted belonging and perceived burdensomeness that leads to suicidal intent and hopelessness. And more importantly, if these factors are found to have some bearing on a person’s decision to take their own life, this creates a further and deeper arguments for issues like racism, sexism, homophobia, transphobia, classism, poverty being considered significant health concerns that need social and cultural redress.

This feels like a lot, and it certainly can sound overwhelming, and I am certainly not proposing that this happens all at once and over night. But, from all of this it certainly seems there is an argument here for more qualitative research into suicidal behaviour rather than looking at numbers. Numbers are helpful, but they are after all just numbers. They show us where we need to be focusing our attention, but not really what needs to be done to deal with the particular difficulties people might be facing and how to deal with them. So, looking at trends is helpful, but there are some limitations to it.

Anyway, that’s it for me on this topic. I hope you have found it informative. Please do let me know your thoughts. I took a long time to write this, but at the same time I know it is not a perfect piece of writing, or even a perfect argument. I have my blind spots, so please do point them out. If you think this would be helpful or interesting for someone else to read, please hit the share button below.

P.S. - please excuse any spelling or grammatical errors… I am my own editor and I am really not the man for the job!

Thanks as always.

Nice-ish