Suicide in Men: How Men Differ from Women in Expressing Their Distress 0398087946, 9780398087944

Table of contents :
Editors and Contributors
Preface
Contents
List of Illustrations
PART I. OVERVIEW
1. Men and Suicide: An Overview • Karolina Krysinska
PART II. CAUSES
2. Male Depression and Suicide • David Lester
3. Fatal Loneliness: The Role of Loneliness in Men’s Suicide • John F. Gunn III
4. Drugs, Alcohol, and Suicidal Behavior in Men • John F. Gunn III and David Lester
5. Risk and Protective Factors for Male Suicide • John F. Gunn III and David Lester
6. The Role of Testosterone • David Lester
7. Men, Guns and Suicide • David Lester
8. Suicide Among Male Athletes • John F. Gunn III
9. Suicide in the Armed Forces • John F. Gunn III and David Lester
10. Suicide in Mass Murderers and Serial Killers • David Lester
11. Suicide Bombers • David Lester
12. Murder-Suicide • David Lester
13. Suicide in Gay Men • John F. Gunn III
14. Suicide in Creative Men • David Lester
15. The Influence of Race and Ethnicity on Suicide in Men • John F. Gunn III and Allison L. Gunn
PART III. MEN IN OTHER CULTURES
16. Male Suicide in China • Jie Zhang
17. Changing Culture, Prolonged Conflict, and the Specter of Suicide Terrorism: Exploring Suicide in Palestinian Men • Jessica Bonnan-White
18. Suicidal Behavior in Ugandan Men • Birthe Loa Knizek, Eugene Kinyanda and Heidi Hjelmeland
19. Suicide and Hegemonic Masculinity in Australian Men • Jo River
20. Suicide in Ghanaian Men • Mensah Adinkrah
PART IV. OTHER ISSUES
21. The Impact of Suicide Bereavement • John F. Gunn III
22. Men, Economic Strain and Suicide in the Movies,1900–2013 • Steven Stack and Barbara Bowman
PART V. PREVENTING SUICIDE IN MEN
23. Preventing Suicide in Men versus Women • David Lester
24. Men and Suicide Prevention: Why Can’t a Man be More Like a Woman? • Paul Quinnett
25. A Study of QPR and Help-Seeking in Men • John A. Cascamo
26. Help-Seeking and Men: An Innovative Suicide Prevention Program from the Construction Industry • Graham Martin and Jorgen Gullestrup
PART VI. CONCLUSIONS
27. Final Thoughts
Name Index
Subject Index

Citation preview

SUICIDE IN MEN

SUICIDE IN MEN How Men Differ from Women in Expressing Their Distress

Edited by DAVID LESTER JOHN F. GUNN III PAUL QUINNETT

(With 14 Other Contributors)

Published and Distributed Throughout the World by CHARLES C THOMAS • PUBLISHER, LTD. 2600 South First Street Springfield, Illinois 62704

This book is protected by copyright. No part of it may be reproduced in any manner without written permission from the publisher. All rights reserved.

© 2014 by CHARLES C THOMAS • PUBLISHER, LTD. ISBN 978-0-398-08794-4 (paper) ISBN 978-0-398-08795-1 (ebook) Library of Congress Catalog Card Number: 2013048762

With THOMAS BOOKS careful attention is given to all details of manufacturing and design. It is the Publisher’s desire to present books that are satisfactory as to their physical qualities and artistic possibilities and appropriate for their particular use. THOMAS BOOKS will be true to those laws of quality that assure a good name and good will.

Printed in the United States of America MM-R-3

Library of Congress Cataloging-in-Publication Data Suicide in men : how men differ from women in expressing their distress / edited by David Lester, John F. Gunn III, Paul Quinnett ; (With 14 Other Contributors). pages cm Includes bibliographical references and index. ISBN 978-0-398-08794-4 (pbk.) -- ISBN 978-0-398-08795-1 (ebook) 1. Suicide. 2. Men—Psychology. I. Lester, David, 1942—editor in compilation. HV6545.S8327 2014 362.28¢20811–dc23 2013048762

EDITORS AND CONTRIBUTORS EDITORS David Lester, Ph.D. The Richard Stockton College of New Jersey [email protected] John F. Gunn III, M.A. Turnersville, NJ [email protected] Paul Quinnett, Ph.D. The QPR Institute – www.qprinstitute.com [email protected] CONTRIBUTORS Mensah Adinkrah, Ph.D., M.A., M.A., B.A. (Honors) Department of Sociology, Anthropology and Social Work Central Michigan University Mount Pleasant, MI [email protected] Jess Bonnan-White, Ph.D. The Richard Stockton College of New Jersey School of Social and Behavioral Sciences Criminal Justice Program [email protected]

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Suicide in Men

Barbara Bowman, JD Center for Suicide Research Troy, MI John A. Cascamo, Ph.D. Cuesta College San Luis Obispo, CA [email protected] Jorgen Gullestrup CEO, MATES in Construction Queensland, Australia [email protected] Allison L. Gunn, M.A. Turnersville, NJ [email protected] Heidi Hjelmeland, Ph.D. Department of Social Work and Health Science Norwegian University of Science and Technology Trondheim, Norway [email protected] Eugene Kinyanda, Ph.D. Mental Health Research Project MRC/UVRI Uganda Research Unit on AIDS Entebbe, Uganda [email protected] Birthe Loa Knizek, Ph.D., Mag.art.psych Faculty of Nursing Sør-Trøndelag University College Trondheim, Norway [email protected] Karolina Krysinska, Ph.D. KU Leuven—University of Leuven Faculty of Psychology and Educational Sciences Clinical Psychology Belgium [email protected]

Contributors

Graham Martin, MD, MBBS, FRANZCP Department of Psychiatry The University of Queensland Australia [email protected] Jo River University of Sydney Australia [email protected] Steven Stack, Ph.D. Department of Psychiatry and Department of Criminology Wayne State University Detroit, MI 48202 [email protected] Jie Zhang, Ph.D. Shandong University School of Public Health Center for Suicide Prevention Research, China State University of New York Buffalo State Department of Sociology [email protected]

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PREFACE he 1980s saw a growth of interest in feminist approaches to the study of behavior, and Lester (1990) looked at suicidal behavior from a feminist perspective based on Schuster and Van Dyne (1985) who described six stages in this process (which they applied primarily to teaching): (1) invisible women scholars in the field, (2) the search for missing women, (3) women as disadvantaged, (4) women studied on their own terms, (5) women as a challenge to disciplines, and (6) transformed curricula. Lester (1988) edited a book on suicide in women, and Canetto and Lester (1995) edited a book on suicide in women from a feminist perspective. However, there has not been as great an interest in suicide in men. Although many more women engage in nonfatal suicidal behavior than men, it has long been known that men die by suicide at a greater rate than women. The aim of the present book is to address this imbalance and focus on suicidal behavior in men. There have been two recent, but limited, collections of articles on suicide in men. Silvia Canetto and Anne Cleary (2012) edited a special issue of Social Science and Medicine on the topic. In that issue, Scourfield et al. (2012) used coroners’ files in England for a qualitative study of suicide in men and found that men killed themselves more often in response to problems related to work and debt, while women’s suicides were more often triggered by problems related to children. Relationship problems seemed to be equally common in both men and women. Adinkrah (2012; see Chapter 20) used police data to study the pattern and meaning of suicide in men in Ghana. The vast majority of suicides in Ghana were by men, and the most common motives were shame and dishonor from a variety of sources, including unemployment and indebtedness, stigmatizing physical conditions (such as epilepsy and HIV-AIDS), and deviant or criminal behavior (such as armed robbery and bestiality). McMahon et al. (2012) studied the impact of bullying in adolescent Irish boys and found that self-harm behavior was four times more likely if the boys had been the victims of bullying. Mac an Ghaill and Haywood (2012)

T

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Suicide in Men

presented a qualitative analysis of interviews concerning 28 school children in England aged 9–13 in order to explore how the boys construe masculinity, but this was not related to suicidal behavior in any meaningful way. Cleary (2012) interviewed 52 young Irish men who had attempted suicide and identified high levels of emotional pain in these men. Despite this pain, the men had problems in identifying symptoms and disclosing distress to others because of masculine norms. Their poor coping skills resulted in them perceiving fewer options so that suicide seemed to be the only way to escape from their distress. Oliffe et al. (2012) studied suicidal ideation in 38 Canadian men. Those who sought support, primarily through using their masculine roles, did better at resolving the suicidal thoughts than those who isolated themselves and turned to drugs and alcohol. Alston (2012) discussed male suicide in rural Australia, focusing on issues such as the stress of farming (especially as a result of the prolonged drought), the social isolation of farmers, the reluctance of men to seek help when it is needed, and the easy access to firearms. A study of suicide in gay men indicated that the increased risk of suicidal ideation was found in gay adolescents and in young gay adult men (Russell & Toomey, 2012). Braswell and Kushner (2012) discussed suicide by men in the military, concluding that the masculine ideologies governing military life play a major role in their suicides, especially because their strong social integration into military networks decrease their social integration into social networks (including the family) outside of the military. This collection suffers from the heavy reliance on qualitative studies and the sense that many of the authors are primarily interested in masculine ideologies and are using suicidal behavior as a vehicle to write about their views on this ideology. The Samaritans in the United Kingdom have placed a collection of articles online entitled Men, suicide and society: Why disadvantaged men in mid-life die by suicide.1 As indicated by the title, the collection is meant to focus on men in mid-life who are from the lower social classes. The focus seems to be unique to the United Kingdom where suicide rates are higher in middle-aged men and in men from the lower social classes, which is not necessarily the case elsewhere in the world. The book begins with a good general introduction which introduces many of the facts and theories relevant to suicide, with a focus on Rory O’Connor’s Integrated Motivational-Volitional Theory (IMVT). IMVT begins with biological and personality background factors which make individuals vulnerable to stressors. When triggering events occur, indi1. www.samaritans.org/sites/default/files/kcfinder/files/Men%20and%20Suicide%20Research%20 Report%20210912.pdf

Preface

xi

viduals then feel defeated and trapped, feelings that are made worse by poor problem-solving skills and by rumination. The third phase (volitional) focuses on what causes individuals to engage in suicidal acts, including having a suicidal plan, a preferred method for suicide, and easy access to that method (see Lester, 2010). The introduction also discusses the role of masculine identities which make suicide a more likely option. For men, their masculine role is typically defined by their occupation, and so unemployment, underemployment and the trend toward service jobs and away from manual labor can be especially stressful for men. The prototypical masculine role (which modern writers like to call hegemonic masculinity) also includes providing for the family and engaging in risky and harmful bodily practices (such as neglecting health care needs and abusing alcohol), and this role is more inflexible than women’s roles. Men also appear to be more impacted by breakdowns in their marital and romantic relationships, perhaps because they benefit more from marriage and perhaps because men find it hard to meet the modern expectations for increased intimacy. The authors suggest that separation from their children is a significant factor in some suicides by men, as is punishing their spouse (although we think that these factors are probably as strong in separated and divorced women). Men, especially when separated or divorced, have fewer meaningful social relationships, and experience more loneliness. They are less likely to communicate their distress and their emotions to others, especially those men born in the last century when “keeping things to yourself” was the norm for men. Evans et al. (2012) carried out a systematic review of research on relationship breakdown and suicide risk. Seventeen studies found the suicide risk to be greater for men, six found a higher risk for women, and six found no consistent difference. Guided by the IMVT, Kirtley and O’Connor (2012) reviewed the cognitive, personality and psychobiological factors that have been found to be associated with suicidal behavior, while Kennelly and Connolly (2012) reviewed the research on the impact of economic factors on suicidal behavior. Brownlie (2012) discussed the possible role of changing norms in the society for being more emotionally expressive and the changing nature of social relationships which are now less bound by traditions and social structures (such as marriage) and more by individualistic choices. Both of these changes are very difficult for lower class middle-aged men. Finally, Chandler (2012) reviewed the impact of masculine identities on suicide. This collection is limited by its focus on one small group of men (lower social class, middle-aged men), and the early chapters are general introductions to some aspects of suicidology and not focused on men. The chapters

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which do focus on men (by Brownlie and Chandler) discuss the issues that have become standard in cursory discussions of suicide in men. The present book has the ability to look at suicidal behavior in men more extensively than these two earlier limited collections. We examine the epidemiology of suicide in men, the risk factors for suicide in men, the types of suicidal behavior more commonly found in men (such as suicide by mass murderers), and the changes in suicide prevention techniques that might be necessary in order to prevent suicide in men. We hope this book is the beginning of a discussion of these important issues. REFERENCES Adinkrah, M. (2012). Better dead than dishonoured. Social Science & Medicine, 74, 474–481. Alston, M. (2012). Rural male suicide in Australia. Social Science & Medicine, 74, 515– 522. Braswell, H., & Kushner, H. I. (2012). Suicide, social integration, and masculinity in the U.S. military. Social Science & Medicine, 74, 530–536. Brownlie, J. (2012). Males suicide in mid-life. In C. Wyllie, S. Platt, J. Brownlie et al. (Eds.), Men, suicide and society (pp. 91–110). London, UK: The Samaritans. Canetto, S. S., & Cleary, A. (2012). Men masculinities and suicidal behavior. Social Science & Medicine, 74, 461–465. Canetto, S. S., & Lester, D. (1995). Women and suicidal behavior. New York: Springer. Chandler, A. (2012). Exploring the role of masculinities in suicidal behavior. In C. Wyllie, S. Platt, J. Brownlie et al. (Eds.), Men, suicide and society (pp. 111–125). London, UK: The Samaritans. Cleary, A. (2012). Suicidal action, emotional expression, and the performance of masculinities. Social Science & Medicine, 74, 498–505. Evans, R., Scourfield, J., & Moore, G. (2012). Gender, relationship breakdown and suicide risk. In C. Wyllie, S. Platt, J. Brownlie, et al. (Eds.), Men, suicide and society (pp. 36–56). London, UK: The Samaritans. Kennelly, B., & Connolly, S. (2012). Men, suicide and society: An economic perspective. In C. Wyllie, S. Platt, J. Brownlie et al. (Eds.), Men, suicide and society (pp. 73–90). London, UK: The Samaritans. Kirtley, O., & O’Connor, R. (2012). Men, suicide and society: The role of psychological factors. In C. Wyllie, S. Platt, J. Brownlie et al. (Eds.), Men, suicide and society (pp. 57–72). London, UK: The Samaritans. Lester, D. (1988). Why women kill themselves. Springfield, IL: Charles C Thomas. Lester, D. (1990). The study of suicide from a feminist perspective. Crisis, 11, 38–43. Lester, D. (2010). Preventing suicide: Closing the exits revisited. Hauppauge, NY: Nova Science. Mac an Ghaill, M., & Haywood, C. (2012). Understanding boys. Social Science & Medicine, 74, 482–489.

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McMahon, E. M., Reulbach, L., Keeley, H., Perry, I. J., & Arensman, E. (2012). Bullying victimisation, self-harm and associated factors in Irish adolescent boys. Social Science & Medicine, 74, 490–497. Oliffe, J. l., Ogrodniczuk, J. S., Bottoroff, J. l., Johnson, J. L., & Hoyak, K. (2012). “You feel like you can’t live anymore.” Social Science & Medicine, 74, 506–514. Russell, S. T., & Toomey, R. B. (2012). Men’s sexual orientation and suicide. Social Science & Medicine, 74, 523–529. Schuster, M. R., & Van Dyne, S. R. (1985). Women’s place in the academy. Totowa, NJ: Rowman & Allanheld. Scourfield, J., Fincham, B., Langer, S., & Shiner, M. (2012). Sociological autopsy. Social Science & Medicine, 74, 466–473.

CONTENTS Page Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ix List of Illustrations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix Chapter PART I. OVERVIEW 1. Men and Suicide: An Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Karolina Krysinska PART II. CAUSES 2. Male Depression and Suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 David Lester 3. Fatal Loneliness: The Role of Loneliness in Men’s Suicide . . . . . . 34 John F. Gunn III 4. Drugs, Alcohol, and Suicidal Behavior in Men . . . . . . . . . . . . . . . . 44 John F. Gunn III and David Lester 5. Risk and Protective Factors for Male Suicide . . . . . . . . . . . . . . . . . . 51 John F. Gunn III and David Lester 6. The Role of Testosterone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 David Lester 7. Men, Guns and Suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 David Lester 8. Suicide Among Male Athletes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 John F. Gunn III 9. Suicide in the Armed Forces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 John F. Gunn III and David Lester 10. Suicide in Mass Murderers and Serial Killers . . . . . . . . . . . . . . . . 109 David Lester xv

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Suicide in Men

11. Suicide Bombers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 David Lester 12. Murder-Suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 David Lester 13. Suicide in Gay Men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 John F. Gunn III 14. Suicide in Creative Men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164 David Lester 15. The Influence of Race and Ethnicity on Suicide in Men . . . . . . . . 175 John F. Gunn III and Allison L. Gunn PART III. MEN IN OTHER CULTURES 16. Male Suicide in China . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193 Jie Zhang 17. Changing Culture, Prolonged Conflict, and the Specter of Suicide Terrorism: Exploring Suicide in Palestinian Men . . . . . . . 204 Jessica Bonnan-White 18. Suicidal Behavior in Ugandan Men . . . . . . . . . . . . . . . . . . . . . . . . 226 Birthe Loa Knizek, Eugene Kinyanda and Heidi Hjelmeland 19. Suicide and Hegemonic Masculinity in Australian Men . . . . . . . . 248 Jo River 20. Suicide in Ghanaian Men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262 Mensah Adinkrah PART IV. OTHER ISSUES 21. The Impact of Suicide Bereavement . . . . . . . . . . . . . . . . . . . . . . . . 279 John F. Gunn III 22. Men, Economic Strain and Suicide in the Movies, 1900–2013 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288 Steven Stack and Barbara Bowman PART V. PREVENTING SUICIDE IN MEN 23. Preventing Suicide in Men versus Women . . . . . . . . . . . . . . . . . . 303 David Lester

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xvii

24. Men and Suicide Prevention: Why Can’t a Man be More Like a Woman? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312 Paul Quinnett 25. A Study of QPR and Help-Seeking in Men . . . . . . . . . . . . . . . . . . 323 John A. Cascamo 26. Help-Seeking and Men: An Innovative Suicide Prevention Program from the Construction Industry . . . . . . . . . . . . . . . . . . . . 332 Graham Martin and Jorgen Gullestrup PART VI. CONCLUSIONS 27. Final Thoughts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 353 Name Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 359 Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367

LIST OF ILLUSTRATIONS Page

Tables 1.1: 6.1: 10.1: 13.1: 13.2: 14.1: 14.2: 14.3: 14.4: 16.1: 16.2: 17.1: 17.2:

17.3: 17.4:

22.1:

Suicide Rates in Males and Females in Selected Countries . . . . 7–9 Suicide Rates by Gender, 1980 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Serial Killers Who Complete Suicide (20th Century) . . . . . 119–121 Biased, Inadequate, or Inappropriate Practice Themes . . . . . . . . 159 Exemplary Practice Themes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 Six Creative Men: Birth, Death, Age, Birth Order . . . . . . . . . . . 166 Six Creative Men: Marital Status, Children, Family Deaths . . . . 166 Six Creative Men: Method, Prior attempts/method, Psychiatric Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 Male Celebrities Who Died by Suicide . . . . . . . . . . . . . . . . . 170–171 Characteristics of the Case Control Samples for Men and Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200 Logistic Multiple Regressions Predicting Suicide of Men and Women in Rural China . . . . . . . . . . . . . . . . . . . . . . . . . . . 201 Palestinian Patients Interviewed by Nadia Daggabh Following Suicide or Reported Suicide Attempts . . . . . . . . . . 209 Frequency of Violent Acts Committed by Family Member During Preceding 12-Month Period Among Never Married Males, Ages 18–64 . . . . . . . . . . . . . . . . . . . . . . . . . . . 213 Frequency (%) of Reported Location of Acts of Violence Against Never Married Palestinian Males, Ages 18–64 . . . . . . 214 Frequency (%) of Reported Perpetrators of Violence Against Never Married Palestinian Males, Ages 18–64, During Preceding 12-Month Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214 The Relationship Between Gender of the Suicide and the Portrayal of Economic Strain as a Cause of Suicide, 1900–2013 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295 xix

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22.2:

25.1: 25.2:

Suicide in Men

The Relationship between Gender of the Suicide and the Portrayal of Economic Strain as a Cause of Suicide: Panel A, 1900–1950 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296 Description of the Sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 326 Means and Standard Deviations for IASMHS Total Scores Pre- and Post-QPR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327

Figures 25.1:

The Effect of QPR Training (pre/post) an Gender on Total IASMHS Scores . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 328

26.1:

Pattern of Usage of the After-hours Emergency Line . . . . . . . . . 345

26.2:

Presenting Issues on Referral to Case Management . . . . . . . . . . 346

SUICIDE IN MEN

Part I

OVERVIEW

Chapter 1 MEN AND SUICIDE: AN OVERVIEW KAROLINA KRYSINSKA Although women were more exposed to mental illness than men (...) suicide is less frequent among them. Observers from all nations are in agreement on that issue. (Esquirol, 1821, in Kushner, 1993, p. 467)

There are more suicides among men than women (. . .) which will not surprise those who know the energy, courage, and patience of women under misfortune; men more readily give way to despair, and to the vices consequent upon it (Winslow, 1840, in Kushner, 1993, p. 468)

lthough written more than 150 years ago, these quotes are a good introduction to the theme of “male suicidal behavior” or “suicide in males.” They raise issues, such as the higher incidence of fatal suicidal behavior among males and the male vulnerability to negative life events, which are frequently described in the contemporary literature on the subject of male suicide. This chapter presents an overview of international epidemiological data and the “gender paradox of suicide,” that is, the inverse relationship between suicidal morbidity and mortality in the two genders (Canetto & Cleary, 2012; Canetto & Sakinofsky, 1998). It also looks at the impact of cultural models of masculinity on the ability to cope with stress and depression, and presents a number of risk factors which seem particularly pertinent to the discussion of suicide in males. A few comments should be made before presenting the epidemiological data and the frameworks proposed to explain the phenomenon of male sui-

A

5

6

Suicide in Men

cidal behavior. Although “gender” (or “sex”) is one of the most frequently used sociodemographic variables in the study of epidemiology and a wellestablished risk factor for suicide, it is also one of the most oversimplified and misused concepts (Cleary, 2012; Möller-Leimkühler, 2002). The complicated issues of differences and overlap between “gender” and “sex” are usually reduced to the simple dichotomy of “male versus female” (Canneto & Cleary, 2012). On the other hand, the varieties of cultural models of “masculinity” (Connell, 2012) are overlooked, and males often are treated as a uniform, homogenous group. Consequently, variables which are significantly related to the levels of suicidal behavior in males, such as age, sexual orientation, cultural background, race, socioeconomic and marital status are ignored (The Samaritans, 2012). As Cleary (2012, p. 499) pointed out, “some men, rather than all men, are vulnerable to suicide” and it remains a serious challenge for both researchers and clinicians to identify risk and protective factors which make “some men” vulnerable to suicide, while others remain resilient when faced with life adversity or psychopathology. Given the social and economic inequalities among the sexes related to the historical, religious and cultural determinants, sensitivity to the issues of gender often implies sensitivity to female gender issues and consequently, “gender-related research has mainly focused on the situation of women because women are believed to suffer more from ill health and from multiple social roles than men. . . . Research on men’s health has not yet achieved the societal and scientific relevance of women’s health studies” (Möller-Leimkühler, 2002, pp. 1–2). Given the high prevalence of male suicide mortality, it seems paradoxical that this observation applies also to the field of suicide research and prevention. Nonetheless, there is a scarcity of studies and interventions focusing specifically on male suicidal behavior, a gap identified in relation to suicide in young males (Pitman, Krysinska, Osborn, & King, 2012) and middle-aged males (Kirtley & O’Connor, 2012). FATAL, NONFATAL SUICIDAL BEHAVIOR AND SUICIDAL IDEATION IN MEN

Fatal Suicidal Behavior When studying the epidemiology of suicide worldwide, one is usually struck by the sheer numbers, usually translated into standardized and comparable suicide rates, of males who take their own lives. Not all countries have developed suicide mortality registration systems or report the data to the World Health Organization, and the reliability of suicide statistics can be questionable even in countries with well-established mortality databases (e.g., Gun-

7

Men and Suicide: An Overview

nell, Hawton, & Kapur, 2011). Nonetheless, the available epidemiological data shed some light on the extent of male suicide mortality. According to the World Health Organization (WHO) data presented in Table 1.1 (WHO, 2013), the highest male suicide rates over the period of 2005–2009 were found in East-Central Europe (61.3 per 100.000 per year in Lithuania, 53.9 in the Russian Federation, and 48.7 in Belarus) and in SouthEast Asia (39.9 in the Republic of Korea and 36.2 in Japan). The lowest rates were reported in Azerbaijan (1.0), South Africa (1.4), Kuwait and Peru (both 1.9). Data collected in the 27 member countries of the European Union (EU27) in 2007, showed that suicide was a major cause of death for males and accounted for 1.75 percent of total male deaths (European Commission, 2011). In 2010, the average male suicide rate in the EU27 was 16.6 with significant differences among the countries. The lowest rates were found in South Europe, including Greece (5.2), Cyprus (6.1), and Italy (8.9), while the highest rates were reported in Central-Eastern European countries, such as Hungary (37.4), Latvia (35.2), and Lithuania (52.9) (Eurostat, 2013).

Table 1.1. SUICIDE RATES IN MALES AND FEMALES IN SELECTED COUNTRIES (PER 100,000), 2005–2009 (WHO, 2013). COUNTRY

YEAR

MALES

FEMALES

RATIO M:F

Lithuania

2009

61.3

10.4

5.9

Russian Federation

2006

53.9

9.5

5.7

Belarus

2007

48.7

8.8

5.5

Kazakhstan

2008

43.0

9.4

4.6

Hungary

2009

40.0

10.6

3.8

Latvia

2009

40.0

8.2

4.9

Republic of Korea

2009

39.9

22.1

1.8

Guyana

2006

39.0

13.4

2.9

Ukraine

2009

37.8

7.0

5.4

Japan

2009

36.2

13.2

2.7

Slovenia

2009

34.6

9.4

3.7

Estonia

2008

30.6

7.3

4.2

Republic of Moldova

2008

30.1

5.6

5.4

Finland

2009

29.0

10.0

2.9 continued

8

Suicide in Men Table 1.1—Continued. COUNTRY

YEAR

MALES

FEMALES

RATIO M:F

Croatia

2009

28.9

7.5

3.8

Belgium

2005

28.8

10.3

2.8

Serbia

2009

28.1

10.0

2.8

Poland

2008

26.4

4.1

6.4

Switzerland

2007

24.8

11.4

2.2

France

2007

24.7

8.5

2.9

Czech Republic

2009

23.9

4.4

5.4

Suriname

2005

23.9

4.8

4.9

Slovakia

2005

22.3

3.4

6.5

Romania

2009

21.0

3.5

6.0

China (Hong Kong Sar)

2009

19.0

10.7

1.8

Ireland

2009

19.0

4.7

4.0

Bulgaria

2008

18.8

6.2

3.0

Sweden

2008

18.7

6.8

2.7

Chile

2007

18.2

4.2

4.3

New Zealand

2007

18.1

5.5

3.3

Germany

2006

17.9

6.0

2.9

Trinidad & Tobago

2006

17.9

3.8

4.7

United States of America

2005

17.7

4.5

3.9

Denmark

2006

17.5

6.4

2.7

Norway

2009

17.3

6.5

2.7

Canada

2004

17.3

5.4

3.2

Iceland

2008

16.5

7.0

2.3

Luxembourg

2008

16.1

3.2

5.0

Portugal

2009

15.6

4.0

3.9

Kyrgyzstan

2009

14.1

3.6

3.9

Puerto Rico

2005

13.2

2.0

6.6

Netherlands

2009

13.1

5.5

2.4

India

2009

13.0

7.8

1.7

El Salvador

2008

12.9

3.6

3.6

9

Men and Suicide: An Overview Table 1.1—Continued. COUNTRY

YEAR

MALES

FEMALES

RATIO M:F

Singapore

2006

12.9

7.7

1.7

Australia

2006

12.8

3.6

3.5

Argentina

2008

12.6

3.0

4.2

Spain

2008

11.9

3.4

3.5

Mauritius

2008

11.8

1.9

6.2

United Kingdom

2009

10.9

3.0

3.6

Ecuador

2009

10.5

3.6

2.9

Costa Rica

2009

10.2

1.9

5.4

Italy

2007

10.0

2.8

3.6

Nicaragua

2006

9.0

2.6

3.5

Panama

2008

9.0

1.9

4.7

Colombia

2007

7.9

2.0

3.9

Brazil

2008

7.7

2.0

3.8

Cyprus

2008

7.4

1.7

4.3

Georgia

2009

7.1

1.7

4.2

Israel

2007

7.0

1.5

4.7

Mexico

2008

7.0

1.5

4.7

Uzbekistan

2005

7.0

2.3

3.0

Belize

2008

6.6

0.7

9.4

Greece

2009

6.0

1.0

6.0

Malta

2008

5.9

1.0

5.9

Guatemala

2008

5.6

1.7

3.3

Venezuela

2007

5.3

1.2

4.4

Paraguay

2008

5.1

2.0

2.5

Bahrain

2006

4.0

3.5

1.1

Armenia

2008

2.8

1.1

2.5

Kuwait

2009

1.9

1.7

1.1

Peru

2007

1.9

1.0

1.9

South Africa

2007

1.4

0.4

3.5

Azerbaijan

2007

1.0

0.3

3.3

10

Suicide in Men

In almost all countries the male suicide rate exceeds the female suicide rate. The ratio of 3–4 male suicides to one female suicide is frequently quoted in the literature. However, this number should be treated with caution, as it is based predominantly on suicide statistics collected in English-speaking and European countries (European Commission, 2011; Liu, Chen, Cheung, & Yip, 2009). A global overview of suicide mortality in both genders presents a more complex picture (see Table 1) (WHO, 2013). The male to female suicide ratio ranges from 9.4:1 in Belize and 6.6:1 in Puerto Rico, to 1.1:1 in Bahrain and Kuwait. Chen, Wu, Yousuf and Yip (2012) observed that the gap between male and female suicide rates is relatively small in some Asian countries, such as China (1.2:1), South Korea (1.9:1), Hong Kong (1.9:1), India (2:1), and Singapore (2:1). The low gender ratios of suicide mortality in China, including the male to female ratio of 0.9:1 reported in selected rural and urban areas of China in 1999 (WHO, 2013), is a well-known phenomenon. Nonetheless, the suicide mortality of Chinese males has increased since 2005, and in 2009 the ratio reversed to 1.2:1 (Chen et al., 2012). Historically, elderly men have been regarded as the group at highest risk of death by suicide, and this phenomenon can be still observed in some countries and regions of the world. For example, in the European Union, suicide rates in males rise significantly with age, and the risk of suicide among older males (aged 65 years and older) is three times higher than among young adult males (aged 15–24 years) (European Commission, 2011). In East Asia, suicide rates in the older groups are high, and the ratios of suicide in elderly males as compared to the general population are as high as 6.6:1 in urban China and 6.2:1 in Singapore (Chen et al., 2012; Pritchard & Baldwin, 2002). However, globally, the highest suicide rates shifted between 1950 and 1999 from elderly people towards middle-aged people (aged 35–45 years), and in some countries to younger age groups (aged 15–25 years) (Pitman et al., 2012). By the mid-1980s suicide had become a leading cause of death in men aged 25–34 years in high-income countries, accounting for up to a third of mortality in young men (Diekstra, 1989). Since the 1990s, suicide rates in young men have decreased in countries such as Australia, China, the Czech Republic, New Zealand, Thailand, United States, and some Western European countries, including Austria, Italy, England, Scotland and Wales. Meanwhile, rates have risen in countries such as Brazil, Ireland, Lithuania, Northern Ireland, Singapore, and South Korea, (Pitman et al., 2012). Within the 27 member countries of the European Union, the general suicide rate decreased by 15 percent from 11.8 in 2000 to 9.8 in 2007. However, suicide remains the principal cause of death in men aged 30–39 years (European Commission, 2011). Over the last two decades, the incidence of suicide has increased in middle-aged males in the United States (CDC, 2013) and the United Kingdom

Men and Suicide: An Overview

11

(Department of Health, 2012). In the United States, there has been a significant increase in the overall suicide rate among middle-aged adults (aged 35–64), relative to a small decline in suicide rates among older persons and a small increase in suicide among younger age groups (CDC, 2013). Between 1999 and 2000, suicide rates for men and women increased by 28 percent (from 21 to 27 for males, and from 2 to 8 for females). Before 2002, there was a significant increase in the suicide rate among young males (aged 25–34) in the United Kingdom (Department of Health, 2012). However, over the last decade suicide mortality in this age group has fallen considerably, and this decrease has been accompanied by a continuous decline in suicide rate in elderly males (aged 75+). In contrast, suicide rates among middle-aged males (aged 35–49 years) have remained relatively stable, with a slight increase in recent years. Currently middle-aged males in the United Kingdom have the highest suicide rate in the country. The threeyear (2008–2010) average suicide rate in this group was 20.8 while the general population suicide rate was 7.9 (Department of Health, 2012).

Nonfatal Suicidal Behavior and Ideation The WHO World Mental Health Surveys, conducted in 21 countries (2001–2007), showed that the 12-month prevalence of suicidal ideation was lower for males than for females in both developed (1.7% versus 2.2%) and developing countries (1.6% versus 2.4%) (Borges et al., 2010). However, suicidal plans were less frequent among males than females only in developing countries, and there were no differences between genders in the prevalence of suicide attempts either in developing or in developed countries. According to the WHO/EURO Multicentre Study on Suicidal Behavior, the “average European” suicide attempt rate for individuals older than 15 years-of-age (data for 1995–1999) was 170 per 100,000 for males and 209 for females (Schmidtke et al., 2004a). In 15 centers participating in the study, the personbased suicide attempt rates were higher among women than among men (average gender ratio of 1:1.2). However, three centers (Helsinki, Innsbruck, and Ljubljana) reported more suicide attempts among males than females, and the lowest gender ratio was found in Tallinn (1:0.7). In half of the participating centers, young adult males (those aged 25–34) comprised the group at the highest risk of a suicide attempt among males and, in general, the male suicide attempt rates decreased with age (Schmidtke et al., 2004a). The high prevalence of nonfatal suicidal behavior among young and middle-aged males, with the risk decreasing with age, was also reported in a more recent European Multicentre Study on Suicidal Behavior and Suicide Prevention (MONSUE) (European Commission, 2008). On average, in the eight participating centers, the highest person-based percentage for male suicide

12

Suicide in Men

attempters was found in those aged 15–24, followed by the 25–34-year-olds and 35–44-year-olds (28%, 25% and 22%, respectively). The lowest percentage was found among elderly males over the age of 85 years of age (1%). The U.S. National Survey on Drug Use and Health (CDC, 2011), showed that adult (18+) females more frequently thought seriously about suicide in the previous year than adult males (3.9% versus 3.5%). There were no differences between the two genders regarding the 12-month prevalence of making suicidal plans (1.0% for both males and females) and suicide attempts (0.5% in females and 0.4% in males). The 2007 National Survey of Mental Health and Wellbeing in Australia ( Johnston, Pirkis & Burgess, 2009) showed that the lifetime prevalence of suicidal ideation, plans and attempts was consistently higher among females than males (15% versus 11.5%, 4.9% versus 2.9%, and 4.4% versus 2.1%, respectively). However, although males reported lower levels of suicidal behavior in the last 12 months than females (1.8% versus 2.7% thought about suicide, 0.4% versus 0.7% made a suicide plan, and 0.3% versus 0.5% made a suicide attempt), these differences did not reach a level of statistical significance. The Australian survey also found different age-related patterns of suicidal ideation and nonfatal suicidal behavior for both genders. In males, the prevalence of suicidal behavior in the last 12 months was the highest in the middle-age group (those aged 35–44 years), while for females the peak was in the youngest age group (those aged 16–24 years) and decreased with age ( Johnston et al., 2009). SUICIDE METHODS The discussion of male suicidal behavior would not be complete without presentation of suicide methods used by males. According to the WHO (Ajdacic-Gross et al., 2008), between 1994 and 2005, hanging was the predominant method of suicide among males worldwide. The highest proportion of hanging among male suicides (around 90%) was observed in Eastern European countries. This method accounted for approximately half of male suicides in Australia and New Zealand, and in many Western and South European countries. Hanging was also a popular method of suicide in Asia (e.g., 92% of male suicides in Kuwait and 69% in Japan), and in the Americas (e.g., 77% of male suicides in Cuba, 69% in Mexico and 68% in Puerto Rico). Firearm suicide was the dominant method of male suicide in the United States, Uruguay, and Switzerland (61%, 48%, and 33% of male suicides, respectively) and, after hanging, was the second most often used suicide method in Argentina (38%) (Ajdacic-Gross et al., 2008). Pesticides were the most frequently used suicide method among males in rural Latin American countries, such as El Salvador, Nicaragua, and Peru (86%, 61%, and 55%, respec-

Men and Suicide: An Overview

13

tively), several Asian countries (including 38% of male suicides in the Republic of Korea), and in Portugal, where, after hanging, it was the second most frequently used suicide method (14% of male suicides). Poisoning with drugs played an important role in male suicide in Canada, the Nordic countries and the United Kingdom, while jumping from a height accounted for high proportions of male suicides in small, predominantly urban societies such as Hong Kong, Malta, and Luxemburg. For example, in Hong Kong this method was used by 43 percent of males (Ajdacic-Gross et al., 2008). In addition, new and highly lethal suicide methods have emerged in the Far East, including home manufactured hydrogen sulphide and other chemical suicide methods (Pitman et al., 2012). Charcoal-burning and other forms of gas poisoning have rapidly increased as a new method especially in men (and women) aged 24–39 years in Taiwan and Hong Kong, and middle-aged men (40–59 years of age) in Hong Kong (Liu, Beautrais, Caine et al., 2007). Regarding nonfatal suicidal behavior, the European multi-center studies showed gender differences regarding the use of “soft” (such as self-poisonings) and “hard” suicide methods (such as cutting, shooting, jumping or lying before a moving object). In the WHO/EURO Study, 29 percent of males used a “hard” method compared to 15 percent of females (Schmidtke et al., 2004b). In the MONSUE Study, the “hard” methods were employed by 42 percent of males and 22 percent of females (European Commission, 2008). THE GENDER PARADOX OF SUICIDE One of the common themes in the literature on male suicide mortality is the concept of the “gender paradox of suicide,” that is, the observation that “. . . in most countries where the prevalence of suicidal behavior has been studied, females have higher rates of suicidal ideation and behavior than males, yet mortality from suicide is typically lower for females than for males” (Canetto & Sakinofsky, 1988, p. 1). The inverse relationship between suicidal mortality and morbidity in the two genders can be observed in many countries of the world, but there are exceptions to the rule. Canetto and Sakinofsky (1998) have acknowledged this cross-cultural difference by adding the following comment to the definition of the gender paradox of suicide. “This statement is based on mortality and mortality studies conducted primarily in Western countries. We know little about the epidemiology of suicidal behaviors in a majority of countries in the world” (Canetto & Sakinofsky, 1988, p. 1). Indeed, a more comprehensive analysis of the epidemiology of fatal and non-fatal suicidal behavior among males presents an even more complex picture of suicide mortality and morbidity. As presented earlier in this chap-

14

Suicide in Men

ter, although currently suicide mortality among males exceeds female suicide mortality in practically all countries worldwide (where the data are available), the gender ratios of suicide vary significantly. A closer look at male suicide across the lifespan in an international perspective shows an even more complicated picture. For example, an analysis of suicide trends in the United Kingdom shows decreasing mortality in young adult males and the elderly, accompanied by stable and recently slightly increasing suicide rates in middle-aged males (Department of Health, 2012) while, in the United States suicide rates among the middle-aged males have been rising over the last decade (CDC, 2013). The multi-center monitoring studies in Europe show that, although, in general, females attempt suicide more frequently than males, in some regions, including Estonia and Slovenia, suicide attempts are more common among males (Schmidtke et al., 2004a). In addition, the risk of a suicide attempt varies with age and, according the European data, male adolescents, young adults and middle-aged males engage more often in non-fatal suicidal behavior than older males (European Commission, 2008). General population studies also yield results which contradict the notion of the female predominance in regards to nonfatal suicidal behavior. For example, the lifetime prevalence of suicidal behavior is higher among Australian females than males, but no statistically significant differences are found in the incidence of suicidal thoughts, plans and attempts in the last 12 months ( Johnston et al., 2009). Although probably applicable only to suicidal behavior and ideation in some of the Western countries, the gender paradox of suicide is an interesting concept which has inspired many studies and discussions regarding variety of risk and protective factors for male and female suicide (e.g., McKay, Milner, & Maple, 2013; Schrijvers, Bollen, & Sabbe, 2012). Different explanations for the observed gender differences, originally reported and analyzed in the context of the epidemiological data collected in the United States (Moscicki, 1994), have been proposed (Canetto & Sakinofsky, 1998). These include references to the differences in suicide methods used by males and females (the lethality theory), the greater willingness of females than males to report nonfatal suicidal behavior and ideation (the recall bias theory), and the higher effective depression treatment rates among females and the higher incidence of (untreated) alcohol abuse among males. A closer inspection of these explanations, however, reveals their limitations. Although in general males use the “hard,” highly lethal means of suicide (e.g., shooting or hanging) more often, and females prefer “soft” methods, less likely to result in death, the “lethality theory” does not take into account the intent to die of the person engaging in suicidal behavior. Another proposed explanation, the “recall bias theory,” does not account for the report-

Men and Suicide: An Overview

15

ed higher rates of substance abuse and antisocial behavior, potentially as socially undesirable and embarrassing as suicidal tendencies, among males. According to the theory of differential rates of depression and alcohol abuse, females are as depression-prone as males, but their willingness to seek treatment and the effectiveness of psychotherapy and pharmacotherapy for depression protects them against fatal suicidal behavior. Substance abuse, on the other hand, is more prevalent among males and, in interaction with depression and stressful life events, might lead to suicide. Nonetheless, the lack of evidence regarding the relation between the effectiveness of depression treatment in females, treatment for substance abuse in males, and suicidal behavior seems to invalidate this model (Canetto & Sakinofsky, 1998). The most popular explanation of the gender differences in the suicidal behavior is the “socialization theory” or the “cultural script theory” (Canetto, 2008; Canetto & Sakinofsky, 1998). According to this theory: suicide is viewed as a masculine behavior, as are alcohol and illegal substance abuse. They are disapproved in women, but tolerated and even encouraged in men in some circumstances. . . . Conversely, “attempting suicide” is regarded as feminine. It is a behavior that is viewed negatively, especially by males, but one that is expected in females, in some circumstances. (Canetto & Sakinofsky; 1998, p. 17)

Thus, the process of socialization during the lifespan is likely to affect the type of suicidal behavior one is likely to engage in, as well as the choice of a suicide method. For example, in the United States and Western European countries, some means of suicide, such as hanging or guns (i.e., hard methods), might be considered more “masculine” than the less lethal (i.e., soft) methods, such as self-poisoning, which are perceived as “feminine.” The cultural understanding of gender, including the Western model of “hegemonic masculinity” (Connell, 2012), might also contribute to the male vulnerability to suicide through reinforcing self-destructive or aggressive behavior, preventing help-seeking and reluctance to talk about emotions and problems (the latter could be seen as typically “female” reactions and behaviors) (Cleary, 2012; Johal, Shelupanov, & Norman, 2012). According to MöllerLeimkühler (2003), the traditional Western male gender-role includes: attributes such as striving for power and dominance, aggressiveness, courage, independency, efficiency, rationality, competitiveness, success, activity, control and invulnerability. (. . .) [It] implies not perceiving or admitting anxiety, problems and burdens which might develop under the conditions of danger, difficulties and threats. Traditionally, anger, aggressiveness and hostility are socially accepted as the male code of expressiveness. (p. 3)

16

Suicide in Men

In relation to depression in men, the model of “big-build” provides an interesting insight into the interaction between feelings and behaviors (Brownhill, Wilhelm, Barclay, & Schmied, 2005). According to Brownhill et al.: gender differences in depression appear to lie not in the experience of depression per se (both men and women experience depression similarly), but in the expression of depression. What men ‘do’ has (unfortunately) been associated with ‘men behaving badly’ rather than associated with men being depressed. (p. 928)

For example, risk-taking, antisocial behavior, aggression and violence, suicide, and drug and alcohol abuse in males might be interpreted as symptoms of “masked depression” (Rutz & Rihmer, 2007). THE MALE VULNERABILITY TO SUICIDAL BEHAVIOR Some of the risk factors related to suicidal behavior in men seem equally relevant for both genders, while others might relate particularly to male suicide. For example, a Danish study on gender differences in risk factors for suicide identified a history of hospitalized mental illness as a suicide risk factor for both men and women (Qin et al., 2000). On the other hand, single marital status, unemployment, retirement and physical illness were related to increased suicide risk in males. Pitman et al. (2012) summarized the evidence-based risk factors pertinent to suicide in young adult males. Among the individual level risk factors are psychiatric disorder (substance use, and schizophrenia, affective, personality and anxiety disorders), being single, lower socioeconomic status, residence in a rural or remote areas, and Indigenous status. The population-level risk factors in young adult males include unemployment, social deprivation, social fragmentation and media influences. Homosexuality might be related to the increased suicide risk in young males, although more studies are needed to confirm the link between sexual orientation and suicidal behavior (Plöderl et al., 2013). Among population-level factors which might contribute to the recent increase in suicide among middle-aged males (and females) in the USA are the recent economic crisis and a cohort effect—high suicide rates in the “baby boomer” generation which was reported also during adolescence (CDC, 2013). Changes in the availability and acceptability of suicide methods might be linked to the rising suicide rates in this population, as there has been a rise in intentional overdoses associated with the higher availability of prescription opioids and an increase in the prevalence of suicide by suffocation (mostly hanging). Again, race/ethnicity is an important factor. The significant

Men and Suicide: An Overview

17

increase in suicide rates has been observed among Whites and American Indian/Alaska Natives, while no increase in suicide rates among Black and Hispanic middle-aged males and females has been reported (CDC, 2013). Stack (2000) presented an overview of psychological, social and cultural factors which contribute to the male vulnerability to suicide, contrasted with variables strengthening female resilience. In general, as a result of having to adapt to numerous changes in their social roles across the lifespan, women cope better than males with life stressors and develop better support networks. Women are more likely to recognize the signs of depression and other warning signs of suicide, and to seek professional help. Other protective factors include higher religiosity among females, lower prevalence of alcohol abuse, lower acceptability of fatal suicidal behavior (although a more positive attitude towards nonfatal suicidal behavior), and historically-determined lower access to lethal suicide means, especially firearms. In addition, the dominant model of masculinity, focusing on competitiveness, impulsiveness, decisiveness and strength, might increase the risk of male lethal suicidal behavior. The gender differences in primary adult roles (economic success for males and successful relationships for females) might make males more vulnerable to suicide in case of a failure. A failed personal relationship might be less visible to others than an unsuccessful professional career (Stack, 2000). An innovative sociological autopsy study of suicide in men (Shiner, Scourfield, Fincham, & Langer, 2009) looked at diverse social circumstances of suicidal women and men at different ages (the young age, the mid-life, and the old-age groups). In general, the study found more significant differences among the three age groups than between the two genders. In the youngest group (“young people in crisis”), a history of previous suicide attempts, negative childhood experiences and damaged family attachments, including separation, neglect and abuse, were linked to suicide in both genders. In the oldest group (“older people in decline”), physical illness and a loss, including bereavement, resulting in the weakening of social networks and loss of significant social relationships, was related to fatal suicidal behavior. Gender differences were found only in the middle-aged suicides (“mid-life gendered patterns of work and family”). Work-related problems, such as redundancy and unemployment, financial problems and criminal behavior were related to suicide among males. The female suicides experienced more problems with children, including separation and estrangement, as well as isolation and depression. Although relationship breakdown was linked to suicide in both males and females, it served as the main trigger for suicide more frequently for males than for females. The link between relationship breakdown and suicide differed between the two genders. For females it was related mostly to the excessive emotional dependence on the ex-partner, while sex-

18

Suicide in Men

ual jealousy, a wish for punishment or revenge, and disputes over children, were the most important for males (Shiner et al., 2009). Male vulnerability to the negative impact of unemployment and marital breakdown (or a breakdown of an intimate relationship, a broader term which seems more suitable in the context of changing family models, frequently including co-habiting outside formal marriage or civil partnerships [Evans et al., 2012]) might be explained by the dominant Western models of masculinity. Despite changes in gender roles and expectations, investment in work and employment, and the ability to provide for the family, are still seen by many men (especially working class men) as a way of constructing their male identity (Chandler, 2012; Hanlon, 2012). In this context, loss of work and unemployment can be experienced as a double failure. On the one hand, it means loss of professional pride and male identity (sometimes accompanied by loss of male companionship at work) and, on the other hand, it results in an inability to fulfill the role of a provider for the family. Scourfield (2005, p. 6) observed that “men are more brittle to relationship breakdown than are women” and this vulnerability can be analyzed on several levels (Evans, Scourfield, & Moore, 2012; Ide, Wyder, Kolves, & De Leo, 2010; Shiner et al., 2009). The breakdown of an intimate relationship often results in a loss of a major (or the only) source of emotional support, while separation from children might lead to an additional loss of social connection and support for a separated or divorced man. For some males, loss of a relationship means a failure to maintain a dominant position and might result in a desire for revenge and punishment, or trigger a negative reaction to a new relationship of the ex-partner. A breakdown triggered by a partner’s infidelity or abandonment might be perceived as disrespect and loss of honor, while societal pressure and expectations of a “happy marriage” could contribute to the feeling of a personal failure (Evans et al., 2012). TOWARDS A BETTER UNDERSTANDING OF MALE SUICIDAL BEHAVIOR Epidemiological data reveal the extent of male suicide mortality and morbidity, and the studies shed light on a variety of factors which increase the male vulnerability to suicide. Despite the seriousness of the problem, there are gaps in our knowledge regarding the risk and protective factors for suicide among males, including pathways to suicide and effective interventions. In the literature one can find terms such as “lethal masculinities” (Ridge et al., 2011, p. 152) and “toxic masculinities” (The Samaritans, 2012, p. 28). Although they are used to indicate sociocultural models of masculinity con-

Men and Suicide: An Overview

19

tributing to increased suicide risk among males, and are presented in the context of a much needed “critical reflection on gender roles” (Evans et al., 2012; p. 45), they might lead to a conclusion that just being a male in a contemporary Western society is a risk factor for self-destructive behavior. A study of men’s narratives regarding the personal experience of depression (Emslie, Ridge, Ziebland, & Hunt, 2006) offer an example of research providing a deeper and refreshing perspective on male suicidal behavior. One of the themes emerging in the study was a perception of suicide as a means of gaining control over depression. [One of the participants] suggested that contemplating suicide as a teenager had given him a feeling of power when the relationship with his violent father spiraled ‘out of control’. (. . .) [Another participant] described the strength and comfort he derived from an internet discussion group for depressed people contemplating suicide. His powerful account concluded with the realization that having the option of suicide gave him a sense of control. (Emslie et al., 2006, p. 2252)

Such alternative understanding of male suicidal behavior could contribute to a constructive discussion about gender roles, and could help develop and provide effective help for men in need. REFERENCES Ajdacic-Gross, V., Weiss, M. G., Ring, M., Hepp, U., Bopp, M., Gutzwiller, F., & Rössler, W. (2008). Methods of suicide: International suicide patterns derived from the WHO mortality database. Bulletin of the World Health Organization, 86, 726–732. Borges, G., Nock, M. K., Abad, J. M. H., Hwang, I., Sampson, N. A., Alonso, J., & Kessler, R. C. (2010). Twelve month prevalence of and risk factors for suicide attempts in the WHO World Mental Health Surveys. Journal of Clinical Psychiatry, 71, 1617–1628. Brownhill, S., Wilhelm, K., Barclay, L., & Schmied, V. (2005). “Big build”: Hidden depression in men. Australian & New Zealand Journal of Psychiatry, 39, 921–931. Canetto, S. S. (2008). Women and suicidal behavior: A cultural analysis. American Journal of Orthopsychiatry, 78, 259–266. Canetto, S. S., & Cleary, A. (2012). Men, masculinities and suicidal behavior. Social Science & Medicine, 74, 461–465. Canetto, S. S., & Sakinofsky, I. (1998). The gender paradox in suicide. Suicide & LifeThreatening Behavior, 28, 1–23. Centers for Disease Control and Prevention (CDC). (2011). Suicidal thoughts and behaviors among adults aged 18 years—United States, 2008–2009. Morbidity & Mortality Weekly Report, 60(13), 1–22.

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Centers for Disease Control and Prevention (CDC). (2013). Suicide among adults aged 35–64 years—United States, 1999–2010. Morbidity & Mortality Weekly Report, 62(17), 321–325. Chandler, A. (2012). Exploring the role of masculinities in suicidal behavior. In Men, Suicide and Society. Retrieved June 30, 2013, from: www.samaritans.org/sites /default/files/kcfinder/files/Men%20and%20Suicide%20Research%20Report%2 0210912.pdf Chen, Y. Y., Wu, K. C. C., Yousuf, S., & Yip, P. S. (2012). Suicide in Asia: Opportunities and challenges. Epidemiologic Reviews, 34, 129–144. Cleary, A. (2012). Suicidal action, emotional expression, and the performance of masculinities. Social Science & Medicine, 74, 498–505. Connell, R. (2012). Masculinity research and global change. Masculinities & Social Change, 1, 4–18. Department of Health. (2012). Statistical update on suicide (September 2012). Retrieved June 30, 2013, from: www.gov.uk/government/uploads/system /uploads/attachment_data/file/216931/Statistical-update-on-suicide.pdf Diekstra, R. F. W. (1989). Suicide and the attempted suicide: An international perspective. Acta Psychiatr Scandinavica, 80 (suppl. 354), 1–24. Emslie, C., Ridge, D., Ziebland, S., & Hunt, K. (2006). Men’s accounts of depression: Reconstructing or resisting hegemonic masculinity? Social Science & Medicine, 62, 2246–2257. European Commission. (2008). Monitoring suicidal behavior in Europe (MONSUE). Retrieved June 30, 2013, from: ec.europa.eu/health/ph_projects/2003 /action1/docs/2003_1_31_inter_en.pdf European Commission. (2011). The state of men’s health in Europe. Retrieved June 30, 2013, from: ec.europa.eu/health/population_groups/docs/men_health_extended _en.pdf. Eurostat. (2013). Death due to suicide, by sex (males). Retrieved June 30, 2013, from: epp.eurostat.ec.europa.eu/tgm/refreshTableAction.do;jsessionid=9ea7d07d30e7c adf7a6503914a54bf58dffe15093636.e34OaN8PchaTby0Lc3aNchuMc3eQe0?tab =table&plugin=1&pcode=tps00122&language=en Evans, R., Scourfield, J., & Moore, G. (2012). Gender, relationship breakdown and suicide risk: A systematic review of research in western countries. In Men, suicide and society. Retrieved June 30, 2013, from: www.samaritans.org/sites/default/files /kcfinder/files/Men%20and%20Suicide%20Research%20Report%20210912.pdf Gunnell, D., Hawton, K., & Kapur, N. (2011). Coroners’ verdicts and suicide statistics in England and Wales. British Medical Journal, 343. Hanlon, N. (2012). Masculinities, care and equality: Identity and nurture in men’s lives. New York: Palgrave Macmillan. Ide, N., Wyder, M., Kolves, K., & De Leo, D. (2010). Separation as an important risk factor for suicide: A systematic review. Journal of Family Issues, 31, 1689–1716. Johal, A., Shelupanov, A., & Norman, W. (2012). Invisible men: Engaging more men in social projects. Retrieved June 30, 2013, from: www.biglotteryfund.org.uk/er _invisible_men.pdf

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Johnston, A. K., Pirkis, J. E., & Burgess, P. M. (2009). Suicidal thoughts and behaviors among Australian adults: Findings from the 2007 National Survey of Mental Health and Wellbeing. Australian & New Zealand Journal of Psychiatry, 43, 635–643. Kirtley, O., & O’Connor, R. (2012). Men, suicide and society: The role of psychological factors. In Men, suicide and society. Retrieved June 30, 2013, from: www .samaritans.org/sites/default/files/kcfinder/files/Men%20and%20Suicide%20Res earch%20Report%20210912.pdf Kushner, H. I. (1993). Suicide, gender, and the fear of modernity in nineteenth-century medical and social thought. Journal of Social History, 26, 461–490. Liu, K. Y., Beautrais, A., Caine, E., Chan, K., Chao, A., Conwell, Y., & Yip, P. (2007). Charcoal burning suicides in Hong Kong and urban Taiwan: An illustration of the impact of a novel suicide method on overall regional rates. Journal of Epidemiology & Community Health, 61, 248–253. Liu, K. Y., Chen, E. Y., Cheung, A. S., & Yip, P. S. (2009). Psychiatric history modifies the gender ratio of suicide: An East and West comparison. Social Psychiatry & Psychiatric Epidemiology, 44, 130–134. McKay, K., Milner, A., & Maple, M. (2013). Women and suicide: Beyond the gender paradox. International Journal of Culture & Mental Health, in press. Möller-Leimkühler, A. M. (2002). Barriers to help-seeking by men: A review of sociocultural and clinical literature with particular reference to depression. Journal of Affective Disorders, 71, 1–9. Möller-Leimkühler, A. M. (2003). The gender gap in suicide and premature death or why are men so vulnerable? European Archives of Psychiatry & Clinical Neuroscience, 253, 1–8. Moscicki, E. K. (1994). Gender differences in completed and attempted suicides. Annals of Epidemiology, 4, 152–158. Pitman, A., Krysinska, K., Osborn, D., & King, M. (2012). Suicide in young men. Lancet, 379, 2383–2392. Plöderl, M., Wagenmakers, E. J., Tremblay, P., Ramsay, R., Kralovec, K., Fartacek, C., & Fartacek, R. (2013). Suicide risk and sexual orientation: A critical review. Archives of Sexual Behavior, 42, 715–727. Pritchard, C., & Baldwin, D. S. (2002). Elderly suicide rates in Asian and Englishspeaking countries. Acta Psychiatrica Scandinavica, 105, 271–275. Qin, P., Mortensen, P. B., Agerbo, E., Westergard-Nielsen, N. I. E. L. S., & Eriksson, T. O. R. (2000). Gender differences in risk factors for suicide in Denmark. British Journal of Psychiatry, 177, 546–550. Ridge, D., Emslie, C., & White, A. (2011). Understanding how men experience, express and cope with mental distress: Where next? Sociology of Health & Illness, 33, 145–159. Rutz, W., & Rihmer, Z. (2007). Suicidal behavior in men: Practical issues, challenges, solutions. Journal of Men’s Health & Gender, 4, 393–401. Schmidtke, A., Weinacker, B., Löhr, C., Bille-Brahe, U., DeLeo, D., Kerkhof, A., & Rutz, W. (2004a). Suicide and suicide attempts in Europe: An overview. In A. Schmidtke, U. Bille-Brahe, D. De Leo, & A. Kerkhof (Eds.), Suicidal behavior in Europe (pp. 15–28). Göttingen, Germany: Hogrefe & Huber.

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Schmidtke, A., Bille-Brahe, U., De Leo, D., Kerkhof, A., Lohr, C., Weinacker, B., & Rutz, W. (2004b). Sociodemographic characteristics of suicide attempters in Europe: Combined results of the monitoring part of the WHO/EURO Multicentre Study on Suicidal Behavior. In A. Schmidtke, U. Bille-Brahe, D. De Leo & A. Kerkhof (Eds.), Suicidal behavior in Europe (pp. 29–43). Göttingen, Germany: Hogrefe & Huber. Schrijvers, D. L., Bollen, J., & Sabbe, B. G. (2012). The gender paradox in suicidal behavior and its impact on the suicidal process. Journal of Affective Disorders, 138, 19–26. Scourfield, J. (2005). Suicidal masculinities. Sociological Research Online, 10(2), unpaged. Shiner, M., Scourfield, J., Fincham, B., & Langer, S. (2009). When things fall apart: Gender and suicide across the life-course. Social Science & Medicine, 69, 738– 746. Stack, S. (2000). Suicide: A 15-year review of the sociological literature. Part I: Cultural and economic factors. Suicide & Life-Threatening Behavior, 30, 145–162. The Samaritans. (2012). Men, suicide and society. Retrieved June 30, 2013, from: www.samaritans.org/sites/default/files/kcfinder/files/Men%20and%20Suicide%2 0Research%20Report%20210912.pdf World Health Organisation (WHO). (2013). Suicide rates per 100,000 by country, year and sex. Retrieved June 30, 2013, from: www.who.int/mental_health /prevention/suicide_rates/en/#

Part II

CAUSES

Chapter 2 MALE DEPRESSION AND SUICIDE DAVID LESTER urveys of depression typically find that depression is twice as common in women then in men (e.g., Kessler et al., 1994), and recent discussion about this difference has focused on factors such as the reluctance of men to seek treatment and their tendency to underreport symptoms of depression. However, several researchers have suggested that the symptoms of depression may differ in men and women and that, if the symptoms of male depression are taken into account, the gender differences in the incidence of depression may be much smaller.1 It has been suggested that male depression is characterized by lowered stress tolerance, acting-out behavior, poor impulse control, irritability, restlessness, alcohol and drug abuse, and anger and aggression. Rutz et al. (1995) established a training program for physicians in the island of Gotland in Sweden on depression and suicide, with the aim of increasing the ability of the physicians to detect depression, prescribe appropriate medication and, thereby, prevent suicide. The result was that the suicide rate for females declined on that island, but the suicide rate for men did not decline. This suggested that the symptoms of depression in men were different from the symptoms of depression in women, and the physicians were failing to detect this male form of depression. This led the team to devise a measure of male depression. The phenomenon of a distinct type of male depression has been noted in many contexts. Foli and Gibson (2011) surveyed professionals who work with adoptive parents, and these professionals noted that depression is com-

S

1. This type of depression has also been called masked depression since it is often unrecognized as depression by mental health professionals.

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mon after a couple adopts a child but, rather than showing the typical symptoms of depression, the husbands are more likely to become disengaged from the family and to show anger and frustration rather than sadness or melancholy. A similar style has been observed in fathers who show postpartum depression. Melrose (2010) found that new fathers, as well as new mothers, are prone to postpartum depression, but fathers are more likely to seem angry and anxious rather than sad. This distinct type of depression is thought to especially characterize the phenomenology of depression in young black men. Perkins (2013) noted that young black men have restricted emotionality and conceal emotions when distressed. Perkins cited one young man who said: “I think everbody has done something to cover up their depression. Nobody wants to walk around showing that type of emotion on their sleeve” (Watkins & Neighbors, 2007, p. 276). Perkins also suggested that, because of the racism and discrimination that they experience, young black men accept depression as a fact of life and, therefore, learn to deal with it (and suppress it) early in life. There is also the possibility that the stigma associated with mental illness is stronger in the African American community than in other ethnic groups. Winkler et al. (2006) described the symptoms of male depression as irritability and dysphoria, acting-out and aggressiveness, low impulse control, anger attacks, a tendency to blame others and be unforgiving, low stress tolerance, a higher willingness to take risks, behavior on the verge of social or legal standards, substance abuse (especially alcohol), general dissatisfaction with oneself and one’s behavior, and a high suicide risk. In a study of depressed patients without any psychiatric comorbidity (except for their major depressive disorder), Winkler, Pjrek and Kasper (2005) found that men more often had symptoms of irritability, overreaction to minor annoyances, and anger attacks on the Gotland Male Depression Scale, whereas the women had more hypersomnia and leaden paralysis. The men and women did not differ, however, in average depression scores on the Hospital Anxiety and Depression Scale or the Beck Depression Inventory. Oliffe and Phillips (2008) noted that depression in men is associated with a strong drive for achievement and success as well as a high level of restricting emotionality. The dominant ideals of masculinity, which include norms that prescribe that men should be tough, strong and independent, prevent men from expressing depression in a direct manner. If they act depressed in this traditional way, they attract societal punishment and punish themselves for deviating from these masculine scripts.

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RESEARCH ON THE GOTLAND SCALE FOR MALE DEPRESSION (GSMD) Zierau et al. (2002) devised the GSMD using a sample of male patients seeking help for alcohol dependence. The 13-item scale has items concerned with depression (e.g., constant, inexplicable tiredness) and distress (e.g., more aggressive, outward-reacting, difficulties keeping self-control). Scores on these two subscales were strongly associated (r = 0.73), and both scores were associated with a standard measure of depression. Patients who had been placed on antidepressants scored higher on the depression subscale but not significantly higher on the distress subscale, suggesting that psychiatrists did not realize that patients with high levels of distress were depressed and might benefit from antidepressants. Madsen and Juhl (2007) studied 549 Danish men six weeks after their wives had given birth. On a standard measure of postpartum depression (the Edinburgh Postnatal Depression Scale: EPDS) 5.9 percent of the fathers had a score above the cut-off score for depression. On the GSMD, 3.4 percent of the fathers had a score above the cut-off score for depression. The percentage of fathers with high scores on both scales was 2.1 percent, while 3.1 percent were high only on the EPDS and 1.3 percent only on the GSMD. The results of this study suggest, therefore, that administration of both scales would be useful in assessing postpartum depression in fathers. In a sample of patients (of whom 87% were men) with chronic daily headaches, Innamorati et al. (2009) found that GSMD scores predicted a measure of the disability caused by these headaches better than the scores on the Beck Hopelessness Scale. Möller-Leimkühler et al. (2007) gave the GSMD to a community sample of male adolescents and found that 22 percent were at risk for depression using a WHO scale of well-being. The adolescents at risk for depression did not differ significantly on the depression and distress items of the GSMD, but those at risk for depression significantly more often had distress scores that were higher than depression scores. Not all research has documented the benefits of screening men with the GSMD. Strömberg et al. (2010) gave men at a drop-in clinic for primary care a regular depression scale (the Beck Depression Inventory) and the GSMD and found that 23 percent of the men scored high on the Beck Depression Inventory but only 14 percent on the GSMD. The Gotland Scale did not identify any additional depressed men beyond those identified by the Beck Depression Inventory.

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The Masculine Depression Scale Magovcevic and Addis (2008) argued that the GSMD was inadequate from a psychometric point of view. They felt that the items were poorly worded and that the reliability and validity of the GSMD was not well established.2 They devised a much longer measure of male depression, and their psychometric analysis identified two subscales, a 33-item measure of internalizing symptoms (such as blunting of affect and worries about the future) and an 11-item measure of externalizing symptoms (such as aggression and irritability). Scores on these two subscales were only moderately associated (r = 0.57). Scores on the internalizing scale had much stronger association with conventional measures of depression such as the Beck Depression Inventory (rs = 0.80 versus 0.36 for the externalizing scale). The men in the sample who were in mental health treatment had higher scores than the normal men only on the internalizing subscale (and not on the externalizing subscale). Men who adhered to typical masculine norms (that is, hegemonic masculinity3—a competitive style, dominating other men as well as women, stressing toughness and social ascendancy [Connell, 1980]) scored higher on the externalizing subscale but not on the internalizing subscale. However, this scale has not been studied for its ability to predict suicidal behavior in either men or women.

Male Depression in Women? Having developed scales for male depression, the obvious question to be asked is whether and to what extent women show symptoms of male depression. Möller-Leimkühler and Yücel (2010) gave the GSMD to German undergraduates and found that men and women obtained similar mean scores. However, every symptom on the 13-item scale was endorsed more by the women, except for feeling burned-out and overconsumption of alcohol and drugs. Stress and aggressiveness were especially pronounced in the women. Möller-Leimkühler and Yücel also gave the students a sex-role inventory and found that, for the men and women combined, positive masculinity scores were negatively associated with GSMD scores and negative femininity scores were positively associated with GSMD scores. Unfortunately, Möller-Leimkühler and Yücel did not examine these associations by gender, but they did note that more of the females most at risk for male depression were feminine or undifferentiated in their sex role orientation, while more of the men at risk for male depression were undifferentiated. 2. Other researchers have also tried to develop better measures of male depression (e.g., Rice et al., in press). 3. The dictionary definition of hegemonic is “predominant.”

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In a study of women in the days after giving birth, Girardi et al. (2011) found that only 4 percent had high scores on the Beck Hopelessness Scale, while 10 percent reported mild depression on the GSMD (with none reporting moderate or severe depression). It seems then that the GSMD may identify depressed women, as well as depressed men, missed by other depression scales. Martin and her colleagues (2013) devised a scale to measure only alternative male-type symptoms of depression. They then examined the responses of a national sample of adults in the United States from which a subsample was drawn of those who met the criteria for having had a psychiatric disorder during their lifetime. Men and women obtained almost identical scores on the 8-item scale (6.05 and 6.07, respectively). However, women were more likely to report stress, irritability, sleep problems and loss of interest in things they usually enjoy. Men were more likely to report anger attacks/aggression, substance abuse and risk-taking behavior. Men and women did not differ in reporting hyperactivity. If a male form of depression does exist, more research is needed to clarify which symptoms belong on a male depresison scale so that each item differentiates men from women.

Male Depression and Suicide Innamorati et al. (2011a) gave the Beck Depression Inventory and the GSMD to both male and female psychiatric inpatients and found that men and women obtained similar mean scores on the GSMD. Scores on the Beck Depression Inventory and the GSMD were positively associated (r = 0.66), but, in a multiple regression analysis, GSMD scores predicted whether the patents had attempted suicide in the past 48 hours, while scores on the Beck Depression Inventory did not. The effect of gender was not significant in predicting a recent suicide attempt. Innamorati et al. (2011b) found that the GSMD scores of psychiatric inpatients were positively associated with scores on a suicidal history self-rating screening inventory. In both of these studies, the GSMD was useful in mixed samples of men and women. Pompili et al. (2009) compared psychiatric patients with and without substance abuse (about 50% men and 50% women) and found that the substance abusers more often reported prior suicide attempts and had somewhat higher scores on the GSMD, but the researchers did not study the association of GSMD scores and a suicidal history. Pompili et al. (2012) found that the GSMD, along with psychological measures of hopelessness and temperament, contributed to the prediction of suicidal risk and a history of attempted suicide in both men and women. Unfortunately, for our present concern, they did not report the associations separately for men and women in either of these studies.

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Can suicide be predicted in men with a diagnosis of major depression? Dumais and colleagues (2005) compared 104 depressed men in Quebec (Canada) who died by suicide with living men as a comparison group. They found that the suicides were more likely to have been alcohol abusers and drug abusers and, especially in the younger suicides, to have had Cluster B personality disorders (that is, antisocial, borderline, histrionic or narcissistic personality disorder), and these two factors were independent predictors of suicide. The Cluster B personality disorders are characterized by impulsive and aggressive behaviors, and Dumais suggested that these men were born with a disposition to impulsivity and aggression, which increased the likelihood of a Cluster B personality disorder developing which, in turn, increases the likelihood of drug and alcohol abuse and, eventually suicide. DISCUSSION Payne et al. (2008) noted that male gender roles are more stereotyped than those of women. The typical male role of toughness and suppressed emotionality, the so-called hegemonic male gender role, makes completed suicide a sign of toughness whereas attempting suicide is a sign of weakness and failure. Not only may this role shape the type of outcome of a suicidal action, but it may also shape the method chosen (men choose the more violent methods for suicide). Emslie et al. (2006) reported a qualitative study of how 16 depressed men talked about their depression and their recovery.4 They found that the majority of the men incorporated hegemonic masculinity into their recovery. They endeavored to become one of the boys, reestablished control, and became more responsible toward others. However, Emslie and her colleagues noted that this adaptation had worrying suicidal implications. One of these men “forced” himself to jump from a multistory car park by deriding himself as a coward. They quote from one narrative: “I started to climb over . . . and I climbed back and then I sort of ridiculed myself that I was a coward and wouldn’t do it. And now I think it would have been a lot braver not to do it” (p. 2251). He jumped, but survived, and he was aware of how his gender identity differed from the hegemonic masculinity of the other men on his medical ward. In contrast, recovery appeared to be better for those men, a minority, who constructed a “different” identity, that of men as sensitive, intelligent and creative. The implication is the psychotherapists should carefully assess suicidal 4. Five of the men were diagnosed with bipolar depression and eleven with unipolar depression.

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men in order to decide whether to reinforce and encourage hegemonic masculinity or help the men develop an alternative gender role. FINAL THOUGHTS Clearly much more research is warranted on masculine depression. Is it really “masculine depression” or simply another form of depression found in both men and women? How well does it predict suicidal behavior in men and in women, and does it add a predictive component to more traditional measures of depression? Is the Masculine Depression Scale developed by Magovcevic and Addis more useful than the more widely used Gotland Male Depression Scale, or do we need improved scales to assess male depression? However, the research to date indicates that assessment of male depression as measured by these scales should become a routine part of the clinical assessment of all patients, especially patients with any level of suicidal risk. Incorporation of these assessment tools may improve our ability to prevent suicidal behavior in our clients. REFERENCES Connell, R. W. (1987). Gender and power. Stanford, CA: Stanford University Press. Dumais, A., Lesage, A, Alda, M., Rouleau, G., Dumont, M., Chawky, N., Roy, M., Mann, J. J., Benkelfat, C., & Turecki, G. (2005). Risk factors for suicide completion in major depression. American Journal of Psychiatry, 162, 2116–2124. Emslie, C., Ridge, D., Ziebland, S., & Hunt, K. (2006). Men’s accounts of depression. Social Science & Medicine, 62, 2246–1157. Foli, K. J., & Gibson, G. C. (2011). Sad adoptive dads. International Journal of Men’s Health, 10, 153–162. Girardi, P., Pompili, M., Innamorati, M., Serafini, S., Berrettioni, C., Angeletti, G., Koukopoulos, A., Tatarelli, R., Lester, D., Roselli, D., & Primiero, F. M. (2011). Temperament, postpartum depression, hopelessness, and suicide risk among women soon after delivering. Women & Health, 51, 511–524. Innamorati, M., Pompili, M., De Filippis, S., Gentili, F., Erbuto, D., Lester, D., Tamburello, A., Iacorossi, G., Cuomo, I., Dominici G, Tatarelli, R., & Martelletti, P. (2009). The validation the Italian Perceived Disability Scale (IPDS) in chronic daily headache sufferers. Journal of Headache & Pain, 10, 21–26. Innamorati, M., Pompili, M., Gonda, X., Amore, M., Serafini, G., Niolu, C., Lester, D., Rutz, W., Rihmer, Z., & Girardi, P. (2011a). Psychometric properties of the Gotland Scale for Depression in Italian psychiatric inpatients and its utility in the prediction of suicide risk. Journal of Affective Disorders, 132, 99–103.

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Innamorati, M., Pompili, M., Serafini, G., Lester, D., Erbuto, D., Amore, M., Tatarelli, R., & Girardi, P. (2011b). Psychometric properties of the Suicidal History Self-Rating Screening Scale. Archives of Suicide Research, 15, 87–92. Kessler, R. C., McGonagle, K. A., Zhao, S., Nelson, C. B., Hughes, M., Eshelman, S. et al. (1994). Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Archives of General Psychiatry, 51, 8–19. Madsen, S. A., & Juhl, T. (2007). Paternal depression in the postnatal period assessed with traditional and male depression scales. Journal of Men’s Health & Gender, 4, 26–31. Magovcevic, M., & Addis, M. E. (2008). The Masculine Depression Scale. Psychology of Men & Masculinity, 9, 117–132. Martin, L., Neighbors, H. W., & Griffith, D. M. (2013). The experience of symptoms of depression in men versus women. JAMA Psychiatry, 70, 1100–1106. Melrose, S. (2010). Paternal postpartum depression. Contemporary Nurse, 34, 199–210. Möller-Leimkühler, A. M. M., Heller, J., & Paulus, N. C. (2007). Subjective wellbeing and ‘male depression’ in male adolescents. Journal of Affective Disorders, 98, 65–72. Möller-Leimkühler, A. M., & Yücel, M. (2010). Male depression in females? Journal of Affective Disorders, 121, 22–29. Oliffe, J. L., & Phillips, M. J. (2008). Man, depression and masculinities. Journal of Men’s Health & Gender, 5, 194–202. Payne, S., Swami, V., & Stanistreet, D. L. (2008). The social construction of gender and its influence on suicide. Journal of Men’s Health & Gender, 5, 23–35. Perkins, D. E. K. (2013). Challenges to traditional clinical definitions of depression in young Black men. American Journal of Men’s Health, in press. Pompili, M., Innamorati, M., Lester, D., Akiskal, H. S., Rihmer, Z., Del Casale, G., Amore, M., Girardi, P., & Tatarelli, R. (2009). Substance abuse, temperament and suicide risk. Journal of Addictive Diseases, 28(1), 13–20. Pompili, M., Innamorati, M., Rihmen, Z., Gonda, X., Serafini, G., Akiskal, H., Amore, M., Niolu, C., Sher, L., Tatarelli, R., Perugi, G., & Girardi, P. (2012). Cyclothymic-depressive-anxious temperament pattern is related to suicide risk in 346 patients with major mood disorders. Journal of Affective Disorders, 136, 405–411. Rice, S. M., Fallon, B. J., Aucote, H. M., & Möller-Leimkühler, A. M. (in press). Development and preliminary validation of the male depression risk scale. Jourtnal of Affective Disorders, in press. Rutz, W., von Knorring, L., Pihlgren, H., Rihmer, Z., & Walinder, J. (1995). Prevention of male suicides. Lancet, 345, 524. Strömberg, R., Backlund, L. G., & Löfvander, M. (2010). A comparison between the Beck Depression Inventory and the Gotland Male Depression Scale in detecting depression among men visiting a drop-in clinic in primary care. Nordic Journal of Psychiatry, 64, 258–264. Watkins, D. C., & Neighbors, H. W. (2007). An initial exploration of what “mental health” means to young Black men. Journal of Men’s Health & Gender, 4, 271–282. Winkler, D., Pjrek, E., & Kasper, S. (2005). Anger attacks in depression. Psychotherapy & Psychosomatics, 74, 303–307.

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Winkler, D., Pjrek, E., & Kasper, S. (2006). Gender-specific symptoms of depression and anger attacks. Journal of Men’s Health & Gender, 3, 19–24. Zierau, F., Bille, A., Rutz, W., & Bech, P. (2002). The Gotland Male Depression Scale. Nordic Journal of Psychiatry, 56, 265–271.

Chapter 3 FATAL LONELINESS: THE ROLE OF LONELINESS IN MEN’S SUICIDE JOHN F. G UNN III It is strange to be known so universally and yet to be so lonely.1 Albert Einstein (1897–1955)

hen someone thinks of the factors that cause men to die, they will probably begin by listing various diseases. They will discuss heart disease, stroke, cancer, homicide, and perhaps even suicide, but what the vast majority will not say is that loneliness should be included on that list. However, Joiner (2011) would disagree with those who deny the role of loneliness. Lonely at the Top: The High Cost of Men’s Success is a book about why men have poorer health and higher suicide rates than women. Drawing heavily on his Interpersonal-Psychological Theory of Suicide (IPTS), Joiner outlines the role of loneliness in suicide among men and uses the IPTS as a means of explaining the higher rate of death from suicide among men. Before discussing the arguments made by Lonely at the Top, we will first discuss the IPTS.

W

THE INTERPERSONAL-PSYCHOLOGICAL THEORY OF SUICIDE (IPTS) The IPTS is perhaps one of the most researched theories of suicide today. Joiner’s (2005) book Why People Die By Suicide outlined the theory and the empirical evidence that supports it. According to Joiner, suicide occurs be1. http://thinkexist.com/quotation/it_is_strange_to_be_known_so_universally_and_yet/222581.html

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cause of three factors: thwarted belonging, perceived burdensomeness, and the acquired capability to enact lethal self-harm. Thwarted belonging is the main point of interest for this chapter, but for the sake of understanding the theory as a whole, the other two variables will also be discussed. Thwarted belonging is a feeling of disconnection from others, of feeling lonely and as if you had very weak social support. Individuals who are high in a sense of thwarted belonging may have (or perceive themselves to have) poor interpersonal relationships culminating in a breakdown of these relationships (e.g., divorce). Perceived burdensomeness is perceiving oneself as a burden to those around you. This may be a cognitive distortion (i.e., imagined burdensomeness that does not exist) or may be realistic (e.g., a severely depressed person who depends heavily on his/her family for financial and emotional support). People who perceive themselves as being a burden on those around them may make statements to the effect that their suicide would be beneficial for those around them. They may say things like, “They will be better off without me” or “This is for the best.” Thwarted belonging and perceived burdensomeness make up the motivational aspect of the IPTS. When thwarted belonging and perceived burdensomeness are present, suicidal ideation will occur, but the likelihood of a fatal suicide attempt is greatly diminished if the third variable of the theory is not present. The acquired capability for lethal self-injury refers to the difficulty in committing suicide. Through constant exposure to painful situations (e.g., previous suicide attempts, self-injury, and childhood sexual abuse), some individuals habituate to the pain of self-injury and to the fear of dying. As a result of this, they are much more likely to make a lethal suicide attempt by utilizing a more effective suicide method (e.g., a firearm). This aspect of the theory helps explain the discrepancies between the fatal suicide rates of men and women. Men, according to the theory, are more likely to become habituated to pain and to the fear of death because they live more violent lives than do women. To best visualize the IPTS, picture three circles that all intersect at only one point. Each circle represents a different variable of the IPTS. Where the three circles intersect represents most fatal suicides.

Lonely at the Top In Lonely at the Top: The High Cost of Men’s Success, Joiner (2011) outlined the trajectory of men’s social lives. Beginning at a young age, men and women are not very different in the acquisition of friends. A young child sits on a school bus with another young child, and the next day they are best friends. In childhood, friendships come easily but, as men and women age, things change. Women, adapting to this change, reach out and maintain friendships,

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while men allow their friendships to atrophy. By the time a man is in his 30s, he may have virtually no friends or only a handful. These friends, when lost, are not easily replaced. Therefore, older men find themselves in the predicament of pervasive loneliness. Joiner pointed out that this trend is especially pronounced in successful men since they have allowed their social relationships to atrophy even further so that they can focus on success in their careers. Joiner noted the many detrimental effects that accompany loneliness, including a higher rate of heart problems, declines in health, and suicide. While anecdotal, many male readers of this chapter can attest to the authenticity of this argument. I myself do very little to maintain my friendships, relying on the understanding that they will be there and not bothering to strengthen them or secure new ones. My wife, on the other hand, communicates with her friends more often and works to maintain the friendships she has and works to expand her friendship pool. The majority of men, I suspect, and Joiner theorizes, are like me. They are lazy in the sense that we have a certain number of friends, sometimes gathered from when we were children, and we do little to expand that pool. New employment or a change in location may force us to acquire new friends, but the likelihood is that the friendships we already have are taken for granted, and their importance is ignored. This chapter is meant to draw attention to the importance of maintaining friendships and the role that loneliness plays in suicidal behavior. Now that we have reviewed the IPTS and Lonely at the Top, we will review some of the research on loneliness, its prevalence among men and its relationship to suicidal behavior. Following this, we will discuss ways of combating loneliness among men and the clinical implications of these findings.

Empirical Support Loneliness and Suicide Thus far we have discussed the IPTS and Lonely at the Top in terms of their theoretical perspectives. Both works stress the importance of loneliness (i.e., thwarted belonging) in understanding suicidal behavior. This section will examine what empirical literature has to say regarding the connection between loneliness and suicidal ideation and behavior. Stravynski and Boyer (2001) examined the relationship between loneliness and suicidal ideation and attempted suicide in a population-wide study conducted in Quebec in 1987. Overall, they found a strong association between variables measuring loneliness and suicidal behavior. Specifically, they found association between suicidal ideation and living alone, having no friends, and feeling alone very often. Additionally, “[t]wenty-one percent of the indi-

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viduals who have felt lonely very often reported having thought seriously about suicide, in contrast with 2.5% of those who did not” (Stravynski & Boyer, 2001, p. 35). With regard to attempted suicide, the results were similar. The researchers also examined suicidal behavior in (1) those who reported not being alone or feeling lonely, (2) those who reported being alone but not lonely, (3) those who reported being alone and felt lonely, and (4) those who reported intense loneliness, being alone, and having no friends. They found a significant increase in reports of suicidal ideation in all groups with the exception of the fourth group which did not differ significantly from the third group. Of those who reported not being lonely, less than 2 percent reported suicidal ideation, while 29 percent of those who reported intense loneliness reported suicidal ideation. For the most part, these findings held true for men and women alike. However, there was one significant gender difference and one that should be kept in mind throughout reading the remainder of this chapter. There was a stronger association between suicidal ideation and living alone in men as compared to women. The authors concluded that, “. . . married status has a better protective value for men than for women” (p. 36). Joiner and Rudd (1996) examined the interrelations between hopelessness, loneliness, and suicidal ideation in an attempt to clarify the relationship that the three share. They examined two models explaining the relationship between the three variables. The first model proposed that hopelessness acts as a mediator between loneliness and suicidal ideation. The second model viewed hopelessness as having a direct relationship to suicidal ideation and loneliness and, because of this direct relationship, there is a relationship between loneliness and suicidal ideation. The authors found support for the second model but not the first, indicating that the interrelations between the three variables are a result of the direct effect of hopelessness on both loneliness and suicidal ideation. Accordingly, this study would suggest that loneliness is not a risk factor for suicide, but rather has an indirect relationship to suicide through its relationship to hopelessness, which itself is a well-documented risk factor for suicide. Page et al. (2006) also examined hopelessness and loneliness in students from Taiwan, the Philippines and Thailand, and hypothesized that hopelessness would continue to be associated with suicide attempts after controlling for loneliness. Hopelessness was found to be strongly associated with suicide attempts. However, when loneliness was controlled, the relationship between hopelessness and attempting suicide was greatly weakened and in some cases became nonsignificant. This suggests a strong relationship between loneliness and attempted suicide. Lasgaard, Goossens, and Elklit (2011) examined the relationship between loneliness, depressive symptoms, and suicidal ideation among adolescents in

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a longitudinal study. They found that depressive symptoms increased the occurrence of loneliness over time, but loneliness did not predict depressive symptoms over time. When examined cross-sectionally, loneliness was found to predict depressive symptoms but did not predict suicidal ideation when depression was controlled. This indicated that the relationship previously found between suicidal ideation and loneliness may be a by-product of the relationship between depression and loneliness. Conner et al. (2007) examined the relationship between thwarted belonging, perceived burdensomeness, and loneliness and suicide attempts among a sample of subjects with opiate dependence. The authors found support for the role of belongingness in suicide attempts, with those reporting low belonging being at an increased risk of a suicide attempt. The role of perceived burdensomeness received partial support, suggesting its possible role in suicidal behavior. However, of interest to this chapter, loneliness was not found to predict suicide attempts. This points to the importance of belonging over loneliness measures when evaluating suicide risk. The research reviewed in this section has both supported and failed to support a relationship between loneliness and suicidal behavior. Some of the findings suggest a relationship, while others suggest that the relationship of loneliness to suicidal behavior was connected to its relationship to hopelessness, a well-documented risk factor for suicidal behavior. Regardless of whether the relationship between suicidal behavior and loneliness is a direct or indirect one, loneliness is a problem that must be dealt with in order to promote good mental health among men. The next section will review the relationship between men and loneliness.

Loneliness in Men Few studies have focused specifically on the question of whether or not men experience more loneliness or more severe loneliness than do women. Instead, findings regarding gender differences and loneliness must be drawn from the larger loneliness literature. As previously discussed, Stravynski and Boyer (2001) found a stronger association between suicidal ideation and living alone in men than in women. However, there were no gender differences in measures of loneliness. On the other hand, Wiseman, Guttfreund, and Lurie (1995) examined differences in loneliness and depression among college students who were seeking counseling. While much work regarding gender differences in loneliness has failed to find significant differences between men and women, Wiseman et al. found that men reported more loneliness than did women among those who were seeking counseling.

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Iecovich, Jacobs, and Stessman (2011) examined the relationship between loneliness and the risk of mortality in a longitudinal study examining elderly people (older than 70 years of age). They found that women reported more loneliness than did men, but that the experience of loneliness was different for men than for women. Men’s loneliness fluctuated and changed over time, usually in connection with situational factors (e.g., loss of a partner), whereas women handled these situational factors better and had more social support to fall back on to deal with their loneliness. Additionally, they found that loneliness was predictive of mortality among men, but not among women. This could potentially point to the greater impact of loneliness on men’s health than on women’s health. One potential explanation for this can be found in a study by Dykstra and de Jong Gierveld (2004) who found that men rely heavily on family support, particularly their spouses, but do not have the more general social support that women have. Could it be then that, while men and women do not differ in the amount of loneliness they experience, women have a greater abundance of social support outside the home that protects them from the negative effects of loneliness? DISCUSSION This chapter has discussed one potential risk factor for suicide among men, namely loneliness. While some evidence supports the role of loneliness in suicidal behavior, other evidence points to the significance of thwarted belonging which, while correlated with loneliness, is a more robust measure of social integration. The literature reviewed in this chapter, while far from conclusive, highlights some of the key findings relating loneliness to suicidal behavior and examines loneliness in terms of gender differences. According to Joiner (2011), loneliness is a problem that leads to poor health outcomes and increased suicide rates among men (and especially successful men). While the research reviewed has pointed to a similar trend in loneliness among men and women, men have also been hypothesized to have a greater deficit in their social support system outside the home. Without the ability to fall back upon social support outside the family unit, men are very susceptible to loneliness prompted by the loss of a family member, especially their spouse. For example, Rossow (1993) examined the relationship between the suicide rates of men and women in Norway and divorce rates, and found that divorce rates were significantly associated with male suicide rates, but not with female suicide rates.

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Implications What suicide prevention implications can be drawn from understanding the relationship between loneliness and suicide among males? There are a number of rather simple implications that can be drawn from understanding loneliness as a risk factor for suicide among men. Due to the discrepancy between men and women in the availability of social support from outside the home, men should focus on increasing their social support as they age. While a spouse and family are strong and valuable sources of support, they should not be the only source of support. One potential way of increasing social support outside the home would be to foster social activities outside the home through memberships with organizations that involve large numbers of men. For example, membership in sporting clubs or sporting leagues could lead to the development of new friendships outside the family unit. Additionally, men should focus on strengthening the relationships they do have outside the home. Time can be allotted to meet on a weekly basis with friends and to socialize. A weekly poker game or football on Sunday night might seem simple and unimportant, but this can allow men to develop and strengthen the social relationships that they do have. This time should be valued and given priority. Many might think that this is unrealistic, as their wives may not support it. However, women, who value relationships outside the home more than men, should see the necessity for this and encourage such behavior. Finally, while men have a tendency to focus on the family unit at the exclusion of social relationships, the family unit can be expanded to increase social relationships. Many people have an extended family with whom they have limited contact. By reaching out to cousins, aunts, uncles, nephews and nieces, men can make their family unit broad enough to help fulfill the missing elements in their social lives. Facebook and other social media websites, while perhaps not ideal if they are the only social connection one has, allow for a wider range of contacts with friends and family. Through these sites, men can keep in contact with family members around the country and even the world. This, while not sufficient in itself, can allow men to maintain the social relationships that might have been lost in the past as a result of a lack of contact. FINAL THOUGHTS We hope that this chapter has brought light to an important issue concerning suicide among men. Social relationships are vital to the health of an individual. Dating as far back as 1897, the noted sociologist Durkheim

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acknowledged the importance of social relationships in his book On Suicide. Durkheim’s concept of social integration called attention to the role that social relationships play in suicidal behavior. Yet, 115 years since the publication of On Suicide, the problem of loneliness among men is still relatively ignored. When Joiner (2011) published Lonely at the Top, it was one of very few works focusing on loneliness and its effects on men in relation to suicide and other health problems. As long as men continue to put aside their social relationship needs, they will continue to face the physical and mental health problems that are common in those who suffer from pervasive loneliness. We hope that those who read this chapter will take our recommendations to heart and work on improving their social relationships. Finally, we would be remiss if we did not point to the rest of this book as being important in preventing suicide among men. Loneliness is one factor that affects suicide among men and, while it is important to focus on alleviating loneliness, we must not focus on one factor to the exclusion of the other risk factors. I feel it necessary to close this chapter with words other than my own. While preparing for this chapter I researched the literature on loneliness and its relationship to suicide and, in my (albeit short) career, I have focused a good deal of my work on Joiner’s theory. However, no one is more qualified to discuss suicidal behavior than those who engaged in suicidal behavior or those who died by suicide and have left behind clues for us in diaries, letters or notes. The following passage is an excerpt from the book Eight Stories Up: An Adolescent Chooses Hope over Suicide, written by Lezine and Brent (2008), which is a diary entry written just before Lezine’s first brush with suicide while he was a college student: I think I flipped today. . . . I talked to Mom on the phone and that question, How do you feel?, came up again. How do I feel? Does she really want to know? Frustrated but goal-driven, hopeless yet motivated, alone with friends, lost but in the middle of it all, like I’ve lost all faith, yet stronger than I’ve ever been. How do I feel? What kind of question is that? I feel like a million and 15 different people live in my head, like I’m doing all I ever wanted and it’s not what I expected, like I’m not sure whether I can succeed—-resentment, envy, despair, hurt, unloved, uncared for, unfound, lonely, estranged, angry, left out, forgotten, I don’t know, pick one!!! (Lezine & Brent, 2008, pp. 1–2)

And then a little later on, but in the same entry: I went for a walk and told myself it was scary because I didn’t care much then. I walked, I looked at the ground moving randomly beneath the soles of my shoes. I walked. I came to the hill and left campus, I walked to the bridge . . .

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Suicide in Men The water trickled into the canal and the water—oh, the water—it looked so peaceful and the rail so short. “I wonder how long it would take them to find my body. I wonder who would care. It would probably make the news, it would probably even make the news back home . . . another Ivy League suicide. Tears streaked from my eyes and burned down my cheeks. Why! Nobody gives a damn and they all love not you, my friend. Fuck them all! The world can go to hell! (Lezine & Brent, 2008, p. 2)

Reading a chapter such as this, I often find myself getting lost in the scholarly mentality. I become overly focused on what information I can take out of the articles and the research I do. As a result, I lose the human element, the pain and the agony. I lose the suffering associated with suicide. For the purpose of drawing our attention back to that human element, I have ended this chapter with these two passages. They are striking in the fact that they are articulate and they are moving. The author, Lezine, discusses his feelings regarding his suicidal ideation in a heart-wrenching way. He talks about being lonely, about being “alone with friends” and discusses that, when he was considering jumping from the bridge, he felt that “nobody gives a damn.” While this chapter has discussed the relationship of loneliness to suicidal behavior from an empirical perspective, these entries highlight the role of belonging and loneliness from the perspective of someone who has walked in the shoes of the suicidal individual. REFERENCES Conner, K. R., Britton, P. C., Sworts, L. M., & Joiner, T. E., Jr. (2007). Suicide attempts among individuals with opiate dependence: The critical role of belonging. Addictive Behaviors, 32, 1395–1404. Durkheim, E. (1897). Le suicide. Paris, France: Felix Alcan. Dykstra, P. A. & de Jong Gierveld, J. (2004). Gender and marital-history differences in emotional and social loneliness among Dutch older adults. Canadian Journal on Aging, 23, 141–155. Iecovich, E., Jacobs, J. M., & Stessman, J. (2011). Loneliness, social networks, and mortality: 18 years of follow-up. International Journal of Aging & Human Development, 72, 243–263. Joiner, T. E., Jr. (2005). Why people die by suicide. Cambridge, MA: Harvard University Press. Joiner, T. E., Jr. (2011). Lonely at the top: The high cost of men’s success. New York: Palgrave Macmillan.

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Joiner, T. E., Jr. & Rudd, M. D. (1996). Disentangling the interrelations between hopelessness, loneliness, and suicidal ideation. Suicide & Life-Threatening Behavior, 26, 19–26. Lasgaard, M., Goossens, L., & Elklit, A. (2011). Loneliness, depressive symptomatology, and suicide ideation in adolescence: Cross-sectional and longitudinal analyses. Journal of Abnormal Child Psychology, 39, 137–150. Lezine, D. A., & Brent, D. (2008). Eight stories up: An adolescent chooses hope over suicide. New York: Oxford University Press. Page, R. M., Yanagishita, J., Suwanteerangkul, J., Zarco, E. P., Mei-Lee, C., & Miao, N. (2006). Hopelessness and loneliness among suicide attempters in school-based samples of Taiwanese, Philippine, and Thai adolescents. School Psychology International, 27, 583–598. Rossow, I. (1993). Suicide, alcohol, and divorce. Addiction, 88, 1659–1665. Stravynski, A. & Boyer, R. (2001). Loneliness in relation to suicide ideation and parasuicide: A population-wide study. Suicide & Life-Threatening Behavior, 31, 32–40. Wiseman, H., Guttfreund, D. G., & Lurie, I. (1995). Gender differences in loneliness and depression of university students seeking counseling. British Journal of Guidance & Counseling, 23, 231–243.

Chapter 4 DRUGS, ALCOHOL, AND SUICIDAL BEHAVIOR IN MEN JOHN F. G UNN III and DAVID LESTER They talk of my drinking, but never my thirst. Scottish proverb

n June 17, 2012, Thomas (aka Trey) Malone committed suicide by jumping from the Sunshine Skyway, a bridge located in Florida.1 He was 20 years old and had been an on-again off-again student at Amherst College. Malone had been the victim of a sexual assault and had been deeply depressed. In order to deal with this depression, or perhaps because of a comorbid substance abuse disorder, Trey drank alcohol in excess. Additionally, Malone had been arrested for hosting a party, resisting arrest and assaulting a police officer. It is likely that Malone’s suicide was fueled, in part, by alcohol. This chapter examines the role that alcohol and drug abuse play in suicidal behavior. However, it is important to keep in mind that alcohol and drug use/abuse are only part of the story. As Malone himself wrote in his suicide note:

O

These days, I’ve become more tired of remembering the past and wondering about the future. I’ve slowly watched that future collapse in on itself whether by my own actions or those of others and now I’m simply tired. My future is rubble and while below that rubble, there is still a foundation, my arms are weak and my tools are broken. My job is gone, relationships strained, and mugshot posted. Entropy is a funny thing I suppose. A house of stone may take

1. www.callmemiss.com/2012/11/14/hiding-in-plain-sight-alcohol-and-the-suicide-of-trey-malone/

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a millennia to collapse, but it will collapse. Unfortunately, it would appear that imaginary building blocks of my future were far less sturdy.2

This section will review the evidence concerning suicidal behavior and alcohol and drug use. The questions that will be asked are: (1) is alcohol use and abuse associated with suicidal behavior, (2) is drug use and abuse related to suicidal behavior, and (3) are there gender differences in the prevalence of alcohol and drug abuse? INCIDENCE OF SUICIDE IN ALCOHOL AND DRUG ABUSERS In a series of meta-analyses, Harris and Barraclough reviewed studies of suicide mortality in patients with medical and psychiatric illnesses. Harris and Barraclough (1997) presented estimates of standard mortality rates (SMRs) of those with substance use disorders: 586 for alcohol,3 1400 for heavy drinkers, 2034 for sedatives, hypnotics and anxiolytics, and 385 for heavy users of cannabis. (In contrast, the SMR for schizophrenia was 845, for major depression 2035, and for anxiety disorders 1505). Harris and Barraclough (1998) found these increased SMRs for both men and women. For example, for alcohol dependence and abuse, the SMR for suicide in men was 491 and for suicide in women 1818. For opioid abuse the SMR for men was 553 and for women 610. Inskip, Harris and Barraclough (1998) analyzed follow-up studies of patients with schizophrenia, affective disorder and alcohol dependence and estimated that the predicted proportion dead from suicide (after all the cohort had died) was 7 percent for those with alcohol dependence, 6 percent for those with affective disorder, and 4 percent for those with schizophrenia. Thus, it is clear that drug and alcohol abuse is associated with a greatly increased rate of death by suicide.

Alcohol and Suicidal Behavior Macrolevel Studies There is a relatively large body of evidence studying the association of suicidal behavior and alcohol use/abuse. For example, Pridemore and Chamlin (2006) found a positive and significant relationship between heavy drinking

2. www.goodmenproject.com/ethics-values/lead-a-good-life-everyone-trey-malones-suicide-note/# ICFM7hoUxep8iatH.99 3. Based on 641 observed suicides compared to an expected number of 109.44.

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and both suicide and homicide mortality in Russia between the years 1956 and 2002. Norstrom (1988) examined the relationship between alcohol consumption rates and suicide rates in Denmark during the period 1931 to 1980, Finland (1932 to 1980), Norway (1931 to 1980), and Sweden (1922 to 1970). He proposed that different drinking cultures of the countries would affect the relationship between alcohol consumption and suicide rates, and predicted that the relationship would be strongest in Finland, weakest in Denmark, and moderate in Sweden and Norway. However, he found that only Norway and Sweden showed a significant relationship between alcohol consumption and suicide rates. As alcohol consumption increased in Norway and Sweden, so did the suicide rate. Norstrom (1995a, p. 1466) tested the relationship between alcohol consumption and suicide rates by comparing the suicide rates of Sweden and France. France was chosen as a comparison to Sweden since the alcohol cultures of France and Sweden were quite different.4 Both countries showed a positive association between alcohol consumption and suicide rates over time, with Sweden showing a stronger association than France. Norstrom estimated that “a 1-litre increase in consumption entails a 10% increase in the suicide rate in Sweden, while the corresponding figure for France is 3–4 percent.” Next Norstrom (1995b, p. 310) examined the impact of alcohol and suicide rates in Sweden controlling for other sociological variables (including unemployment and divorce rates). While the impact of unemployment on suicide rates was evident, the impact was “substantially smaller than the alcohol effect.” Norstrom concluded that the impact of divorce on suicide, while generally supported at the individual-level, was not supported at an aggregate level, and so variables such as alcohol consumption may be much more important in determining societal suicide rates than the traditionally studied variables (such as divorce and unemployment rates).

Microlevel Studies While Norstrom was interested in investigating the relationship at a national level (that is, the suicide rates of nations), Hayward, Zubrick, and Silburn (1992) examined the relationship between alcohol consumption and suicide at a more individual level. They measured the blood alcohol levels of 515 consecutive suicides (414 males and 101 females) in Western Australia

4. France is considered to be a “wet” culture, while Sweden is a “dry” culture, meaning that in France alcohol consumption is more culturally acceptable.

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between 1986 and 1988. They found that 36 percent of the cases had a positive blood alcohol reading, indicating that while the majority of suicides were not drinking prior to their suicide, a significant proportion of suicidal acts do involve the use of alcohol. Those who had a positive blood alcohol level were more likely to be younger males who used carbon monoxide as their method of suicide and who had experienced a recent break-up in a relationship. They were also less likely to have sought professional help (perhaps linked to the alcohol use or to the fact that many of them were males). Cherpitel, Borges, and Wilcox (2004) reviewed the research on alcohol use at the time of suicidal behavior. The majority of the studies measured the proportion of completed and attempted suicides that tested positive for blood alcohol, and the percentage of alcohol positive cases was found to range from 10 percent to 69 percent for completed suicides, and 10 percent to 73 percent for attempted suicides. Alcohol may be used to increase the probability of death if medications are used for the suicidal act, or alcohol may help the suicidal individual overcome any inhibitions against going through with the act. Kettl and Bixler (1993) examined the relationship between death by suicide and alcohol in Alaska Natives. Alaskan Natives who died by suicide were found to differ from age, sex, and race-matched controls only in a history of alcohol abuse and in a history of a prior suicide attempt.

Drugs and Suicidal Behavior Felts, Chenier and Barnes (1992) investigated the relationship between substance abuse and suicidal ideation and behavior in adolescents using the Youth Risk Behavior Survey (YRBS). While all the drugs examined were associated with a history of suicide attempts, the use of cocaine or crack was the most strongly associated, followed by alcohol, marijuana, and needle drugs, respectively. Hallfors, Waller, Ford, Halpern, Brodish and Iritani (2004), using the National Longitudinal Study of Adolescent Health data from 1994–1995, evaluated the relationship between depression, suicidal ideation, and previous suicidal behavior and the effects of gender, race/ethnicity, family structure and parental education. Youths who were involved in drinking, smoking, and/ or sexual activity were significantly more likely to report depression, suicidal ideation, and past suicide attempts, but youths who were engaged in illegal drug use were the most at risk for reporting depression, suicidal ideation and previous suicide attempts. Boys were more likely than girls to engage in highrisk behaviors, but less likely to report depression, suicidal ideation, and suicide attempts.

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To study the association of cocaine use with suicide, Garlow (2002) examined completed suicides in Fulton County, Georgia from 1994–1998 and found that the majority of the suicides who used cocaine prior to their suicide were males (95%) and 51 percent were African American. Tondo et al. (1999) reviewed the literature examining the relationship between substance abuse and suicidal behavior and concluded that the association between suicidal behavior and substance abuse is generally supported, especially for alcohol, heroin, cocaine and tobacco, but that the relationship between marijuana and hallucinogens and suicidal behavior is less clear. Tondo and his colleagues also examined 504 patients with mood disorders and found that those patients with comorbid substance use disorders were more likely to report a history of serious suicide attempts. The studies reviewed above are representative of the research at large and indicate a relationship between alcohol, drug use, and suicidal behavior. Both alcohol use and abuse and drug use and abuse are significant risk factors for suicidal behavior. The question remains whether or not there are gender differences in the prevalence of alcohol and drug use/abuse.

Gender Differences in Prevalence One of the best sources for information on drug and alcohol use and abuse is the National Survey on Drug Use and Health (NSDUH). According to a NSDUH report (SAMHSA, 2004): Males are more likely to use, abuse, and be dependent on alcohol or illicit drugs than females. . . . In 2003, males aged 12 or older were twice as likely as females to be dependent on or abuse alcohol or an illicit drug in the past year...males had higher rates than females of dependence on or abuse of alcohol or an illicit drug for all age groups, with the exception of 12 to 17 year olds . . . (p. 1)

Goldstein and colleagues (2012) examined data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) and noted that the lifetime prevalence of alcohol abuse was 26.7 percent among men and 12.5 percent among women. For alcohol dependence, the percentages were 21.0 percent and 9.9 percent, respectively, for men and women. The same difference was found for drug abuse—13.9 percent for men and 6.7 percent for women—and drug dependence—4.4 percent for men and 2.5 percent for women. As can be seen by these reports, males are more at risk to report alcohol and substance use and abuse. Given the relationship between alcohol and

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drug use/abuse and suicidal behavior, this implies a greater risk of suicide among men linked to the greater prevalence of alcohol and drug use/abuse. CONCLUSIONS This chapter has reviewed some of the research investigating the relationship between alcohol and drug use and abuse and suicidal behavior. The studies indicate a significant relationship between alcohol and drug use/ abuse and suicidal behavior. It is important to keep in mind, as the case of Trey above indicates, that substance use and abuse are one risk factor, but perhaps not the driving force behind the decision to die by suicide.

Recommendations Given the relationship between substance abuse and suicidal behavior and the prevalence of substance abuse among men, therapy and suicide intervention programs should evaluate those reporting suicidal ideation or behavior for substance use and abuse. Any therapeutic progress that is made with a client who is abusing or using substances could be undone by their substance use. Additionally, those who report substance use or abuse should be regularly screened for suicide risk. Foster (2005), in an editorial for the British Medical Journal, called for a greater response regarding alcohol use disorders and suicide from the suicide prevention community. He concluded that: Global suicide prevention strategies should include a focus on alcohol use disorders in terms of prevention, brief intervention by adequately trained and supported non-specialist staff (including in primary care), availability of multidisciplinary specialist alcohol services, and aggressive treatment of comorbid depression. (Foster, 2005, p. 818)

Foster also called for greater communication and cooperation amongst government strategies that are focused on alcohol abuse and suicide prevention. By connecting these services, as well as the services for drug abuse, an environment may be created where cooperation is fostered, and a focus drawn on the relationship between these factors.

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REFERENCES Cherpitel, C. J., Borges, G. L. G., & Wilcox, H. C. (2004). Acute alcohol use and suicidal behavior: A review of the literature. Alcoholism: Clinical & Experimental Research, 28(5), 18s–28s. Felts, W. M., Chenier, T., & Barnes, R. (1992). Drug use and suicide ideation and behavior among North Carolina public school students. American Journal of Public Health, 82, 870–872. Foster, T. (2001). Dying for a drink: Global suicide prevention should focus more on alcohol use disorders. British Medical Journal, 323, 817–818. Garlow, S. J. (2002). Age, gender, and ethnicity differences in patterns of cocaine and ethanol use preceding suicide. American Journal of Psychiatry, 159, 615–619. Goldstein, R. B., Dawson, D. A., Chou, S. P., & Grant, B. F. (2012). Sex differences in prevalence and comorbidity of alcohol and drug use disorders. Journal of Studies on Alcohol & Drugs, 73, 938–950. Hallfors, D. D., Waller, M. W., Ford, C. A., Halpern, C. T., Brodish, P. H., & Iritani, B. (2004). Adolescent depression and suicide risk: Association with sex and drug behavior. American Journal of Preventative Medicine, 27, 224–230. Harris, E. C., & Barraclough, B. M. (1997). Suicide as an outcome for mental disorders: A meta-analysis. British Journal of Psychiatry, 170, 205–228. Harris, E. C., & Barraclough, B. M. (1998). Excess mortality of mental disorder. British Journal of Psychiatry, 173, 11–53. Hayward, L., Zubrick, S. R., & Silburn, S. (1992). Blood alcohol levels in suicide cases. Journal of Epidemiology & Community Health, 46, 256–260. Inskip, H. M., Harris, E. C., & Barraclough, B. M. (1998). Lifetime risk of suicide for affective disorder, alcoholism and schizophrenia. British Journal of Psychiatry, 172, 35–37. Kettl, P. & Bixler, E. O. (1993). Alcohol and suicide in Alaska Natives. American Indian & Alaska Native Mental Health Research, 5(2), 34–45. Norstrom, T. (1988). Alcohol and suicide in Scandinavia. British Journal of Addiction, 83, 553–559. Norstrom, T. (1995a). Alcohol and suicide: A comparative analysis of France and Sweden. Addiction, 90, 1463–1469. Norstrom, T. (1995b). The impact of alcohol, divorce, and unemployment on suicide: A multilevel analysis. Social Forces, 74, 293–314. Pridemore, W. A. & Chamlin, M. B. (2006). A time-series analysis of the impact of heavy drinking on homicide and suicide mortality in Russia, 1956–2002. Addiction, 101, 1719–1729. SAMHSA (Substance Abuse and Mental Health Services Administration, Office of Applied Studies). (2004). Gender differences in substance dependence and abuse. Retrieved from: http://www.samhsa.gov/data/2k4/genderDependence/gender Dependence.pdf. Tondo, L., Baldessarini, R. J., Hennen, J., Minnai, G. P., Salis, P., Scamonatti, L., & Mannu, P. (1999). Suicide attempts in major affective disorder patients with comorbid substance use disorders. Journal of Clinical Psychiatry, 60, 63–69.

Chapter 5 RISK AND PROTECTIVE FACTORS FOR MALE SUICIDE JOHN F. G UNN III and DAVID LESTER isk factors for suicide refer to those experiences and personal characteristics that increase the risk that an individual will die from suicide at some point during their life. They are long-term predictors, and many are not amenable to change. For example, men have a higher suicide rate than women, but gender is a static variable. When assessing a psychiatric patient, experiences of childhood physical and sexual abuse or loss of a parent by suicide are experiences that are a given. Other risk factors may be amenable to change. A psychiatric disorder, for example, may be ameliorated by medication and psychotherapy. In contrast to risk factors, there are also warning signs for suicide, changes in individuals in the weeks, days, and hours prior to their suicidal action. For example, it has been noted that psychiatric inpatients have been recorded by staff as showing an improvement in mood in the 24 hours prior to their suicide (Clements et al., 1985). The American Association of Suicidology has proposed a list of warning signs for suicide, captured by the mnemonic IS PATH WARM: Suicide Ideation, Substance Abuse, Purposelessness, Anger, Trapped, Hopelessness, Withdrawal, Anxiety, Recklessness, and Mood Change. Gunn, Lester and McSwain (2011) used data from the National Survey on Drug Use and Health from 2009 to see whether seven of these warning signs predicted suicidal ideation and attempted suicide in the 12 months prior to the survey (the survey has no data relevant to purposelessness, feeling trapped and mood change). Gunn and his colleagues found that aggression, hopelessness, withdrawal, drug abuse, alcohol abuse, and recklessness predicted suicidal ideation while anger and withdrawal predicted attempted suicide. In unpub-

R

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lished data, Gunn and Lester found that alcohol abuse did not play a role in predicting suicidal behavior in men, possibly because alcohol use and misuse is more common in men than in women. While many risk factors have been found to be linked empirically to suicidal behavior, what risk factors (and protective factors) are of particular importance to men? Before moving on to a discussion of differences in risk factors by gender, it is important to indicate first what risk factors have been identified for suicidal behavior. Below is a list of some of the risk factors that have been shown to have a relationship to suicidal behavior: – – – – – – – – – – – – – – – – – – –

Mental disorders (Nock, Hwang, Sampson, & Kessler, 2009) Previous suicide attempts (Beautrais, 2002) Social isolation (Stack, 1990) Aggression and violence (Gunn, Lester, & McSwain, 2011) Physical illness (Obafunwa & Busuttil, 1994) Unemployment (Platt, 1992) Family conflict (Foster, 2003) Family history of suicide (Roy & Segal, 2001) Impulsivity (Renaud et al., 2008) Incarceration (Dooley, 1990) Hopelessness (Beck, Steer, Kovacs, & Garrison, 1985) Time of year or season (Chew & McCleary, 1995) Serotonergic dysfunction (Mann et al., 2000) Agitation or sleep disturbance (Pompili et al., 2009) Childhood abuse (Beautrais, 2001) Exposure to suicide (Exeter & Boyle, 2007) Homelessness (Haw et al., 2006) Combat exposure (Kang & Bullman, 2008) Low self-esteem (Foster, 2003)

In addition to these risk factors for suicide, research has revealed a number of protective factors that, when present, lower the risk of suicide. Below is a list of some of these protective factors: – – – – –

Social support (Montross, Zisook, & Kasckow, 2005)1 Positive coping skills (Montross et al., 2005) Life satisfaction (Montross et al., 2005) Resiliency (Montross et al., 2005) Hopefulness (Kaslow et al., 2002)

1. See Chapter 3.

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– Self-efficacy (Kaslow et al., 2002) – Effectiveness in obtaining material resources (Kaslow et al., 2002) As can be seen from this partial list, many factors have been empirically linked to suicidal behavior. However, what are the differences between men and women in their experience of these risk factors, and in the relevance of these factors? GENDER DIFFERENCES IN RISK AND PROTECTIVE FACTORS

Completed Suicide Qin, Agerbo, Westergard-Nielsen, Eriksson, and Mortensen (2000) found that both Danish men and women were at risk of completed suicide if they had a history of psychiatric hospitalization. However, men were at increased risk if they were unemployed, had retired, were single, or were absent from work due to illness. Having children under two years of age was protective for women, but not for men. Skogman, Alsén and Őjehagen (2004) followed up Swedish suicide attempters and found that dying by suicide in men was predicted by making repeated suicide attempts and the use of a violent method, whereas older age and high scores on Beck’s Suicide Intent Scale (SIS) were associated with dying by suicide in women. Dumais et al. (2005) examined the role of impulsivity and aggression in suicidal behavior among men. They found that current alcohol or drug abuse/dependency and cluster B personality disorders were both independent predictors of completed suicide among men who had a major depression. Additionally, they found impulsivity and aggression were predictors, but not independently of alcohol abuse/dependency and cluster B personality disorders. Women were not included in the study and, therefore, the predictors of completed suicide for men cannot be compared with those for women.

Nonlethal Suicidal Behavior in Clinical Samples Haatainen et al. (2003) found that both men and women were likely to report greater hopelessness if they had experienced adverse childhood experiences. However, after controlling for other variables, the relevance of adverse childhood experiences for men disappeared. Men were more likely than women to report hopelessness having to do with unemployment, but

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both men and women reported hopelessness linked to having a poor subjective financial situation. Simon and colleagues (2002) found that relative to the control subjects, those who attempted impulsively (defined as those who attempted within five minutes of the decision) were more likely to be male, to report involvement in fights, and to feel hopeless. Donald, Dower, Correa-Velez, and Jones (2005) examined risk and protective factors among a clinical sample of 18–24 year-olds and found that those who left school early, experienced distress due to problems with friends or distress due to the break-up of a romantic relationship, reported tobacco use or high alcohol use, had current depressive symptoms, and had a previous diagnosis for depression were all at risk for medically serious suicide attempts. Parental divorce was found to be a risk factor for men while “distress due to problems with parents” was a risk factor for women. They found that social connectedness, problem-solving confidence and locus of control were protective factors, regardless of sex. Lizardi et al. (2007) examined the reasons for living (and for not committing suicide, a protective factor) and future suicidal behavior among depressed inpatients and found that high scores on the Reasons for Living Inventory predicted fewer future suicide attempts among women at the twoyear follow-up period, but not for men.

Nonlethal Suicidal Behavior in High School and College Samples Rich, Kirkpatrick-Smith, Bonner, and Jans (1992) examined gender differences in a number of psychosocial correlates of suicidal ideation in a large sample of high school students. They found that males reported greater loneliness and substance abuse than did females and that females reported greater suicidal ideation, depression, and reasons for living (this last variable is a protective factor). Additionally, they found that females reported greater fear of death and injury associated with suicidal ideation wheras males reported greater fear of social disapproval. The authors hypothesized that this fear of social disapproval, higher levels of anger and impulsivity, and less help-seeking behavior among males could explain the gender differences in suicide rates. However, the predictors of suicidal ideation were identical for boys and girls, although the size of the regression coefficients in the linear regressions differed in magnitude. Borowky, Ireland, and Resnick (2001) used the National Longitudinal Study of Adolescent Health to examine risk and protective factors among adolescent girls and boys. They found that previous suicide attempts, violence victimization and perpetration, alcohol use, marijuana use and school

Risk and Protective Factors for Male Suicide

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problems were risk factors for attempting suicide for both boys and girls (and for all races). However, they found that somatic symptoms, attempted and completed suicide in one’s friends, other illicit drug use, and a history of mental health treatment were predictive of suicide attempts in black, Hispanic and white girls. Additionally, carrying a weapon at school and samesex romantic attraction was predictive of suicide attempts for boys of all ethnicities. Borowsky et al. found that perceived parent and family connectedness was protective for black, Hispanic, and white boys and girls. Nonetheless, emotional well-being was a protective factor only for girls, and high grade point average was a protective factor only for boys. Fleming, Merry, Robinson, Denny, and Watson (2007) found no difference in the risk factors for attempting suicide for 9–13 year-old boys and girls. Depressive symptoms, alcohol abuse, having a friend or family member attempt suicide, family violence, and nonheterosexual attractions were all independently associated with the risk of suicide for both sexes. Fleming et al. identified no sex differences in protective factors. Parents caring, other family members caring, teachers being fair, and feeling safe at school all lowered suicide risk for both boys and girls. Gould, Velting, Kleinman, Lucas, Thomas, and Chung (2004) examined attitudes to coping and help-seeking in high school students in regard to suicidal ideation and behavior. They found that boys were more likely to report maladaptive coping strategies, such as using drugs and alcohol, handling the problem by themselves, and keeping one’s feelings to oneself. Stephenson, Pena-Shaff, and Quirk (2006) examined suicide ideation in a sample of college students to determine what effect gender had on risk factors. They found that recent hopelessness and depression, less frequent alcohol consumption and being a victim of a sexual assault were predictive of suicide ideation in the women in the sample, while recent hopelessness and depression and being the victim of a physical assault was predictive of suicide ideation in men. Anestis, Bender, Selby, Ribeiro, and Joiner (2011) examined gender differences in relation to the acquired capability for suicide (a component of the Interpersonal Theory of Suicide which is meant to capture the ability to inflict pain on oneself in the suicidal act) using a sample of undergraduate students. They found that college age males had higher levels of the acquired capability than did college-age women. Lamis and Lester (2013) compared male and female university students and found that the women had higher scores on a measure of depression, but lower scores on measures of alcohol-related problems, and thwarted belongingness (that is, problems in their interpersonal relationships). The women scored higher on reasons for living and for social support from friends and

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significant others. The predictors of suicidal ideation differed for the men and women. For the men, suicidal ideation was predicted by scores for hopelessness, perceived burdensomeness, alcohol-related problems, reasons for living and social support from the family. For the women, suicidal ideation was predicted by scores for depression, hopelessness, perceived burdensomeness and reasons for living. The differences lend support to the proposal that depression in men manifests itself with different symptoms than depression in women (see Chapter 2) since Lamis and Lester noted that, whereas scores on a measure of depression predicted suicidal in women, these scores did not do so for men. They suggested that men suppress their depression with alcohol use, and this notion was supported by the fact that alcohol-related problems predicted suicidal ideation for men, but not for women. Interestingly, men and women at this university did not differ in the presence of suicidal ideation even though the women obtained higher depression scores. In this study, Lamis and Lester found that men scored lower on measures of reasons for living and social support from friends and significant others than did women, but higher reasons for living scores predicted less suicidal ideation for both men and women. Social support played a role in predicting suicidal ideation only for the men, but only for support from their families (not from friends or significant others) and, in a counterintuitive manner, more family support predicted more suicidal ideation. This result requires replication before being considered reliable. Lamis and Lester (2012) also explored what predicted scores on a measure of reasons for living in male undergraduate students. They found that scores on a measure of reasons for living were predicted by scores for hopelessness, depression, and alcohol-related problems, as did social support from family and friends (but not from significant others). As in their study comparing male and female undergraduates, Lamis and Lester stressed the need for clinicians to focus on atypical symptoms of depression when evaluating men, the so-called male depression (see Chapter 2).

Older Adults Range and Stringer (1996) examined the relationship between coping skills and reasons for living among older adults. They found that women, on average, scored higher than men for their reasons for living scores. However, there was no gender difference in relation to coping skills.

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57

CONCLUSIONS This chapter set out to review the existing literature on gender differences in relation to a number of risk factors and protective factors. Men die by suicide at a greater rate than do women, even though women attempt suicide more. Several of the risk factors discussed above have been found to be present more often in men than in women (e.g., the acquired capability for suicide) while other factors are thought to have a greater impact on suicide among men (e.g., unemployment). Additionally, some protective factors that lower the risk of suicide are not protective for men (e.g., reasons for living) or are not utilized by them (e.g., help-seeking behavior). While the current literature does not have a clear answer to what risk factors and protective factors are affected by gender, the existence of gender differences cannot be ignored. Further research is needed to get a clearer picture of the gender differences in risk factors and protective factors. Additionally, clinicians should be aware of what risk factors are particularly important to their clients based on gender. One theory of suicide, the Interpersonal Theory of Suicide, focuses on social support (a protective factor) as being of vital importance in preventing suicide among men and women. Given the importance of protective factors in lowering suicide risk, much more work is needed to investigate what protective factors are effective in the treatment and prevention of suicide. The research by Lamis and Lester indicates that clinicians should be sensitive to and assess atypical symptoms of depression in men (such as alcohol use and abuse). The sex difference in risk factors is compounded by the sex difference in seeking help. In their literature review on gender differences in help-seeking behavior, Galdas, Cheater, and Marshall (2005) reviewed research that indicates men delay help-seeking when they become ill (e.g., depression, physical illness, substance abuse) primarily because of “masculine” beliefs and attitudes, and their attempts to conform to a traditional masculine role. REFERENCES Anestis, M. D., Bender, T. W., Selby, E. A., Ribeiro, J. D., & Joiner, T. E., Jr. (2011). Sex and emotion in the acquired capability for suicide. Archives of Suicide Research, 15, 172–182. Beautrais, A. L. (2001). Child and young adolescent suicide in New Zealand. Australian & New Zealand Journal of Psychiatry, 35, 647–653. Beautrais, A. L. (2002). A case control study of suicide and attempted suicide in older adults. Suicide & Life-Threatening Behavior, 32, 1–9.

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Beck, A. T., Steer, R. A., Kovacs, M., & Garrison, B. (1985). Hopelessness and eventual suicide: A 10-year prospective study of patients hospitalized with suicidal ideation. American Journal of Psychiatry, 142, 559–563. Borowsky, I. W., Ireland, M., & Resnick, M. D. (2001). Adolescent suicide attempts: Risks and protectors. Pediatrics, 107, 485–493. Chew, K. S., & McCleary, R. (1995). The spring peak in suicides: A cross-national analysis. Social Sciences & Medicine, 40, 223–230. Clements, C., Bonacci, D., Yerevanian, B., Privitera, M., & Kiehne, L. (1985). Assessment of suicide risk in patients with personality disorder and major affective disorder. Quality Review Bulletin, 11(5), 150–154. Dooley, E. (1990). Prison suicide in England and Wales, 1972–1987. British Journal of Psychiatry, 156, 40–45. Donald, M., Dower, J., Correa-Velez, I., & Jones, M. (2005). Risk and protective factors for medically serious suicide attempts: A comparison of hospital-based with population-based samples of young adults. Australian & New Zealand Journal of Psychiatry, 40, 87–96. Dumais, A., Lesage, A. D., Alda, M., Rouleau, G., Dumont, M., Chawky, N., Roy, M., & Turecki, G. (2005). Risk factors for suicide completion in major depression: A case-control study of impulsive and aggressive behaviors in men. American Journal of Psychiatry, 162, 2116–2124. Exeter, D. J., & Boyle, P. J. (2007). Does young adult suicide cluster geographically in Scotland? Journal of Epidemiology & Community Health, 61, 731–736. Fleming, T. M., Merry, S. N., Robinson, E. M., Denny, S. J., & Watson, P. D. (2007). Self-reported suicide attempts and associated risk and protective factors among secondary school students in New Zealand. Australian & New Zealand Journal of Psychiatry, 41, 213–221. Foster, T. (2003). Suicide note themes and suicide prevention. International Journal of Psychiatry in Medicine, 33, 323–331. Galdas, P. M., Cheater, F., & Marshall, P. (2005). Men and health help-seeking behaviour: Literature review. Journal of Advanced Nursing, 49, 616–623. Gould, M. S., Velting, D., Kleinman, M., Lucas, C., Thomas, J. G., & Chung, M. (2004). Teenagers’ attitudes about coping strategies and help-seeking behavior for suicidality. Journal of the American Academy of Child & Adolescent Psychiatry, 43, 1124–1133. Gunn, J. F., III., Lester, D., & McSwain, S. (2011). Testing the warning signs of suicidal behavior among suicide ideators using the 2009 National Survey on Drug Use and Health. International Journal of Emergency Mental Health, 13, 147–154. Haatainen, K. M., Tanskanen, A., Kylma, J., Honkalampi, K., Koivumaa-Honkanen, H., Hintikka, J., Antikainen, R., & Viinamaki, H. (2003). Gender differences in the association of adult hopelessness with adverse childhood experiences. Social Psychiatry & Psychiatric Epidemiology, 38, 12–17. Haw, C., Hawton, K., & Casey, D. (2006). Deliberate self-harm patients of no fixed abode: A study of characteristics and subsequent deaths in patients presenting to a general hospital. Social Psychiatry & Psychiatric Epidemiology, 41, 918–925.

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Kang, H. K., & Bullman, T. A. (2008). Risk of suicide among U.S. veterans after returning from the Iraq or Afghanistan war zones. Journal of the American Medical Association, 300, 652–653. Kaslow, N. J., Thompson, M. P., Okun, A., Price, A., Young, S., Bender, M., Wyckoff, S., Twomey, H., & Goldin, J. (2002). Risk and protective factors for suicidal behavior in abused African American women. Journal of Consulting & Clinical Psychology, 70, 311–319. Lamis, D. A., & Lester, D. (2012). Risk and protective factors for reasons for living in college men. International Journal of Men’s Health, 11, 189–201. Lamis, D. A., & Lester, D. (2013). Gender differences in risk and protective factors for suicidal ideation among college students. Journal of College Student Psychotherapy, 27, 62–77. Lizardi, D., Currier, D., Galfalvy, H., Sher, L., Burke, A., Mann, J., & Oquendo, M. (2007). Perceived reasons for living at index hospitalization and future suicide attempt. Journal of Nervous & Mental Disease, 195, 451–455. Mann, J. J., Huang, Y. Y., Underwood, M. D., Kassir, S. A., Oppenheim, S., Kelly, T. M., & Arango, V. (2000). A serotonin transporter gene promoter polymorphism (5-HTTLPR) and prefrontal cortical binding in major depression and suicide. Archives of General Psychiatry 57, 729–738. Montross, L. P., Zisook, S., & Kasckow, J. (2005). Suicide among patients with schizophrenia: A consideration of risk and protective factors. Annals of Clinical Psychiatry, 17, 173–182. Nock, M. K., Hwang, I., Sampson, N. A., & Kessler, R. C. (2009). Mental disorders, comorbidity and suicidal behavior: Results from the National Comorbidity Survey Replication. Molecular Psychiatry, 15, 868–876. Obafunwa, J. O., & Busuttil, A. (1994). Clinical contact preceding suicide. Postgraduate Medical Journal, 70, 428–432. Platt, S. (1992). Suicide and unemployment in Italy. Social Science & Medicine, 34, 1191–1201. Pompili, M., Lester, D., Grispini, A., Innamorati, M., Calandro, F., Iliceto, P., & Girardi, P. (2009). Completed suicide in schizophrenia: Evidence from a case-control study. Psychiatry Research, 167, 251–257. Qin, P., Agerbo, E., Westergard-Nielsen, N., Eriksson, T., & Mortensen, P. B. (2000). Gender differences in risk factors for suicide in Denmark. British Journal of Psychiatry, 177, 546–550. Range, L. M., & Stringer, T. A. (1996). Reasons for living and coping abilities among older adults. International Journal of Aging & Human Development, 43(1), 1–5. Renaud, J., Berlim, M. T., McGirr, A., Tousignant, M., & Turecki, G. (2008). Current psychiatric morbidity, aggression/impulsivity, and personality dimensions in child and adolescent suicide: A case-control study. Journal of Affective Disorders, 105, 221–228. Rich, A. R., Kirkpatrick-Smith, J., Bonner, R. L., & Jans, F. (1992). Gender differences in the psychosocial correlates of suicidal ideation among adolescents. Suicide & Life-Threatening Behavior, 22, 364–373.

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Roy, A., & Segal, N. L. (2001). Suicidal behavior in twins: A replication. Journal of Affective Disorders, 66, 71–74. Simon, T. R., Swann, A. C., Powell, K. E., Potter, L. B., Kresnow, M., & O’Carroll, P. W. (2002). Characteristics of impulsive suicide attempts and attempters. Suicide & Life-Threatening Behavior, 32, 49–59. Skogman, K., Alsen, M., & Őjehagen, A. (2004). Sex differences in risk factors for suicide after attempted suicide: A follow-up study of 1052 suicide attempters. Social Psychiatry and Psychiatric Epidemiology, 39, 113–120. Stack, S. (1990). New micro-level data on the impact of divorce on suicide, 1959–1980: A test of two theories. Journal of Marriage & the Family, 52, 119–127. Stephenson, H., Pena-Shaff, J., & Quirk, P. (2006). Predictors of college student suicidal ideation: Gender differences. College Student Journal, 40, 109–117.

Chapter 6 THE ROLE OF TESTOSTERONE DAVID LESTER n obvious way in which men differ from women is in the levels of circulating sex hormones. Women have higher levels of estrogen, and it has been documented that women’s suicidal behavior varies in frequency over the menstrual cycle (Lester, 1990). Indeed, the “female” hormones may also affect suicidal behavior in men. Martin et al. (1997) found that adolescent boys who attempted suicide in the past, had suicidal ideation in the past and had current suicidal ideation had higher levels of progesterone (a hormone that prepares the uterus for pregnancy) in their blood. This association was not found for adolescent girls. However, the more likely candidate for having an influence on suicide in men is the male hormone, testosterone. In a study of salivary testosterone levels, Gouchie and Kimura (1991) found a level of 175 pg/ml for men and 51 for women. There is evidence that individual levels of testosterone have in part a genetic basis (Meikle et al., 1987). There have been many studies on whether testosterone affects human behaviors. For example, Gouchie and Kimura (1991) proposed that testosterone levels may impact right-hemisphere functioning. However, two possible correlates of testosterone levels may impact suicidal behavior.

A

TESTOSTERONE, DEPRESSION AND VIOLENCE There is no evidence that testosterone levels have any impact on depression. Blood serum testosterone levels1 do not seem to be associated with depression in either adolescent boys or girls (Paikoff et al., 1991; Susman et 1. Blood blood serum is blood plasma minus both the cells and the clotting factors.

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al., 1991). Nor are blood serum testosterone levels associated with serotonin, the neurotransmitter thought to be responsible for depression (Gonzales et al., 1989). However, Dabbs et al. (1990) reported an association between affective disorders (as assessed by symptoms and by MMPI scores) and blood serum testosterone levels in men. Markianos et al. (1991) found that men treated with a monoamine oxidase inhibitor (moclobemide) showed a reduced level of depression scores, an increase in blood plasma levels of testosterone, and a decrease in urinary levels of 5-HIAA (the breakdown product of serotonin). Thus, there may be an association between testosterone levels and depression. More clearly documented, however, is an association between testosterone levels and aggression. Salivary testosterone levels are associated with violence involved in the crimes committed by juvenile delinquents (Dabbs et al., 1991), with violent crimes committed by adult males (Dabbs et al., 1987), and even with unprovoked violence in women offenders (Dabs et al., 1988).

Suicide as an Aggressive Behavior It has been common in the past to view suicidal behavior as an outcome, or even a symptom, of depression. Some inventories to measure depression often have an item on suicidal behavior, past and current, for example, the Beck Depression Inventory (Beck et al., 1961). However, suicidal behavior has also been conceptualized as an aggressive behavior to be contrasted with outward directed aggression such as murder (Henry & Short, 1954). Research has linked serotonin, not only to depression, but also to habitually violent and impulsive aggression (Molcho et al., 1991; Virkkunen, 1990). This led Lester (1993) to propose that, because of their higher levels of testosterone, men would have higher rates of completed suicide than women (which is a well-known fact—see Chapter 1), and also that men would have higher rates of violent suicide (that is, using firearms, hanging, jumping, etc.) than women, but not necessarily higher rates of nonviolent suicide (that is, using the ingestion of solid, liquid and gaseous substances). Lester collected data on rates of violent and nonviolent suicide by men and women in 25 nations. The rates per 100,000 per year are shown in Table 6-1. It can be seen that the male/female ratio of the suicide rates by nonviolent methods was only 1.35, but for violent methods the ratio was 2.97. The major difference in suicide rates is accounted for by the higher rate of violent suicide in men. Värnik et al. (2011) confirmed this by showing that in 16 European countries the suicide rate using poisoning by medications and drugs was the same for men and women, while the suicide rate by other methods was much higher in men. The ratios of male/female suicide rates were 1.1 for poisoning by

63

The Role of Testosterone Table 6.1. SUICIDE RATES BY GENDER, 1980. Violent Methods

Nonviolent Methods

Male

Females

Male

Females

Australia Austria Belgium Brazil Canada Denmark England & Wales Finland France Hungary Ireland Italy Japan Netherlands New Zealand Norway Poland Scotland Spain Sweden Switzerland Turkey United States Venezuela West Germany

10.70 31.62 23.83 3.86 16.41 25.07 6.35 34.66 26.23 49.93 6.20 9.28 19.07 11.49 10.03 13.86 19.69 8.18 6.38 19.78 28.76 1.45 15.91 7.22 21.01

2.46 10.56 10.91 1.36 3.37 10.71 2.85 7.17 8.42 13.57 2.31 3.77 10.86 5.54 4.22 3.88 4.15 2.89 1.89 6.67 10.70 1.33 3.35 1.22 8.76

5.67 6.17 4.50 0.76 4.85 16.04 4.56 6.97 2.85 14.51 2.16 0.97 4.10 2.48 4.53 4.39 1.64 4.67 0.35 7.75 7.42 0.40 2.72 0.75 7.43

3.08 4.45 5.09 0.61 3.42 11.60 3.78 3.52 2.65 12.97 2.01 0.86 2.21 2.54 2.94 2.76 1.30 4.46 0.29 4.64 4.37 0.15 2.11 1.17 5.30

Mean Standard deviation

17.00 11.33

5.72 3.78

4.75 3.96

3.53 3.03

medication and drugs, 3.6 for poisoning by other substances, and 3.9 for all other methods. An indirect test of this hypothesis was carried out by Zhang (2000). It became evident in the 1990s that women in China had a higher suicide rate than men, an anomaly found in no other country (He & Lester, 1997). Zhang noted that, in general, men outperform women in athletic events, and this is a result, in part, of their testosterone levels. Therefore, Zhang used athletic performance of Chinese men and women to see, indirectly, whether Chinese men perform up to the male standard found elsewhere in the world. He compared national records for American and Chinese athletes in track and field

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events and in swimming. American men outperformed women in all of the 29 events studied, while Chinese men outperformed women in 28 of the 29 events (the record for the shot put was higher for Chinese women than for Chinese men). On average, the gender difference was less for Chinese athletes than for American athletes: for field events 3.21 versus 5.51 meters, for track events 29.58 versus 54.01 seconds and for swimming 10.10 versus 15.25 seconds). Zhang concluded that American men perform much better than American women in these events, but Chinese men perform only a little better than Chinese women in these events. Of course, gender roles and behavior have social and cultural bases, but Zhang’s results indicate that it would of interest to study differences in hormonal levels of testosterone in Chinese men and women as compared to men and women in other nations. There have been some studies that have explored the levels of testosterone in attempted suicides, and the results of these studies are reviewed in the following section.

Testosterone in Attempted Suicides Blood Plasma Testosterone Tripodianakis et al. (2007) studied 80 men admitted after a suicide attempt and 56 normal male volunteers. The attempters had significantly lower testosterone blood plasma levels, with the violent attempters having the lowest levels. The difference was significant for the attempters diagnosed as schizophrenic, marginally for patients diagnosed with major depression, but not significant for patients diagnosed with an adjustment disorder or a personality disorder. The attempters diagnosed with schizophrenia had lower testosterone levels than hospitalized schizophrenics. Repeat attempters did not differ in testosterone levels from one-time attempters. Perez-Rodriguez et al. (2011) studied 112 men who had attempted suicide and healthy controls. The blood plasma levels of testosterone did not differ between the two groups, and the level did not differ in those attempters using violent versus nonviolent methods. This study controlled for age and the time lapse between the suicide attempt and the blood sampling. However, the lethality of the attempt was associated with testosterone levels, but in a confusing way—the association was negative for blood drawn between 2 p.m. and 6 p.m. and positive for blood drawn between 6 p.m. and 6 a.m. The authors made no attempt to explain this result! Sher et al. (2012) studied 16 men and 51 women with bipolar disorder and at least one prior suicide attempt. The level of blood plasma testosterone was positively associated with the number of manic episodes and the number of

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past suicide attempts, but not with scores on the Beck Suicidal Ideation Scale, the Reasons for Living Scale, or the maximum lethality of the suicide attempts. These results held after controlling for the sex of the patients (by means of partial correlation coefficients), but the report is flawed by the failure to analyze the data separately for the men and for the women. Markianos et al. (2009) compared 15 men who attempted suicide by jumping, 18 men who fell from a height accidentally, and 40 healthy controls. Blood plasma levels of testosterone were lower in the men with suicidal and accidental falls than in the controls, and the levels in the suicide attempters were almost significantly lower than the levels in the accidental group (p = 0.065). The levels in the attempters with schizophrenia did not differ from the levels in the attempters with depression. Giotakos et al. (2003) compared rapists with normal men and found no differences between the two groups in a measure of suicidal risk, but the rapists had higher levels of blood plasma testosterone. In a multiple regression analysis, however, testosterone levels did not predict the suicide risk score.

Blood Serum Testosterone Roland, Morris and Zelhart (1986) found that male suicides had significantly higher blood serum levels of testosterone (immediately upon reception at the morgue) compared to men dying suddenly of other causes, even after controlling for the age of the men. Bergman and Brismar (1994) studied blood serum testosterone in 49 male alcoholics. Thirteen (27%) had a history of attempting suicide at least once. Thirty-five percent admitted to having abused someone at some time. Attempting suicide and abusing others were significantly associated. However, testosterone levels were not associated with a history of attempting suicide at least once, or with making three or more attempts. The repeated attempters did have lower levels of dehydroepiandrosterone sulfate (DHEAS)—an adrenocortical hormone under the direct influence of the adrenocorticotrophic hormone ACTH. Butterfield et al. (2005) studied 130 men with post-traumatic stress disorder. Those who had attempted suicide in the prior six months did not differ from those without such a history in testosterone (or androstenedione—a steroid hormone) but did have higher levels of DHEA (dehyrdoepiandrosterone—a steroid hormone) and estradiol (a female sex hormone). Clearly, more studies of completed suicides, rather than attempted suicides, are needed to confirm the results of Roland et al. (1986).

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Cerebrospinal Fluid Levels of Testosterone Gustavsson et al. (2003) examined the cerebrospinal fluid (CSF) concentration of testosterone in 43 male suicide attempters admitted to an emergency department, but did not use a control group. Within this sample, the testosterone levels were not associated with using a violent method for the attempt, with being a repeated attempter or with CFS levels of 5-HIAA, the breakdown product of serotonin. Coccaro et al. (2007) studied 31 men with a variety of personality disorders and found that the CSF level of testosterone was not associated with a past history of a suicide attempt.

Conclusion Five of these studies found no association between testosterone levels and suicidal behavior, two found evidence for a lower level, and one possibly for a higher level. The results, therefore, do not support the existence of an association between testosterone levels in men and attempted suicide.

Mechanisms There are several possible mechanisms that have been proposed as mediators for a possible association between testosterone levels and suicidal behavior, if such an association existed. Depressed men may have lower blood serum testosterone levels (Ebinger et al., 2009), and so the association may result from the association of testosterone and depression. In laboratory experiments, Schipper (2012) found that salivary testosterone levels in men were negatively associated with risk aversion, and suicidal behavior can be conceptualized as a risk-taking behavior. If testosterone does have an impact on suicidal behavior, it may be a result of an interaction between testosterone and the hypothalamic-pituitary-adrenal axis (Markianos et al., 2009),2 a set of cortical and other structures that has been suggested as playing a role in suicidal behavior. The stress response, mental and physical, can lower testosterone levels (Zitzmann & Nieschlag, 2001), and suicidal individuals are presumably under stress. Finally, testosterone has an impact on both perinatal and postnatal stages of development (Berenbaum, 1999), and so the stage at which testosterone may impact suicidal behavior is unknown at the present time.

2. Or possibly the hypothalamus-pituitary-gonadal axis.

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DISCUSSION Given that most of the studies reviewed above found little evidence to link testosterone with suicidal behavior, it seems rather premature to speculate on the mechanism by which testosterone may impact suicide. However, the research reviewed above is quite poor. First, all of the studies were of attempted suicides. Attempted suicide is engaged in more often by women than by men. It is completed suicide that is engaged in more often by men than by women. Therefore, research should focus on completed suicides. To be sure, studies of completed suicides will be more difficult than those of attempted suicides. Attempted suicides arrive at the emergency department and are available for blood (or CSF) sampling. Completed suicides may not be discovered immediately, and so testosterone levels may not be obtainable close to the time of the suicidal action. However, many suicides are discovered immediately and do not die immediately. They are taken to hospitals (where they die), and so testosterone levels could be measured. They may die at the scene or in the ambulance and taken to the morgue, but their testosterone levels could be measured as soon as they arrive. Of course, this is more difficult than studying attempted suicides in an emergency department, but good research is not always easy to carry out. However, even if one restricts our research to attempted suicide, Lester et al. (1975, 1979) proposed that, if a researcher wants to extrapolate from attempted suicide to completed suicide, it is necessary to divide the group of attempted suicides by suicidal intent into at least three groups of suicidal intent, and then look for monotonic (linear) trends. If, for example, hopelessness scores increase monotonically from the group with the lowest intent to the group with the highest intent, then one can infer that completed suicides (who obviously have the highest intent) might have even higher hopelessness (or at least as high as the attempters with the highest intent). This strategy has not been employed by the researchers reviewed in this chapter and, indeed, their sample sizes were often too small for this to be done meaningfully even had they thought of it. Sher (2012, 2013) reviewed the literature on the association between testosterone and suicidal behavior (and included research on the association between steroids and suicidal behavior) and concluded that low testosterone levels may be associated with suicidal behavior in older men while high testosterone levels may be related to suicidal behavior in adolescents and young adults. Sher proposed four possible explanations for these associations: (1) there may be a direct effect of testosterone on suicidal behavior via particular brain mechanisms, (2) testosterone may have an impact on aggression which in turn impacts suicidal behavior, (3) testosterone may affect

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mood (for example, depression) which may then affect suicidal behavior, and (4) testosterone may affect cognitive processes which may make suicidal behavior more likely. With regard to this last possibility, Thilers, MacDonald and Herlitz (2006) found that elderly men with low testosterone levels performed poorly on tests of cognitive function,3 and cognitive impairment in elderly men may increase their suicide risk. Thus, at the present time, it remains unknown whether or not testosterone has an influence on suicide in men, but it remains an interesting possibility. REFERENCES Beck, A. T., Ward, C., Mendelson, M., Mock, J., & Erbaugh, J. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, 561–571. Berenbaum, S. A. (1999). Effects of earlyandrogen on sex-type activities and interests in adolescents with congenital adrenal hyperplasia. Hormones & Behavior, 35, 102–110. Bergman, B., & Brismar, B. (1994). Hormone levels and personality. Alcoholism: Clinical & Experimental Research, 18, 311–316. Butterfield, M. I., Stechuchak, K. M., Connor, K. M., Davidson, J. R. T., Wang, C., MacKuen, C. L., Pearlstein, A. M., & Marx, C. E. (2005). Neuroactive steroids and suicidality in post-traumatic stress disorder. American Journal of Psychiatriy, 162, 380–382. Coccaro, E. F., Beresford, B., Minar, P., Kaskow, J., & Geracioti, T. (2007). CSF testosterone. Journal of Psychiatric Research, 41, 488–492. Dabbs, J. M., Frady, R. L., Carr, T. S., & Besch, N. F. (1987). Saliva testosterone and criminal violence in young adult prison inmates. Psychosomatic Medicine, 49, 174–182. Dabbs, J. M., Hopper, C. H., & Jurkovic, G. J. (1990). Testosterone and personality among college students and military veterans. Personality & Individual Differences, 11, 1263–1269. Dabbs, J. M., Jurkovic, G. J., & Frady, R. L. (1991). Salivary testosterone and cortisol level among late adolescent male offenders. Journal of Abnormal Child Psychology, 19, 469–478. Dabbs, J. M., Ruback, R. B., Frady, R. L., Hopper, C. H., & Sgoutas, D. S. (1988). Saliva testosterone and criminal violence among women. Personality & Individual Differences, 9, 269–275. Ebinger, M., Sievers, C., Ivan, D., Schneider, H. J., & Stalla, G. K. (2009). Is there a neuroendocrinological rationale for testosterone as a therapeutic option in depression? Journal of Psychopharmacology, 23, 841–853. Giotakos, O., Markianos, M., Vaidakis, N., & Christodoulou, G. N. (2003). Aggression, impulsivity, blood plasma sex hormones, and biogenic amine turnover in a forensic population of rapists. Journal of Sex & Marital Therapy, 29, 215–225. 3. Verbal fluency, semantic and episodic memory and visuospatial abilities.

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Gonzales, G. F., Garcia-Hjarles, M. A., Napuri, R., Coyotupa, J., & Guerra-Garcia, R. (1989). Blood serotinin blood serum levels and male infertility. Archives of Andrology, 22, 85–89. Gouchie, C., & Kimura, D. (1991). The relationship between testosterone levels and cognitive ability patterns. Psychoneuroendocrinology, 16, 323–334. Gustavsson, G., Traskman-Benz, L., Higley, J. D., & Westrin, A. (2003). CSF testosterone in 43 male suicide attempters. European Neuropsychopharmcacology, 13, 105– 109. He, Z., & Lester, D. (1997). The gender difference in Chinese suicide rates. Archives of Suicide Research, 3, 81–89. Henry, A. F., & Short, J. F. (1954). Suicide and homicide. New York: Free Press. Lester, D. (1990). Suicide and the menstrual cycle. Medical Hypotheses, 31, 197-200. Lester, D. (1993). Testosterone and suicide. Personality & Individual Differences, 15, 347–348. Lester, D., Beck, A. T., & Mitchell, B. (1979). Extrapolation from attempted suicides to completed suicides: A test. Journal of Abnormal Psychology, 88, 78–80. Lester, D., Beck, A. T., & Trexler, L. (1975). Extrapolation from attempted suicides to completed suicides. Journal of Abnormal Psychology, 84, 563–566. Markianos, M., Alevizos, V., & Stefanis, C. (1991). Blood plasma sex hormones and urinary biogenic amine metabolites during treatment of male depressed patients with the monoamine oxidase inhibitor moclobemide. Neuroendocrinology Letters, 13, 49–55. Markianos, M., Tripodianakis, J., Istikoglou, C., Rouvali, O., Christopoulos, M., Papageorgopoulos, P., & Seretis, A. (2009). Suicide attempt by jumping: A study of gonadal axis hormones in male suicide attempters versus men who fell by accident. Psychiatry Research, 170, 82–85. Martin, C. A., Mainous, A. G., Mainous, R. O., Oler, M. J., Curry, T., & Vore, M. (1997). Progesterone and adolescent suicidality. Biological Psychiatry, 42, 956–958. Meikle, A. W. D., Bishop, T., Stringham, J. D., & West, D. W. (1987). Quantitative genetic and nongenetic factors that determine blood plasma sex steroid variation in normal male twins. Metabolism, 35, 1090–1095. Molcho, A., Stanley, B., & Stanley, M. (1991). Biological studies and markers in suicide and attempted suicide. International Clinical Psychopharmacology, 6, 77–92. Paikoff, R. L., Brooks-Gunn, J., & Warren, M. P. (1991). Effect of girls’ hormonal status on depressive and aggressive symtpoms over the course of one year. Journal of Youth & Adolescence, 20, 191–215. Perez-Rodriguez, M. M., Lopez-Castroman, J., Martinez-Vigo, M., Diaz-Sastre, C., Ceverino, A., Nunez-Beltran, A., Sais-Ruiz, J., de Leon, J., & Baca-Garcia, E. (2011). Lack of association between testosterone and suicide attempts. Neuropsychobiology, 63, 125–130. Roland, B. C., Morris, J. I., & Zelhart, P. F. (1986). Proposed relation of testerone levels to male suicides and sudden deaths. Psychological Reports, 59, 100–102. Schipper, B. (2012). Sex hormones and choice under risk. Unpublished working paper, University of California, Davis.

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Sher, L. (2012). Testosterone and suicidal behavior. Expert Review of Neurotherapeutics, 12, 257–259. Sher, L. (2013). Low testosterone levels may be associated with suicidal behavior in older men while high testosterone levels may be related to suicidal behavior in adolescents and young adults. International Journal of Adolescent Mental Health, 25, 263–268. Sher, L., Grunebaum, M. F., Sullivan, G. M., Burke, A. K., Cooper, T. B., Mann, J. J., & Oquendo, M. A. (2012). Testosterone levels of suicide attempters with bipolar disorder. Journal of Psychiatric Research, 46, 1267–1271. Susman, E. J., Dorn, L. D., & Chrousos, G. P. (1991). Negative affect and hormonal levels in young adolescents. Journal of Youth & Adolescence, 20, 167–190. Thilers, P. P., MacDonald, S. W., & Herlitz, A. (2006). The association between endogenous free testosterone and cognitive performance. Psychoneuroendocrinology, 31, 565–576. Tripodianakis, J., Markianos, M., Rouvali, O., & Istikoglou, C. (2007). Gonadal axis hormones in psychiatric male patients after a suicide attempt. European Archives of Psychiatry & Clinical Neurosciences, 257, 135–139. Värnik, A., Sisak, M., Värnik, P., Wu, J. et al. (2011). Drug suicide. BMC Public Health, 11, #61. Virkkunen, M. (1990). Biochemical findings in habitual violence and impulsivity. Psychiatria Fennica, 21, 119–132. Zhang, J. (2000). Gender differences in athletic performance and their implications in gender ratios of suicide. Omega, 41, 117–123. Zitzmann, M., & Nieshclag, E. (2001). Testosterone levels in healthy men and the relation to behavioral and physical characteristics. European Journal of Endocrinology, 144, 183–197.

Chapter 7 MEN, GUNS AND SUICIDE DAVID LESTER s we saw in the previous chapter on the possible role of testosterone in suicide by men, men appear to use violent methods for suicide more than women, while both sexes use nonviolent methods for suicide at the same rate.1 The most common violent method for suicide is, of course, a firearm, most often a handgun. Surprisingly, as far as I know, only one study in the United States has ever tried to identify every completed suicide in a region and every attempted suicide, a study by Shneidman and Farberow (1961). Lester (1969) analyzed their data and found that 41 percent of the men who completed suicide used a firearm versus only 18 percent of the women. The fatality rates (number of completed suicides divided by the number of completed and attempted suicides) for men and women are:

A

Men 4.4 84.0 19.9 22.7 83.5 40.4

Cutting Firearm Barbiturates Poisoning Hanging Other Methods

Women 2.6 30.8 9.6 7.9 47.1 9.9

It can be seen that men were more likely to die by each method for suicide than were women.2 Recently, Cibis et al. (2012) analyzed this phenom1. In the past, this distinction was named active versus passive methods for suicide. 2. Some methods had very small numbers of men and women, but both men and women had fatality rates of 100 for drowning (based on 5 men and 9 women) and women had a higher fatality rate for car exhaust (100 versus 81.7) based on 93 men and 14 women. See also Lester (1979, 1984).

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enon in Germany. They examined 656 completed suicides and 2,579 attempted suicides in Nuremberg and Wurzburg for the period 2000–2004. The fatality rates for each method of suicide for men and women were: Poisoning by drugs Poisoning by other means Hanging Drowning Firearms Sharp Object Jumping Moving Object Other Methods

Men 7.2 28.2 83.5 61.1 78.8 8.6 55.0 70.8 28.6

Women 3.4 12.2 55.3 65.6 50.0 2.5 43.7 33.3 21.4

Men had the higher fatality rate for all methods except drowning. Furthermore, 66 men used firearms, and 50 died. Two women used firearms, and one died. Shneidman and Farberow provided data on what part of the body was wounded by those using a gun. Of the 263 men who used a firearm for completing or attempting suicide, 78.3 percent shot themselves in the head rather than the body, a much more lethal method. In comparison, only 54.2 percent of the 59 women who used a firearm shot themselves in the head.

The Availability of Firearms and Suicide Lester (1988a) used several indirect measures of firearm availability for the nine major regions of the United States, including the percentage of homicides committed with a firearm, the accidental death rate from firearms, and rough estimates of actual firearm ownership obtained from surveys. He found that the suicide rate by firearm was positively associated with these measures (statistically significantly so), while the suicide rate by all other methods was negatively associated with these methods (but not significantly so). Using data from 20 countries, Lester (1990) found that the percentage of homicides using a firearm was positively associated with the suicide by firearm and negatively with the suicide rate by all other methods (both significantly so). For the six Australian states, Lester (1988b) found that the percentage of homicides using a firearm was positively associated with the suicide rate using firearms and negatively with the suicide rate by all other methods. Lester (1994) found the same phenomenon over the Canadian provinces. Thus, it appears that the availability of guns does change the pre-

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ferred method for suicide in those seeking to kill themselves, although it does not seem to change the overall suicide rate. GUN CULTURES Hofstadter (1970) characterized America as a gun culture and, traditionally, ownership and use of guns is primarily a male-only domain, although this has changed somewhat in recent years. Arkin and Dobrofsky (1978, p. 159) noted that a large proportion of American men serve or have served in the military and serve presently in police departments. These experiences serve as a powerful male socialization process and help determine the masculine role. Basic training is designed to produce a “strong, silent, self-reliant man who functions as a loyal member of a team,” and it should be noted, one who is familiar with guns and carries a gun most of the time. Felson and Pare (2010, p. 1357) asked whether there was an honor culture or a gun culture in the United States. Felson and Pare noted that, according to the hypothesis of a Southern subculture of violence, Southerners have an honor culture in which violent retaliation when provoked is the norm. “In honor cultures, men are expected to defend themselves when threatened and to respond to insults with aggression.” Using data from a national survey of 8,000 men and 8,000 women conducted by telephone in 1995–1996, Felson and Pare found that carrying a gun in order to defend oneself or to alert other people was predicted at the individual level by being male, by being African American, living in the Southern states, with above average income, having been victimized, and being concerned for safety. They concluded that Southern and Western men are characterized by a gun culture.3 Osterman and Brown (2011) sought to test the association between a culture of honor and suicide rates, labeling southern and western states as having a culture of honor. In their first multiple regression analysis, states with a culture of honor had higher suicide rates for European Americans and for African Americans. In addition, gun ownership predicted the suicide rates of European Americans, but not African Americans. In their second study, this time for the overall suicide rates of the states, the rates of depression in the states was an additional predictor of the suicide rates. They then studied the impact of a culture of honor in a sample of 800 undergraduate students, and they found that a scale that assessed Honor Ideology for Manhood con3. Felson and Pare say that this gun culture characterizes European Americans as well, but the presentation of their results concerning this is contradictory, with a greater percentage of white males carrying guns than other groups, but with a negative regression coefficient for the variable “white” in their multiple regressions.

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tributed to the prediction of the level of depression for students who identified as European or Hispanic Americans, but not for those who identified as African American, Asian American, or “other.” Bankston et al. (1990) studied 1,177 white respondents in Louisiana selected from a sample of those with driver’s licenses and found that carrying a gun was more common in men and in those living in the part of the state (northern Louisiana) characterized by having a Southern subculture. Cooke and Puddifoot (2000) assessed attitudes toward guns in American and British undergraduate students and found that American students more strongly endorsed the right to own a gun and the protective power of gun ownership than did British students and, furthermore, American men more strongly endorsed this right than did American women. American men also endorsed the view more that guns do not cause crime. Kahan et al. (2007) conducted a large-scale opinion survey of 1,844 United States residents by telephone. Respondents were categorized on two dimensions: (1) communitarianism-individualism (concern for collective versus individual interests), and (2) egalitarianism-hierarchical (attitudes toward group stratification and toward deviance from dominant norms and roles). Respondents were asked to judge how risky they saw environmental threats (such as from nuclear power generators), insufficient regulation of guns, and abortion. Women, minorities, Catholics and Democrats judged each activity to be more risky, as did communitarians and egalitarians. European American men judged each of the activities to be less risky than did African American men. Kahan et al. called their finding the white male effect and viewed it as stemming from the commitment of men to their preferred form of social organization, namely individualistic and hierarchical.

Sex Differences in Choice of Method for Suicide Marks (1977) had college students rate the different methods for suicide according to their personal preference. Women preferred poisons and drugs, gas, drowning and cutting more than did men, whereas men preferred firearms and explosives more. (Men and women did not differ in their preference for jumping, hanging or cars.) Marks concluded that women preferred methods they perceived as more painless while men chose methods that they perceived as more efficient and fitted the masculine stereotype. Marks also found that the women were more knowledgeable about drugs, while the men were more knowledgeable about firearms. It appears that men are less concerned with the appearance of their body after death. The violent methods of suicide (especially gunshots to the face) destroy one’s appearance. Diggory and Rothman (1961) found that women

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rated one consequence of death relevant to the present discussion as more important to them than did men, namely “I am afraid what might happen to my body after death.” Lester (1988c) asked students to rate the use of guns versus overdose as a method for suicide on ten dimensions. Suicide by gun was seen as quick, painful, difficult, irreversible, dramatic, masculine, messy and somewhat courageous and impulsive. Overdoses were seen as slow, painless, easy, cowardly, feminine, tidy, planned, and as somewhat reversible and banal. Lester (1988d) asked 429 students which was their preferred method for suicide and why. Women chose an overdose more than men (1.57:1) and a firearm less often than men (0.35:1). For the reasons for choosing a particular method for suicide, women rated availability, painlessness, and less disfigurement as more important than did the men. Men were less concerned than were women over “I am afraid of what might happen to my body after death,” and those choosing guns were also less concerned with this fear. Joiner (2005) has proposed a theory of suicide that includes a variable relevant to the present discussion. Joiner argued that in order to complete suicide, individuals have to acquire the capability to inflict self-harm. They can acquire this, for example, by experiencing injuries during their lives, by having been victims of physical and sexual abuse, or by having combat experiences in wars. In a study of college students, Witte et al. (2012) administered a paper-and-pencil scale to measure this acquired capability, measured pain thresholds to pressure and to temperature, and administered a scale to measure having a stoic attitude. The men obtained higher scores for acquired capability for self-harm, stoicism, and pain thresholds. In their model, therefore, Witte et al. saw gender as leading to differences in stoicism which then result in differences in fearlessness about death and pain sensitivity, thereby increasing the possibility of self-harm.

Factors Associated with Suicide by Firearm Kaplan and his colleagues (2012) used a national data set to explore the factors associated with the use of a firearm for suicide among older men (65 years and older). Those using firearms rather than another method for suicide were more often white, veterans, living in rural areas and not in the northeast of the country, had less contact with mental health services and more often had a recent stressful life event (especially health related). They did not differ in substance abuse or marital status. Kaplan saw the results as indicating a lesser role of psychopathology (and, therefore, less of a role for mental health services in prevention) and a greater role of subculture (the tough, rugged, emotionally inexpressive subculture of rural elderly men).

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DISCUSSION At the social level, men (especially American men) have a gun culture. This culture is shaped for many of them by their experiences in the military and in law enforcement, and the culture is shaped further by movies, from the Western movies of the twentieth century and from more modern movies featuring violence in which guns play a prominent role. Indeed the guns have grown in size, from John Wayne’s revolvers and rifles to the gigantic firearms used in Arnold Schwarzeneggers’s Terminator movies and in other movies (such as Star Wars and Star Trek), as well as in video games. It is this gun culture which is part of what others have called the honor culture and the Southern subculture of violence. At the individual level, men also prefer firearms more than do women as a method for suicide. The use of guns is viewed by men and by women as a masculine method for suicide, and men fear the disfigurement of their bodies when killing themselves less than do women. It might also be that leaving a disfigured body for their female partners to find is a further way for men to aggress against women, leaving a memory picture for their survivors that will be hard to erase. REFERENCES Arkin, W., & Dobrofsky, L. R. (1978). Military socialization and masculinity. Journal of Social Issues, 34, 151–168. Bankston, W. B., Thompson, C. Y., Jenkins, Q. A. L., & Forsyth, C. J. (1990). The influence of fear of crime, gender, and Southern culture on carrying firearms for protection. Sociological Quarterly, 31, 287–305. Cibis, A., Mergl, R., Bramesfeld, A., Althaus, D., Niklewski, G., Schmidtke, A., & Hegerl, U. (2012). Preference of lethal methods is not the only cause for higher suicide rates in males. Journal of Affective Disorders, 136, 9–16. Cooke, C. A., & Puddifoot, J. E. (2000). Gun culture and symbolism among U.K. and U.S. women. Journal of Social Psychology, 140, 423–433. Diggory, J. C., & Rothman, D. Z. (1961). Values destroyed by death. Journal of Abnormal & Social Psychology, 63, 205–210. Felson, R. B., & Pare, P. P. (2010). Gun cultures or honor cultures? Social Forces, 88, 1357–1378. Hofstadter, R. (1970). America as a gun culture. American Heritage, 21(6), 4-11, 82–86. Joiner, T. E., Jr. (2005). Why people die by suicide. Cambridge, MA: Harvard University Press. Kahan, D. M., Braman, D., Gastil, J., Slovic, P., & Mertz, C. K. (2007). Culture and identity-protective cognition. Journal of Empirical Legal Studies, 4, 465–505.

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Kaplan, M. S., Huguet, N., McFarland, B. H., & Mandle, J. A. (2012). Factors associated with suicide by direarms among U.S. older adult men. Psychology of Men & Masculinity, 13, 65–74. Lester, D. (1969). Suicidal behavior in men and women. Mental Hygiene, 53, 340–345. Lester, D. (1979). Sex differences in suicidal behavior. In E. S. Gomberg & V. Franks (Eds.), Gender and disordered behavior (pp. 287–300). New York: Brunner/Mazel. Lester, D. (1984). Suicide. In C. S. Widom (Ed.), Sex roles and psychopathology (pp. 145–156). New York: Plenum. Lester, D. (1988a). Firearm availability and the incidence of suicide and homicide. Acta Psychiatrica Belgica, 88, 387–393. Lester, D. (1988b). Restricting the availability of guns as a strategy for preventing suicide. Biology & Society, 5, 127–129. Lester, D. (1988c). The perception of different methods of suicide. Journal of General Psychology 115, 215–217. Lester, D. (1988d). Why do people choose particular methods for suicide? Activitas Nervosa Superior, 30, 312–314. Lester, D. (1990). The availability of firearms and the use of firearms for suicide. Acta Psychiatrica Scandinavica, 81, 146–147. Lester, D. (1994). Use of firearms for suicide in Canada. Perceptual & Motor Skills, 79, 962. Marks, A. (1977). Sex differences and their effect upon cultural evaluations of methods of self-destruction. Omega, 8, 65–70. Osterman, L. L., & Brown, R. P. (2011). Culture of honor and violence against the self. Personality & Social Psychology Bulletin, 37, 1611–1623. Shneidman, E. S., & Farberow, N. L. (1961). Statistical comparisons between attempted and committed suicide. In N. L. Farberow & E. S. Shneidman (Eds.), The cry for help (pp. 19–47). New York: McGraw-Hill. Witte, T. K., Gordon, K. H., Smith, P. N., & van Orden, K. A. (2012). Journal of Research in Personality, 46, 384–392.

Chapter 8 SUICIDE AMONG MALE ATHLETES JOHN F. G UNN III ester and Gunn (2013) recently published a book on suicide among professional and amateur athletes. While their book is not focused solely on male athletes, the majority of the case studies and the research examined related to male athletes. Many of the sports examined in the book are maledominated (e.g., baseball, football, and cricket) and are, therefore, very relevant to the current book. This chapter will review the findings reported in the book and some of the recommendations.

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ARE ATHLETES AT AN INCREASED RISK OF SUICIDE? One of the key questions is whether or not athletes can be considered an “at-risk” group for suicide. To answer this question, empirical research was examined, as well as theoretical perspectives, that could explain suicide in different sports.

Professional Baseball The first focus was on whether or not professional baseball players are at an increased risk for suicide. Baseball players were chosen for a special chapter because baseball enthusiasts are perhaps the most statistics-oriented group of sports fans. Over the years, baseball players have been tracked down and their careers documented. After examining these records, Coleman and Lester (1989) reported that 45 percent of the suicides by baseball players were pitchers, all of whom were, incidentally, right-handed. Additionally, players who had experienced a decline in performance and who were no 78

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longer playing because of being cut or retirement, were at the greatest risk of death by suicide. Lester (2004) investigated a claim by Bill James (2003) that baseball players, even after retirement, rarely die by suicide during the season and found that suicides by baseball players were spread evenly over all four seasons. Lester and Topp (1989) reported that baseball players who died by suicide did not differ from those who died by homicide in their percentages of games won (for pitchers) and batting averages (if batters). Finally, by examining the professional baseball players who had died by suicide, Lester found that there were 64 suicides out of 6,374 deaths (1.0%). Comparing this to the general population (with data from 2007), this percentage was lower than that of the general population (2.3%). If this is an accurate estimate of suicide deaths among professional baseball players, then it would appear that playing professional baseball may serve as a protective factor for suicide.

Steven Stack’s Analysis of Mortality Data In order to investigate further the relationship between sports participation and suicidal behavior, Stack (2013) utilized mortality data from 21 states for 1989–1996 to investigate mortality among those whose death certificate listed them as “athletes.” Stack found that the relationship between athlete status and death by suicide was somewhat unclear. In three of the years examined, athletes had a significantly higher risk of death by suicide, while in five of the years there was no such relationship. When examining mortality by violent death in general (i.e., homicide, suicide and accidental deaths), Stack found that athlete status was associated with increased risk for all eight years. These findings indicated that athletes have at least the same suicide risk as the general population, but they are more at risk of dying by violent means.

Suicide among Gay, Lesbian, and Bisexual Athletes One of the subgroups of athletes who may be at risk for suicide are gay, lesbian, and bisexual athletes. Some research has indicated that gay men are at an increased risk of psychopathology and suicide (for more on this see Chapter 13 of the present book). However, little to no work has examined the relationship between being gay and an athlete and whether or not this increases the risk of psychopathology and suicidal behavior. Consider the following case studies. Justin Fashanu, a professional British footballer, was openly gay. He had survived the struggle of coming out about his homosexuality but, after allegations

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There are several reasons to hypothesize a relationship between being a gay athlete and having an increased risk of suicidal behavior. Minority stress, defined as psychosocial stress derived from minority status, has been proposed in the past to be a contributing factor to the increased presence of mental illness in gay men (Meyer, 2003). Gay athletes are subjected to a homophobic environment and, therefore, would experience a large amount of minority stress. Additionally, the Interpersonal-Psychological Theory of Suicide (IPTS), discussed in more detail in Chapter 3, focuses on the role of thwarted belonging and perceived burdensomeness as a motivation for suicidal behavior. Thwarted belonging may be a potential problem for gay athletes. Given that sport atmospheres tend to be homophobic, a gay athlete may not be willing to “come out of the closet” and, therefore, must live a lie among his fellow athletes. Additionally, because he must keep up appearances, he would be unable to be open with other gay men. This could create a deep sense of thwarted belonging and social isolation and may increase his risk of suicide.

Cricket Professional cricket players appear to have an elevated risk of suicide. As with baseball, cricket is a male-dominated sport and is very popular around the world. (More people watched the 2011 World Cup cricket semifinal than the 2012 Superbowl.) Based on the data presented by Frith (1990, 2001), death by suicide among cricket players accounted for 2.7 percent of all deaths, which was greater than for the general population (approximately 1.5%). What could possibly explain this increased risk of death by suicide among cricket players? Lester (2013a) hypothesized that the cause of suicide among cricketers was linked to the stress of retirement and being forced from playing the game. The role of retirement will be discussed in more detail later in this chapter.

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COMMON RISK FACTORS What risk factors for suicide are common among professional and amateur athletes?

Steroid Use Steroid use is a common occurrence among athletes and several high profile cases have occurred in the last few years. Chris Benoit is one example. Chris Benoit, a professional wrestler and former champion in the World Wrestling Entertainment group, killed his wife Nancy and strangled their seven-year-old son before hanging himself in June, 2007. The postmortem showed that he had steroids and other drugs in his system at the time of his suicide. His wife was found bound, and she had been strangled. His son had been sedated with alprazolam (Xanax) at the time of his death. (Lester, 2013b, p. 44)

However, Lester reviewed the literature on steroid use and suicidal behavior and concluded that steroid use is associated with psychiatric problems, but that suicidal behavior is found only in some steroid users.

Traumatic Brain Injury Concussions and other traumatic brain injuries are commonplace among professional athletes, especially those in contact sports (e.g., football). Gunn (2013b) reviewed the literature on traumatic brain injury (TBI) and suicidal behavior. TBI is very common among athletes. In fact, 20 percent of all head injuries in the United States are thought to be sports related (McCrea et al., 1997). The majority of studies support a relationship between TBI and psychopathology (e.g., McCleary et al., 1998; Malaspina et al., 2001) and between TBI and suicidal behavior (e.g., Simpson & Tate, 2007). Consider the case of Dave Duerson who died of suicide: Dave Duerson, a former defensive back for the Chicago Bears, is the first NFL player to die by suicide, claiming that his psychological state was a result of the head trauma received from playing. Duerson, age 50, shot himself in his chest, expressly because he wished his brain to be intact for study. His suicide note read, “Please see that my brain is given to the NFL’s brain bank.” Duerson had expressed his concern that he might have CTE [chronic traumatic encephalopathy]. Sitting on a panel concerned with the NFL’s disability plan, he experienced first-hand the testimony of countless players and their families dealing with head trauma-related dementia, and this may have played a role in his request to have his brain examined. (Gunn, 2013b, p. 52)

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While the research reviewed by Gunn supported a relationship between suicidal behavior and TBI, the nature of the relationship is unclear. TBI is connected to the development of psychopathology, such as major depression, and so it is unclear whether suicide following TBI is related to the development of a mental illness or whether other mechanisms play a role. Several recommendations were made by Gunn concerning the identification, prevention, and treatment of patients with TBI-related mental illness. Following a TBI, players should be monitored, not just for physical complications, but also for psychological complications. Depression has been shown to be associated with TBI and, therefore, players who suffer TBI should be monitored for signs of depression and other mental illnesses. Also, because some work has indicated that depression may come later, when players realize they will not get back to their pre-injury condition, screening should be repeated over a long period of time.

The Social Relationships of Athletes In the work on suicide among professional and amateur athletes, Gunn (2013c) discussed the strains in the social relationships of athletes. These strains may lead to increased feelings of loneliness (i.e., thwarted belonging) and increase the risk of suicide in this population. Consider the following case study: Donnie Moore, a former reliever for the Los Angeles Angels struggled for several seasons to stay in the major leagues, and his best year was a 31-save season in 1985, his first year with the Angels. On October 12, 1986, in game 5 of the American League Championships, with the Angels one strike away from the World Series, he gave up a two-run homer to Boston’s Dave Henderson, giving the Red Sox a 6-5 lead. The Angels later tied the game but lost to Boston in extra innings. Boston went on to win the series. Moore remained haunted by memories of loss, and in 1989 shot and killed his wife during a domestic dispute and then killed himself. He had just been released from the Kansas City Royals’ minor league affiliate in Omaha, Nebraska. (Gunn, 2013c, 64)

Sexual Risk Taking One of the strains in the social relationships of athletes comes from their sexual behavior. Wahl and Wertheim (1998) discussed the prevalence of outof-wedlock children among professional athletes, athletes such as Larry Bird, Oscar de la Hoya, and Jim Palmer. Some empirical research has also pointed to a relationship between risky sexual behavior and sports participation (e.g., Wetherill & Fromme, 2007).

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While there is some evidence that sexual risk-taking is common among professional athletes, the empirical research examining this has used populations of high school and college students. This research has produced inconsistent findings, with some finding an increased risk of sexual risk-taking, some finding a decreased risk, and still others finding that the risk-taking behavior is effected by gender (men have an increased risk, women a decreased risk).

Domestic Violence Another potential strain on the social relationships of athletes discussed by Gunn is domestic violence. Nack and Munson (1995) discussed the role of domestic violence in professional athletes’ lives, for example, in the lives of Bobby Cox, Michael Cooper, and O. J. Simpson. While that article was anecdotal, it gave several examples of domestic violence occurring among athletes and pointed to potential reasons for this, such as the violent nature of sports that focus on the domination of another person. Additionally, some empirical evidence exists to support this. Boeringer (1999) found that athletes were more likely to agree with rape-supportive statements than were controls. Forbes and colleagues (2006) found that college athletes in aggressive sports (e.g., football) reported more psychological and physical aggression and more sexual coercion. They caused their partners more physical injuries, and were more accepting of violence, more sexist in their attitudes, more hostile toward women, more accepting of rape myths and less tolerant of homosexuals.

Financial Crises Finally, financial crises are another potential strain on the social relationships of professional athletes. Torres (2009) discussed a number of factors associated with this. First, professional athletes do not make sound, logical investments, and are rather persuaded by the “lure of the tangible” into make risky, but thrilling investments. Second, professional athletes put a lot of faith in those around them and often find themselves trusting their money to those they should not (e.g., family members). Additionally, professional athletes have a very high divorce rate (estimated to be between 60% and 80%), and their divorces often come after retirement. This means that their income has typically ceased, and they now must split their assets. Considering also that they may have child support payments for illegitimate children, the financial burdens can quickly accumulate.

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All of the issues stated above are potential strains on the social relationships of athletes. Social relationships have long been known to be of relevance to suicidal behavior. Additionally, men are viewed as having a more difficult time maintaining their social relationships as they age. This means that athletes may face retirement, financial crisis, and other hardships alone. This loneliness could very well be a contributing factor to suicide among male athletes. It is therefore important that professional athletes, and men in general (see Chapter 3), should be encouraged to development and maintain their social relationships. Players should be encouraged to keep in contact with former teammates long after they have retired as this could mean the difference between life and death.

Drug and Alcohol Use Lamis, Baum, and Lester (2013) discussed the role of drug and alcohol abuse among athletes. Alcohol and drug abuse has been linked to suicidal behavior (e.g., Hughes, 2008; Wilcox, Conner, & Caine, 2004), and there is evidence that alcohol and drug abuse is common among athletes (e.g., Waddington, Malcolm, Roderick, & Naik, 2005). However, there is a lack of research investigating a potential relationship between drug use among professional athletes and suicidal behavior. There is some anecdotal evidence that points to death by suicide of athletes using prescription medications, such as golfer Erica Blasberg and hockey player Derek Boogaard. Although at present the relationship between drug abuse among athletes and suicidal behavior is unclear, the evidence does suggest a relationship between drug/ alcohol abuse and suicidal behavior, and athletes may exhibit a large amount of risky behavior involving drugs and alcohol.

Psychiatric Disorder Lester (2013c) discussed the role of psychiatric problems among athletes. Mental illness is one of the strongest correlates and predictors of suicidal behavior, especially mood disorders such as major depression and bipolar disorder. There are some well-documented cases of mental illness among athletes, some resulting in suicide. For example: 1. Rick Rypien, an ice hockey player, committed suicide at age 27 and was suffering from depression. 2. Kenny McKinley, an NFL player, committed suicide at age 23 and was depressed over a season-ending injury to his knee. 3. Zack Greinke, a baseball pitcher, has been treated for social anxiety, anger, and depression.

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4. Jennifer Capriati, tennis player, was caught shoplifting and using marijuana and later admitted to depression and suicidal ideation even when she was playing successfully. These are just a small sample of the cases of mental illness and suicidal behavior among professional athletes. Participation in sports and physical exercise have both been linked in research to decreases in the risk of mental illness (e.g., Oler & colleagues, 2011; McElroy, Evans, & Pringle, 2008; Elliot et al., 2012). However, in these studies the focus was on high school and college students. Professional athletes face more occupational stress than high school athletes or collegiate athletes. Little research has been done on professional athletes, but that which has been done has also supported a relationship between athletic participation and a lowered occurrence of mental illness (e.g., Yang et al., 2007). While generally speaking athletes have a lowered risk of mental illness, athletes may face stress that the general population does not. For example, what impact does injury have on mental illness in athletes? Athletes who face injury may face threats to their self-image (Eldridge, 1983) and changes in mood, self-esteem, self-worth and self-confidence (Wiese-Bjornstal et al., 1998). Additionally, given the prevalence of stigma and denial of mental illnesses among athletes (as with men in general), psychiatric problems in athletes may go untreated (e.g., Schwenk, 2000).

Contagion and Bullying Another issue is the role of contagion and bullying in the suicides of athletes. Gunn and Lester (2013) discussed the evidence linking contagion and bullying to suicides occurring in athletes and gave several recommendations for future work and prevention.

Contagion Contagion refers to the clustering of suicides or suicides that occur as “copy cats” of famous or well-documented suicides (e.g., Marilyn Monroe). Clusters of suicide are not unheard of. Swift (2006) described a case of five suicides occurring from a high school football team. A report by Swift (2006) of five suicides from one high school football team in Winthrop, Maine, provides a little more information. Winthrop is a crime-free, middle-class town in central Maine. The first suicide seemed to be the most puzzling. On April 9, 2003, Jason Marston, age 15, had a fight with his girlfriend of nine months. He stayed in his room that night and was missing the

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Suicide in Men next morning. His younger sister found him in the backyard, dead from a shot to the head from a pistol that he and his father used for target practice. There was no history of depression or of drug and alcohol use, but Jason was a mild risk-taker, once jumping off a railway trestle bridge 30 feet into a lake, a rite of passage in the town. The next suicide was ten months later, on February 17, 2004. Lee St. Hilaire was 20 and had been one of the best football players in Winthrop. He killed himself with a shotgun blast to the stomach in an apartment in Bangor that he shared with his girlfriend. A quarterback, he was voted the best football player in Maine in 2001. His parents had divorced when he was in fourth grade, and he had been somewhat undisciplined. He was awarded a football scholarship by the University of Maine, but he disliked the structure of the program and transferred to Husson College in Bangor, where his team went 0–7 in 2003. He was frustrated with losing and told a friend two days before his death that he was thinking of coming back home to coach. Eleven months later Bryant Donavan, 19 years old, hung himself. Three days later, Troy Ellis, 24 years old, also hung himself. Both had played football for the high school team. Ellis had a history of depression and had attempted suicide twice in the past (using carbon monoxide and an overdose of pills). One of his grandmothers had also committed suicide. Ellis had fathered a child and was in arrears in child support. Donavan had been St. Hilaire’s backup. He had been drinking the night he killed himself, and an open bottle of whiskey was beside him in the attic where he hung himself. Donavan had idolized St. Hilaire and was devastated by St. Hilaire’s suicide. Donavan had difficulty adjusting to his parents’ divorce when he was a freshman in high school, and he was suspended from the team in his senior year for breaking rules. Garwood was on the football and basketball teams and had been admitted to Colby College. Once there, he struggled academically, and he ‘was not invited back.’ One assumes that Swift means that his grades were not high enough to remain on the football team. Garwood switched to the University of Southern Maine which did not have a football team. He rented an apartment with friends, and he began drinking heavily. After a night out when he drank a sixpack of beer, he went home and called his girlfriend to ask if he could come over, but she had to get up early the next morning. He hung himself that night. (Gunn & Lester, 2013, pp. 114–115)

This example shows that contagion can happen among athletes as it does in the general population. In Winthrop, football is life! A former member of the school board once suggested cutting back on the football program to save money and was told that, if she ever suggested something like that again, she would “have to be escorted home by the police” (Swift, 2006, p. 64). In an

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environment such as this, where there is such pressure to perform and to perform outstandingly, suicide clusters may result.

Bullying and Hazing When one thinks of bullying and sports, one typically pictures the jocks in high school belittling weaker, smaller kids. However, this is not always the case. The first issue is whether or not bullying and hazing are linked to suicidal behavior. Private Danny Chen was a United States Army private who died in Afghanistan of a self-inflicted gunshot wound to the head (Chen, 2012). Chen had aspirations to join the New York Police Department and had joined the army as a means of preparing himself for that career. According to reports surrounding his death, Chen endured brutal hazing at the hands of his fellow soldiers. He was tormented with racial slurs about his Chinese-American heritage, he was forced to run sprints while carrying a sandbag, he had rocks thrown at him, and he was forced to yell orders to his fellow soldiers in Chinese. As a result of his apparent suicide, eight soldiers have been charged with negligent homicide and involuntary manslaughter. (Gunn & Lester, 2013, p. 116) Ashlynn Conner was only 10 years old when she died from suicide. She had been bullied by her classmates. It began with calling her “pretty boy” when she had her hair cut short, and culminated in being called a “slut” (Inbar, 2011). When the bullying became too much, Ashlynn hung herself with a scarf in her bedroom. (Gunn & Lester, 2013, p. 116)

These two examples of suicide, the first involving hazing and the second involving bullying, present anecdotal evidence of the effects that hazing and bullying can have. Bullying has been a topic of much discussion following some high profile suicides, especially among lesbian, gay, and bisexual teens (e.g., Tyler Clementi). The question then arises as to whether bullying and hazing are common among athletes. Evidence suggests that hazing is a common occurrence in the athletic environment (e.g., Waldron & Kowalski, 2009), especially among the more aggressive, and predominately male, contact sports (e.g., football). Additionally, while athletes are often viewed as the bullies, athletes also face bullying themselves from their coaches who treat their young charges with punitive and aggressive language, and sometimes behavior (Lang, 2010). In order to help lower the likelihood of suicide because of contagion or bullying, Gunn and Lester made several recommendations. In relation to contagion, the CDC has outlined several aspects of news coverage that could promote suicide (O’Carroll et al., 1994):

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1. 2. 3. 4. 5. 6. 7.

Presenting simplistic explanations for suicide. Reporting suicide in the news excessively. Providing sensational coverage of suicide. Reporting “how-to” descriptions. Casting suicide as a “tool” for accomplishing certain ends. Glorifying suicide or those who commit suicide. Focusing on the positive characteristics of the suicide.

However, while these are a good start to limiting the likelihood of contagion, suicide is often newsworthy and will be reported, especially the suicide of high-profile individuals like professional athletes. Gould (2001) has also given recommendations to limit the likelihood of contagion occurring: 1. Questioning if the suicide is newsworthy. 2. Do not portray suicide as happening out of the blue or as mysteriously striking a healthy person. 3. Indicate that suicide is often a result of different types of mental illness. 4. Do not report suicide as a reasonable way of problem solving. 5. Do not make suicide appear heroic or romantic. 6. Be very careful in using pictures of the victim(s) or of the grieving family so that the death is not glorified, and to stop overidentification with the victims. Suicide among professional athletes is a newsworthy event and will be reported by the media. However, by following the above recommendations we may be able to avoid the occurrence of suicide contagion. News organizations need to train their journalists to report responsibly in such cases. Bullying and hazing must also be dealt with within school and athletic settings. Programs are needed that focus on altering the mind frame of athletes and athletic personnel. Currently, those who are hazed or bullied are often silent about their plight. Encouragement should be given for reporting such occurrences. Additionally, once cases are reported, the administration has to be prepared to respond. By continuing to ignore the problem of bullying and hazing, more suicides such as Ashlynn Conner’s and Danny Chen’s may occur.

Sexual Abuse Little work has examined the relationship between sports participation and sexual abuse. Gunn (2013d) examined the existing literature and gave several recommendations related to this problem. Sexual abuse and athletics

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has come to light in the recent Penn State University controversy when Jerry Sandusky, the defensive coordinator for the football team, had charges of sexual abuse filed against him. The subsequent outrage resulted in the firing of long-time coach Joe Paterno and the resignation of the university’s president. Most of the work that has examined sexual abuse among athletes has focused on girls and women in sports such as gymnastics. However, some work has examined sexual abuse among male athletes. Most of the research indicate that athletes face a similar risk of sexual abuse as the general population but that, when they do face sexual abuse, it is typically encountered in the athletic environment (e.g., by coaches or staff). Hartill (2009) argued that part of the problem in athletic environments is a blurring of the line between child and adult. As the author put it: In organized sports, where boys are perpetually required to prove themselves through an adultist, hetero-patriarchal model of success in a context structurally and socially arranged to value conquest above all else, the adult-child distinction is constantly under negotiation. Despite age-group distinctions, one use of organized sports in (late) modernity is to fulfill the role of an initiation rite (Burstyn, 1999) where the dominant script for a boy to be successful at being a boy means to be manlike and to adopt ‘manly’ qualities such as bravery, aggression, stoicism, and risk taking (Connell, 1995). Such a standard opens up a considerable amount of ‘grey’ area where boys are often expected to ‘suck-it-up,’ ‘shrug-it-off,’ and ‘take it like a man.’ Among others, Burstyn (1999), Messner and Sabo (1990), and Pronger (1990) have drawn attention to the homo-erotic current that runs through much of organized male sports. It is not difficult to see how such expressions generally intended, ostensibly to encourage resolve in the face of adversity or physical discomfort, can be used to coerce many boys into all manner of exploitative practices. (Hartill, 2009, pp. 236–237)

Male athletes, especially young male athletes, are faced with an environment that is conducive to sexual exploitation, and sexual abuse has been shown to have an impact on psychopathology and suicidal behavior (e.g., Fergusson, Horwood, & Lynskey, 1996; Anderson et al., 2002). Given that sporting environments may foster sexual abuse, and that sexual abuse is associated with mental illness and suicidal behavior, it is important to consider what can be done to prevent sexual abuse in athletic environments. Brackenridge (1998) gave several recommendations. 1. Preventive education can be given to children so that they are better able to resist the perpetrator or are more willing to tell their parents about the abuse once it has occurred.

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2. Parents should monitor the staff and other people with whom the children have contact in the sports setting. 3. Parents should rely less on the safety of police checks because these are often expensive and ineffective. 4. Instead of relying on pedophile profiles, widespread screening should be utilized to identify those who are likely to be offenders. 5. Parents should be given access to sporting facilities so that interactions between children and sporting personnel can be monitored more closely. Sexual abuse happens in athletic environments, and more must be done to prevent it before it occurs, and more must be done to respond properly when it does.

Retirement Retirement is a common theme in the suicides of athletes. Lester (2013d) noted that retirement is a hard decision for an athlete to make. For example, Brett Favre changed his mind many times before finally retiring. Retirement is a time of transition and, as such, is often associated with stress. However, retirement for athletes may be especially hard. For years athletes have experienced being idolized by fans. They have focused on sports, typically, throughout high school and college and are, therefore, less educated than many. Additionally, retirement for athletes does not come after a long, distinguished career, but rather comes in the prime of life. Many athletes retire in their 30s and in their 40s. In addition to the fact that they face retirement decades before most in the general population, athletes also face physical ailments far worse than those in their age group. King (2011) followed the members of the 1986 Cincinnati Bengals football team and interviewed a large proportion of the team (39 of the 48 players), now between the ages of 47 and 62. Two of the players had died, one from suicide (safety Bobby Kemp), and one was in prison for burglary (running back Stanley Wilson). The players had careers that averaged 8.75 years. Almost all (95%) experienced daily pain; 22 (56%) had knee problems, the most common ailment; 15 (38%) had back injuries; and 15 had neck injuries. The average player experienced pain in three body parts. Seventeen (44%) of the players blamed their short-term memory loss on football, and 13 (33%) blame their headaches on football. Five other had these problems but were not sure that they were football related. (Lester, 2013d, p. 133)

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This is a glimpse of the plight of a retired athlete. They dedicate themselves to a career that ends far quicker than most normal careers, and are left with debilitating, painful repercussions. Let us look closer at the case of Bobby Kemp, who killed himself. Former safety on the team Bobby Kemp killed himself at the age of 39 on February 7, 1998. He went to the gym, came back home, and waited until his wife and two-year-old daughter went to feed ducks at a park. He then showered, dressed, and shot himself in the chest with a revolver, leaving no suicide note. His wife came home, broke the door open and found him. Kemp was known as the enforcer and played through pain, including a dislocated shoulder one season. He was a voracious reader and soft-spoken loner, and he had often said that he would commit suicide. His first wife of 13 years said that Kemp often talked about suicide as he battled alcohol and drug addiction. He used to say that the day that he killed himself would be like any other day. Kemp became a paramedic after he retired. He seems to have suffered from depression from an early age. He told both wives and a friend that he had put a gun in his mouth and contemplated pulling the trigger for the first time when he was nine years old, and he said that he would not live to be 40 years old. Playing football may have helped him live, and after retirement he seemed to deteriorate, according to his first wife. (Lester, 2013d, pp. 133-134)

Retirement is a difficult time for athletes, especially when we consider the risk factors already discussed. For example, many face the difficulties of dealing with alcohol or drug abuse (such as Bobby Kemp), have strained social relationship due to divorce or domestic violence, and are facing the financial burdens that often face retired athletes. As a means of helping retired athletes, Lester (2013d) discussed the potential of using Kubler-Ross’ (1969) stages of dying to counsel retired athletes. Kubler-Ross’ stages are: (1) denial, (2) anger, (3) bargaining, (4) depression, and (5) acceptance. Retiring athletes may initially face their retirement with denial, trying to join other sports teams or refusing to accept that an injury has ended their careers. Anger may then follow, which could further strain the social relationships in the athletes’ families. Bargaining takes the form of the athletes trying to get “just one more season” of playing. Once these stages are progressed through, and the athletes have realized that their careers are over, then the clinician will need to focus on working the athletes through the stage of depression and to acceptance.

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CONCLUSION In their conclusion, several points were made by Lester and Gunn (2013) in relation to suicide among athletes. • Being an athlete increases the risk of suicide. Professional athletes, as shown by Stack (2013), may have an increased risk of suicide, or at least are as at-risk of death by suicide as the general population, and they are at an even greater risk of death by violence. • Retired athletes are at particular risk. It is apparent that retirement is an atrisk time in athletes’ lives. The adjustment to retirement is not an easy road for many athletes, especially as it is often marred by drug use and physical and psychological pain. Lester and Gunn made several recommendations for the future. 1. Professional sports organizations presently offer seminars on the common problems faced by athletes. These organizations should offer similar programs with a focus on mental illness among athletes. These programs could include: a. A review of the common risk factors for suicide, especially focusing on those discussed above. b. Testimonials from former athletes and current athletes who have a mental illness, as this will help to foster an environment where communication about mental illness is not stigmatized or discouraged. 2. Risk factors for suicide and mental illness should be included in the training of sports personnel who interact with the athletes (e.g., trainers). 3. Better screening should be included for identifying mental illness in young athletes who are just starting their careers. 4. Retirement, a particularly at-risk period, should be targeted. For example: a. Have members of sports organizations keep in contact with each other, and follow up with former teammates could help ensure they receive the help they need. b. Former players should be encouraged to form support groups to foster an environment where athletes speak openly with one another about their problems. 5. More research is needed that focuses on suicide risk among professional athletes. Most previous research has focused on amateur athletes, who may not have the same strains as professional athletes.

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Suicide among athletes is puzzling to many of us since we see these men as reaching the pinnacle of their profession. They are celebrities and famous. We see their wealth and fame and mistakenly think that they are not touched by the same problems and hardships that we ourselves face. We hope this chapter will sensitize people to the plight of athletes. Too many have died recently by their own hand, and more work is needed to try and stop this from happening. REFERENCES Anderson, P. L., Tiro, J. A., Price, A. W., Bender, M. A., & Kaslow, N. J. (2002). Additive impact of childhood emotional, physical, and sexual abuse on suicide attempts among low-income African American women. Suicide & Life-Threatening Behavior, 32, 131–138. Boeringer, S. B. (1999). Associations of rape-supportive attitudes with fraternal and athletic participation. Violence Against Women, 5, 81–90. Brackenridge, C. (1998). Child protection in sport. Available: www.celiabracken ridge.com Burstyn, V. (1999). The rites of men: Manhood, culture and the politics of sport. Toronto, Canada: University of Toronto Press. Chen, D. W. (2012, January 05). Private Chen’s family learns more about hazing by fellow G.I.’s. New York Times. Available: www.nytimes.com/2012/01/06/nyregion /pvt-chens-family-learns-more-about-hazing Coleman, L., & Lester, D. (1989). Boys of summer, suicides of winter. In D. Lester (Ed.), Suicide ‘89 (p. 238). Denver: American Association of Suicidology. Connell, R. W. (1995). Masculinities. Stafford, Australia: Polity. Eldridge, W. D. (1983). The importance of psychotherapy for athletic-related orthopedic injuries among adults. Comprehensive Psychiatry, 24, 271–277. Elliot, C. A., Kennedy, C., Morgan, G., Anderson, S. K., & Morris, D. (2012). Undergraduate physical activity and depressive symptoms. American Journal of Health Behavior, 36, 230–241. Fergusson, D. M., Horwood, L. J., & Lynskey, M. T. (1996). Childhood sexual abuse and psychiatric disorder in young adulthood: II. Psychiatric outcomes of childhood sexual abuse. Journal of the American Academy of Childhood & Adolescent Psychiatry, 34, 1365–1374. Forbes, G. B., Adams-Curtis, L. E., Pakalka, A. H., & White, K. B. (2006). Dating aggression, sexual coercion, and aggression-supporting attitudes among college men as a function of participation in aggressive high school sports. Violence against Women, 12, 441–455. Frith, D. (1990). By his own hand. London, UK: Stanley Paul. Frith, D. (2001). Silence of the heart. London, UK: Mainstream Publishing. Gould, M. S. (2001). Suicide and the media. Annals of New York Academy of Sciences, 932, 200–224.

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Gunn, J. F. III. (2013a). Suicide among lesbian, gay, and bisexual athletes. In D. Lester & J. F. Gunn III (Eds.), Suicide among professional and amateur athletes (pp. 99–111). Gunn, J. F. III. (2013b). Concussions, traumatic brain injury, and suicide. In D. Lester & J. F. Gunn III (Eds.), Suicide among professional and amateur athletes (pp. 52–63). Springfield, IL: Charles C Thomas. Gunn, J. F. III. (2013c). The social relationships of athletes. In D. Lester & J. F. Gunn III (Eds.), Suicide among professional and amateur athletes (pp. 64–73). Springfield, IL: Charles C Thomas. Gunn, J. F. III. (2013d). Sexual abuse among athletes. In D. Lester & J. F. Gunn III (Eds.), Suicide among professional and amateur athletes (pp. 123–131). Springfield, IL: Charles C Thomas. Gunn, J. F. III, & Lester, D. (2013). Contagion, bullying, and suicide among high school and college athletes. In D. Lester & J. F. Gunn III (Eds.), Suicide among professional and amateur athletes (pp. 112–122). Springfield, IL: Charles C Thomas. Hartill, M. (2009). The sexual abuse of boys in organized male sports. Men & Masculinities, 12, 225–249. Hughes, J. R. (2008). Smoking and suicide. Drug & Alcohol Dependence, 98, 169–178. Inbar, M. (2011). Mom: Bullying drove my 10-year-old girl to suicide. Available: http: //today.msnbc.msn.com/id/45354766/ns/today-parenting_and_family/t /mom-bullying James, B. (2003). The new Bill James historical baseball abstract. New York: Free Press. King, P. (2011, December 12). One team, 25 years on. Sports Illustrated, 115, 74–84. Kubler-Ross, E. (1969). On death and dying. New York: Macmillan. Lamis, D. A., Baum, A. L., & Lester, D. (2013). Substance abuse and suicide in athletes. In D. Lester & J. F. Gunn III (Eds.), Suicide among professional and amateur athletes (pp. 74–84). Springfield, IL: Charles C Thomas. Lang, M. (2010). Intensive training in youth sport: A new abuse of power? Available: www.inter-disciplinary.net/wp-content/uploads/2009/10/lang.pdf. Retrieved February 4, 2012. Lester, D. (1987). A subcultural theory of teenage suicide. Adolescence, 22, 317–320. Lester, D. (2004). Suicides among former major league baseball players. Perceptual & Motor Skills, 99, 1122. Lester, D. (2013a). Cricket suicides. In D. Lester & J. F. Gunn III (Eds.), Suicide in professional and amateur athletes (pp. 220–226). Springfield, IL: Charles C Thomas. Lester, D. (2013b). Steroids and suicide. In D. Lester & J. F. Gunn III (Eds.), Suicide in professional and amateur athletes (pp. 43–51). Springfield, IL: Charles C Thomas. Lester, D. (2013c). Psychiatric problems in athletes. In D. Lester & J. F. Gunn III (Eds.), Suicide in professional and amateur athletes (pp. 85–98). Springfield, IL: Charles C Thomas. Lester, D. (2013d). The effect of retirement on athletes. In D. Lester & J. F. Gunn III (Eds.), Suicide among professional and amateur athletes (pp. 132–144). Springfield, IL: Charles C Thomas. Lester, D. & Gunn, J. F. III. (2013). Suicide among professional and amateur athletes. Springfield, IL: Charles C Thomas.

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Lester, D., & Topp, R. (1989). Major league baseball performances of players who were later suicides or homicide victims. Perceptual & Motor Skills, 69, 272. Malaspina, D., Goetz, R. R., Friedman, J. H., Kaufmann, C. A., Faraone, S. V., Tsuang, M., Cloninger, C. R., Nurnberger, J. I., & Blehar, M. C. (2001). Traumatic brain injury and schizophrenia in members of schizophrenia and bipolar disorder pedigrees. American Journal of Psychiatry, 158, 440–446. McCleary, C., Satz, P., Forney, D., Light, R., Zaucha, K., Asarnow, R., & Namerow N. (1998). Depression after traumatic brain injury as a function of Glasgow Outcome Score. Journal of Clinical & Experimental Neuropsychology, 20, 270–279. McCrea, M., Kelly, J., & Randolph, C. The Standardized Assessment of Concussion (SAC): Manual for Administration, Scoring and Interpretation. Ed 1. Alexandria, VA: The Brain Injury Association; 1997. McElroy, P., Evans, P., & Pringle, A. (2008). Sick as a parrot or over the moon. Practice Development in Health Care, 7, 40–48. Messner, M. A., & D. Sabo (Eds.). (1990). Sport, men and the gender order: Critical feminist perspectives. Leeds, UK: Human Kinetics. Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129, 674–697. Nack, W., & Munson, L. (1995, July 31). Sports’ dirty secret. Sports Illustrated. Available: http://sportsillustrated.cnn.com/vault/article/magazine/MAG100688 4/index.htm O’Carroll, P. W., Potter, L. B., Aronowitz, E., Kahn, P., Linksey, D., Bildner, E., Moscicki, E., & Jarvis, J. (1994). Suicide contagion and the reporting of suicide: Recommendations from a national workshop. Morbidity & Mortality Weekly Report, 43, 9–18. Oler, M. J., Mainous, A. G., Martin, C. A., Richardson, E., Haney, A., Wilson, D., & Adams, T. (1994). Depression, suicidal ideation, and substance abuse among adolescents. Archives of Family Medicine, 3, 781–785. Pronger, B. (1990). The arena of masculinity: Sport, homosexuality and the meaning of sex. Toronto, Canada: University of Toronto Press. Schwenk, T. L. (2000). The stigmatization and denial of mental illness in athletes. British Journal of Sports Medicine, 34, 4–5. Simpson, G., & Tate, R. (2007). Suicidality in people surviving a traumatic brain inury. Brain Injury, 21, 1335–1351. Stack, S. (2013). Athlete suicides and violent deaths. In D. Lester & J. F. Gunn III (Eds.), Suicide among professional and amateur athletes (pp. 17–40). Springfield, IL: Charles C Thomas. Swift, E. M. (2006, January 9). What went wrong in Winthrop? Sports Illustrated, 104, 60–65. Torres, P. S. (2009, March 23). How (and why) athletes go broke. Sports Illustrated. Available: http://sportsillustrated.cnn.com/vault/article/magazine/MAG101276 2/index.htm Waddington, I., Malcolm, D., Roderick, M., & Naik, R. (2005). Drug use in English professional football. British Journal of Sports Medicine, 39, e18.

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Wahl, G. & Wertherim, L. J. (1998, May 04). Paternity ward. Sports Illustrated. Available: http://sportsillustrated.cnn.com/vault/article/magazine/MAG1012762 /index.htm Waldron, J. J. & Kowalski, C. L. (2009). Crossing the line: Rites of passage, team aspects, and ambiguity of hazing. Research Quarterly for Exercise & Sport, 80, 291– 302. Wetherill, R. R., & Fromme, K. (2007). Alcohol use, sexual activity, and perceived risk in high school athletes and nonathletes. Journal of Adolescent Health, 41, 294– 301. Wiese-Bjornatal, D. M., Smith, A. M., Shaffer, S. M., & Morrey, M. A. (1998). An integrated model of response to sport injury. Journal of Applied Sport Psychology, 10, 46–69. Wilcox, H. C., Conner, K., & Caine, E. (2004). Association of alcohol and drug use disorders and completed suicide. Drug & Alcohol Dependence, 76, S11–S19. Yang, J., Peek-Asa, C., Corlette, J. D., Cheng, G., Foster, D. T., & Albright, J. (2007). Prevalence of and risk factors associated with symptoms of depression in competitive collegiate student athletes. Clinical Journal of Sport Medicine, 17, 481–487.

Chapter 9 SUICIDE IN THE ARMED FORCES JOHN F. G UNN III and DAVID LESTER t the end of the twentieth century, suicide among members of the armed forces and veterans was not perceived to be a major problem. For example, Chaffee (1982) reported suicide rates of 7.2 per 100,000 per year for Navy personnel and 15.2 for Marines, rates not that high when compared to the suicide rates for men in the general populations (18.6 for men in 1980, a rate which was based on the total population [aged 0+] rather than on adult men as are armed forces suicide rates). Kawahara et al. (1989) reported a suicide rate of 6.6 for the Navy, and McDowell and Wright (1988) found a low suicide rate for Air Force personnel. Overall, the Marines seemed to have higher suicide rates than those in the Air Force, Army and Navy. There were some discrepancies. Women in the army had suicide rates as high as men (Datel et al., 1981), and African Americans had rates as high as European Americans (Moldeven, 1988). There are also national differences with military personnel having higher suicide rates than the general population in Norway, but lower rates in Finland and Sweden (Hytten & Weisaeth, 1989). Veterans did not appear to have higher suicide rates in the United States (Anon, 1987) or in Australia (Adena et al., 1985), although perhaps Vietnam and Korean War veterans had a higher suicide rate than World War Two veterans (Baker, 1982). Again, Marine Vietnam veterans seemed to have higher suicide rates than Army Vietnam veterans (Breslin et al., 1988). Bullman et al. (1990) found no differences in the suicide rates of those who served in Vietnam and those who did not, while Pollack et al. (1990) found a normal suicide rate in Vietnam veterans. Pollack and associates reviewed other research on this issue and found nine studies reporting normal rates, one a lower rate and three a higher rate. The consensus seemed to be a normal suicide rate for Vietnam veterans.

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Today, however, there is great concern about the suicide rate in active duty personnel and in veterans. What has happened? Is the suicide rate really high? Are the armed services recruiting different kinds of personnel these days, personnel who are more at risk of suicide? Or does the kind of combat experience in today’s wars differ from that of earlier wars? Writing in the Washington Post, Ernesto Londono noted the rising rate of suicide among military personnel and observed that “[t]he U.S. military lost more service members to suicide than combat last year as the number of troops who took their lives rose to a record high” (Londono, 2013, p. 1). According to the article, 349 active-duty suicides occurred in 2012 compared to 229 troops killed in combat. Before we discuss the empirical research regarding suicide among those in the military, two brief case studies highlight the problem. Maj. Jeff Hackett was a Marine who served in the military for 26 years, including 2 tours of duty in Iraq. When he returned from active duty he drank too much, suffered from public breakdowns and was hospitalized for panic attacks. Hackett was an officer. In June of 2010, Hackett committed suicide. At the time of his death he had a wife and 4 sons, and over $460,000 in debt. After leaving the Marines, he worked a “menial” job at an oil refinery, but was laid off 9 months before his suicide and was unable to find employment. His wife was quoted as saying “I watched Jeff die twice. He died once when he came home from Iraq and a second time when he shot himself.” ( Jaffe, 2012, p. 1) Dr. Peter Linnerooth was a mental-health professional with the U.S. Army. Dr. Linnerooth was in the Army for 5 years, including 12 months in Iraq. In his capacity as a psychologist he helped soldiers deal with PTSD and suicidal behavior. After Dr. Linnerooth returned home from active duty, he continued to work with vets. However, while continuing to work with vets, Dr. Linnerooth was dealing with depression and PTSD himself. At the age of 42, Dr. Linnerooth died by suicide. Dr. Linnerooth often discussed the burnout that was faced by army mental-health practitioners such as himself. (Thompson, 2013)

These case studies point to one common important factor in suicides that occur in the military, post-traumatic stress disorder (PTSD). Additionally, the case studies illustrate the difficulties faced by those in the military following discharge. We will discuss the literature on these and other factors that may result in an increased rate of suicide among those serving or who have served in the military. Prevention and treatment recommendations will also be given.

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SUICIDE RISK The first question that must be discussed is whether or not military personnel represent an at-risk group.

Suicide in Relation to Active Duty Schroderus, Lonnqvist and Aro (1992) examined the suicide rates among conscripts in Finland and compared them to the suicide rates of age-matched men in the general population. Military conscripts had half the suicide rate of nonmilitary men, indicating a protective factor for military service. Helmkamp (1995) found that white males accounted for 79 percent of all American military suicides and had the highest rates across all ages. Suicide risk among active duty males was more than twice that of all active duty females, but half that of males in the general population. Active duty females also had lower suicide risk than females in the total population. Sentell, Lacroix, Sentell, and Finstuen (1997) compared military rates of suicide between 1980 and 1992 in the United States with the suicide rates of the general population and found that military suicide rates were consistently lower than civilian rates and that military female rates were lower than military male rates, similar to the findings of Helmkamp (1995). The conclusion seems to be clear, namely that serving in the military does not increase one’s risk for suicide in these older studies. The American Foundation for Suicide Prevention (www.afsp.org) has a PDF on file entitled Military personnel and veteran suicide prevention, which states that the active duty Army suicide rate increased from 9.6 in 2004 to 21.9 in 2009 and 22.9 in 2011. This is certainly a large increase. In 2010, the suicide rates for the Marine Corps and the Army were greater than those for the Air Force and Navy. However, are these rates high? First, the Army is primarily male. According to the Department of Defense (http:/prhom.defense.gov accessed February 10, 2013), 75,507 of the 561,979 active duty Army personnel were female (13.4%). According to the American Association of Suicidology (www.suicidology.org), there were 38,364 suicides in the United States in 2010, 30,277 by men and 8,087 by women. Although the suicide rates for Americans in general are reported to be 20.0 for men and 5.2 for women, these are based on the total population. Using the population aged 15 and over, the suicide rates are 25.2 and 6.4 respectively. Weighing these by the proportion of men and women in the Army, the suicide rate for the Army, based on the general population aged 15+,

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should be 22.7 which is roughly what the suicide rate was for the Army in 2009–2011.1 However, if the number of suicides in active duty personnel continue to rise, even though the suicide rate of the general population is also increasing slowly in the United States as a whole, then the suicide rate in the active duty personnel may soon be higher than expected. It is not possible to do similar calculations for veterans since we do not know exactly how many suicides each year are veterans and how many veterans there are in the general population. However, veterans constitute about 13 percent of the male population in the United States and 1 percent of the female population (www.infoplease.com), and the proportion of suicides who are veterans in the 21 states that have such information was 21 percent in 2010 (Kemp & Bossarte, 2012). This suggests that being a veteran does increase the risk of suicide.

Suicide in Relation to Combat Experience2 Farberow, Kang and Bullman (1990) examined the relationship between combat experience and suicide among Vietnam veterans. None of the military service factors were associated with suicide. Symptoms of PTSD were more common among those who died by suicide than those who died in motor vehicle accidents, but the extent of combat experience was not a good predictor of suicide. Bullman and Kang (1996) found an increasing risk of suicide in Vietnam veterans with increased experience of combat trauma. Additionally, those who had been injured more than once, and who had subsequently been hospitalized for their wounds, were at the greatest risk of suicide, and their suicide rate was higher than that for men in the general population. In addition to studies examining the relationship between suicide and combat exposure, several studies have found linkages between combat exposure and well-documented risk factors for suicide. For example, Prigerson, Maciejewski and Rosenheck (2002) investigated the relationship between combat exposure and reports of psychopathology and found that post-traumatic stress disorder, major depressive disorder, substance abuse disorder, job loss, current unemployment, current divorce or separation, and spouse or partner abuse were more common in those who had exposure to combat. 1. Using Londono’s estimate of 349 suicides-active duty suicides in 2012 and the active duty numbers in 2010, the suicide rate comes out to 24.4, still not appreciably much higher than the rate for the general population. 2. For recent reviews of PTSD and suicide see Pompili et al. (2009b) and Krysinska and Lester (2010).

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EXPLANATIONS FOR SUICIDE RISK While the research has shown that service in the military may be associated with a lower risk of suicide, exposure to combat is a risk factor for suicide. Several theorists have proposed explanations for this.

PTSD In recent years, more attention has been paid to the development of PTSD among veterans who have experienced combat. Both of the case studies discussed above point to the potential connection that PTSD and other mental illnesses have with suicidal behavior. Tarrier and Gregg (2004) examined the relationship between PTSD and suicide risk in a nonmilitary clinical sample. As expected, patients with PTSD had a very high incidence of suicidal ideation (38%), making plans for suicide (9%) and actually attempting suicide (10%), percentages that seemed to be higher than those for the general population. Life impairment and depression were independently and significantly linked to suicidal behavior. Freeman, Roca, and Moore (2000) compared patients with combat-related PTSD with and without a history of suicide attempt. Soldiers with a history of suicide attempts reported more severe symptoms of depression, anxiety and PTSD. However, they did not differ in the experience of combat exposure, the experience of pain, symptoms of dissociation, or histories of alcohol and substance use. Kotler, Iancu, Efroni and Amir (2001) compared patients with PTSD to patients with anxiety disorders and to healthy controls and found that the PTSD patients had higher levels of suicide risk (as measured by a suicide risk scale), impulsivity and anger. For the PTSD patients, impulsivity predicted a higher suicidal risk while social support predicted a lower suicidal risk. For the patients with anxiety disorders, only social support was associated with suicidal risk while, for the healthy controls, only anger was associated with suicidal risk. These studies are representative of the research into the relationship between PTSD and suicidal behavior and indicate that those suffering from PTSD are at an increased risk of suicide, especially when the PTSD is comorbid with other mental illnesses (e.g., depression) and risk factors (e.g., impulsivity).

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The Acquired Capability for Suicide The Interpersonal-Psychological Theory of Suicide (IPTS)3 postulates that suicide occurs when three risk factors co-occur: (1) thwarted belonging, (2) perceived burdensomeness, and (3) the acquired capability for suicide. Of particular importance in understanding the increased risk of suicide among veterans with combat experience is the acquired capability for suicide. The acquired capability of suicide can be thought of having two components: (1) a reduced fear of death, and (2) habituation to pain. By being exposed to life and death situations in combat and by experiencing wounds and injuries, veterans can be seen to rate very high in the acquired capability for suicide. Brenner and his colleagues (2008), in a qualitative study of soldiers returning from Operation Enduring Freedom and Operation Iraqi Freedom, found that a major theme that emerged was the exposure to pain that soldiers undergo in combat and an increase in pain tolerance. Supporting the IPTS, they also found themes of perceived burdensomeness and thwarted belonging. Bryan and Cukrowicz (2011) examined the relationship between the acquired capability for suicide and combat exposure and found that all types of combat exposure contributed independently to the acquired capability for suicide. In a sample of military personnel deployed in Iraq, Bryan, Cukrowicz, West, and Morrow (2010) also found that a greater range of combat exposure predicted the acquired capability of suicide independently of depression, PTSD symptoms and previous suicidal behavior. PREVENTION AND CLINICAL RECOMMENDATIONS4 Several recommendations can be made to help prevent and treat suicidal behavior in veterans. The IPTS has linked suicidal behavior to the acquired capability for suicide, perceived burdensomeness and thwarted belonging, but little can be done to alleviate the acquired capability for suicide that is present among those who experience combat. However, the other two risk factors, perceived burdensomeness and thwarted belonging, could be the focus of interventions. By alleviating a sense of burdensomeness and by increasing a sense of belonging in veterans, suicide risk could be alleviated. Groups where veterans can meet and discuss their experiences could help foster a sense of belonging. Additionally, improvement in programs that find 3. See Chapter 3. 4. Suicidal behavior and the need for prevention is also important for those armed forces involved in peacekeeping missions around the world (Pompili et al., 2009a).

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work for veterans could help to alleviate a sense of burdensomeness. In the case study mentioned at the start of this chapter, Major Hackett had found only menial work following his discharge and, when he was unemployed, could not find work. This may have contributed to a sense of being a burden to his family and led him to his decision to die by suicide. Additionally, careful assessment of those who are suffering from PTSD and other comorbid mental illnesses should be mandatory since previous research has shown that this is a group that is particularly at risk for suicide. Risk factors for suicide, such as impulsivity, should be monitored, as these will generate a greater risk among veterans. Finally, all military personnel should be monitored for suicide risk. While many may focus only on those who have experienced combat, others such as Dr. Linnerooth above, who aid veterans, may also experience PTSD and suicidal ideation. However, let us look at the reality of the situation. In a report in the July 23, 2012, issue of Time, Gibbs and Thompson (2012) examined two military suicides. One of them was by Ian Morrison, an AH-64 Apache helicopter pilot who had battled depression for many years. His wife urged him to call the Pentagon’s crisis hotline. He did and was put on hold for 45 minutes. His final text to his wife was that he was still on hold, and he shot himself that night. Let us be clear about this. It is great to set up suicide prevention programs, as some units in the Department of Defense have done. It is unprofessional and unethical to run these programs incompetently. We will see later in this book (chapters 25 and 26) how difficult it is to get men to seek help. They are reluctant to admit that they need help and also reluctant to seek it. Hegemonic masculine values, which are prevalent in many groups and especially in the military, make admitting the need for and seeking help extremely difficult. When men finally do get to this point, to put them on hold at a crisis hotline, for example, is counterproductive. Gibbs and Thompson cite research that soldiers are much more willing to admit to problems such as depression and suicidal ideation in anonymous questionnaires than in face-to-face questions. However, commanders tell their men that to admit such moods and thoughts will risk their careers, thereby deterring the men from seeking help. Morrison did go to a health clinic at Fort Hood prior to his suicide. He waited for three hours, and then was told that they could not see him or prescribe anything. He was told that he needed to see the doctor who was assigned to his unit. This doctor then reprimanded Morrison for not following procedures and for not being there hours earlier. As a result of this reception, Morrison mentioned only his sleeplessness. Two days later, Morrison saw another Army doctor who, in a single 20-minute interview, diagnosed clinical depression and gave him medications for depression and anxiety.

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In the second case, Dr. Michael McCaddon’s wife went to her husband’s commanding officer to inform her of his depression and suicidal thoughts. The commander did call McCaddon in, but she refused to order him into treatment, and she told his wife that this did not seem to be an Army issue, but rather a family issue. After her husband’s suicide in the hospital where he worked, his wife wished she could confront that commanding officer and ask her whether she still thought it was merely a family issue. One potential root of this problem is that those in command at the Pentagon do not really care. Because of public and congressional concern, they pretend to care, but 350 suicides a year in a force of 1.4 million are easily replaced.5 As Gibbs and Thompson reported, Army Major General Dana Pittard, commander of the 1st Armored Division at Fort Bliss in Texas, wrote on his blog that he was fed up with absolutely selfish troops who kill themselves, leaving him and others to clean up the mess. The military is an authoritarian organization. If the leader says jump, the underlings jump. If the chiefs in the Pentagon had forcibly retired General Pittard (and others like him) or had reprimanded him in a meaningful way, behavior would change. Gibbs and Thompson quote the Secretary of Defense, Leon Panetta, saying that the military had to do everything it could to prevent suicide, but this statement may be merely for public relations. Unless the military services hire sufficient numbers of qualified staff for their clinics and hotlines, then matters will not improve. Saying that they wish to prevent suicide in the military is not enough. Actions speak louder than words and, at present, the upper echelons of the military are failing in their duty to prevent suicide among soldiers.

The Air Force and the Veterans Administration A comparison of the response of the Air Force and the Veterans Administration (VA) to the problem of suicide provides an interesting contrast. The VA is slowly dealing with the problem of veterans attempting and completing suicide, beginning in 2007 with plans to set up a surveillance program, research to identify risk and protective factors and development of effective prevention interventions. In 2008, the VA’s Mental Health Services established a surveillance program to collect data on suicidal behavior among veterans. Kemp and Bossarte (2012) reported the results of this program from 2009–2012. The suicide 5. Lester experienced the same administrative indifference at Cambridge University where one of his fellow scholars completed suicide, and the college seemed to be unconcerned. There are thousands of students who want to go to that university, and so they did nothing to prevent future suicides.

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rate among users of the Veterans Health Administration (VHA) has been stable at about 35–36 per 100,000 per year (38.3 for men in 2009 and 12.8 for women). The VA has been asking states to provide data on whether the suicides in their regions are veterans or not and, based on data from 21 states, about 20 percent to 25 percent of suicides are veterans. This percentage is higher for older suicides, most likely because there are more elderly veterans (survivors of World War Two, the Korean War and the Vietnam War). VHA clients engage in roughly 15,000 nonfatal suicidal acts each year, with a rate of about 200 per 100,000 per year in 2010. The VHA is also documenting the number and type of calls to the Veterans Crisis Line, and an increase in the use of inpatient and outpatient services after a nonfatal suicide attempt has been observed. The VA is at the monitoring stage of their prevention program. In contrast, after the suicide rate in Air Force personnel increased in the early 1990s, the Air force command implemented an intensive program to prevent suicide. Several initiatives were established, including: 1. Education for leaders (including squadron leaders) 2. Improving referrals to mental health personnel 3. Basic training for all personnel for identifying suicide risk factors, intervention skills and referral procedures 4. Requiring suicide assessment for all personnel in legal (and other) troubles 5. Establishment of multidisciplinary teams to respond to traumatic events (including completed suicides) 6. Establishment of client-therapist confidentiality to encourage help-seeking 7. Surveillance of the program and evaluation of the outcomes The Air Force program has been successful in achieving its aims. Knox and colleagues (2003, 2010) have documented that since the program’s inception, the suicide rate declined by 33 percent from 1990–1996 to 1997– 2002. What is also noteworthy is that, in addition, the incidence of homicide declined by 51 percent, accidental deaths by 16 percent, and serious family violence by 54 percent. Instituting the suicide prevention program improved the help-seeking behavior of Air Force personnel and the treatment that they received in general, thereby improving the mental health of the personnel in all aspects. It is important to note that this program was established by those in command and involved training of everyone in the Air Force and, in particular, the squadron leaders and commanders. As noted above, a successful pro-

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gram in the military requires leadership from the top of the command and an insistence that everyone follow the program.6 REFERENCES Adena, M. A., Cobbin, D., Fett, M., Forcier, L., Hudson, H., Long, A., Nairn, J., & O’Toole, B. (1985). Mortality among Vietnam veterans compared with non-veterans and the Australian population. Medical Journal of Australia, 143, 541–544. Anon. (1987). Post-service mortality among Vietnam veterans. Journal of the American Medical Association, 257, 790–795. Baker, J. F. (1984). Monitoring of suicidal behavior among patients in the VA health care system. Psychiatric Annals, 14, 277. Brenner, L. A., Gutierrez, P. M., Cornette, M. M., Betthauser, L. M., Bahraini, N., & Staves, P. J. (2008). A qualitative study of potential suicide risk factors in returning combat veterans. Journal of Mental Health Counseling, 30, 211–225. Breslin, P., Kang, H. K., Lee, Y., Burt, V., & Shephard, B. M. (1988). Proportional mortality study of U.S. Army and U.S. Marine Corps veterans of the Vietnam War. Journal of Occupational Medicine, 30, 412–419. Bryan, C. J. & Cukrowicz, K. C. (2011). Associations between types of combat violence and the acquired capability for suicide. Suicide & Life-Threatening Behavior, 41, 126–136. Bryan, C. J., Cukrowicz, K. C., West, C. L., & Morrow, C. E. (2010). Combat experience and the acquired capability for suicide. Journal of Clinical Psychology, 66, 1044–1056. Bullman, T. A. & Kang, H. K. (1996). The risk of suicide among wounded Vietnam veterans. American Journal of Public Health, 86, 662–667. Bullman, T. A., Kang, H. K., & Watanabe, K. K. (1990). Proportionate mortality among U.S. Army Vietnam veterans who served in Military Region 1. American Journal of Epidemiology, 132, 670–674. Chaffee, R. B. (1982). Completed suicide in the Navy and Marine Corps. US Naval Health Research Center Reports, #82–17. Datel, W. E., Jones, F., & Esposito, M. (1981). Suicide in U.S. Army personnel. Military Medicine, 146, 387–392. Farberow, N. L., Kang, H. K., & Bullman, T. A. (1990). Combat experience and postservice psychosocial status as predictors of suicide in Vietnam veterans. Journal of Nervous & Mental Disease, 178, 32–37. Freeman, T. W., Roca, V., & Moore, W. M. (2000). A comparison of chronic combatrelated posttraumatic stress disorder (PTSD) patients with and without a history of suicide attempt. Journal of Nervous & Mental Disease, 188, 460–463. Gibbs, N., & Thompson, M. (2012). The war on suicide? Available: www.time.com /time/magazine/article/0,917,2119337,00.html, accessed January 30, 2013. 6. See also Pompili et al. (2009c) for further recommendations.

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Helmkamp, J. C. (1995). Suicides in the military: 1980–1992. Military Medicine, 160, 45–50. Hytten, K., & Weisaeth, L. (1989). Suicide among soldiers and young men in the Nordic countries 1977–1984. Acta Psychiatrica Scandinavica, 79, 224–228. Jaffe, G. (2012, February 11). Marine’s suicide is only start of family’s struggle. The Washington Post. Retrieved from: http://articles.washingtonpost.com/2012-02-11 /world/35444956_1_mental-illness-marine-corps-marine-commandant Kawahara, Y., Palinkas, L. A., Burr, R. A., & Coben, P. (1989). Suicides in active duty Navy personnel. US Naval Health Research Center Reports, #89–34. Kemp, J., & Bossarte, R. (2012). Suicide data report, 2012. Washington, DC: Department of Veterans Affairs. Knox, K. L., Litts, D. A., Talcott, G. W., Feig, J. C., & Caine, E. D. (2003). Risk of suicide and related adverse outcomes after exposure to a suicide prevention programme in the U.S. Air Force. British Medical Journal, 327, 1376–1378. Knox, K. L., Pflanz, S., Talcott, G. W., Campise, R. L., Lavigne, J. E., Bajorska, A., & Caine, E. D. (2010). The U.S. Air Force suicide prevention program. American Journal of Public Health, 100, 2457–2463. Kotler, M., Iancu, I., Efroni, R., & Amir, M. (2001). Anger, impulsivity, social support, and suicide risk in patients with post-traumatic stress disorder. Journal of Nervous & Mental Disease, 189, 162–167. Krysinska, K., & Lester, D. (2010). Post-traumatic stress disorder and suicide risk. Archives of Suicide Research, 14, 1–23. Londono, E. (2013, January 14). Military suicides rise to a record 349, topping number of troops killed in combat. The Washington Post. Retrieved from: http: //articles.washingtonpost.com/2013-01-14/world/36343832_1_military-suicides-risesuicide-rate-active-duty-suicides McDowell, C. P., & Wright, A. M. (1988). Suicide among active duty USAF members. In M. Moldeven (Ed.), Suicide prevention programs in the Department of Defense (pp. 3/6–3/70). Del Mar, CA: Moldeven. Moldeven, M. (1988). Suicide prevention programs in the Department of Defense. Del Mar, CA: Moldeven. Pollack, D. A., Rhodes, P., Boyle, C. A., Decoufle, P., & McGee, D. L. (1990). Estimating the number of suicides among Vietnam veterans. American Journal of Psychiatry, 147, 772–776. Pompili, M., Cuomo, I., Dominici, G., Falcone, I., Iacrossi, G., Saglimbene, A., Lester, D., Tatarellu, R., & Ferracuti, S. (2009a). Suicidal behaviour among current and former peacekeepers. In L. Sher & A. Vilens (Eds.), Suicide in the military (pp. 41–55). Hauppauge, NY: Nova Science. Pompili, M., Forte, A., De Simoni, E., Telesforo, L., Lester, D., Tatarelli, R., & Ferracuti, S. (2009b). Post traumatic stress disorder and suicidal behavior. In S. Sher & A. Vilens (Eds.), War and suicide (pp. 113–139). Hauppauge, NY: Nova Science.

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Pompili, M., Rigucci, S., Di Cosimo, D., Pugliese, M., Pontremolesi, S., Sapienza, L., Innamorati, M., & Lester, D. (2009c). Suicide prevention in the Army. In L. Sher & A. Vilens (Eds.), Suicide in the military (pp. 57–69). Hauppauge, NY: Nova Science. Prigerson, H. G., Maciejewski, P. K., & Rosenheck, R. A. (2002). Population attributable fractions of psychiatric disorders and behavioral outcomes associated with combat exposure among U.S. men. American Journal of Public Health, 92, 59–63. Schroderus, M., Lonnqvist, J. K., & Aro, H. M. (1992). Trends in suicide rates among military conscripts. Acta Psychiatrica Scandinavica, 86, 233–235. Sentell, J. W., Lacroix, M., Sentell, J. V., & Finstuen, K. (1997). Predictive patterns of suicidal behavior: The United States armed services versus the civilian population. Military Medicine, 162, 162–171. Tarrier, N. & Gregg, L. (2004). Suicide risk in civilian PTSD patients. Social Psychiatry & Psychiatric Epidemiology, 39, 655–661. Thompson, M. (2013, January 11). Dr. Peter J. N. Linnerooth, 1970–2013. Time. Retrieved from: http://nation.time.com/2013/01/11/dr-peter-j-n-linnerooth-19702013/

Chapter 10 SUICIDE IN MASS MURDERERS AND SERIAL KILLERS 1

DAVID LESTER urder followed by suicide is not an uncommon event, and several research reports have appeared on the topic. For example, Palermo et al. (1997) found that typical murder-suicide in Midwest America was a white man, murdering a spouse, with a gun in the home. In England, Milroy (1993) reported that 5 percent to 10 percent of murderers committed suicide. Most were men killing spouses, with men killing children second in frequency. Shooting was the most common method. Similar patterns have been observed in Canada (Cooper & Eaves, 1996) and Japan (Kominato et al., 1997). This chapter will discuss suicide occurring in mass murderers and serial killers, groups which are predominately male.

M

MASS MURDERERS Mass murder has become quite common in recent years, from workers at post offices “going postal” to school children killing their peers in school. Data from the United States indicate that the percentage of homicides with more than one victim increased over the period from 1976 to 1996 from 3.0 percent to 4.5 percent (Lester, 2002). Indeed, Lester (2004) recently called mass homicide “the scourge of the twenty-first century. Examples are easy to find. Here are three cases from media reports.

1. This is based on Lester (2010).

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March 11, 2009 Winnenden, Baden-Württemberg, Germany Tim Kretschmer, aged 17, a former student, enters the Albertville-Realschule and kills 9 students and a teacher, flees and kills 3 others before committing suicide when confronted by police. April 3, 2009 Binghamton, New York Jiverly Wong, aged 41, a Vietnamese immigrant, kills 13 immigrants and wounds 4 others at a community center, and then commits suicide. April 30, 2009 Baku, Azerbaijan Farda Gadyrov, a Georgian citizen, enters the Azerbaijan State Oil Academy, kills 12 and injures 13 before turning his gun on himself. There are many categories of mass homicide, including familicides (in which a person slaughters other members of his or her family), terrorists such as Timothy McVeigh who killed 168 people at the Alfred P. Murrah Federal Building in Oklahoma city on April 19th, 1995 (Michel & Herbeck, 2001), and those who simply “run amok,” such as Martin Bryant who killed 35 people and wounded over 30 others at Port Arthur, Australia, on April 29th, 1996 (Cantor, Sheehan, Alpers, & Mullen, 1999). Holmes and Holmes (1992) classified mass killers into five types: disciples (killers following a charismatic leader), family annihilators (those killing their families), pseudocommandos (those acting like soldiers), disgruntled employees, and set-and-run killers (setting a death trap and leaving, such as poisoning food containers or over-the-counter medications). It has been difficult to study several of these categories of mass murderers because no one has developed a comprehensive list of murderers falling into the groups. The only category studied hitherto has been the pseudocommandos (also known as rampage murders). In a preliminary study of mass murderers, Lester, Stack, Schmidtke, Schaller and Müller (2004) examined 143 incidents of mass murder committed by 144 men and one woman reported in Frankfurter Allgemeine Zeitung between January 1, 1993 and August 31, 2002. They found that the death toll was significantly higher for those murderers who committed suicide (an average of 5.6 victims) than for those killed by police officers (4.2 victims) or captured (3.1 victims). Mass murders in Europe (2.8 victims) and the Americas (2.8 victims) had fewer victims than mass murders committed elsewhere in

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the world (6.3 victims).2 The number of victims was not associated with the year of the event, the sex or age of the murderer, the number of offenders, or whether strangers, friends or family were the victims. Lester, Stack, Schmidtke, Schaller and Müller (2005) studied 100 rampage homicides since 1949, listed in an article on rampage murders in the United States published in the New York Times (www.nytimes.com/library/national /040900shoot-list.htm). They sought to explore two facets of the sample (the outcome and the deadliness) and two questions: (1) what are the differences between those rampage killers who completed suicide at the time of the act and those who were captured, and (2) whether any of the characteristics of the rampage killers were associated with the deadliness of the rampage. Several attempts were made to obtain the data set that the New York Times reported as having collected. The requests were rejected. Since access to this purported data set was refused, data were collected on each of the 100 rampage homicide incidents using searches of the Internet (from www .google.com and other search engines) and the electronic data-base provided by Lexis-Nexis. For some killers, information was easily available. For example, Charles Whitman who killed 16 and wounded 31 on August 1st, 1966, on the University of Texas campus, has a full-length biography available (Lavergne, 1997), while others had only a paragraph or two available from the Internet (such as Drew Cade who killed one and wounded two in a supermarket in Pennsylvania on June 20th, 1997). The reports were coded for characteristics of the rampage and of the killer. Characteristics (such as marital status) were coded when the information was available, and lack of information was coded as missing data. On the other hand, characteristics such as prior psychiatric care and interest in guns were coded as present if mentioned and absent if not mentioned in the reports. The 98 incidents with a single perpetrator took place from 1949 to 1999, with 90 percent taking place in the period 1980–1999. The age of the 98 killers ranged from 14 to 70 with an average age of 34. There were 93 men and 5 women. It was noticeable that fewer of these incidents took place on Saturdays or Sundays (an average of only 4.5% each day) compared to weekdays (an average of 17.8% each day). This is in contrast to homicide in general in the United States for which the incidence is higher on weekends (Rogot, Fabsitz & Feinleib, 1976). The mean number of victims killed was 4.15 (SD = 3.84) and the mean number of victims wounded was 4.72 (SD = 5.99). The number killed in the 98 incidents and the number wounded were moderately associated (Pearson 2. This may be related to the phenomenon that more people have to die in an incident of any kind in under-developed nations than in Western nations for it to be reported in Western newspapers.

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r = .50, two tailed p < .001), and the correlates of these two measures of deadliness were similar. Fifty-six of the killers were captured, 7 were killed by the police and one by a civilian, and 34 completed suicide at the time of the act (that is, within a few hours of the first killing and before capture). For all three measures of deadliness (the number killed, the number wounded, and the total number of victims), the acts of rampage killing had become less deadly in recent years, but were more deadly if the killer had shown an interest in guns and had parents who divorced. Several variables were positively associated with two of the measures of deadliness: killing significant others, prior evidence of violence in the killer, paranoia and suspiciousness, and prior service in the military. The deadliness of the rampage homicides was also associated with the outcome. Those killers who were killed by the police were more deadly than those who killed themselves who, in turn, were more deadly than those who surrendered or who were captured. Overall, those killed by police killed and wounded an average of 18.3 victims, those who completed suicide had 10.1 victims, and those who surrendered or were captured had 6.9 victims. These differences were also found separately for the number killed (8.1, 4.8, and 3.2, respectively) and the number wounded (10.1, 5.3, and 3.8, respectively). Since only seven individuals were killed by the police, the analysis of outcome compared the 56 who surrendered or were captured with the 34 who completed suicide. Only a few significant differences emerged. Suicide as an outcome was less likely if the killers were adolescents or diagnosed as schizophrenic, and more likely if the killer had friction with coworkers or the killings took place at work. These results are of interest because they suggest that it may be possible to create a classification of rampage killers as well as profiles of the different types of killers. However, the results of this study were limited because of the lack of detailed information on many of the rampage killers. The study had to rely primarily on newspaper reports and websites maintained by individuals interested in mass murder. Thus, information for many of the variables in the study was not available, and absence of a mention of a characteristic (such as interest in guns) was coded as “absent” whereas it may instead not have occurred to the newspaper reporter to ask about this characteristic. Reports in the press and online may also be limited in accuracy. Only for cases in which several alternative reports exist, could the reliability of the information (i.e., does it appear in several independent reports) be checked. Ideally, in the future, researchers trained in psychological autopsies should investigate a sample of rampage killers, using a detailed interview schedule, so that all of the critical variables can be explored for their absence or pres-

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ence in each case. If this were done, the data and results obtained would have greater validity than those obtained for the present study.

A Case Study: Joseph Wesbecker On September 14th, 1989, Joseph Wesbecker went to the printing plant where he worked (although he was on disability leave at the time) and, firing his semi-automatic assault weapon, killed eight coworkers and wounded many more. He then shot himself in the head with a pistol and died (Cornwell, 1996). At the time of the massacre, Wesbecker lived alone and had been on disability for about a year. Occasionally he visited and slept with his second exwife, Brenda. He was seeing a psychiatrist, Dr. Lee Coleman, who had given Wesbecker lithium for his manic-depressive disorder and Prozac for his depression, but Coleman was beginning to think that Wesbecker had a schizoaffective disorder, a psychosis that is a mix of schizophrenia and depression. Wesbecker had been in and out of treatment before, attempting suicide in 1984 with an overdose and with car exhaust. Over the years, all kinds of psychotropic medications had been tried, but the current medications did not seem to be helping Wesbecker, and they seemed to be making him agitated. Coleman had tried to persuade Wesbecker to go into the hospital on September 11th, but Wesbecker refused. On September 13th, Wesbecker drove his son James to his college classes and picked him up after class. He insisted on buying a textbook James needed for class. He spent that night with Brenda, his ex-wife. On September 14th, Wesbecker failed to pick James up. He was already on his way to the Standard Gravure printing plant to get revenge. Wesbecker was born on April 27th, 1942, in Louisville to Martha Wesbecker who had married the previous year at the age of 15. Wesbecker’s father fell to his death while mending a church roof the next year, and Wesbecker’s grandfather (who had become his surrogate father) died when Wesbecker was almost two. The next few years were filled with moves as Wesbecker’s mother moved to different sets of relatives and then back to Louisville. He was even placed in an orphanage for a year when he was ten. Although he was back with his mother the next year, life was still unstable. For example, Martha attempted suicide by drinking rat poison soon after Wesbecker arrived back with her. As a teenager, Wesbecker was rather wild. He dropped out of high school and was arrested several times for disorderly conduct and fighting. He spent a night in jail for siphoning gas out of someone else’s truck. He often carried a starter gun which he fired just to scare people. At the age of 18, Wesbecker

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went to work as a printer and married Sue White. For the next 12 years, Wesbecker settled down. He worked hard and moved to Standard Gravure in 1971, bought better and better houses for his family, and had two sons, Kevin who developed curvature of the spine and James who later became a compulsive exhibitionist, causing Wesbecker a great deal of stress. Wesbecker had some strange traits. He was a perfectionist and seemed to have an unusual desire to be clean. He frequently quarreled with his neighbors. His mother lived with him for a time, and the problems with the two boys began to get worse when they became teenagers. The stress in the marriage grew, and it ended for good in 1980. Meanwhile, the stress at Standard Gravure had become overwhelming. The printing plant had once belonged to the local newspaper, the CourierJournal, but the paper was sold to Gannett (who published USA Today). The plant was then sold to Brian Shea who ran it independently. Faced with rising costs and a demand for increased productivity, the plant installed highspeed machines, and the men were forced to work sixteen-hour shifts. The noise was tremendous, and the fumes from the toluene used in the ink made the men pass out. The men were made to work night and weekend shifts, and there were pay cuts and erosion of job security as men were laid off. Strangely, rather than banding together against the foremen, the men started taking out their frustration on one another, such as pouring water on the printing paper and fouling up the machines that others were trying to run. In the mid1980s, the men began bringing guns to work. Wesbecker attended Parents without Partners and met Brenda Beasley who had two teenage girls. They married in 1981. Wesbecker wanted Kevin to have surgery for his spinal problem, but Kevin refused and the relationship between the two grew distant. James continued to expose himself, and Brenda’s ex-husband was concerned about the safety of his daughter, eventually getting custody of his daughters. Wesbecker paid for residential psychiatric care for James, but James continued his exhibitionism. Wesbecker and his ex-wife continued to fight. Wesbecker won a lawsuit against Sue for slander, and she was placed on two-years probation for threatening him. Wesbecker thought that the foremen at Standard Gravure were deliberately assigning him the most stressful jobs, and he talked to the plant’s social worker about it. Eventually, his psychiatrists wrote to the plant to insist that Wesbecker get less stressful tasks. It was at this time that Wesbecker attempted suicide and was committed to a psychiatric hospital (on April 16th, 1984) where he was diagnosed with Major Affective Illness, Depressed, Recurrent Type. The hospital’s psychologist thought that Wesbecker also had a borderline personality disorder. After his discharge, Wesbecker was put on an antidepressant (one of the many medications that he tried). Brenda moved out

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and divorced him in 1984. Despite this separation, they remained good friends and lovers. Wesbecker continued to press for easier working conditions, even going to the Human Relations Commission in Louisville in May 1987, but his case worker there made little progress in his negotiations with the plant. Wesbecker began to buy weapons in 1988 and to read magazines such as Full Auto Firearms and Soldier of Fortune. He went to shooting ranges with Brenda. His son James was caught exposing himself again and was sentenced to 90 days in jail. Wesbecker was so irritable that, when he had trouble with his lawnmowers, he wrecked them with an axe and drove his car over them. He often talked to his friends and coworkers about bombing the plant or “wiping the whole place out.” On September 7th, 1988, Dr. Lee Coleman got Wesbecker placed on disability leave, but Wesbecker believed that he had been cheated over the amount of his disability pay. Wesbecker visited a funeral home and arranged and paid for his cremation. He deeded his house to Brenda, and he continued to accumulate an arsenal of guns. As 1989 passed, Wesbecker’s son James continued to get into trouble almost every week. In July, Wesbecker discussed suicide with his friend James Lucas. Wesbecker’s grandmother, who had been a surrogate mother for him, died on August 5th, 1989, and a few days later Dr. Coleman switched Wesbecker to Prozac and began to wean him off the other medications. Wesbecker told his friend Lucas not to go to work because he had a plan to eliminate the place. He had a list of seven people there he wanted to eliminate. Lucas swore (later in court) that he warned the managers at the plant but that they did not take the threat seriously. On September 14th, 1989, Wesbecker arrived at the printing plant just after 8:30 a.m. and began his shooting rampage. What makes this mass murder of special interest is that those who were wounded, but who survived the massacre, sued Eli Lilly, the makers of Prozac, arguing that Prozac was responsible for Wesbecker’s rampage at the plant. The jury decided that Eli Lilly was not responsible, but the author of the book on the case, John Cornwell (1996) suspects that a deal may have been made “under the table” between Eli Lilly and the plaintiffs. SERIAL KILLERS In contrast to mass murder, serial killers are defined as those who kill two or more victims on separate occasions (Lester, 1995). No study had appeared prior to 2008 on the extent to which serial killers complete suicide, but the informal impression gained from studying the cases (e.g., Lester, 1995) is that suicide is infrequent among them. However, serial killers occasionally do complete suicide.

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For example, Herb Baumeister was a married man with three children who was suspected of killing 16 gay men by strangulation in Indiana and Ohio during the 1990s. An organized lust killer, he buried some of his victims on his property. Baumeister began killing when he was 33 years of age. When Baumeister became a suspect in the disappearances of gay men in the area, and when his marriage fell apart, he drove to Ontario and shot himself in the head, leaving a two-page suicide note. Another example of a serial killer who chose suicide over prison was Leonard Lake. He and his partner, Charles Ng, built a bunker in which to keep female sex slaves, and it is believed they killed 12 people. When apprehended for shoplifting, Lake took a cyanide capsule and died. Some serial killers commit suicide after being sent to prison. Richard Trenton Chase suffered from paranoid schizophrenia when he killed and mutilated six people in Sacramento, California in 1978. Chase drank the blood of some of his victims because he thought that his own blood was turning into powder. After being arrested, charged, and convicted of murder, he was sentenced to die in the gas chamber. Chase committed suicide in prison by taking an overdose of his medication that he had saved for several weeks. Some serial killers have made failed suicide attempts (e.g., Cary Stayner) before they embarked upon their serial killing. They appear to have turned their suicidal urges into murderous rampages. Newton (2006) provided a detailed listing of serial killers, and his data were used to explore the occurrence of suicide in his sample of serial killers in a study by White and Lester (2008). Newton listed solo serial killers and group serial killers. He also listed cases from around the world and back into the nineteenth century. In order to make the sample comparable to the study of mass murderers in the United States by Lester et al. (2005), the cases were restricted to solo killers in the United States from 1950 to 2002. Newton provided data on age, sex, race, the year that the murders took place, and the number of murdered victims. The types of serial murderers were classified as nomadic, territorial or stationary. The motives were classified as criminal enterprise, personal causes, sexual and sadistic, and some killers were classified as having more than one motivation. The outcome was coded as suicide, captured, killed by police during attempts to capture, and other (including murdered by others and death from natural causes). The sample consisted of 594 serial killers: 559 men, 31 women and 4 of unknown sex; 392 were white, 95 African American, 38 Hispanic, 5 “other” and 64 unknown. The mean number of victims was 6.4 (standard deviation 7.1) with a range of 3 to 70. Several cases were listed as having “numerous” victims, and these were entered as “missing data.” Of the 594 killers, 26 committed suicide, 67 were executed, 481 others caught and processed by the

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criminal justice system but not executed, 8 were killed by police officers, 6 were murdered and 6 had missing data. By decade, 19 cases came from the 1950s, 66 from the 1960s, 162 from the 1970s, 196 from the 1980s, 134 from the 1990s, 13 from the 2000s, and 4 had missing data. Three hundred and seventeen were classified as territorial killers, 27 as stationary, 246 as nomadic, and 4 had missing data. Twenty-nine percent were classified as having a criminal enterprise motive, 37 percent as personal cause, 50 percent as sexually motivated and 14 percent as sadistic. (Some killers were assigned multiple motives.) The number of victims was associated with the type of crime: Territorial killers killed fewer victims (5.2) than stationary (8.0) or nomadic (7.8) killers. The number of victims was not related to whether the motive was criminal enterprise, personal cause, sex, or sadism. The number of victims was not associated with the decade that the killings began, but men did kill more victims than did women (means 6.6 versus 3.9). There were no differences by race (White, Black and Hispanic) in the number of victims. Those executed tended to kill fewer victims than those captured but not executed (means 4.9 versus 6.7). Those committing suicide (n = 26) were compared with those captured (n = 547). The two groups did not differ in sex, race, whether territorial, stationary or nomadic, or motive (personal cause, sex, or sadism). However, those killing for criminal enterprise were more likely to complete suicide (5.7% versus 1.8%). In this very large sample of serial killers in the United States from 1950 to 2002, only 26 committed suicide, that is, 4.4 percent. In contrast, in the study on rampage mass murderers in the United States during the same period, reported above, 34.7 percent committed suicide, a far higher proportion. It is perhaps possible that rampage murderers are energized by such a great amount of anger that even killing many victims is not sufficient to discharge the anger, and the residual anger is turned inward on the self. Serial killers, on the other hand, may be less impulsive, with much more cognitive planning and self-control. Empirical studies comparing the psychodynamics of rampage and serial killers are needed to explore such potential psychological differences. The study was limited by the variables that Newton used to describe the serial killers. Future research should explore more characteristics of the serial killers and their criminal acts for their relationship to the deadliness of the killings and to the outcome (suicide versus capture).

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A More Extensive Study of Suicide in Serial Killers In order to pursue the study of suicide in serial killers, a data set for serial killers who completed suicide was created. The list of serial killers is shown in Table 10.1, and data were available for 58 serial killers. For these, the timing of the suicide was as follows: Prior to identification: To avoid arrest During arrest Before trial After conviction

5 (8.6%) 10 (17.2%) 13 (22.8%) 15 (25.9%) 15 (25.9%)

It can be seen that the timing of the suicide varies quite widely. Only 9 percent completed suicide prior to identification, motivated by guilt perhaps or despair at their uncontrollable murderous impulses, 17 percent completed suicide to avoid arrest, and 23 percent completed suicide during the arrest process. In contrast, almost all mass murderers complete suicide during these phases of the process. Suicide after arrest and suicide after conviction were equally common, each accounting for 26 percent of the suicides. Analysis of the psychodynamics of the motives of these serial killers is difficult because the biographies are typically written by journalists or crime writers (rather than mental health professionals), and most of their accounts focus on the details of the crimes and crime scenes rather than psychodynamically-relevant information. Whereas it has been relatively easy to profile the typical rampage mass murderer, there is no “typical” serial killer who completes suicide. However, it is of some interest to examine briefly two cases.

Two Cases of Serial Killers Who Completed Suicide Herbert Baumeister Baumeister was born on April 7, 1947, in Indiana (Weinstein & Wilson, 1998). His father was an anesthesiologist. He had one younger sister and two younger brothers. He experienced an apparently normal childhood. In adolescence, however, he exhibited bizarre behavior, playing with dead animals and having strange fantasies such as wondering what urine tastes like. He was diagnosed as schizophrenic (or multiple personality—the journalistic report confuses the two diagnoses), but he did not receive any treatment. He had a series of jobs, worked hard, but continued to exhibit bizarre behavior, such

1978 1896 1947 1951 1956 1957

Akinmurele, Stephen Ball, Joe Baumeister, Herbert Birnie, David Brandt, Carl Butts, Vernon Carr, Hank Carter, Jonathan Chanal, Pierre Chase, Richard Clements, Robert Costa, Antone Cota, Fernando Crutchley, John DeJesus, Carmello Denke, Karl Edwards, Mack Ray Evonitz, Richard Fazekas, Julia Gamper, Ferdinand Glover, John Wayne Grossman, George Hatcher, Charles Herzog, Loren Hohenberger, Robert Iqbal, Javed 1959

1980 1946 1950 1890 1945 1946 1946 1934 1870 1919 1963 1865 1957 1932 1863 1929 1966

Birth year

Name 1999 1938 1996 2005 2004 1981 1998 1999 2003 1980 1947 1974 1984 2002 1973 1924 1971 2002 1929 1996 2005 1921 1984 1999 1978 2000

England USA USA Australia USA USA USA USA France USA England USA USA USA USA Silesia USA USA Hungary Italy Australia Germany USA USA USA Pakistan

Year of death Nationality

hanging gun plastic bag gun hanging hanging gun poison gun hanging hanging hanging gun hanging

during arrest after conviction

hanging gun gun hanging hanging hanging gun gun cut medication

Method

before trial during arrest avoid arrest after conviction at crime scene before trial during arrest prior to capture after arrest after conviction avoid arrest after conviction traffic stop after conviction prior to identification after arrest after conviction during arrest avoid arrest during arrest after conviction ? after conviction

Suicide

Table 10.1. SERIAL KILLERS WHO COMPLETED SUICIDE (20TH CENTURY).

continued

public place prison

jail prison home prison van prison field jail prison public place home home prison jail prison

jail his bar park prison home jail store

Place

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1945 1945 1948 1908 1967 1965 1960

Jackson, Michael Lake, Leonard Macek, Richard Merrett, John Moore, Douglas Perry, Calvin Player, Michael Pleil, Rudolf Poehlke, Norbert Pough, James Prudom, Barry Rezala, Sid Ahmed Richards, Robert Robbins, Gary Rodriguez, Robert Rolle, Randal Rooyen, Gert van Sack, George Savini, Paul Schlatter, Darrell Schmidt, Helmuth Schmidt, William Shipman, Harold Succo, Roberto Tannenbaum, Gloria Travis, Maury Unterwager, Jack 1965 1952

1933 1946 1962

1952

1935 1950 1918

1948 1944 1979

Birth year

Name 1986 1985 1987 1954 2004 1984 1986 1958 1985 1990 1982 2000 1989 1988 1992 1949 1990 1963 1992 1993 1918 1989 2004 1998 1971 2002 1994

USA USA USA UK Canada USA USA Germany Germany/Italy USA England France USA USA USA USA South Africa USA Italy USA USA USA UK Italy USA USA Austria/Czech/USA

Year of death Nationality

hanging plastic bag poison hanging hanging

hanging

gun hanging hanging gun hanging gun gun gun fire v-p murder gun poison gun gun

to avoid arrest? after arrest after arrest prior to identification after conviction avoid arrest during mass murder during arrest after arrest ? during arrest to avoid arrest? ? during arrest avoid arrest? after arrest? after arrest avoid arrest after conviction after conviction after conviction after arrest after conviction

gun cyanide

Method

during arrest after arrest

Suicide

Table 10.1—Continued.

prison prison mental hospital jail prison

jail jail

jail jail hotel room prison car business place public place jail cell highway highway home in public

barn jail

Place

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Vakrinos, Dimitros Vermilyea, Louise Weber, Jeanne Wenzinger, Gerd West, Fred West, John Wheat, Clarence Whitt, Jimmy Wilcox, Donald Wilder, Christopher

Name

1971 1968 1945

1875 1944 1941

Birth year 1997 1910 1910 1997 1995 1948 1980 1994 2003 1984

Greece USA France Germany/Brazil UK USA USA USA USA Australia/USA

Year of death Nationality after arrest during home arrest after conviction awaiting extradition after arrest during arrest prior to identification during arrest during arrest during arrest

Suicide

Table 10.1—Continued.

hanging poison strangulation hanging hanging gun gun gun gun gun

Method

highway motel gas station

jail home asylum jail jail public place

Place

Suicide in Mass Murderers and Serial Killers 121

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as ranting at fellow workers and urinating on his boss’s desk. He once sent a Christmas card with a photo of himself and another man dressed in drag. He married Juliana Saiter in 1971 and had three children, but Juliana reported later that they had sex only six times in their 25 years of marriage, and she never saw her husband nude. He founded the Sav-A-Lot chain of discount stores in 1988 and quickly rose to affluence and prominence in his community. By the mid-1990s, however, the business began to falter. In the 1990s, a number of gay men in the Indianapolis area disappeared, and in 1993, police were contacted by a man claiming that a “Brian Smart” had killed a friend of his and attempted to murder him. Baumeister (aka Brian) had the man strangle him while he masturbated, and then they reversed roles. In 1995, he saw the man again, recorded the license plate of the car, and the police traced the car to Baumeister. Investigators approached Baumeister, informed him that he was a suspect and requested permission to search his house. Baumeister refused. In 1996, his wife filed for divorce, frightened by Baumeister’s mood swings and erratic behavior, and she permitted the search while Baumeister was on vacation. The search yielded the remains of eleven men, four of whom were identified. Baumeister fled to Ontario where he committed suicide in Pinery Provincial Park by shooting himself in the head. His suicide note gave his failed marriage and his business problems as the cause. It made no mention of the murders. Baumeister is also suspected of the murder of nine men found along Interstate 70 in Indiana and Ohio. Baumeister showed early signs of psychiatric disturbance but, despite this, was reasonably successful at work and managed to marry and have a family. His disturbance, whatever it was, did not grossly impair his life-path. He had homosexual inclinations and sadistic fantasies and, in killing gay men, an obvious hypothesis is that he projected his self-loathing for his own homosexual desires onto others, permitting him to abuse and murder them. In the opinion of Virgil Vandagriff (unpublished), Baumeister fits the profile of a “lust killer” (rather than the psychotic, the missionary or the thrill killer).

Richard Chase Richard Chase is an example of a psychotic serial killer (Biondi & Hecox, 1992). He was born on May 23, 1950, in California. He was abused by his mother and, by the age of ten showed the classic triad of danger signs—bedwetting, pyromania and sadism toward animals. In his teenage years, he abused alcohol and drugs and had impotence problems. He developed delusions that his heart occasionally stopped beating and that someone had stolen his pulmonary artery. He tried to absorb vitamin C by holding

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oranges over his head, and he shaved his head so that he could watch his cranial bones move around. He left his mother’s home, believing that she was trying to poison him. In his apartment, he captured, killed and disemboweled animals which he ate raw to prevent his heart from shrinking. In 1975, he poisoned his blood by injecting rabbit blood into his veins and was committed to a psychiatric institution. He was treated with medication and released in 1976. His first murder victim was a man, killed in a drive-by shooting on December 29, 1977, but he then switched to women. Chase entered the home of Teresa Wallin on January 21, 1978, shot her, had intercourse with her dead body and bathed in her blood. On January 27th, he entered the home of Evelyn Miroth, shot a man there and her son, and her nephew, and then repeated his pattern with her body. He fled with the dead 22-month-old nephew and ate parts of him. The police arrested him at his apartment, where he proclaimed his innocence. He was found guilty of six counts of murder and sentenced to death. He was found in his cell on December 26, 1980, where he had committed suicide using an overdose of antidepressants that he had hoarded after being given them by the prison doctor. DISCUSSION It is clear that serial killers are less likely to complete suicide than mass murderers. The reasons for this are far from clear, and psychological autopsy studies are needed to suggest hypotheses for this difference. For American rampage mass murderers, those who completed suicide (typically at the scene of the crime) killed and wounded more victims than those who were captured, but had fewer victims than those killed by the police. An understanding of the reasons why a small percentage of serial killers complete suicide (only about 3% to 5%), as well as the timing of their suicide, must await a sound psychological autopsy study. REFERENCES Biondi, R., & Hecox, W. (1992). The Dracula killer. New York: Pocket Books. Cantor, C. H., Sheehan, P., Alpers, P., & Mullen, P. (1999). Media and mass homicides. Archives of Suicide Research, 5, 282–290. Cooper, M., & Eaves, D. (1996). Suicide following homicide in the family. Violence & Victims, 11, 99–112. Cornwell, J. (1996). The power to harm. New York: Viking.

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Holmes, R. M., & Holmes, S. T. (1992). Understanding mass murder. Federal Probation, 56(1), 53–61. Kominato, Y., Shimada, I., Hata, N., Takizawa, H., & Fujikura, T. (1997). Homicide patterns in the Toyama prefecture, Japan. Medicine, Science & the Law, 37, 316–320. Lavergne, G. M. (1997). A sniper in the tower. Denton, TX: University of North Texas. Lester, D. (1995). Serial killers. Philadelphia: Charles Press. Lester, D. (2002). Trends in mass murder. Psychological Reports, 90, 1122. Lester, D. (2004). Mass murder: The scourge of the 21st Century. Hauppauge, NY: Nova Science. Lester, D. (2010). Suicide in mass murderers and serial killers. Suicidology Online, 1, 19–27. Lester, D., Stack, S., Schmidtke, A., Schaller, S., & Müller, I. (2004). The deadliness of mass murderers. Psychological Reports, 94, 1404. Lester, D., Stack, S., Schmidtke, A., Schaller, S., & Müller, I. (2005). Mass homicide and suicide. Crisis, 26, 184–187. Michel, L., & Herbeck, D. (2001). American terrorist. New York: Regan Books. Milroy, C. M. (1993). Homicide followed by suicide (dyadic death) in Yorkshire and Humberside. Medicine, Science & the Law, 33, 167–171. Newton, M. (2006). The encyclopedia of serial killers. New York: Checkmark Books. Palermo, G. B. (1997). The berserk syndrome. Aggression & Violent Behavior, 2, 1–8. Palermo, G. B., Smith, M. B., Jenzten, J., Henry, T. E., Konicek, P. J., Peterson, G. F., Singh, R. P., & Witeck, M. J. (1997). Murder-suicide of the jealous paranoia type. American Journal of Forensic Medicine & Pathology, 18, 374–383. Rogot, E., Fabsitz, R., & Feinleib, M. (1976). Daily variation in U.S.A. mortality. American Journal of Epidemiology, 103, 198–211. Vandagriff, V. (undated). Who is a serial killer? Unpublished. Weinstein, F., & Wilson, M. (1998). Where the bodies are buried. New York: St. Martin’s Press. White, J., & Lester, D. (2008). Suicide and serial killers. American Journal of Forensic Psychiatry, 29(2), 41–45.

Chapter 11 SUICIDE BOMBERS DAVID LESTER erari (2010) noted that, of the 2,896 known suicide bombers worldwide during the period 1974–2008, 95 percent were men. The proportion of men differs by region, with those affiliated with Al-Qaeda having the smallest percentage of women (less than 3%) and those from the Kurdistan Workers Party in Turkey having the largest (62%). Groups with an Islamic ideology had the largest proportion of men (96%) and those with a nationalist orientation a lower percentage of men (79%). Overall, the typical (modal) suicide bomber, according to Merari, is an unmarried Muslim male under the age of 25. Two assertions are common in essays on suicide bombers. The first is that suicide bombers do not appear to be characterized by the risk factors that predict suicidal behavior (e.g., Israeli, 1997). The second is that psychological profiles of suicide bombers are not possible (Merari, 1990). Both assertions are certainly premature and probably incorrect. Both of these tasks (identifying suicide risk factors and constructing psychological profiles) require extensive biographies of the individuals involved. For some behaviors, this is possible. For some serial killers and for celebrity suicides, detailed biographies are available, but none have appeared on suicide bombers. If detailed biographies are not available, it is necessary to conduct a psychological autopsy (Weisman & Kastenbaum, 1968). A psychological autopsy involves reconstructing the life of the suicide from birth on, with a particular focus on recent events, stressors, mood, statements, and behaviors by means of interviews with all of the significant others, friends and colleagues in the suicide’s life. This can be guided by a structured interview protocol (Clark & Horton-Deutsch, 1992). No psychological autopsy has yet been conducted on any suicide bomber.

M

125

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The speculations that have appeared about the suicide bombers have been made primarily by political scientists and sociologists, none of whom have in-depth training in psychology and none of whom have been trained in psychological autopsies. With rare exceptions, none of them have talked to, or administered psychological tests to samples of suicide bombers. In his recent book, Lankford (2013) notes that almost every “expert” has declared that suicide bombers are psychologically normal and driven by a single purpose: self-sacrifice.1 As we will see later, Lankford clearly demonstrates that these so-called experts are wrong. Most suicide bombers are escaping from unbearable psychological pain, and their “martyrdom” is a cover for their underlying death wishes. The problem is compounded by the fact that suicide bombers are, by definition deceased, and so only two possibilities present themselves. First, failed suicide bombers who have been arrested can be interviewed, but this raises an objection similar to that which has been raised when studying attempted suicides as substitute individuals for completed suicides. Are those who failed (because their courage failed them or because the bomb failed to detonate) the same kinds of individuals as those who carried out a successful mission? Second, suicide bombing is a highly charged social and political issue. Interviews with the significant others of the deceased are much less likely to identify psychologically meaningful data since those interviewed are aware of these social and political issues. They are likely to be very careful about which details they reveal about the suicide bomber. Similarly, analyses of the videos left behind by suicide bombers (e.g., Hafez, 2006, p. 175) are limited by the political purpose of such videos. As a result, several studies have used newspaper reports of suicide bombers. I used such reports to present an analysis of female suicide bombers (Lester, 2011). However, I noted that journalists, who are, of course, not psychologists and who are untrained in conducting psychological autopsies, reported many more details about the lives of female suicide bombers than they did for male suicide bombers. This results in much better hypotheses about the motivations and etiological factors for the women than for the men. The drawbacks of using journalists’ accounts are supported also by analyses of newspaper reports on suicide bombings, reports which provide the basis for the social construction of reality (e.g., Sela-Shayovitz, 2007). When samples of subjects, or substitute subjects, are interviewed, then commentators (and reviewers of potential articles) often criticize the methodology, and so the data do not get published or, if published, are dismissed. 1. I have sat in a room with many of the experts that Lankford cites and can attest to the veracity of Lankford’s claim.

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For example, Merari (2010) presented data on 15 would-be suicide bombers and 12 Palestinian prisoners, and Lancet rejected the paper for publication because of methodological drawbacks in the study.2 Yet we need data on suicide bombers, even if it is not the best. STUDIES OF SUICIDE BOMBERS Murder followed by suicide is not rare (West, 1966), but the motive in western nations is usually interpersonal between the victim(s) and the murderer. A husband may murder his wife (or ex-wife) before committing suicide, or a mother may murder her children before killing herself. It is rarely politically motivated. Politically motivated killing in which the killer dies is not uncommon historically, as in the Japanese kamikaze pilots in the Second World War. In the Old Testament, Samson killed thousands of Philistines, dying in the act. Today, suicide bombers detonate bombs, killing themselves and bystanders. Very little of the analysis of suicide bombers has focused on the psychodynamics behind the acts.3 Salib (2003) noted that most discussions of suicidal terrorists mention the charisma of the leader and the social structure of the group, the irrationality of their beliefs (especially in regard to what will happen to them in the afterlife), and the possibility that they have been brainwashed. A focus on situational theories and the role of the leader makes the suicide bomber appear to be a vulnerable person who is easily manipulated. In this case, the question may be asked what in this person’s childhood, adolescence and socialization experience led him to become so vulnerable. SOCIODEMOGRAPHIC CHARACTERISTICS While Schbley (2000) argued that religious martyrs rarely come from the wealthy social classes, Kushner (1996) noted that the Palestinian bombers do not always come from poverty. Many are from affluent families and are students or graduates from the West Bank’s Bir Zeit University. Nolan (1996) reported on 13 Palestinian suicide bombers in 1994–1996 and found them to be unmarried men, aged 19–25, from devout Muslim families. They were middle children from large families, high-school educated and students in 2. I was a reviewer for the article and recommended acceptance. 3. Much of the commentary discusses the morality of the acts (e.g., Wolin, 2003), the irrationality and criminality of the acts (e.g., Rosenberger, 2003) and whether suicide bombers can be viewed as heroes and martyrs (Israeli, 1997).

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Islamic fundamentalist education centers, had lived in refugee camps, and had a father or brother (or close relative) killed in the Intifada (uprising). They had a strong Palestinian identity and a sense of hopelessness,4 and they were unable to find work and were too poor to study. Their act improved their own social status and that of their family who were praised and given money. Kushner (1996) noted that the families may receive $1,000 a month, as well as scholarships for the siblings of the suicide bomber. On the other hand, Sprinzak (2000) noted that the suicide bombers belonging to the Black Tigers of Sri Lanka are equally often male and female and come from the toughest combat battalions. The suicide bombers from the Kurdistan Workers’ Party in Turkey are most often young women, 17–27, with no professional skills, from large, poor families, and had lost a relative or loved one in the Kurdish struggle against the Turks. The September 11th perpetrators were all Arab and Muslim, but somewhat older than Nolan’s sample of Palestinian suicide bombers and better educated. Recently too, older married men have become suicide bombers as well as some unmarried young women. The demographics of the perpetrators seems to change with time and place. For example, in Sri Lanka, female suicide bombers are quite common,5 and Hoffman (2003) has noted in the Middle East the increasing participation of children and the middle-aged as well as the married in suicide bombings, including some who have children. Merari (1990, 2004) provided good sociodemographic data on samples of suicide bombers. The mean age of the Lebanese suicide bombers was 21 (range 16–28), the early (1933–1938) Palestinian suicide bombers 22 (range 18–38), and from the current Intifada (2000–present) 22 (range 17–53). The Sri Lankan suicide bombers tended to be much younger (as a matter of policy). The majority of the Lebanese sample was single, but Hizballah had trouble continuing to recruit single men since Lebanese Shi’ites prefer to marry young. Thirty-eight of the Lebanese sample were men and seven women, but all of the early Palestinian suicide bombers were men. In the later Intifada, secular groups began to use women, as did the Kurdish suicide bombers in Turkey and the Tamil suicide bombers in Sri Lanka. Groups that are religiously Islamic, therefore, seem to avoid recruiting women. The social class of the early Palestinian suicide bombers matched that of the Palestinian general population, but their educational level was above average and they were more often refugees than the general population of 4. Some commentators dispute the presence of personal despair (e.g., Ganor, 2000). 5. Hage (2003) saw the planning and carrying out a suicide bombing as grounded in a masculine culture, but he was writing from the narrow perspective of Palestinian acts and did not take into account variations in the acts by culture and nationality.

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the Gaza Strip and the West Bank. As for the role of revenge, only 12 of the 34 early Palestinian suicide bombers had a relative or friend killed by the Israelis. Seven had a close family member jailed, 15 had been beaten by Israeli forces and 18 jailed. The majority (27) had been active or very active in the Intifada. In this early study of his, Merari could find no indications of major suicide risk factors in the early Palestinian sample (affective disorder, substance abuse or prior suicide attempts) based on the superficial information available. In a rare study designed to test hypotheses about suicide bombers, Pedahzur, Perliger and Weinberg (2003) hypothesized that suicidal bombing is an altruistic and/or fatalistic act in Durkheim’s (1897) classification system, types of suicide which are to be found, according to Johnson (1965), in less developed societies. The suicide bomber is overly integrated into his society and overly regulated. Pedahzur et al. tested this hypothesis using a sample of 819 Palestinian terrorists for the period 1993–2002, 80 of whom committed suicide in the act. They predicted that the suicide terrorists from an altruistic suicide point of view would more often have a religious education (confirmed) and a religious rather than a nationalistic ideology (confirmed), and from a fatalistic suicide point of view, be younger (not confirmed—they were older), unmarried (confirmed), and from a lower social class (confirmed). Thus, four of the five hypotheses were confirmed.6 The culture and political context clearly affect the sociodemographic characteristics of suicide bombers. The question of whether the culture and political context affect the psychological characteristics of the suicide bombers remains unanswered.

Psychodynamic Speculations Israeli (1997) speculated that suicide bombers do not appear to possess any of the risk factors commonly associated with suicide. They are instead the type of individuals who join cults or revolutionary groups—young with few life responsibilities, not particularly successful in life (in work or in interpersonal relationships), and with low self-esteem. The organization gives them recognition and acceptance, and they transform their frustration and failure into glory and victory. In the West, if they did not join such an organization (or cult), they might well become drug abusers. Kushner (1996) suggested that the Palestinian suicide bombers may be experiencing feelings of hopelessness and anger. He noted that they range in age from 12 to 17, usually have a relative or close friend killed, wounded or 6. The suicide and non-suicide terrorists did not differ in sex.

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jailed by the Israelis, and often have personal frustrations such as shame for not joining in battles during the Intifada. Salib (2003) also suggested that the suicide bombers are experiencing anger and hopelessness, but he also hypothesized that they may be suffering from shared delusions, a psychiatric disorder which may be called folie à plusiers. Rosenberger (2003) concurred with this appraisal, seeing the suicide bombers as having paranoid delusions in order to keep despair at bay. On the other hand, Gordon (2002) felt that most suicide bombers were not psychiatrically disturbed. None of these commentators, of course, gave any suicide bombers a psychiatric interview, a prerequisite for a meaningful psychiatric diagnosis. Volkan (2002) suggested that potential suicide bombers have disturbed personal identities and are seeking some external agent to internalize so as to stabilize their internal world. The youths must have experienced events which humiliated them and interfered with healthy and adaptive identifications (which in healthy families would be with their successful parents). Volkan hypothesized that recruiters for the groups which train suicide bombers are skilled at identifying the youths who fit this profile and who will succumb to the group influences. Although the Saudi Arabian suicide terrorists responsible for the September 11th attack were older, better-educated and from wealthier families, Volkan suspected that they, too, had experienced psychological trauma which had impacted deleteriously upon their personal identities. Rosenberger (2003) suggested the motive of vengeance (destruction of the enemy rather than conquering it) and the restoration of self-esteem. He saw the suicide bombers as idealistic and immature (making them susceptible to a charismatic leader). He reported the case of a middle-aged man who had lost his job and, thereby, the means to support his family, resulting in a depression, all of which motivated him to seek the role of a suicide bomber. Gordon (2002) noted the possible attainment of a sense of power, self-actualization and recognition within the community. He noted that others have suggested identification with a symbol of power or with the defeated, a desire for revenge, and symbolic sexual acting-out. The latter suggestion from Juergensmeyer (2001) was based on the limited sexual outlets for the men as a result of their unemployment and low status, the explosive nature of the act of bombing and the promise of many virgins in the afterlife for the suicide bomber.7 Lachkar (2002, p. 352) suggested that suicide bombers have a borderline personality disorder, a personality type that she felt is characteristic of many 7. They are also promised eternal life in paradise for themselves and many relatives and permission to see the face of Allah.

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Arabs in the Middle East (as compared to the narcissistic personality of many Israelis). Borderline personality types are dominated by shame, and they use defense mechanisms which involve blaming others. They have defective bonding and dependency needs, they are envious, and they are prone to retaliate. “They are impulsive, have poor reality testing, and impaired judgments. . . . Borderlines suffer from profound fears of abandonment and annihilation, as well as persecutory anxieties.” Borderlines tend to distort and misperceive reality. Lachkar saw the genesis of this personality type in the Islamic child rearing practices which frustrate the child’s dependency needs, which view personal desires as signs of weakness and failure. As a result, they revert easily to feelings of omnipotence as a defense against intolerable feelings of helplessness. DeMause (2002) has supported this analysis by documenting the violence, cruelty and sexual exploitation of children in Islamic societies. The fathers, who are supposed to be in charge of their sons’ child-rearing, are usually absent, and the child-rearing is left to the oppressed mothers who direct their own pain onto their sons. Lachkar argued that boys raised in such a society can easily form an intense identification with a charismatic leader who appeals to the society’s mythological fantasies and allows them to act out their anger and aggression. The possibility that many of the suicide bombers are shy and introverted boys who want to be idols and heroes is consistent with this hypothesis. Hage (2003) noted that surveys in the Gaza Strip indicate that over 70 percent of the adolescents reported that they wanted to be martyrs, but he noted that the presence of a disposition is not the same as actually sacrificing oneself. For example, in the field of suicidology, many more people report suicidal ideation (past or current) than go on to attempt or complete suicide.

Are Psychological Profiles of Suicide Bombers Possible? In most discussions as to whether a psychological profile can be proposed for suicide bombers, the prevailing opinions is that there is no psychological profile (Merari, 2004) and that psychological profiles would have little use, especially in preventing suicide bombings. In contrast, after Word War Two when social scientists endeavored to understand the motivations and personalities of those who participated in the German atrocities against the Jews, Gypsies, and other groups in Europe, it was felt that understanding the psychodynamics of the perpetrators would be of great utility. Stern (2003, pp. 39, 48, 50, 51) argued that developing a single psychological profile for suicide bombers was impossible, yet she noted earlier that recruiters look for troubled youths, and she reported a check list of traits that

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recruiters look for, including mental immaturity, pressure to work yet no job, no social safety net, absence of a girlfriend, no means for him to enjoy life, and an absence of meaning in life. Stern also noted that a leader of Hamas said that those who use knives have nervous personalities and get violent as a direct reaction to an incident, those who use guns are well-trained, and those who use a bomb need to have just a moment of courage. These statements comprise the beginnings of a psychological profile (or profiles) of the suicide bombers. Later in her book, Stern (2003) talks to Mir Aimal Kansi, a lone-wolf assassin who shot several CIA employees in 1993 outside the CIA headquarters in the United States, but who did not commit suicide. Although Stern is not skilled in psychological autopsies, she notes, in passing, that Kansi was the only child of his father’s second wife. The father had seven children with his first wife. Kansi was a brooding and introspective boy, a loner. He had a seizure disorder as a child. His mother died in 1982 and his father in 1989. The few simple facts of Kansi’s life raise many questions which could open up the exploration of the psychodynamic forces in his choice of becoming an assassin. In order to construct psychological profiles, we need extensive biographies of the subjects, with details of birth, infancy, childhood, and adolescence. As was mentioned in the introduction above, detailed biographies of suicide bombers have not been collected. Despite this, there are indications that psychological profiling and typologies of terrorists and suicide bombers might be possible. For example, there is a detailed biography of Timothy McVeigh, who bombed the federal building in Oklahoma City at 9:02 a.m. on April 19th, 1995, killing 168 people and injuring more than 500, which enables us to categorize him (Michel & Herbeck, 2001). Although McVeigh did not die with the bomb, he had been prepared to detonate the bomb in a way that would have killed him. As he drove into Oklahoma City with the bomb, he decided that if cars restricted his access to his chosen parking space, he would simply drive the truck into the building and die in the blast. As for his trial and sentence: McVeigh would welcome death; it would be his crowning achievement. The government, he reflected, would be doing him a favor, ending a long march that had turned hollow in the final years. His execution would be a relief. . . . “I knew I wanted this before it happened. I knew my objective was a stateassisted suicide . . . (Michel & Herbeck, 2001, p. 358)

The details provided in the biography of McVeigh makes it clear that he is the type of man labeled by Steiner (1974) as a “Woman Hater.” This type

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of man does not like women. He is usually a bachelor, probably in the military and takes his energy out in activities such as hunting and sports in which women have no place. He thinks of women as the weaker sex and incompetent, and he is proud of the fact that he has no need for them. For sex, he uses prostitutes or pick-ups in bars.8 Steiner noted that such men do not get far in society, and as a result, they end up bitter and unhappy about their circumstances. Their bitterness against women eventually spreads to include all people and even children. Steiner noted that such men probably learned as children “Don’t be close” and “Don’t trust.” What is of interest would be to explore how many terrorists fit into this category and what other categories are common among such terrorists. McVeigh, of course, does not necessarily resemble any of the suicide bombers in the Middle East, Sri Lanka or Chechnya. He is mentioned only to illustrate that a typology of the personalities of suicide bombers may be feasible. It is probable that, were detailed biographies available for a sample of suicide bombers, it would be possible to categorize them into personality types. They may not all fit into one or two types, but the frequency of different types would be of interest, and the comparison of distribution of types between the suicide bombers from different nations would be of interest. The impact of the culture and the sociopolitical context on the typologies and the profiles could be explored. The possibility of profiling suicide bombers is illustrated by Beardsley and Beech (2013) who applied the Violent Extremist Risk Assessment (VERA), developed by Pressman (2009), to five terrorists—Ted Kaczynski (the Unabomber), Timothy McVeigh, Andreas Baeder (the leader of the Red Army Faction in Germany), Patrick Magee (a Northern Irish IRA terrorist), and Ikuo Hayashi (who led a Sarin gas attack in the Tokyo subway). All five fitted the VERA profile which assesses attitudes, context, personal history, protective factors and demographic factors.

Why Suicide Bombers? Suicide bombing involves, of course, killing others while killing oneself. It is possible to kill others without committing suicide. Guerrillas may die in their attacks on their enemy, but they do not actively seek death. Snipers endeavor to kill their enemies from a safe and secure position, and they hope to escape. There is some evidence that occasional attacks such as these do occur in those regions where suicide bombers occur. For example, Orbach 8. McVeigh was intrigued when Terry Nichols married a “mail-order wife” from the Philippines, and he thought of doing the same himself. He liked the idea of a wife who was available just for sex and for child-care.

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(2004) mentions an attack in May 2001 in which two 14-year-old Israelis from the Tekoa settlement in the occupied territories were found brutally beaten to death. The killers had left. Why then do some become suicide bombers rather than guerrillas? It is also possible to protest by self-immolation, an act which has a long history. The Vietnam War in the 1960s was a time when many Buddhist monks in Vietnam burned themselves to death to protest the policies of the South Vietnam government, and when several Americans also self-immolated in order to protest the involvement of America in the fighting in Vietnam. Park (2004) has described recent protests of this nature in Vietnam and South Korea and analyzed the motives left by the protesters in their suicide notes and diaries. Why then do some become suicide bombers rather than selfimmolators? These questions are critical, yet no psychological research has been conducted on these issues. The way to answer these questions is to collect detailed biographies or conduct psychological autopsies on each of these types of individuals (guerrillas, protest self-immolators and suicide bombers).

Are Suicide Bombers Suicidal? 9 It was common to assert that the suicide bombers are not typical suicides. Merari (2004), for example, said that none of the typical risks factors for suicide characterize the suicide bombers, risk factors such as an affective disorder, alcohol and drug abuse, childhood loss or recent stress. Yet, as noted above, no psychological autopsy study has been conducted on any suicide bombers, and those who report on particular individuals have been unable, or unwilling, to compile an extensive psychological history of them. Hassan (2001) asserts that none of the suicide bombers in the Middle East have a “typical” suicide profile, which Hassan says is uneducated, desperately poor, simple-minded or depressed! This profile would come as a great surprise to suicidologists, let alone Ernest Hemingway, Judas Iscariot, Yukio Mishima, Cleopatra or Adolf Hitler, all of whom committed suicide. Hassan’s suicide profile is not one which is applicable to any of the industrialized nations for which suicide profiles are available. Unfortunately, suicide has rarely been studied in the Middle East. Indeed, the Islamic nations in that region of the world do not consistently report mortality statistics to the World

9. Suicide is proscribed by the Koran, but the Islamic commanders of the suicide bombers do not consider the acts to be suicide, but rather martyrdom or self-sacrifice in the service of Allah. This attitude may be necessary to persuade individuals to become suicide bombers, but the behavior is clearly suicidal.

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Health Organization (www.who.int), and Middle Eastern scholars rarely publish articles on samples of completed suicides. However, even Hassan unwittingly gives away clues to the suicidal motivation of the suicide bombers. Hassan noted that the word “suicide” was not allowed to be spoken when talking to the potential suicide bombers. (They preferred the term “sacred explosions.”) Spiegel and Neuringer (1963) in their study of suicide notes, noted that suicides typically avoided mentioning the word suicide or suicide synonyms prior to their act. One final way in which suicide bombers resemble ordinary suicides is that both groups of individuals appear to be susceptible to social contagion (Stern, 2003). Lester, Yang and Lindsay (2004) suggested that suicide bombers might have an authoritarian personality, a personality characterized by such traits as conventional adherence to values, authoritarian submission (to their leaders), authoritarian aggression (toward the designated out-group), and other traits (Adorno, 1950). The Middle Eastern terrorists and suicide bombers are typically raised in very strict fundamentalist Islamic sects whose teachings they accept. They do not come to their belief systems by a rational appraisal of alternative ideologies as adults. They accept the ideology in which they are raised. They show conventionalism. The society in which they live provides them with moral authorities, the religious and political leaders (who are often the same people), and they find more leaders at their schools and universities (where the teaching is imbued with Islamic studies). The society and the times also provide them with out-groups against whom to aggress. First there were the Soviets who had invaded Afghanistan, followed by the Americans who crushed Saddam Hussein in Kuwait and Iraq and stationed troops in Saudi Arabia, and there are always the Jews, a traditional out-group for many nations. Lewis (2002) noted that Middle Eastern nations have often sought to blame others for this state of affairs—the Mongols in the thirteenth century, then the Turks, the Western imperialists, the British and French, the Americans, and the Jews. Some blame Islamic society itself—the religion, religious extremists, the oppression of women, socialism, and nationalism. Lewis saw the problem as a basic lack of freedom—freedom of the mind from constraint and indoctrination, freedom of women from male oppression, and freedom of the economy from corrupt and inept management.

Female Suicide Bombers Lester (2011) used journalist accounts of the background of female suicide bombers and argued that they showed evidence of post-traumatic stress, feelings of being a burden to their families, feelings of hopelessness and despair,

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and a desire to transform their images in their families and in their society. For example, Bennet (2002) reported some details of the life of Arien Ahmed, a 20-year-old Palestinian female student who was sent to an Israeli town wearing an explosive backpack. She turned back from her mission and was captured by the Israelis. Her father died when she was only six, a common occurrence in the histories of suicides (Lester, 1989; Lester & Beck, 1976). Her mother remarried but left her with other family members, so that she lost both her father and mother. Her relatives noticed that she hid behind a happy facade, and they suspected that she was unhappy. She fell in love with a leader of a violent Palestinian group in Bethlehem, Jaad Salem, but he was killed on March 8th in a confrontation with Israeli forces. Arien said, “So I lost all my future.” Soon after his death, Israeli forces occupied Bethlehem, and Arien thought about avenging Salem’s death and joining him in paradise. Before Arien volunteered for a suicide mission, she quarreled with her aunt. Arien went through no indoctrination or training. Five days after volunteering, the Palestinian group sent her on her suicide mission. Arien Ahmed has several risk factors for suicide: early loss, recent loss of the man she loved, a loss made worse by being sensitized to this later loss by the earlier loss of her father. She had even more recent stress (a quarrel with her aunt). She was hopeless about the future without the man she loved, and she was angry at the Israelis. In other cases, Lester noted the abuse experienced by these women and the coercion. Zarema Muzhikhoyeva was from Chechnya. After losing both parents by age seven and experiencing a loveless childhood with her grandparents, she was kidnapped by a man 20 years older than she was and married to him.10 After giving birth to a daughter her husband was killed, and her in-laws took her daughter away from her and gave her to her husband’s brother to raise. Zarema was sent back to her grandparents. Zarema tried to visit her daughter, but her daughter now called her adopted parents Mommy and Daddy. Zarema stole jewelry from her grandmother in order to kidnap her daughter and flee to Moscow, but she was caught. Her family beat her and said they wished that she was dead. Feeling worthless, abandoned and alone, she volunteered to become a suicide bomber, but her mission was botched and she was captured.

10. Kidnapping potential wives is a tradition in Chechnya.

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RESEARCH ON SUICIDE BOMBERS There are very few studies of suicide bombers, and not all of those that have appeared draw appropriate conclusions. For example, Araj (2012) interviewed the close relatives and friends of 42 randomly selected Palestinian suicide bombers. Araj is a sociologist with no training in psychological autopsies. He asked about the motives of the suicide bombers (primary, secondary and tertiary) and found, in order, the motives to be state repression (41%), religion (28%), and liberation of the homeland (22%), with economic, social, mental illness, exploitation and other motives to each constitute less than 2 percent. Araj (2012, p. 219) claimed that 40 of the 42 suicides bombers were “physically and mentally healthy.” Yet even with the limited data available to him, Araj found six cases with personal crises (such as being wanted for murder), 74 percent had been arrested or injured by Israeli forces (and reports indicate that Israeli forces are often brutal), and several cases had the potential for PTSD, a psychiatric disorder that Araj appears to be unaware of and which increases the risk of violence and self-destructive behavior. For example, Iyad al-Masri was 17 years old and became a suicide bomber to avenge the death of his 14-year-old cousin and his 15-year-old brother who died in Itad’s arms after being shot by Israeli forces. Lester (2008) proposed a role for PTSD in both Palestinian and Israeli suicide terrorists. Just as the incidence of PTSD in American forces returning from the wars in Iraq and Afghanistan is now viewed as extremely high, the incidence of PTSD of civilians in war zones is also probably very high. Lester described two cases from CNN programs narrated by Christiane Amanpour (God’s Muslim Warriors and God’s Jewish Warriors). Baruch Goldstein was present when Palestinians in a car shot some Jewish settlers, two of whom died in his arms as he rushed to their side. Three months later he entered a mosque when Muslims were praying, killed 29 Palestinians and wounded 150 others before they were able to kill him. Yousef Swatat watched Israeli forces shoot a young Palestinian girl in West Bank. He carried her to a hospital, but she died in his arms. He was recruited for a mission in which he opened fire in the Israeli town of Hadera, killing four people and wounding dozens before being killed by police. Araj’s study is welcome and the results of interest. To conclude that these data demonstrate the absence of Axis I and Axis II psychiatric disorders is foolish.

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Speckhard and Akhmedova Speckhard and Akhmedova (2005, pp. 130, 133) interviewed suicide terrorists, their families and their friends in Chechnya, Russia, and in Palestine. They concluded that personal trauma was one of the precipitating causes of the choice to become a terrorist in almost all of the cases, either direct personal experiences of torture, beatings and incarceration or witnessing this, as well as death, in others, inflicted by the Russian and Israeli forces, respectively. These individuals often had post-traumatic symptoms, and dissociation was a common defense mechanism. The children and adolescents growing up in these war zones become psychologically deadened, with inner psychic numbing, and they often refer to themselves as “already being dead.” Speckhard and Akhmedova talked to Mustafa, an 18-year-old Palestinian who reported being beaten in an Israeli jail and seeing his cellmate beaten to death. Others reported continual fear as they moved about their region as they encountered checkpoints manned by the military, feeling threatened with abuse and even death on each occasion. In Chechnya, one young boy reported seeing the Russian soldiers bring two men into the center of his village with grenades strapped to their legs. The soldiers then exploded the grenades so that the bodies were scattered into pieces. Many of those interviewed used anger to keep themselves “psychological together in the face of these overwhelming fear states.” Subjected to daily humiliation and hardship, they try to make meaning out of their lives and seek to fight back and exact revenge. The ideology of their group helps provide this, similar to the way in which many psychiatric patients in the West turn to religion to make sense of their lives and experiences. Because those who are traumatized are seeking meaning, and the bereaved are seeking reunion, contagion can occur, and this lowers the barrier to suicide as they seek relief from their psychic pain. When interviewed about the reasons they became suicide bombers, they rarely attribute their choices to trauma, which Speckhard and Akhmedova saw as a protective strategy. A denial of trauma, therefore, should not be taken at face value.

Jacques and Taylor Jacques and Taylor (2008) used biographies of 30 male and 30 female suicide bombers obtained from newspapers, the Internet, and other sources to see how they differed. This study is limited, of course, by the different manner in which journalists have approached their stories of the men and women involved, focusing on the personal lives of the women to a much greater

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extent than the lives of the men. However, the study is one of the few available, and the data are of some interest. Jacques and Taylor classified the motives as personal (such as to end life and family problems), revenge, key event (such as a family member killed), and religious/nationalistic (such as overtly religious). The women reported 21 personal motives compared to only four for the men. (The coding system permitted more than one motive for each suicide bomber.) The men reported 36 religious/nationalistic motives compared to only 18 for the women. The two groups did not differ in revenge and key event motives. As I have noted above, this reflects more on the journalists’ choice of focus than on the actual motives of the suicide bombers.

Ariel Merari’s Study Merari (2010) studied 15 would-be suicide bombers during the second Intifada who were arrested by Israeli security forces before they could carry out their act, and compared them with 12 Palestinian prisoners who were not suicide bombers, matched only for age and marital status. The suicide bombers were of higher social class and better educated, but did not differ in higher status employment and were not more religious. The suicide bombers less often came from refugee families and refugee camps. Merari’s team of psychologists administered psychological tests to the men and conducted clinical interviews (in Arabic). Their conclusions were that the suicide bombers were much more often avoidant-dependent personalities (60% versus 17%), depressed (53% versus 8%) and suicidal (40% versus 0%), and less often impulsive-unstable (27% versus 67%) and psychopathic (0% versus 25%). Overall, Merari described the suicide bombers in this way: Most of the would-be suicides were shy, socially marginal, followers rather than leaders. Many were loners and outsiders, with a history of failure in school, and harbored the feeling of having disappointed their parents. More than one-third had suicidal tendencies, which may have played an important role in their willingness to become martyrs. (p. 119)

Adam Lankford’s Research Lankford (2013) collected data on 130 suicide bombers or would-be suicide bombers. Although data are often lacking from reports concerning the lives of these individuals, Lankford was able to document serious physical injury or disability in 9 percent of them, depression, PTSD or other mental health problems in 34 percent, the unexpected death of a loved one or close friend in 51 percent, a precipitating crisis event in 80 percent, and experi-

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ences such as rape and sexual assault and heroin addiction in many. In a comparison of suicide terrorists and rampage mass murderers in the United States during 1990–2010, Lankford found the two groups to be very similar—almost entirely male, average age about 40, socially marginalized, and with family problems and work problems. About three-quarters of both groups had mental health problems. Lankford defined four types of suicide terrorists: conventional, coerced, escapist, and indirect. The conventional suicide terrorist is suicidal because of the same reasons most people in a society become suicidal, and they have the same risk factors. The coerced suicide terrorist is forced into the act and fears the consequences if he or she fails. The escapist suicide terrorist becomes suicidal because of the fear of being captured and punished by the enemy. The indirect suicide terrorist is unconscious of his or her suicidal desires. Lankford does not present a breakdown of these four types by gender, but Lester (2011) saw most female suicide bombers as coerced. It is likely that the coerced type is relatively uncommon in men while the other three types are more common. Lankford provides many case studies in his book, but two will suffice here. He compares two men. Nidal Hasan is the 39-year-old Major who killed 13 and wounded 31 at the Fort Hood base in Texas, claiming his was the act of a martyr. George Sodini was a 48-year-old loner with a grudge against women who went into a health club in Pittsburgh on August 4th, 2009, and killed three women before killing himself. Both men wanted to marry but had failed to find wives, both had difficulties at work, both felt that they were victims, bullied by others, both were anticipating crises in the near future, both had mental health problems, and both became angry, suicidal and desperate for a way out. The one difference was that Sodini was aware that his act was personally motivated, whereas Hasan saw himself as a selfless martyr. DISCUSSION In this chapter, it has been argued that suicide bombers, who are primarily men, are often suicidal and that they fit the profile of other suicidal men, especially those who commit mass rampage murders. They may convince themselves that they are selfless martyrs, but this is a delusion. They differ from women who become suicidal bombers in that the women are typically brutalized and forced into the act (coerced in Lankford’s typology), whereas the men are probably more often conventionally suicidal or indirectly suicidal. Clearly much more research is needed before we can make more definitive conclusions about suicide bombers, but the studies reviewed above pro-

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vide some interestingly hypotheses into the psychodynamics of suicide terrorists that could guide future research. REFERENCES Adorno, T. W., Frenkel-Brunswick, E., Levinson, D. J., & Sanford, R. N. (1950). The authoritarian personality. New York: Harper. Araj, B. (2012). The motivations of the Palestinian suicide bombers in the second Intifada (2000–2005). Canadian Review of Sociology, 49, 211–232. Beardsley, N. L., & Beech, A. R. (2013). Applying the violent extremist risk assessment (VERA) to a sample of terrorist case studies. Journal of Aggression, Conflict & Peace Research, 5, 4–15. Bennet, J. (2002). Mideast turmoil: The bombers. The New York Times, June 21, A1, A10. Clark, D. C., & Horton-Deutsch, S. L. (1992). Assessment in absentia. In R. W. Maris, A. L. Berman, J. T. Maltsberger & R. I. Yufit (Eds.), Assessment and prediction of suicide (pp. 144–182). New York: Guilford. DeMause, L. (2002). The childhood origins of terrorism. Journal of Psychohistory, 29, 340–348. Durkheim, E. (1897). Le suicide. Paris, France: Felix Alcan. Ganor, B. (February 15, 2000). Suicide terrorism. ww.ict.org Gordon, H. (2002). The ‘suicide’ bomber. Psychiatric Bulletin, 26, 285–287. Hafez, M. M. (2006). Rationality, culture, and structure in the making of suicide bombers. Studies in Conflict & Terrorism, 29, 165–185. Hage, G. (2003). “Comes a time we are all enthusiasm.” Public Culture, 15, 65–89. Hassan, N. (2001). An arsenal of believers. The New Yorker, November 19, 36–41. Hoffman, B. (2003). The logic of suicide terrorism. Atlantic Monthly, June, 40–47. Israeli, R. (1997). Islamikaze and their significance. Terrorism & Political Violence, 9(3), 96–121. Jacques, K., & Taylor, P. J. (2008). Male and female suicide bombers. Studies in Conflict & Terrorism, 31, 304–326. Johnson, B. D. (1965). Durkheim’s one cause of suicide. American Sociological Review, 30, 876–886. Juergensmeyer, M. (2001). Terror in the mind of God. Berkeley, CA: University of California Press. Kushner, H. W. (1996). Suicide bombers. Studies in Conflict & Terrorism, 19, 329–337. Lachkar, J. (2002). The psychological make-up of a suicide bomber. Journal of Psychohistory, 20, 349–367. Lankford, A. (2013). The myth of martyrdom. New York: Palgrave. Lester, D. (1989). Experience of parental loss and later suicide. Acta Psychiatrica Scandinavica, 79, 450–452. Lester, D. (2008). Possible role of post-traumatic stress disorder in suicide terrorists. Psychological Reports, 102, 614–615.

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Lester, D. (2011). Female suicide bombers. Suicidology Online, 2, 62–66. Lester, D., & Beck, A. T. (1976). Early loss as a possible sensitizer to later loss in attempted suicides. Psychological Reports, 39, 121–122. Lester, D., Yang, B., & Lindsay, M. (2004). Suicide bombers. Studies in Conflict & Terrorism, 27, 283–295. Lewis, B. (2002). What went wrong? Atlantic Monthly, 289(1), 43–45. Merari, A. (1990). The readiness to kill and die. In W. Reich (Ed.), Origins of terrorism (pp. 192–207). New York: Cambridge University Press. Merari, A. (2004). Suicide terrorism. In R. Yufit & D. Lester (Eds.), Assessment, treatment and prevention of suicide (pp. 431–453). New York: John Wiley. Merari, A. (2010). Driven to death. New York: Oxford University Press. Michel, L., & Herbeck, D. (2001). American terrorist. New York: Regan Books. Nolan, S. (1996). Portrait of a suicide bomber. Independent on Sunday, March 10th, 13. Orbach, I. (2004). Terror suicide. Archives of Suicide Research, 8, 115–130. Park, B. C. B. (2004). Sociopolitical contexts of self-immolations in Vietnam and South Korea. Archives of Suicide Research, 8, 81–97. Pedahzur, A., Perliger, A., & Weinberg, L. (2003). Altruism and fatalism. Deviant Behavior, 24, 405–423. Pressman, D. E. (2009). Risk assessment decisions for violent political extremism. User Report 2009-02. Ottawa, Canada: Public Safety Canada. Rosenberger, J. (2003). Discerning the behavior of the suicide bomber. Journal of Religion & Health, 42, 13–20. Salib, E. (2003). Suicide terrorism. British Journal of Psychiatry, 182, 475–476. Schbley, A. H. (2000). Torn between God, family, and money. Studies in Conflict & Terrorism, 23, 175–196. Sela-Shayovitz, R. (2007). Female suicide bombers: Israeli newspaper reporting and the public construction of social reality. Criminal Justice Studies, 20, 197–215. Speckhard, A., & Akhmedova, K. (2005). Talking to terrorists. Journal of Psychohistory, 33, 125–156. Spiegel, D., & Neuringer, C. (1963). Role of dread in suicidal behavior. Journal of Abnormal & Social Psychology, 66, 507-511. Sprinzak, E. (2000). Rational fanatics. Foreign Policy, September/October, 66–73. Steiner, C. (1974). Scripts people live. New York: Grove. Stern, J. (2003). In the name of God. New York: Harper/Collins. Volkan, V. (2002). September 11 and societal regression. Group Analysis, 35, 456–483. Weisman, A., & Kastenbaum, R. (1968). The psychological autopsy. Community Mental Health Monograph, Number 4. New York: Behavioral Publications. West, D. J. (1966). Murder followed by suicide. Cambridge, MA: Harvard University Press. Wolin, R. (2003). Are suicide bombings morally defensible? The Chronicle of Higher Education, 50(9), B12–B14.

Chapter 12 MURDER-SUICIDE DAVID LESTER wo general approaches have been taken to the problem of murder and suicide. One important theory suggests that both murder and suicide are expressions of the same kind of aggressive impulse. The difference between them is that the murderers have learned to direct their aggressiveness outward, while suicides have learned to turn their aggression inward to attack themselves, more or less seriously, when they feel the need to aggress. This theory, from Henry and Short (1954), proposed that people who direct their aggression outward do so because they were punished physically as children. Physical punishment meant that if they retaliated against the parent they might be spanked more, but they would not risk losing the parent’s affection. Suicides, on the other hand, were psychologically punished. The parent reacted to misbehavior by withdrawing love or attention. The child was then afraid to retaliate because a counterattack might mean permanent loss of the parental affection upon which he or she was so dependent. Therefore, according to Henry and Short’s theory, murder and suicide are committed by different individuals. An alternative approach views murder and suicide as aggressive acts which can be carried out by the same, generally aggressive, individual. There are two approaches to studying this hypothesis: (1) studying samples of suicides and looking at those who have committed murder, and (2) studying samples of murderers and looking at those who commit suicide.

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MURDERERS WHO COMPLETE SUICIDE The frequency of suicide after murder varies considerably from country to country. In England, one study (West, 1966) found that 33 percent of murderers subsequently killed themselves, whereas Wolfgang’s (1958) study in Philadelphia found that only 4 percent of murderers there did so. There are clearly national (and cultural) differences in this behavior. Wolfgang (1958) investigated a group of murderers in Philadelphia who killed themselves after their crime. The suicide occurred soon after the murder in most cases, and the victim was much more likely to be a relative or lover in the case of the suicidal murderers. Wolfgang found that the suicidal murderers were more likely than nonsuicidal murderers to be men and that they were more likely to be brutal in their killing. Wolfgang attributed the excessive brutality to a greater reservoir of frustration and anger. Wolfgang also noted that the suicidal murderers were older, more often white, and their victims younger than in the case of the nonsuicidal murderers. The suicidal murders were more likely to take place in the home, and the killer and victim were more likely to be of opposite sexes. Alcohol intoxication was less common in the suicidal murderers. Wolfgang suggested the two possible reasons for some murderers killing themselves after the murder, excessive frustration and guilt, but these reasons were difficult to document. However, he noted that the murderers who killed themselves were less likely to have records of arrests than nonsuicidal murderers and that this perhaps indicated a greater degree of law abiding and conformity to the social mores. Thus, the notion that guilt or the desire to escape punishment may be responsible for the subsequent suicides of murderers may have some degree of validity. Wolfgang (1958) also looked at a group of wives who killed their husbands and a group of husbands who killed their wives. He found that ten of the 53 husbands subsequently completed suicide whereas only one of the 47 wives did. He hypothesized that husbands were more likely to precipitate their deaths by provoking their wives (by beating them, for example), and so their wives felt less guilt after murdering them than husbands did after murdering their wives. The husbands’ feelings of guilt would make suicide more probable, while the wives would feel that their acts had, to some extent, been justified. Wolfgang noted, in support of his hypothesis, that 28 of the murdered husbands were classified as victim-precipitated homicides (that is, they precipitated the conflict which resulted in their death) whereas only five of the murdered wives were so classified. The following were typical cases.

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A husband had threatened to kill his wife during several violent family quarrels. He would usually later admit his regret for having beaten her and for having suggested the idea of her death. In the last instance, he first attacked her with a pair of scissors, dropped them, and then grabbed a butcher knife from the kitchen. In the ensuing struggle, which ended on their bed, she had possession of the knife, and there was considerable doubt in the minds of the jury whether the husband invited his wife to stab him or deliberately fell on the knife. In another case a drunken husband, beating his wife in their kitchen, gave her a butcher knife and dared her to use it on him. She claimed that if he should strike her once more she would use the knife, whereupon he slapped her in the face and she fulfilled the promise he apparently expected by fatally stabbing him. (Wolfgang, 1969, p. 92)

The situation is very different in England where murder is much less common than in the United States. West (1966) compared suicidal murderers with a group of nonsuicidal murderers and found that the suicidal murderers were more often females, were older, more often killed victims who were close relatives, used gas and shooting more, and tended to kill earlier in the week and more often in midsummer than the nonsuicidal murderers. They had fewer criminal convictions than the nonsuicidal murderers. The two groups did not differ in marital status (except that the nonsuicidal group had an excess of single males) or in the time of day for the murder. Almost all of the female murder-suicides (92%) murdered children (sometimes along with their spouse), whereas only 17 percent of the male murder-suicides murdered their children. Forty-six percent of the male murder-suicides murdered their spouse and 24 percent their girlfriend/lover, as compared to only 5 percent of the female murder-suicides who murdered husbands or lovers. In England, therefore, murder-suicide in women is most often infanticide or filicide, whereas murder-suicide in men is most often the result of a relationship problem. For the men, whereas 60 percent of the murder-suicides were murdering wives or lovers, only 34 percent of the ordinary murderers did so. Two important factors in the pattern emerge from West’s data. First, suicidal murderers in England are on the whole a different kind of person from nonsuicidal murderers. They are much more likely to be killing a spouse or child and less likely to use brutal methods such as strangulation, blows, stabbing, or a blunt instrument. Gas and shooting are more frequently used, and these methods are distinguished by the fact that they involve killing at a distance. This makes sense when one remembers the close relationship between many suicidal murderers and their victims, which may inhibit the killers from carrying out their acts brutally or in a way which requires close observation of the dying person.

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Secondly, the suicidal murderers lie between the nonsuicidal murderers and the nonhomicidal suicides in their characteristics. Only 12 percent of the nonsuicidal murderers were women, while women made up about 40 percent of the suicidal murderers. (About 39% of the completed suicides in England are women.) In age, the suicidal murderers were somewhere between the younger age-range typical of murderers and the older age- range typical of suicides. West concluded that the suicidal murderer was representative of the general community, unlike the nonsuicidal murderers, who were more often single males and from the lower classes. He found that the suicidal murderers were neither all insane, nor all sane. The proportion of offenders with psychiatric disturbances was roughly the same as that in the nonsuicidal murderers. There was little evidence in his study that indicated that the suicidal murderers killed themselves in order to avoid punishment. The large number of infanticides, death pacts, mercy killings, and accidental killings may indicate that a large number of the suicidal murderers were motivated by feelings of despair rather than hostility. In other cases, there appeared to be long-standing histories of violent and suicidal behavior. West felt that a large number, although by no means all, of suicidal murderers were individuals with a high level of aggression which may turn against others or themselves according to the circumstances. The following is a case of a typical suicidal murderer reported by West. The offender was an excitable, talkative, boastful man of low intelligence. He was constantly unemployed on account of symptoms of backache, which were considered by hospital doctors to be largely hysterical. He was referred to a psychiatrist and put on a tranquilizer. He was in severe conflict with his wife, and various authorities had been approached to intervene on account of his violence toward her and his children. He was described by a family doctor as “a pale little man, full of resentments against the world and immensely aggressive.” He so resented interference that when his baby had pneumonia he turned out of the house the doctor who called to examine the child. He was reported to have been so irritated by his baby crying during a fatal illness that he picked it up and threw it across the room. His wife had been seen by social workers badly bruised and with a tooth knocked out following arguments with her husband, and on another occasion he had attacked his wife in a very frightening way in the presence of a social worker who had called about the children. Six weeks before the murder, the offender’s wife finally left the home, and two children remained behind. He made numerous threats that unless she returned he would kill the children and himself. Finally, he did so, leaving behind a note blaming his wife. [pp. 83–84]

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West felt that suicidal murderers resembled completed suicides more than murderers, and he concluded that homicidal-suicidal acts were extensions of suicidal acts. The suicidal individual is likely to be as angry and outwardly aggressive as the nonsuicidal person. If one accepts the theory that the typical suicidal is a frustrated murderer, it is quite conceivable that the aggression might spill over and manifest itself in outwardly aggressive acts, even to the point of murder. Let me next look at the results of three recent studies, using different methodologies, and from three countries: the United States, Italy and Australia. RESEARCH ON MURDER-SUICIDE

Murder-Suicide in the United States Bridges and Lester (2011) compared the 2,215 murder-suicides in the United States from 1968–1975 with the 121,252 other murders. The murdersuicides comprised 6.1 percent of all female victims of murder but only 0.5 percent of male victims. Of the 2,215 murder-suicide offenders 1,129 (51%) were husbands killing wives, and 100 (5%) were wives killing husbands. The murderers in the murder-suicides were more likely to use a firearm, and the murder occurred less often during the course of a felony. These results confirm the older research of Wolfgang who found in his Philadelphia data that men killing wives were more likely to commit suicide than were wives killing husbands. Earlier research confirms these patterns. Aderibigbe (1997) classified American murder-suicides using the victim-murderer relationship. The most common types were, in order, fathers murdering children, spouses murdering each other, lovers murdering consorts and extra-familial victims. Murders by mothers were less common than murders by fathers, and murders of children under the age of 16 were rare. Perpetrators were most often male and used firearms. In the Midwest, Palermo et al. (1997) found that the typical murder-suicide was a male assailant, white, murdering a spouse, using a gun, and in the home. Rosenbaum (1990) compared couples in which murder-suicide occurred with those in which only murder occurred. The perpetrators of murder-suicides were more often men, depressed, older, white, of higher social class, married or separated and less often alcohol or drug abusers or drunk at the time of the act. In Chicago, Stack (1997) found that murder-suicide (compared to simple murder) more often involved a victim who was a child/spouse/ex-lover/friend, a white victim, a white offender, a female victim, an older offender and a male offender. In a sample of murder-

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suicides in Fulton County (Georgia), Hanzlick and Koponen (1994) found that the modal murderer was male, black, using a firearm and 34 years old, while the modal victim was female, spouse or lover, of the same race and 28 years old.

Murder-Suicide in Italy Roma et al. (2012) used newspaper reports to study 662 murder-suicides in Italy during the period 1985–2008. Of these cases, 560 were men and 102 women. These 662 murder-suicides killed 1,114 victims, of whom 68 percent were female victims, and 74 percent of the murder-suicides occurred in a domestic situation. Jealousy was the most common motive for men (26% for men versus 12% for women), while financial and family stressors were more often the motive for women than for men (21% versus 16%). In all types of murder-suicide, the number of men outnumbered the number of women, including mercy killing and escape from problems, as well as romantic jealousy.

Australian Suicides who Killed Others Haines, Williams and Lester (2010) studied 22 suicides in Tasmania, Australia, who died by suicide immediately after committing a murder. They matched these murder-suicides for age and sex with suicides who had not murdered. The murder-suicides were less often never married (10% versus 50%). They were less often in poor health (18% versus 52%) and had less often consulted their family doctor recently (0% versus 47%). The two groups did not differ in recent psychiatric consultations, whether they had received psychiatric treatment, or in their previous suicidal history (prior attempts) and whether they left a suicide note. However, the murder-suicides were more often angry prior to the act (86% versus 27%) and behaving erratically (14% versus 0%) and less often withdrawn and quiet (9% versus 32%). The murder-suicides were more often involved in an interpersonal conflict (86% versus 55%) and less often motivated by a physical illness (0% versus 32%). Haines et al. (2010) concluded that murder-suicides were primarily motivated by interpersonal conflicts with a significant other toward whom they felt anger and hostility.

Mercy Killings Mercy killing refers to the intentional killing of an individual in order to end his or her suffering. In many cases, the person carrying out the killing

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commits suicide at the same time.1 Wickett (1989) documented 97 cases of double suicide involving spouses in the United States from 1980 to 1987. Two-thirds of these were mercy killings followed by suicide (with the remaining one-third suicide by the two people). In the typical mercy killing cases, the wife or both spouses were suffering, and the husband was the instigator. The couple was living alone, and pets were also killed. The method used most often was a gun, and the couple felt exhausted and helpless and had a fear of being separated and institutionalized. It was very rare for the wife to be the instigator, and usually the husband could not bear his wife’s suffering or life without her. In the double suicides, the decision was more likely to be mutual and less impulsive, and there was less despondency. Canetto and Hollenshead (2000–2001) analyzed 112 cases of mercy killings recorded by the Hemlock Society in the United States for the period 1963–1993, of whom 102 died and ten survived. They found that women were more likely to die as a result of mercy killing than were men (65% of the deceased were women), and 72 percent were older adults. The median age of those killed was 68. Ninety-two percent of the deceased had a physical illness, 7 percent had failing health, and 1 percent was healthy. The majority of the mercy killers were men (70%), with a median age of 63. In 80 percent of the cases, the mercy killer was a family member of the deceased, spouses or partners in 45 percent of the cases and parent-child in 23 percent of the cases. Men most often killed female partners (54% of the cases involving male mercy killers), while women most often killed children (38% of the female mercy killers). Although suicide pacts are often thought of as common among thwarted lovers, the Romeo and Juliet syndrome, Cohen (1961) found that 72 percent of suicide pacts in England involved spouses, and Fishbain et al. (1984) found that 70% of the suicide pacts in Dade County, Florida, involved spouses. Fishbain et al. found that the mean age of spouses in suicide pacts was 58 versus 31 for lovers. A history of depression was found in 54 percent of the spouses versus 0 percent of the lovers. Whereas the suicides in Cohen’s study mentioned old age, ill health, decreased vitality and poor sleep in their suicide notes, Fishbain et al. found no differences in the mention of these factors in the suicide notes from suicide pacts involving spouses versus all other suicide pacts.2 Brown et al. (1995) described nine suicide pacts in a town in England and found that all involved a man and a woman, most commonly spouses. 1. Clinicians also engage in mercy killing of their patients, but this is not the focus of this section. 2. More recently, especially in Asia, suicide pacts involving strangers, usually young adults, who meet simply for the purpose of dying by suicide together have become common (Ozawa-de Silva, 2008).

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Psychiatric disorders were common, and usually one member of the pair was suicidal while the partner was devoted or dependent. The most common motive was to obtain relief from a medical illness or from a psychiatric disorder. In a later report, Brown and Barraclough (1997) found no evidence for coercion of one partner by the other. In the United States, Rosenbaum (1983) described six suicide pacts where one member of the pact survived. Typically, the instigator was a man who was depressed, with a history of attempted suicide, and the instigator died. The survivor was a woman, not psychiatrically disturbed and with no history of suicidal behavior. Unfortunately, as for mercy killings, no in-depth studies involving psychological autopsies have been carried out on those involved in suicide pacts, although Lester (1997) documented two cases of famous male writers (Arthur Koestler and Stefan Zweig) who wanted to die (Koestler because of a degenerative disease and Zweig because of fear that Hitler would conquer the world) and whose healthy wives decided to die with them. Lester based his report on published biographies of the two men and argued that both men coerced their dependent wives into dying by suicide along with them. DISCUSSION The majority of suicides are men, as are the majority of murderers. Therefore, it is not surprising that the majority of the instigators of murdersuicides are men. In cases of murderers who then complete suicide, it appears that the killer may die by suicide after committing murder as a result of guilt or because the reservoir of anger has not completely dissipated and the remaining anger is directed onto the self. In cases of suicidal individuals, it appears that the suicides, primarily men, persuade their partners to die with them, either because both partners are physically ill or frail, or because the partner has decided that she (and less often he) cannot live happily or meaningfully alone. It is surprising that no in-depth studies (such as those involving psychological autopsies) have been carried out on murder-suicide. Most of the published studies have used data from police and coroner investigations (as well as newspaper accounts based on such information). The role of the interpersonal relationship between the individuals involved in murder-suicide, especially the role of coercion by one partner, is of great importance, but has not been investigated in methodologically sound research.

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REFERENCES Aderibigbe, Y. A. (1997). Violence in America. Journal of Forensic Sciences, 42, 662–665. Bridges, F. S., & Lester, D. (2011). Homicide-suicide in the United States, 1968–1975. Forensic Science International, 206, 185–189. Brown, M., & Barraclough, B. M. (1997). Epidemiology of suicide pacts in England and Wales. British Medical Journal, 315, 286–287. Brown, M., King, E., & Barraclough, B. M. (1995). Nine suicide pacts. British Journal of Psychiatry, 167, 448–451. Canetto, S. S., & Hollenshead, J. D. (2000–2001). Older women and mercy killing. Omega, 42, 83–99. Cohen, J. (1961). A study of suicide pacts. Medico-Legal Journal, 29, 144–151. Fishbain, D. A., D’Achille, L., Barsky, S., & Aldrich, T. E. (1984). A controlled study of suicide pacts. Journal of Clinical Psychiatry, 45, 154–157. Haines, J., Williams, C. L., & Lester, D. (2010). Murder-suicide: A reaction to interpersonal crises. Forensic Science International, 202, 93–96. Hanzlick, R., & Koponen, M. (1994). Murder-suicide in Fulton County, Georgia, 1988-1991. American Journal of Forensic Medicine & Pathology, 15, 168–173. Henry, A. F., & Short, J. F. (1954). Suicide and homicide. New York: Free Press. Lester, D. (1997). The sexual politics of double suicide. Feminism & Psychology, 7, 148–154. Ozawa-de Silva, C. (2008). Too lonely to die alone: Internet suicide pacts and existential suffering in Japan. Culture, Medicine & Psychiatry, 32, 516–551. Palermo, G. B., Smith, M. B., Jenzten, J., Henry, T. E., Konicek, P. J., Peterson, G. F., Singh, R. P., & Witeck, M. J. (1997). Murder-suicide of the jealous paranoia type. American Journal of Forensic Medicine & Pathology, 18, 374–383. Roma, P., Spacca, A., Pompili, M., Lester, D., Tatarelli, R., Girardi, P., & Ferracuti, S. (2012). The epidemiology of murder-suicide in Italy. Forensic Science International, 214, e1–e5. Rosenbaum, M. (1983). Crime and punishment. Archives of General Psychiatry, 40, 979–982. Rosenbaum, M. (1990). The role of depression in couples involved in murder-suicide and homicide. American Journal of Psychiatry, 147, 1036–1039. Stack, S. (1997). Homicide followed by suicide. Criminology, 35, 435–453. West, D. (1966). Murder followed by suicide. Cambridge, MA: Harvard University Press. Wickett, A. (1989). Double exit. Eugene, OR: Hemlock Society. Wolfgang, M. (1958). Patterns of criminal homicide. Philadelphia, PA: University of Pennsylvania Press. Wolfgang, M. (1969). Suicide by means of victim-precipitated homicide. In H. L. P. Resnick (Ed.), Suicidal behaviors (pp. 89–103). Boston, MA: Little Brown.

Chapter 13 SUICIDE IN GAY MEN JOHN F. G UNN III n September 22, 2012, Tyler Clementi, a student at Rutgers—The State University of New Jersey, jumped to his death off the George Washington Bridge. Why did he make the decision to die by suicide? Tyler’s roommate, using his computer to spy on Tyler and an unidentified man he had brought back to his dormitory room, had broadcasted the interaction between Tyler and the man over the Internet. Tyler’s response was to jump off the George Washington Bridge. Two months later, Josh Pacheco, 17, committed suicide on November 17, 2012. He was gay, and had been the victim of bullying both at school and outside of school. The purpose of this chapter is to better understand suicide among gay men. We will discuss the prevalence of suicide among homosexuals in comparison to heterosexuals, potential explanations for the differences in the suicide rates, and possible methods for prevention.

O

PSYCHOPATHOLOGY AND SUICIDAL BEHAVIOR First we must determine whether gay men are at particular risk for mental illness. If this is in fact the case, then they are likely to be at an increased risk of suicidal behavior since psychiatric disorder is a major risk factor for suicide.

Studies with Adult Populations Meyer (1995) examined the role of minority stress and its relationship to psychopathology among homosexual men. Minority stress in gay people 152

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results from living in a predominately heterosexual environment and, therefore, having minority status and suffering from stigmatization. Meyer conceptualized minority stress as “internalized homophobia, which relates to gay men’s direction of societal negative attitudes toward the self; stigma, which relates to expectations of rejection and discrimination; and actual experiences of discrimination and violence” (Meyer, 1995, p. 38). In a large sample of homosexual men, Meyer found that these three types of minority stress (internalized homophobia, stigma, and actual discrimination and violent events) predicted psychological distress in gay men. Using the results of a national survey in England and Wales, Warner et al. (2004) examined rates and predictors of mental illness among gay men, lesbians, and bisexuals and found high levels of deliberate self-harm and high levels of psychopathology among all three groups. Bolton and Sareen (2011) investigated the relationship between sexual orientation, mental illness, and suicidal behavior but, unique to their study, they examined specific mental disorders and their relationship to sexual orientation. They found that lesbians and bisexual women had a three-fold increase in the likelihood of substance use disorders, whereas gay and bisexual men had increased rates of anxiety disorders, schizophrenia, and psychotic illness. Additionally, they found an increased risk of suicide attempts among those who identified themselves as bisexual. Remafedi, Farrow, and Deisher (1991) investigated what risk factors are likely to increase the risk for suicide among a sample of homosexual and bisexual men. They found that those who had attempted suicide had a more feminine gender role and had adopted their sexual orientation at a younger age. Additionally, and in line with research on heterosexual populations, suicide attempters were more likely to report sexual abuse, drug abuse, and criminal pasts. Wichstrom and Hegna (2003, p. 148) examined the risk of suicide among homosexual men and women in a longitudinal study of Norwegian students. They found that same-sex sexual contact was associated with an increased likelihood of reporting a previous suicide attempt, but that an increased likelihood of future suicide attempts was found only in the girls, and not the boys. The majority of the reported suicide attempts occurred after or around the same time that the person realized they were “not exclusively heterosexual.” Plöderl, Krolovec, and Fartacek (2010, p. 1403) examined suicide among an Austrian population in relation to a number of dimensions related to sexual orientation. They found that “[s]uicide attempts were more frequently reported by those participants with homosexual or bisexual fantasies, partner preference, behavior, and self-identification, compared to their heterosexually classified counterparts.” This finding was replicated when

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examining different dimensions of the suicide attempt as well (i.e., the intent to die and whether or not the attempt required medical treatment). Paul et al., (2002) examined the lifetime prevalence of suicide attempts among “men who have sex with men (MSM).” This differs from the previous studies, as they do not rely on self-identification of bisexual or homosexual, but rather use MSM as their variable. They concluded that MSM are at an increased risk of suicide and that this risk often occurred earlier in their lives. Russell and Toomey (2012) investigated the risk for suicide among men in the National Longitudinal Study of Adolescent Health that assessed adolescents at four different waves (i.e., Wave 1 1994–1995, Wave 2 1996, Wave 3 2001–2002, Wave 4 2007–2009) in the United States. They examined suicidal ideation and suicide attempt behavior, but not completed suicide. They found that for men who identified as having same-sex attraction, the risk for suicide (both thoughts and behavior) was present only during adolescence. This indicates that perhaps the increased risk of suicide that homosexual or bisexual men face is only during adolescence. Once they reach maturity, homosexual men may be no less likely to die by suicide than heterosexual men. While the majority of the research has focused on nonlethal suicidal behavior, Mathy, Cochran, Olsen, and Mays (2011) investigated sexual orientation and its relationship to completed suicide. They examined suicide mortality in relation to same-sex registered domestic partners in Denmark and found that men in a same-sex partnership were at increased risk of death by suicide.

Studies with Adolescent Populations Proctor and Groze (1994) administered the Adolescent Health Questionnaire (AHQ) to a large sample of gay, lesbian and bisexual youths (n=276). The AHQ includes: (1) a Family Scale - parent sibling relations, medical history and suicide attempts, and relocations; (2) a Social Environment Scale—school performance, church involvement, views of their country, and relationships with peers; and (3) a Self-perception Scale - symptoms of depression and other perceptions. There were significant differences between those who attempted suicide, those who thought about suicide but did not attempt, and those who neither thought about suicide nor attempted suicide. In particular, those who had attempted suicide scored the lowest on all three scales (indicating poorer family, social, and self-perceptions). Remafedi, French, Story, Resnick, and Blum (1998) found that there was a significant risk of suicide (measured with an item asking if they had at-

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tempted to kill themselves in the last year and with an item on current suicidal ideation from the Beck Depression Inventory) among male adolescents who identified as bisexual or homosexual, when compared to heterosexuals, but that among female adolescents there was no significant increased risk for suicide. Van Heeringen and Vincke (2000) found that those adolescents who reported being homosexual or bisexual had a twofold increase in the likelihood of reporting suicide ideation. However, when it came to prior suicide attempts, an increased risk was significant only for female respondents. Additionally, they found that, independent of sexual orientation, suicide ideation was significantly associated with depression, while suicide attempts were associated with lower self-esteem, higher levels of hopelessness, and suicidal behavior in close peers. Interestingly, they also found that having poor homosexual friendships was associated with suicidal behavior. Lebson (2002) reviewed the literature on suicide risk among homosexual youth and concluded that, in comparison to heterosexual youth, homosexual youth are at an increased risk of attempting suicide and experiencing suicidal ideation.

Meta-Analyses Meyer (2003, p. 19) reported a meta-analysis that examined the question of whether or not members of the LGB (lesbian, gay, bisexual) community have an increased incidence of mental illness. Meyer concluded that members of the LGB community do in fact have an elevated rate of mental illness, but that “the answer is complicated because of methodological limitations in the available studies.” These methodological issues involved relying on volunteers, lack of sophistication in the measurement of sexual orientation, and small LGB sample sizes. King et al. (2008) conducted a meta-analysis of 28 studies on the prevalence of mental illness, substance misuse, suicidal behavior and deliberate selfharm among gay men, lesbians, and bisexuals, and concluded that all three groups were at higher risk for suicidal behavior, psychopathology, and substance misuse and dependency than were heterosexuals. EXPLANATIONS The research reviewed has indicated that members of the LGB community are at an increased risk of suicide and psychopathology. However, the findings have not been consistent. Some research has indicated that this risk

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is present only for homosexual men, and other research has indicated that this risk may be found only in adolescents. What are the potential explanations for this increased risk? Bailey (1999) outlined several possible explanations for why homosexuals may have an increased risk of mental illness and suicidal behavior. The first was that increased depression and suicidal behavior in homosexuals are the result of stress created by societal pressures. In this hypothesis, suicide occurs because of the negative attitudes in society that homosexuals must face, such as being mocked, feared and ostracized. It cannot be denied that such negative aspects exist since homosexuals are still denied the right to marry in many states of the United States. Some religious extremists stand at the funerals of American soldiers and attribute their death to God’s wrath over the existence of homosexuals. This explanation is similar to the view of Meyer (2003) who proposed a minority stress model to explain the prevalence of mental illness among homosexuals. However, there is little research testing this hypothesis, and further research is needed to examine the causes and correlates of psychopathology and suicidal behavior among homosexuals. The increased risk of suicide among gay men, especially during adolescence, has been attributed to the role bullying plays in the development of suicidal behavior. Klomek et al. (2009) investigated the relationship between childhood bullying (measured at age 8) and the development of later suicidal behavior (up to age 25) in a large Finnish sample. As in the research reviewed above, sex differences were once again present. They found that men who reported frequently being the victim of bullying at age 8 were more likely to report later suicide attempts and to die by suicide. This association was no longer significant after controlling for conduct and depression symptoms. Girls who reported frequent victimization by bullying were also likely to report later suicidal behavior, and this relationship existed even after controlling for conduct and depression symptoms. Pranjic and Bajraktarevic (2010) found that relationship victimization and bullying victimization were both associated with an increased risk of suicidal ideation and depression in comparison to the nonvictimized group in a sample of adolescents. Winsper, Lereya, Zanarini and Wolke (2012) investigated the role of bullying and suicidal behavior, examining both roles involved in bullying (victim and bully). They found that those who are involved in bullying are at an increased risk for suicidal ideation and behavior regardless of whether they are a victim or a perpetrator of the bullying. Additionally, they found that those who are both a bully and a victim and those who are “chronic” victims are at even greater risk for suicidal behavior. Klomek, Sourander, and Gould (2010) reviewed the literature on bullying and suicidal behavior and found that most studies point to an increased risk

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of suicidal ideation and attempts associated with bullying (including cyberbullying). While the research they reviewed did not permit causal inferences,1 it did indicate a strong relationship between suicidal behavior and bullying, although sometimes this relationship varied by sex (as discussed above). Cooper, Clements, and Holt (2012, p. 281) examined a large number of studies that investigated the role of bullying in the development of psychopathology and suicidal behavior. They provided ten statements that summarize the existing literature on the topic: 1. There is a strong correlation between childhood bullying and adolescent suicide. 2. The effects of adolescent bullying do not abate with time, but rather persist into adulthood. 3. The risk of suicide increases with increased exposure to bullying. 4. Depression is known to be the single greatest risk factor for adolescent suicidal behavior. 5. Childhood bullying potentially has an independent influence on adolescent suicidal behavior. 6. There is a relationship between cyberbullying and suicidal behavior. 7. Cyberbullying victims are two times more likely to die by suicide. 8. Adolescents with the greatest risk of suicidal behavior are those with multiple roles in bullying and those who experience a high frequency and multiple types of bullying. 9. Being a bully or a victim can increase the incidence of depression, serious suicidal ideation, and suicide attempts, with more frequent involvement being associated with a greater incidence of each. 10. Females are at greater risk for suicidal behavior than males as a result of bullying (particularly cyberbullying) even with less exposure to it. While women seem to be at greater risk for suicidal behavior following bullying, we cannot ignore the fact that men are also at risk. This risk is especially present for adolescent gay males who suffer from bullying at the hands of their heterosexual peers. However, almost all of the research on bullying, including that reviewed above, has been on adolescents in general. Research is needed that focuses on the role of bullying in gay men and lesbians. It is clear that much more research is needed on suicide in the LGB community. For example, O’Donnell, Meyer, and Schwartz (2011) studied predictors of a history of suicide attempts in minority (Black and Latino) gay men and lesbians and, although they found a high incidence of suicidal behavior 1. The research was correlational.

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compared to the incidence among White LGB individuals, this high incidence was not attributable to the presence of substance use or affective disorders. O’Donnell and her colleagues could propose no explanation for the increased risk of suicide attempts in this group.

Treatment Implications Garnets, Hancock, Cochran, Goodchilds, and Peplau (1991), as part of an American Psychological Association (APA) sponsored task-force, examined the responses of a large number of psychologists with the aim of investigating biases that may exist in psychotherapy with lesbian and gay clients. The psychologists indicated a number of biased and inappropriate themes in their open-ended responses. The themes were broken down into the following categories: (1) assessment, (2) intervention, (3) identity, (4) relationships, (5) family, and (6) therapist expertise and education. Table 13.1 reproduces the biased and inappropriate themes, while Table 13.2 shows the exemplary themes. The presence of the biased and inappropriate themes was not uncommon, as the authors indicate. Fifty eight percent of the psychologists surveyed knew of negative incidents, including cases in which practitioners defined lesbians or gay men as ‘sick’ and in need of change, and instances in which a client’s sexual orientation distracted a therapist from treating the person’s central problem” (p. 970). While this article is somewhat dated (the survey data were collected in 1984), it points out several important characteristics that need to be taken into consideration when treating LGB clients. It also points to ethical considerations when dealing with LGB clients. Perhaps the greatest ethical issue is conversion therapy. Although the American Psychiatric Association removed homosexuality as a psychiatric disorder in 1974, conversion therapy (therapy designed to “convert” homosexuals into heterosexuals) persists even to this day. Clearly, according to Garnets et al. (1991) and many commentaries since, conversion therapy is an unethical practice as it involves several of the biases discussed above.

Prevention Implications Several suicide prevention implications for gay men can be drawn from the research and theory reviewed in this chapter. If we consider the findings of Russell et al. (2012), who found that suicide risk was a developmental issue, affecting gay men most in adolescence, then prevention programs need to be devised that would target this specific group. After several high profile suicides (such as Tyler Clementi), advocates have begun to speak up about

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Table 13.1. BIASED, INADEQUATE, OR INAPPROPRIATE PRACTICE THEMES (GARNETS ET AL., 1991, PP. 966–968). Assessment

1. A therapist believes that homosexuality per se is a form of psychopathology, developmental arrest, or other psychological disorder. 2. A therapist automatically attributes a client’s problems to her or his sexual orientation without evidence that this is so. 3. A therapist fails to recognize that a client’s psychological symptoms or distress can be influenced by the client’s own negative attitudes or ideas about homosexuality. 4. A therapist automatically assumes a client is heterosexual or discounts a client’s self-identification as gay or lesbian.

Intervention

1. A therapist focuses on sexual orientation as a therapeutic issue when it is not relevant. 2. A therapist discourages a client from having or adopting a lesbian or gay orientation, makes the renunciation of one’s homosexuality a condition of treatment, or in the absence of a request by the client seeks to change the sexual orientation of the client. 3. A therapist expresses beliefs that trivialize or demean homosexuality and gay male and lesbian orientation or experience. 4. Upon disclosure of homosexuality, a therapist abruptly transfers a client without the provision of appropriate referrals to the client or assistance with the emotional difficulties associated with transfer.

Identity

1. A therapist lacks understanding of the nature of lesbian and gay male identity development. 2. A therapist does not sufficiently take into account the extent to which lesbian or gay male identity development is complicated by the client’s own negative attitudes toward homosexuality. 3. A therapist underestimates the possible consequences of a gay male or lesbian client’s disclosure of his or her homosexuality to others, for example, to relatives or employers.

Relationships 1. A therapist underestimates the importance of intimate relationships for gay men and lesbians. 2. A therapist is insensitive to the nature and diversity of lesbian and gay male relationship and inappropriately uses a heterosexual frame of reference. Family

1. A therapist presumes a client is a poor or inappropriate parent solely on the basis of a gay or lesbian sexual orientation. 2. A therapist is insensitive to or underestimates the effects of prejudice and discrimination on lesbian and gay male parents and their children.

Therapist 1. A therapist lacks knowledge or expertise, or relies unduly on the Expertise and client to educate the therapist about gay male and lesbian issues. Education 2. In an educational context, a therapist teaches information about lesbians or gay men that is inaccurate or prejudiced, or actively discriminates against gay male and lesbian students or colleagues.

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Assessment

1. A therapist understands that homosexuality, in and of itself, is neither a form of psychopathology nor is necessarily evidence of psychopathology or developmental arrest, and recognizes that gay men and lesbians can live fulfilling lives. 2. A therapist recognizes the multiple ways that societal prejudice and discrimination can create problems that lesbians and gay men may seek to address in therapy. 3. A therapist considers sexual orientation as one of many important attributes that characterize a client and does not assume that it is necessarily relevant to the client’s problems. 4. A therapist recognizes the possible synergistic effects of multiple social statuses experienced by ethnic minority gay men and lesbians.

Intervention

1. A therapist uses an understanding of the societal prejudice and discrimination experienced by lesbians and gay men to guide therapy and to help gay male or lesbian clients overcome negative attitudes or ideas about homosexuality. 2. A therapist recognizes that his or her own sexual orientation, attitudes, or lack of knowledge may be relevant to the therapy and tries to recognize these limitations, seeking consultation or making appropriate referral when indicated. 3. A therapist does not attempt to change the sexual orientation of the client without strong evidence that this is the appropriate course of action and that change is desired by the client.

Identity

1. A therapist assists a client with the development of a positive gay male or lesbian identity and understands how the client’s negative attitudes toward homosexuality may complicate this process.

Relationships 1. A therapist is knowledgeable about the diverse nature of lesbian and gay male relationships and supports and validates their potential importance for the client. 2. A therapist recognizes the potential importance of extended and alternative families for gay men and lesbians. 3. A therapist recognizes the effects of societal prejudice and discrimination on lesbian and gay relationships and parenting. 4. A therapist understands that the family of origin of a lesbian or gay male client may need education and support. Therapist 1. A therapist is familiar with the needs and treatment issues of gay male Expertise and and lesbian clients, and uses relevant mental health, educational, and Education gay male and lesbian community resources. 2. A therapist recognizes the importance of educating professionals, students, supervisees, and others about gay male and lesbian issues and actively counters misinformation or bias about lesbians and gay men.

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the bullying of LGB—teens and several organizations have begun to post videos to help bullied gay teens (such as the It Gets Better Project, www .itgetsbetter.org). Given the relationship between suicidal behavior and bullying, especially in adolescence, stricter and better targeting of bullying in schools would likely help prevent suicidal behavior in all school children. Additionally, given the models outlined earlier where minority stress is viewed as a potential explanation for psychopathology and suicidal behavior among gay men, programs that help alleviate the stigmatization and the prejudice that gay men (and lesbians) face could also help prevent the suicidal behavior in this population. Finally, a more consistent stance is needed regarding therapy for gay men. The position on conversion therapy among varying psychological organizations is mixed, with the American Psychological Association coming out against the practice, while the American Counseling Association supports the practice. At the time of writing this chapter, very little has been done to curtail the existence of conversion therapy. California is the only state that has sanctions against the practice, and they ban the use of conversion therapy only for minors. Members of the LGB community need to have faith that, when they seek treatment, they are not going to be ambushed by those who seek to change them. As long as conversion therapy exists relatively unchallenged, gay men may be more hesitant to seek treatment, as they may associate treatment with such practices. FINAL THOUGHTS This chapter has reviewed the literature investigating the prevalence of mental illness and suicidal behavior in gay men. The findings from these studies indicate that gay men are at increased risk for suicidal behavior. Whether this risk is present beyond adolescence is less clear. Future research should investigate the role of sexual orientation in suicide risk at different developmental stages to determine if the risk at adolescence documented by Russell and Toomey (2012) holds true for older gay men and after controlling for a number of known risk factors for suicide. Finally, bullying has been shown by the research to be associated with an increased risk of suicide, and this has been highlighted in a number of high profile suicides such as Tyler Clementi. Again, clear intervention efforts can be made that target bullying as a means of alleviating the stress and, potentially, the suicidal behavior of this population.

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REFERENCES Bailey, J. M. (1999). Homosexuality and mental illness. Archives of General Psychiatry, 56, 883–884. Bolton, S. L., & Sareen, J. (2011). Sexual orientation and its relation to mental disorders and suicide attempts. Canadian Journal of Psychiatry, 56, 35–43. Cooper, G. D., Clements, P. T., & Holt, K. E. (2012). Examining childhood bullying and adolescent suicide: Implications for school nurses. Journal of School Nursing, 28, 275–283. Garnets, L., Hancock, K. A., Cochran, S. D., Goodchilds, J., & Peplau, L. A. (1991). Issues in psychotherapy with lesbians and gay men. American Psychologist, 46, 964– 972. King, M., Semlyen, J., Tai, S. S., Killaspy, H., Osborn, D., Popelyuk, D., & Nazareth, I. (2008). A systematic review of mental disorder, suicide, and deliberate selfharm in lesbian, gay and bisexual people. BMC Psychiatry, 70(8), 1–17. Klomek, A. B., Sourander, A., & Gould, M. (2010). The association of suicide and bullying in childhood to young adulthood: A review of cross-sectional and longitudinal research findings. Canadian Journal of Psychiatry, 55, 282–288. Klomek, A. B., Sourander, A., Niemela, S., Kumpulainen, K., Piha, J., Tamminen, T., Almqvist, F., & Gould, M. S. (2009). Childhood bullying behaviors as a risk for suicide attempts and completed suicides: A population-based birth cohort study. Journal of the American Academy of Child & Adolescent Psychiatry, 48, 254–261. Lebson, M. (2002). Suicide among homosexual youth. Journal of Homosexuality, 42(4), 107–117. Mathy, R. M., Cochran, S. D., Olsen, J. & Mays, V. M. (2011). The association between relationship markers for sexual orientation and suicide. Denmark, 1990– 2001. Social Psychiatry & Psychiatric Epidemiology, 46, 111–117. Meyer, I. H. (1995). Minority stress and mental health in gay men. Journal of Health & Social Behavior, 36, 38–56. Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay and bisexual populations. Psychological Bulletin, 129, 674–697. O’Donnell, S., Meyer, I. H., & Schwartz, S. (2011). Inreased risk of suicide attempts among Black and Latino lesbians, gay men and bisexuals. American Journal of Public Health, 101, 1055–1059. Paul, J. P., Catania, J., Pollack, L., Moskowitz, J., Canchola, J., Mills, T., Binson, D., & Stall, R. (2002). Suicide attempts among gay and bisexual men: Lifetime prevalence and antecedents. American Journal of Public Health, 92, 1338–1345. Plöderl, M., Krolovec, K. & Fartacek, R. (2010). The relationship between sexual orientation and suicide attempts in Austria. Archives of Sexual Behavior, 39, 1403–1414. Pranjic, N. & Bajraktarevic, A. (2010). Depression and suicide ideation among secondary school adolescents involved in school bullying. Primary Health Care Research & Development, 11, 349–362. Proctor, C. D. & Groze, V. K. (1994). Risk factors for suicide among gay, lesbian, and bisexual youths. Social Work, 39, 504–513.

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Remafedi, G., Farrow, J. A., & Deisher, R. W. (1991). Risk factors for attempted suicide in gay and bisexual youth. Pediatrics, 87, 869–875. Remafedi, G., French, S., Story, M., Resnick, M. D., & Blum, R. (1998). The relationship between suicide risk and sexual orientation: Results of a populationbased study. American Journal of Public Health, 88, 57–60. Russell, S. T. & Toomey, R. B. (2012). Men’s sexual orientation and suicide: Evidence for U.S. adolescent-specific risk. Social Science & Medicine, 74, 523–529. Van Heeringen, C. & Vincke, J. (2000). Suicidal acts and ideation in homosexual and bisexual young people: A study of prevalence and risk factors. Social Psychiatry & Psychiatric Epidemiology, 35, 494–499. Warner, J., McKeown, E., Griffin, M., Johnson, K., Ramsay, A., Cort, C., & King, M. (2004). Rates and predictors of mental illness in gay men, lesbians and bisexual men and women: Results from a survey based in England and Wales. British Journal of Psychiatry, 185, 479–485. Wichstrom, L. & Hegna, K. (2003). Sexual orientation and suicide attempt: A longitudinal study of general Norwegian adolescent population. Journal of Abnormal Psychology, 112, 144–151. Winsper, C., Lereya, T., Zanarini, M., & Wolke, D. (2012). Involvement in bullying and suicide-related behavior at 11 years: A prospective birth cohort study. Journal of the American Academy of Child & Adolescent Psychiatry, 51, 271–282.

Chapter 14 SUICIDE IN CREATIVE MEN DAVID LESTER he earliest theories of geniuses and creative people were that they were either feeble-minded or insane, although ancient Greeks such as Aristotle and Plato distinguished between ordinary insanity and the type of insanity geniuses had. This idea persisted into the nineteenth century. It was thought also that insanity promoted genius and creativity by allowing the mind to have experiences that normal people do not have, by leading potential geniuses to have feelings of inferiority which motivate them to do better and excel, or by allowing them to have a richer fantasy life which would facilitate creativity. In contrast, others have proposed that being a genius is a risk factor for becoming insane. Society is not designed for the creative individual. Bright children are placed in classes with average children which is a source of stress for the bright children. Geniuses may be more aware of the shortcomings and injustices in the world, and so they are subject to more wear and tear. Finally, geniuses are often regarded as insane by their average colleagues until their ideas are accepted and, prior to acceptance of their ideas, they may be ridiculed and even persecuted for their ideas. Another proposal is that geniuses and creative individuals are qualitatively different from normal people, and phrases like divine inspiration and the spark of genius capture this view. However, some commentators see geniuses and creative people at the far end of a continuum of ability. Catherine Cox (1926) read biographies of eminent people and estimated their intelligence from accounts of their development. Philosophers had an estimated average IQ of 170, poets and novelists 160, scientists 155, musicians 145, artists 140 and military leaders 125. Cox found that psychological disturbance was more

T

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common in the poets, novelists, musicians and artists and least common in the statesmen and revolutionaries. Jamison (1989) interviewed a sample of 47 living eminent British writers and artists, most of whom were men (87%). Most were Protestants and their average age was 53. Just over a third (38%) had been treated for a mood disorder. Mood disorders were found in the artists, biographers, novelists, playwrights and poets, but only the poets had been diagnosed with bipolar affective disorder. Mood disorders in general were most common in the poets and playwrights (roughly 60%). Jamison, however, reported figures only for treated mood disorders, and many more of those she interviewed reported intensely creative episodes which resembled mild manic episodes. In some cases, it has been possible to document the periods of creativity with manic episodes. For example, Slater and Meyer (1959) found that the composer Robert Schumann’s (1810–1856) most productive periods corresponded with his manic episodes in 1840 and 1849. (Schumann died of self-starvation in an insane asylum in 1856.) In other cases, Jamison (1993) was able to trace the genealogies of creative men, showing the frequency of depression, manicdepression and suicide in the family trees, families such as those of Alfred, Lord Tennyson (the British writer), Henry and William James (writer and psychologist, respectively), and Ernest Hemingway. Andreasen (1987) compared writers attending a workshop at the University of Iowa with a comparison group and found a much higher incidence of any affective disorder in the writers (80% versus 30%), especially bipolar affective disorder (43% versus 10%). The relatives of the writers also had a higher incidence of affective disorders than did the relatives of the control subjects.1 A high incidence of alcoholism has also been noted in writers (Goodwin, 1988), raising the possibility either that alcohol abuse facilitates creative writing or that creative writing increases the risk of alcohol abuse.2 Lester (1991) studied a sample of 70 American writers and found that both alcohol abuse and suicide contributed independently to their premature mortality.

1. There have been many older studies of this issue (for a review see Jamison [1993]) but these suffer from problems from unreliable diagnoses. Ludwig (1992) studied those whose biographies had appeared in the New York Times Book Review and found the highest rates of mania, psychosis and psychiatric hospitalizations in poets. Eighteen percent of the poets had died by suicide! Composers also had a high rate of depression and psychosis. 2. Laing (2013) has written about six American writers who were alcoholics and tried to answer the question of what drives writers to drink: John Berryman, Raymond Carver, John Cheever, F. Scott Fitzgerald, Ernest Hemingway, and Tennessee Williams.

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SIX CREATIVE MEN There are many creative men who have committed suicide. Lester (1993), somewhat arbitrarily, chose six creative men with full biographies available and looked at their characteristics. He chose four writers ( John Berryman, Hart Crane, Vachel Lindsay and Cesare Pavese) and two twentieth century painters (Mark Gertler and Mark Rothko) who died by suicide. Here, I will summarize a few characteristics of their lives, but full biographies can be found in Lester (1993).

Table 14.1.

John Berryman Hart Crane Mark Gertler Vachel Lindsay Cesare Pavese Mark Rothko

Birth

Death

Age

Birth Order

10-25-1924 7-21-1899 12-9-1892 11-10-1879 9-9-1908 9-25-1903

1-7-1972 4-27-1932 6-23-1939 12-3-1931 8-27-1950 2-25-1970

57 33 46 52 41 66

1st of 2 only child 5th of 5 2nd of 6 2nd of 2 4th of 4

Several researchers have claimed to find that people complete suicide on a day close to their birthday, the so-called birthday blues phenomenon (e.g., Kunz, 1978; Shaffer, 1974), although this phenomenon is not always found (e.g., Lester, 1986). Two of these six suicides did show this effect (Lindsay and Pavese). In a review of previous research, Lester (1987) found evidence for a slight increase in the proportion of first and middle-born children among suicides and fewer only and last-born children. However, three of these six men were last-borns! It would be of interest in future research to examine these associations in a large sample of creative men.

Table 14.2.

John Berryman Hart Crane Mark Gertler Vachel Lindsay Cesare Pavese Mark Rothko

Marital Status

Children

married (3rd) single separated married (1st) single separated

2 0 1 2 0 2

Family deaths father/age 11/suicide grandfather/age 13/natural no sisters/age 10/natural father/age 6/natural father/age 10/natural

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Separation and divorce characterizes these suicides (rather than widowhood). In addition to those already separated (Gertler and Rothko), two of the remaining marriages were in severe trouble (Berryman and Lindsay). Lester and Beck (1976) noted that early loss is often found in the lives of suicides. Three of these men had lost parents (the father in each case), and two others had lost close relatives with whom they were living (a grandfather in one case and sisters in another). Bron et al. (1991) noted that loss of the father seems to be especially important in the histories of suicides, and loss of the father was more common in this sample of suicides than was loss of the mother.

Table 14.3. Method

Prior attempts/method (age)

Psychiatric disorder

John Berryman

jumped (bridge)

in front of train (16)

depressed mood alcohol/drug abuse epilepsy

Hart Crane

drowned

wrists (16)/poison (32)

depressive disorder paranoia alcohol abuse

Mark Gertler

gas

wrists (46)/medication (49)

depressive disorder

Vachel Lindsay

poison

none schizophrenia depressed mood paranoia epilepsy

Cesare Pavese

poison

none depressive disorder

Mark Rothko

wrists

none depressive disorder paranoia alcohol abuse

Half of the men had made prior nonfatal attempts, and half had shown evidence of alcohol and drug abuse. Four of the men had depressive disorders and two more had depressed mood. One was schizophrenic (Lindsay). Two men may have had epilepsy, and three showed signs of paranoia (delusions of persecution).

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The Role that Creativity Played John Berryman’s life was disintegrating because of his uncontrollable alcohol abuse. His confidence in his ability to write had gone, and he no longer had the discipline to finish any creative work. He had a profound lack of selfconfidence, preferring to teach undergraduates rather than critical graduate students. Although he had received awards for his writing, his aspirations increased. Once it was sufficient for his work to be published. Then he needed praise, and next to be seen as the greatest living poet. Toward the end of his life, he needed extravagant praise for each draft of a potential poem, and he could no longer tolerate minor criticism. There were other contributing causes to his suicide, including his continuing inability to stop his alcohol abuse and his disintegrating marriage (which was primarily because of his alcoholism). Hart Crane had struggled hard to get his poetry accepted. His work, when published, often received criticism. Furthermore, his lack of education and his abusive personal style made it difficult for him to broaden his scope and write essays or reviews to any great extent. He achieved some recognition and success, eventually obtaining a Guggenheim fellowship. At this point, his lifestyle and alcohol abuse resulted in an almost complete inability to write. It was likely that he would never produce a major work again. In addition, his inability to form lasting intimate relationships with anyone, homosexual or heterosexual, provided important motivations for his suicide. Mark Gertler had doubts about his worth as an artist, especially in comparison to the dynamic trends in art taking place in Paris and the rest of Europe led by Picasso and Matisse, and he had been depressed and suicidal. His interpersonal crises and physical health added to this career stress and made suicide even more likely. Vachel Lindsay had never been a very good writer. Most people agreed that he was better as a reciter and performer of his own work. His later writing was criticized as quite poor, and Vachel continued to be in demand only as a reciter. His suicide seems to have been triggered by his deteriorating relationship with his wife brought about by his psychotic behavior, ending with Vachel violently assaulting her, and the stress resulting from the continual demand to keep touring and reciting in order to support his family. Cesare Pavese was depressed after each novel had been completed, but he had developed many avenues of work in the field of literature, including translating and writing reviews. His suicide, though, seems to be a result of his inability to form lasting relationships with women. He had ended up living with his sister, suffering rejection from the women with whom he was infatuated and enduring loneliness and depression.

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Mark Rothko seemed to be less concerned with doubts about his stature as an artist than with how his art would be viewed after his death. The establishment of a foundation to own, preserve and exhibit his art became a dominant concern for him. His suicide, however seems to have been motivated by his disintegrating marriage and his poor physical and mental health. The creative work of three of the male suicides, therefore, seems to have a played a role in their suicide (Berryman, Crane and Gertler). This influence was weaker in the suicides of Gertler, Lindsay and Pavese. It is also clear that depression, both of psychiatric proportions and of moderate intensity, played a role in almost all of the suicides committed by these six writers and artists. A STUDY OF CELEBRITIES Zhang, Tan and Lester (2013) studied 72 famous individuals who died by suicide, based on summaries of biographies written about them.3 The analysis was based on a theory proposed by Zhang that strains precede suicidal behavior. A strain is not a simple stressor, but rather two or more stressors or forces that are pushing an individual in different directions, creating conflict. There are four types of strain: (1) conflicting values when the individual experiences two conflicting social values or beliefs, such as when Chinese rural women face a conflict between traditional (Confucian) gender roles and modern communist ideology of gender equality, (2) aspiration strain when an individual achieves less than his or her aspirations, (3) relative deprivation when an individual is poor, for example, in a society where most of the citizens are wealthy, and (4) coping deficiency when an individual lacks the ability to cope with the life crises that he or she encounters. For the 72 famous individuals who died by suicide, Zhang et al. (2013) found that one had all four strains, 36 had three strains, 30 had two, four had one, and only one had no strains. The most common strain was aspiration strain (97%), followed by deprivation strain (89%), value strain (54%) and coping deficiency (4%). Fifty-five of the famous suicides were men and 17 were women, and there were no differences in the presence of any type of strain between the men and the women. Thus, even in these famous men who died by suicide, aspiration and deprivation strains played a major role in precipitating their suicidal behavior. The men in this sample, and the strains which they had, are shown in Table 14.4.

3. The summaries are on www.drdavidlester.net

Age 47 64 48 87 78 59 53 49 18 49 27 33 43 30 57 83 54 40 48 44 41 29 62 68 53 46 41 58

Name

Arenas, Reinaldo Armstrong, Edwin H. Benjamin, Walter Bettelheim, Bruno Boyer, Charles Broughton, Henry Castlereagh, Viscount Celan, Paul Chatterton, Thomas Clive, Robert Cobain, Kurt Crane, Hart De Nerval, Gérard Esenin, Sergei Forrestal, James Freud, Sigmund Fumimaro, Konoe Gertler, Mark Goebbels, Joseph Gorky, Arshille Halliwell, Kenneth Heggen, Tom Hemingway, Ernest Hoch, Ludvik Hoffman, Abbie Kammerer, Paul Kees, Weldon Kosinski, Jerzy

writer scientist writer psychologist actor nobility politician poet writer soldier singer poet writer poet politician psychiatrist politician artist Nazi minister painter writer writer writer businessman yippie/writer scientist poet/writer writer

Profession Cuba/USA USA Germany Austria/USA France UK UK France England UK USA USA France Russia USA Austria Japan England Germany USA UK USA USA UK USA Austria USA USA/Poland

Country Dec 17, 1990 Jan 31, 1954 Sep 27, 1940 Mar 13, 1990 Aug 24, 1978 Dec 5, 1942 Aug 12, 1822 Apr 20, 1907 Aug 24, 1770 Nov 22, 1774 Apr 5, 1994 Apr 27,1 932 Jan 26, 1855 Dec 28, 1925 May 22, 1949 Sep 23, 1939 Dec 15,1 945 Jun 23, 1939 May 2, 1945 July 21, 1948 Aug 9, 1967 May 18, 1949 July 2, 1961 Nov 5, 1991 Apr 12,1 989 Sep 23, 1926 July 18, 1955 May 2, 1991

Date of suicide

Table 14.4. MALE CELEBRITIES WHO DIED BY SUICIDE.

yes yes yes yes no no yes no no yes yes no no no yes no yes yes yes yes yes yes yes yes yes yes no yes

V yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes no yes yes yes yes yes yes yes yes yes yes yes yes

A

Strain yes yes yes yes no yes yes yes yes yes yes yes yes yes yes no yes yes yes yes yes yes yes yes yes yes no yes

D

no no no no no no no no no no no no no no no yes yes no no no no no no no no no no no

C

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Russia USA USA Italy USA Germany USA USA Soviet Union UK Japan USA Italy USA USA USA Austria Hungary Germany/USA Germany UK UK Netherlands UK Austria USA Austria

Country

D relative deprivation

buisnessman actor politician writer/chemist poet economist writer writer poet scientist writer folk singer poet/writer comedian soldier painter royalty psychoanalyst activist/writer writer teacher boxer painter osteopath psychoanalyst actor writer

Profession

A aspiration strain

41 51 58 68 52 57 33 39 37 54 45 36 42 22 49 67 31 40 76 45 42 38 37 51 23 65 61

Kovalevski, Vladimir Ladd, Alan La Follette, Robert Levi, Primo Lindsay, Vachel List, Georg Lockridge, Ross London, Jack Mayakovsky, Vladimir Miller, Hugh Mishimam Yukio Ochs, Phil Pavese, Cesare Prinze, Freddie Puller, Lewis Rothko, Mark Rudolph, Prince Tausk, Victor Toller, Ernst Tucholsky, Kurt Turing, Alan Turpin, Randolph Van Gogh, Vincent Ward, Stephen Weininger, Otto Young, Gig Zweig, Stefan

V value strain

Age

Name yes no yes no no no no no yes yes no no no no yes no yes yes yes yes no no no yes yes yes yes

V

C coping skills deficiency

Apr 7, 1883 Jan 29, 1964 Feb 24, 1953 Apr 11, 1987 Dec 4, 1931 Nov 30, 1846 Mar 6, 1948 Nov 21, 1915 Apr 14, 1930 Dec 24, 1856 Nov 25, 1970 Apr 9, 1976 Aug 27, 1950 Jan 29, 1977 May 11, 1994 Feb 24, 1970 Jan 30, 1889 July 3, 1919 May 22, 1939 Dec 21, 1935 June 7, 1954 May 5, 1966 July 29, 1890 Aug 3, 1963 Oct 4, 1903 Oct 19, 1978 Feb 22, 1942

Date of suicide

Table 14.4—Continued.

yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes

A

Strain yes yes no yes yes yes yes yes yes no no yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes

D

no no no no no no no no no no no no no no no no no no no no no no no no no no no

C

Suicide in Creative Men 171

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DOES CREATIVE WRITING HARM SUICIDAL PEOPLE? Is writing therapeutic for creative writers or is it a stressor which contributes to their psychological disturbance? Silverman and Will (1986) analyzed the life and suicide of Sylvia Plath and concluded that, although she tried to control her suicidal impulses by means of her poetry, she failed in this endeavor. Silverman and Will argued that poetry is successful when it bridges the inner worlds of the creative person and the audience. (Presumably they mean critically successful, for even poor poetry can serve a useful psychological function for the writer, even if it is merely cathartic.) To be successful, poetry must first achieve a balance between the writer’s use of the audience to serve his or her own narcissistic needs (a type of exhibitionism) and the desire to give others a way of structuring the terrors and anxieties that afflict us all (a homonomous desire on the part of the writer to use a term coined by Andras Angyal [1965]). The writer must also achieve a balance between the potentially destructive conscious and unconscious forces motivating the writing and the constructive desires to harness these forces for the purpose of writing creatively. Related to this, the writer must balance primary and secondary process mechanisms. The writer must also compromise between the fantasy permissible in writing and the acceptance of reality necessary for successful living. Silverman and Will argued, therefore, that certain styles of writing may increase the risk of suicide, especially if unconscious forces cannot be suppressed. In contrast, Lester and Terry (1992) argued that writing novels and poetry can be useful with suicidal clients. Writing per se may not be helpful to the client, but the revision of the initial drafts may be therapeutically useful. Revising may serve a similar function for clients as the journal assignments devised by cognitive therapists by giving the clients intellectual control over their emotions and distance from the traumatic memories. In the process of revision, writers must concentrate on form rather than content. This allows for both the action that therapists deem to be therapeutic and the distancing of the self from one’s problems. Lester and Terry argued, therefore, that writing may help prolong the life of creative poets and novelists. COMMENT The occurrence of suicide in creative men has received very little attention in the past, and clearly much more research needs to be conducted. At the present time, it is far from clear whether suicidally inclined men are drawn into the creative arts or whether engagement in the creative arts increases the

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suicidal risk of men. It is clear, however, that some groups of artistic men, in particular poets, novelist, artists and composers, have a high incidence of affective disorder, including depressive disorders, bipolar disorders and cyclothymic personality disorder. The dilemma for these creative men is that treatment with medications and electroconvulsive therapy often impairs their creative abilities, and so they have to balance their mental health against the creative work to which they have devoted their lives. REFERENCES Andreasen, N. C. (1987). Creativity and mental illness. American Journal of Psychiatry, 144, 1288–1292. Angyal, A. (1965). Neurosis and treatment. New York: Wiley. Bron, B., Strack, M., & Rudolph, G. (1991). Childhood experiences of loss and suicide attempts. Journal of Affective Disorders, 23, 165–172. Cox, C. M. (1926). Early mental traits of three hundred geniuses. Palo Alto, CA: Stanford University Press. Goodwin, D. W. (1988). Alcohol and the writer. Kansas City, MO: Andrews McNeel. Jamison, K. R. (1989). Mood disorders and patterns of creativity in British writers and artists. Psychiatry, 52, 125–134. Jamison, J. K. 1993). Touched with fire: Manic-depressive illness and the artistic temperament. New York: Free Press. Kunz, P. (1978). Relationship between suicide and month of birth. Psychological Reports, 42, 794. Laing, O. (2013). The trip to Echo Spring. Edinburg, Scotland: Canongate. Lester, D. (1986). The birthday blues revisited. Acta Psychiatrica Scandinavica, 73, 322–323. Lester, D. (1987). Suicide and sibling position. Individual Psychology, 43, 390–395. Lester, D. (1991). Premature mortality associated with alcoholism and suicide in American writers. Perceptual & Motor Skills, 73, 162. Lester, D. (1993). Suicide in creative women. Commack, NY: Nova Science. Lester, D. & Beck, A. T. (1976). Early loss as a possible “sensitizer” to later loss in attempted suicides. Psychological Reports, 39, 121–122. Lester, D., & Terry, R. (1992). The use of poetry therapy. The Arts in Psychotherapy, 19, 47–52. Ludwig, A. M. (1992). Creative achievement and psychopathology. American Journal of Psychotherapy, 46, 330–356. Shaffer, D. (1974). Suicide in childhood and early adolescence. Journal of Child Psychology & Psychiatry, 15, 275–291. Silverman, M. A., & Will, N. P. (1986). Sylvia Plath and the failure of emotional selfrepair through poetry. Psychoanalytic Quarterly, 55, 99–129. Slater, E., & Meyer, A. (1959). Contributions to a pathography of the musician Robert Schumann. Confinia Psychiatrica, 2, 65–04.

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Zhang, J., Tan, J., & Lester, D. (2013). Psychological strains found in the suicides of 72 celebrities. Journal of Affective Disorders, 149, 230–234.

Chapter 15 THE INFLUENCE OF RACE AND ETHNICITY ON SUICIDE IN MEN JOHN F. G UNN III and ALLISON L. G UNN uicide is a complex behavior, as demonstrated by the variety of chapters found in this book discussing suicidal behavior among men. Many factors contribute to suicidal behavior, and one of these factors is the topic of this chapter, namely the role of racial, ethnic and cultural identities. We will discuss the research on suicide among African American men, Asian men, Hispanic men, and Native American men, whether these groups are characterized by a low, moderate or high rate of suicide, and potential explanations for this. Clinical considerations when working with specific ethnic groups will also be discussed.

S

SUICIDE RATES BY ETHNICITY AND GENDER In any discussion on the effects of race and ethnicity on suicidal behavior, it is important to establish whether or not certain groups are more at risk for suicide than others. The most recent data for suicide rates in the United States are for 2010.1 According to the American Foundation for Suicide Prevention, the highest suicides rates in the United States for 2010 were among European Americans and American Indians/Alaskan Natives, with rates of 14.1 and 11.0 per 100,000 per year, respectively. The rates for Asians/Pacific Islanders, African Americans, and Hispanics were much lower: 6.2, 5.1, and 5.9, respectively. McIntosh and Drapeau (2012) also provide data on gender 1. Suicide rates were obtained from the American Foundation for Suicide Prevention, retrieved from https://www.afsp.org/understanding-suicide/facts-and-figures

175

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differences in the suicide rates of European Americans and African Americans for 2010. European American males had a suicide rate of 22.6 and European American females a suicide rate of 5.9, while African American males had a suicide rate of 8.7, and African American females a rate of 1.8.2

African American Men As can be seen by examining the suicide rates discussed above, African American males have a suicide rate much lower than European American males. Given that they have been faced with a history of oppression and racial inequality, one would think that their suicide rate would be higher. There are, however, several possible explanations for why African American males have a lower suicide rate than European American males. There are several protective factors that can be found within the African American community, including religion and spirituality. Previous work has linked both religion and spirituality with a protective effect against suicide (Barnes & Bell, 2003; Stack & Wasserman, 1995). Social support in the form of friends and family has also been suggested as a protective factor for African Americans (Stack, 1996). Additionally, one factor that could set African American males apart from European American males is their experience of racial pride. Kirk and Zucker (1979) found that the more racial pride that African Americans felt, the lower their suicide risk. Of all the causes of death, suicide is the only one for which African Americans have a lower rate than European Americans (Lester, 1998). While adult African Americans have a lower risk of suicide than European Americans, it must be noted that suicide among African American adolescents is a major cause for concern. Lester (1998) showed that rate of attempted suicide was higher in African American adolescents than in European American adolescents, but the attempts were less often fatal. Furthermore, the suicide rate among African American adolescents has risen steadily since 1980 and is now comparable to the overall rate of suicide among European American adolescents. A number of factors have been proposed as potential explanations for this rise in the suicide rate of African American adolescents, including feelings of hopelessness, impulsive behavior, access to guns, domestic partner violence, community violence, family breakdown, economic changes, psychopathology, personal isolation, and sexual abuse (Garland & Zigler, 1993; Lewinsohn, Rhode, & Seeley, 1996; Pastore, Fisher, & Friedman, 1996; Utsey et al., 2008; Watt & Sharp, 2002), but the relative importance of these factors remains unknown. 2. Gender-based rates were not given for Hispanic, Native Americans, or Asian/Pacific Islanders.

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Rowell, Green, Guidry and Eddy (2008) reviewed 266 potential articles on the risk factors for suicide in African American adult men and identified nine empirical studies of good quality. These articles indicated the following risk factors: education, substance abuse (especially cocaine use), economic opportunities (and dependence on public assistance), marital status (especially widowhood), age, negative interactions with the police, levels of violence, disease status (HIV-positive), and geographic region (residing in a region with few minority residents). The picture was, however, sometimes complex. For example, a collge degree increased the risk of suicide for African American men aged 25–44 but decreased the risk of suicide in those aged 55–64.

Suicide Prevention Recommendations What suicide prevention implications do these findings suggest for African American men? In a recent book on cultural diversity and suicide, Leach (2006) gave several concerns to keep in mind when working with African Americans. Leach indicated that primary prevention efforts should target African American youths who, as discussed above, are at the greatest risk of suicide. This could be a difficult task as past research has shown that African Americans are often less willing to trust mental health clinicians and services (Paniagua, 2005). They are far less likely to use available services and, when they do, they are more likely to drop out prior to the completion of treatment. Prevention efforts must target communities to lower this stigma and mistrust if we hope to help African American men who are feeling suicidal. As African American adolescents are the most at risk, prevention efforts might focus on schools and youth centers and services to target the greatest at-risk population. As a secondary prevention effort, Leach recommended early intervention in the form of tutoring, peer counseling and hotlines, as well as limiting the accessibility of guns.3 Finally, Leach also drew attention to the possibility that counselors may believe that there is a lowered risk of suicide among African American clients and, therefore, assume they are not likely to be a suicide risk. This myth must be challenged through education and training. Suicide risk screening is essential regardless of ethnicity and should not be ignored because a client is African American. Leach also noted that when suicidal ideation is experienced, African Americans may be more prone to feel shame and guilt over these feelings and fail to communicate their ideation to others.

3. For more of a discussion on the role of firearms in suicide among men, see Chapter 7.

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Counseling Recommendations Since African American clients may be mistrustful of clinicians, as noted above, it is important for counselors to develop a strong and positive relationship with clients and create a comfortable and supportive environment that will allow the clients to speak more freely. Counselors should also be aware of the negative impact that racism may have on individuals in this population and know that their experiences in dealing with prejudice can contribute to feelings of depression, low self-esteem, helplessness and other distressing symptoms (Day-Vines, 2007; Leong & Leach, 2008; Neukrug, 2007). If it is determined that the client feels the negative impact of racism, the client’s race may be considered a risk factor. If the client feels pride when thinking of his culture, race may be a protective factor (Neukrug, 2007). It is important that counselors take any suicidal thoughts seriously, despite the low rates of suicide among African Americans. In this population, as in others, there is often a strong stigma attached to suicide and, if a client reveals ideation, it is important to acknowledge and explore these feelings (Leong & Leach, 2008). Because of this stigma, it is also important to look for more covert hints that the client is thinking about suicide, as many of the most common behaviors that indicate risk, with the exceptions of hopelessness and despair, may not be displayed (Day-Vines, 2007; Leong & Leach, 2008). Some protective factors for the African American population include involvement in religion, strong family bonds, a sense of belonging to a community, cognitive flexibility, and racial and ethnic pride (Leong & Leach, 2008; Neukrug, 2007). The counselor should assess the client’s use of these resources and other protective factors and encourage their use. This is especially important for men because it has been found that African American women are more likely to use these resources than are men. Determining which resources to use and how much to use them with the client, rather than telling the client what to do, will give him the opportunity to assist in his own treatment, allow for treatment to be tailored to each individual, and increase the chances that he will utilize those resources. However, when using religion as a protective factor, it is important to refrain from taking a judgmental stance, as this may worsen the stigma associated with suicide.

Asian American Men As with African American men, Asian American men complete suicide at a lower rate than do European American men. Among Asian American men, two groups stand out as an increased risk of suicide: those aged 15–24 years and those aged 75+ years (Kachur et al., 1995; Shiang et al., 1997). However,

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one of the problems with examining suicidal behavior among Asian Americans is the variation between the various groups that make up the category of “Asian American.” Japanese Americans have been shown to have the highest rate of suicide of Asian American groups, approximately 9.1 per 100,000 per year (Kalish, 1968; Lester, 1994). This is not surprising since Japan has historically had one of the highest rates of suicide in the world. Braun and Nichols (1997) noted that suicide, while not condoned by Buddhist beliefs, is less condemned in Japan than in other Buddhist countries. Suicide has also been treated with leniency throughout Japan’s history, with seppuku condemned only 150 years ago and still influential in Japanese culture (Hirayama, 1990). Chinese Americans also have an elevated rate of suicide in relation to other Asian Americans, 8.3 per 100,000 per year (Kalish, 1968; Lester, 1994). In his discussion of suicide among Chinese Americans, Leach (2006) noted that: Traditionally, the Chinese have viewed suicide from a much more contextualist perspective than their Western counterparts. The individual is understood as secondary to the needs of the group, and suicide is viewed as an interpersonal, familial act. . . . Suicide is often associated with shame, as in the failure of a son to achieve the expectations of the family, and attitudes toward suicide are associated with saving face, indicating that the person takes responsibility for actions and has saved the family or community from further shame. Therefore, suicide is often perceived as honorable. (Ryan 1985; Leach, 2006, p. 132)

The lowest suicide rates among Asian Americans are found in Filipino Americans, who have suicide rates two or three times lower than Japanese and Chinese Americans (Lester, 1994). Other Asian American groups include Vietnamese Americans, Korean Americans, and Cambodian Americans, but there is little or no research examining these groups.4 The question then arises as to why Asian Americans have a lower suicide rate than European Americans. Chang (1998) found that Asian American college students had higher scores for perfectionism, lower scores for good problem-solving skills and higher hopelessness and suicidal ideation scores than did European Americans. Asian Americans students also reported significantly higher scores for measures of parental expectations and parental criticism. Perhaps the stronger family ties and obligations prevent these risk factors from increasing the risk of dying by suicide in Asian American men? 4. Asia includes Middle Eastern countries as well as Bangaladesh, India and Pakistan, among other nations. However, there is little research on suicide in immigrants from these nations to the United States.

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Suicide Prevention Recommendations Given that Asian Americans do not represent a particularly at-risk group, it is not surprising that there is little in the way of prevention recommendations for, or programs that are geared towards, this group. However, Leach (2006) recommended: 1. Show patience regarding language barriers. 2. Remember that asking personal questions too soon may alienate Asian American clients. 3. Keep in mind that Asian Americans may exhibit symptoms that are not the same as European American clients. For example, somatic symptoms of depression may be reported as these are easier to talk about than emotions and thoughts. 4. Focus on the community as this is a vital part of Asian culture. Ask questions such as how did others react to the suicidal ideation or attempt. The potential role of perceived burdensomeness and thwarted belonging should be examined when working with Asian Americans. Given the importance of the family and the community in Asian cultures, a feeling of social isolation and that one is a burden on others may be especially important risk factors for suicide in Asian Americans.

Counseling Recommendations Counselors should remember there are differences in rates and protective factors for different groups within the Asian population and there may also be differences based on the religious affiliation of the individual. For example, although the most common religions (Buddhism, Confucianism and Hinduism) do not consider suicide to be acceptable, each client should be considered individually and must be understood in the context in which the person was living, with suicide possibly being seen as the only viable option, or as a way to “save face” (Leong et al., 2008). These factors require counselors to learn about the background and beliefs of their clients in order to tailor treatment to meet their needs. In general, Asian Americans do not want to bring shame to their families and may feel extreme guilt if they feel that they have done so. Both shame and guilt may increase the risk of suicidal ideation. It is also common for Asian Americans to have somatic symptoms and to be more willing to talk about these than about psychological discomfort, as physical pain is considered more acceptable. Somatic symptoms may indicate that a psychological problem exists (Neukrug, 2007).

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Counselors should also be aware that many Asian Americans are private in nature and may be reluctant to discuss personal matters. As a result, by the time Asian Americans seek treatment, they are likely to be experiencing intense distress, and the initial session should be considered an emergency. Therefore, it may be beneficial to always assess suicide risk when meeting a new client of Asian descent (Leong et al., 2008). Counselors should also be aware of other risk factors, including those associated with age (given that adolescents and elderly individuals are more likely to complete suicide). In addition, as identification with their cultural heritage increases, depressive symptoms and the likelihood that clients will experience suicidal ideation also increases. When working with Asian American clients, the counselor should remember that individuals from this population tend to be very formal in interactions and relationships (Neukrug, 2007). The counselor should, therefore, avoid asking about personal matters too early in the relationship. It is important for the counselor to build rapport over time and be aware of symptoms and behaviors that imply psychological distress (Leach, 2006). If an Asian American client is found to be at risk for suicide, it is important that action be taken, but in a way that limits the shame felt by the client.

Hispanic Americans As with Asian Americans, Hispanic Americans are a very heterogeneous group. “Hispanic” is a category that incorporates Latinos/Latinas, Chicanos/ Chicanas, Mexican Americans, Cuban Americans, Puerto Ricans, and many other groups. We will use the umbrella term Hispanic American, but we will discuss the groups that comprise Hispanic American when possible. It is important to note that, among Hispanic nations, there is variation in the suicide rates. Cuba, Spain, Puerto Rico, and El Salvador have the highest suicide rates, while Peru, Nicaragua, Guatemala and Colombia have the lowest suicide rates (Canetto & Lester, 1995). However, there is not enough research examining the groups that comprise Hispanic Americans for us to discuss whether or not these differences in rates are present in these ethnic groups in the United States. Generally speaking, Hispanic American suicide rates are much lower than European American rates, with European Americans having rates that are as many as four times those of Hispanic Americans (Oquendo et al., 2001). Furthermore, Hispanic male suicide rates are much higher than Hispanic female suicide rates with a 5:1 ratio (versus 3.8:1 for European Americans). In addition to the gender differences, there are also age differences in Hispanic American suicide rates. There is inconsistency in the findings regard-

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ing Hispanic American youths, but research indicates that Hispanic American youths are more at risk for suicide ideation and attempts than European Americans and African Americans, but not more likely to complete suicide (Canino & Roberts, 2001). However, Hispanics between the age of 20 and 24 have a completed suicide rate of 17.8 per 100,000 per year, placing them above the national average for that age group (Kachur et al., 1995). Finally, those at greatest risk of suicide among Hispanic Americans are those over the age of 65. As with African Americans, Hispanic Americans may have a lower rate of suicide because of the protective nature of religiosity and spirituality that is strong among Hispanic Americans (Barry, 1999). Another potential protective factor associated with a reduced rate of suicide among Hispanic Americans is fatalismo. As Leach (2006) has said: Fatalismo is associated with Catholicism and is defined as “believing that a divine providence governs the world and that an individual cannot control or prevent adversity” (Paniagua, 2005, p. 43). The closest variable within U.S. psychology culture is external locus of control. It maintains an adaptive response to uncontrollable life events and is thus considered healthy. Mirowsky and Ross (1984) contended that while European Americans attempt to control, Hispanic Americans seek to accept, attributing situations to fate or luck. (Leach, 2006, p. 181)

Finally, Hispanic American family dynamics may also account for the lowered rate of suicide. Valle (1986) noted that Hispanic American families offer more support during times of stress. From the point of view of Joiner’s Interpersonal Theory of Suicide, in which thwarted belongingness is a risk factor for suicide (see Chapter 3), this could result in a lowered rate of suicide.

Suicide Prevention Recommendations Again, as with other minority groups, we lack prevention programs and recommendations that are geared for this group. However, given the role that the family plays in providing support for Hispanic Americans, prevention efforts could utilize the family. By increasing interpersonal ties, we may lower the risk of suicide. Therefore, when suicidal ideation or behavior is present, prevention efforts could rely more on the families and friends to instill a greater sense of belonging. This is not to say that individual counseling should not be utilized, but rather that it can be augmented by family therapy and group therapy.

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Counseling Recommendations When working with Hispanic Americans, counselors should remember that absence of depression does not necessarily indicate an absence of suicidal ideation. In Hispanic populations, individuals who are depressed often do not express suicidal ideation, and those who have suicidal thoughts often are not depressed (Leong & Leach, 2008). Counselors must look for other indicators that a client of Hispanic descent may be experiencing suicidal feelings. Similar to Asian Americans, Hispanic Americans may present with somatic symptoms that could indicate psychological distress. Counselors should also assess the level of acculturation, as an increase in acculturation has been linked to an increase in the risk of suicidal behavior (Leach, 2006). Counselors working with Hispanic Americans should use a strengths-based approach, making sure to focus on and improve upon the client’s strengths rather than finding and trying to change weaknesses, an approach that allows the client to view himself more positively (Leach, 2006). Because religion is important in Hispanic cultures, religion may also be a source of strength for clients. If the client’s religion is determined to be a potential protective factor, the counselor may want to examine the view of suicide in the client’s religion and encourage the client to increase his participation in religious activities (Leach, 2006). The family also is important in Hispanic cultures, and counselors should encourage the client to rely on his family as a support system, a role that family members would likely already have.

Native Americans Thus far the ethnic groups discussed have had lower rates of suicide than the national average, but this is not the case for Native Americans. The label “Native American,” as with Hispanic American and Asian American, is somewhat misleading as it implies a single homogenous group. Native Americans comprise over 550 tribal groups (Leach, 2006). While Native Americans have long been recognized as the ethnic group with the highest suicide rates, there is a wide degree of variation in suicide rates by type of Native American culture (Alcantara & Gone, 2008). Kettl and Bixler (1993) found that during the 1980s, the suicide rate of Alaskan Natives was more than 60 per 100,000 per year, and Forbes and Van der Hyde (1988) reported that, between 1978 and 1985, there was a significant increase in Alaskan Native suicide rates. However, the suicide rates of different tribes vary greatly. For example, while the Kwakiutl have a suicide rate of 149, the Pima have a rate of only 7 (Lester, 1997). Furthermore, many Native Americans have joined the mainstream culture (rather than living on

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reservations), and the suicide rate of these fully assimilated Native Americans is unknown. In the United States overall, the greatest at risk-group for suicide is those 65 years or older (McIntosh & Drapeau, 2012). However, this is not the case among elderly Native Americans, who have an average suicide rate of only 25 per 100,000 per year, versus 64 among the general population (Leach, 2006). Between the years 1979 and 1984, Kettl and Bixler (1991) found that there were no suicides among Alaska Natives over the age of fifty-five. These findings are in stark contrast to the suicide rates of other cultures which typically rise with age. One particular explanation for this is the position of honor that older Native Americans carry in Native American communities (Baker, 1994; Kettle & Bixler, 1991). However, Leach noted that: “Suicide rates among Native American groups overall are rising faster than the average rate of increase in the United States, particularly among male adolescent and young adult groups; female adolescent and young adult rates are consistently greater than female rates from other ethnic groups (Leach, 2006, p. 194).” Leach (2006) mentioned several potential explanations for this increased risk of suicide. 1. Alcohol use and abuse: While alcohol use and abuse are often associated with greater risk of suicide, Leach pointed out that alcohol abuse seems to be especially pertinent to Native American suicide. Alcohol has been shown to be involved in 70%–90% Native American suicides ( Johnson, 1994; May et al., 2002).5 2. Adolescents are more impulsive than mature adults. Leach (2006) argued that the increased rate of suicide among Native Americans may be due to the fact that half of the Native American population is younger than 18 years of age. 3. Native Americans suffer from a greater percentage of unemployment and poverty than the United States as a whole and as such may be at an increased risk of suicide (Lester, 1997). 4. Leach also noted that there is possible impact from their history of political and economic oppression. 5. Finally, Leach noted the conflicts involved in acculturation as a potential stressor among Native Americans.

5. For more on the role of alcohol use and abuse among males see Chapter 4.

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Suicide Prevention Recommendations Given the heterogeneity of Native American groups, there is the possibility that any program designed to impact this population may not be useful for all groups. However, given the common risk factors discussed above, any program that focuses on these risk factors (e.g., alcohol and substance abuse) could be beneficial in reducing suicide rates among Native Americans. Further work is needed to examine the uniqueness of suicide among the subdivisions within the umbrella term of Native Americans. For example, Levy (1988) found that suicides on a Shoshoni-Bannock reservation were concentrated in only four families, and so a general suicide prevention program was unnecessary. Lester (1997) reviewed suicide prevention programs that had been set up for Native Americans, but none were specifically tailored for Native American men.

Counseling Recommendations When working with Native Americans, counselors should be aware of multiple factors that may impact treatment (Thomason, 1991; Herring, 1997). First, there are numerous Native American tribes throughout the United States, each with its own unique history, culture and customs. These differences may affect risk factors and treatments, as well as how individuals interact with others, including the counselor. It would be best to learn about the client’s tribe in order to determine how best to proceed. It is also helpful to mirror the client’s behavior in order to act appropriately with him. In general, counselors should be aware of risk factors that are applicable to most tribes. Alcohol use and abuse is very common in Native American suicides, and is more common in men than in women in these communities. Counselors should be aware of the long history of prejudice and oppression that the tribes have been subjected to in the United States and recognize that these experiences may lead to depression, anxiety, loss of traditional identity, family problems, poverty, unemployment, a lack of educational opportunities and alcoholism—all factors that increase a Native American client’s risk for suicide. Lastly, the highest rates of suicide is found in those who are under the age of 35, and there are specific risk factors for adolescent males including involvement in a gang, a history of psychiatric treatment, and having a friend or peer attempt or complete suicide. Counselors should take an active and directive approach with Native Americans. They should focus on the here and now rather than the past or the future, and work to solve problems in the present. Counselors should focus on protective factors for Native American clients, for example, exploring the client’s spirituality, as this will often help a Native American client to

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find meaning in his life. Family and community relationships may also be helpful protective resources, and counselors should consider involving the tribe or the community in treatment for the client. CONCLUSION Throughout this chapter we have discussed suicide among specific ethnic groups, and we have made several recommendations regarding prevention and counseling. As can be seen, the suicide risk among the different ethnic groups varies, and even within the larger groups (e.g., Asian Americans). Throughout all of these ethnicities, men are at greater risk of suicide. Various explanations have been given throughout this chapter for this sex difference and more explanations for this difference can be found throughout this book. Many of the risk factors that are associated with suicide among these groups are also more prevalent among men in general (e.g., alcohol abuse [see Chapter 4]). However, it is noteworthy that very little attention has been given by scholars and clinicians to suicide in men in these ethnic minorities. Therefore, we have been unable to suggest any specific risk factors or prevention tactics that might work for men in these cultures. REFERENCES Alcantara, C., & Gone, J. P. (2008). Suicide in Native American communities. In F. T. L. Leong & M. M. Leach (Eds.), Suicide among racial and ethnic minority groups (pp. 173–199). New York: Routledge. Baker, F. M. (1994). Suicide among ethnic minority elderly: A statistical and psychosocial perspective. Journal of Geriatric Psychiatry, 27, 261–264. Barnes, D. H., & Bell, C. C. (2003). Paradoxes of black suicide. The National Journal, January. Barry, R. (1999). The Catholic condemnation of rational suicide. In J. L. Werth Jr. (Ed.), Contemporary perspectives on rational suicide (pp. 29–34). Philadelphia: Brunner/Mazel. Braun, K. L., & Nichols, R. (1997). Death and dying in four Asian American cultures. Death Studies, 21, 327–359. Canetto, S. S. & Lester, D. (1995). Gender and the primary prevention of suicide mortality. In M. M. Silverman & R. W. Maris (Eds.), Suicide prevention: Toward the year 2000 (pp. 58–69). New York: Guilford. Canino, G., & Roberts, R. E. (2001). Suicidal behavior among Latino youth. Suicide & Life-Threatening Behavior, 31, 122–131.

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Chang, E. C. (1998). Cultural differences, perfectionism, and suicidal risk in a college population. Cognitive Therapy & Research, 22, 237–254. Day-Vines, N. L. (2007). The escalating incidence of suicide among African Americans: Implications for counselors. Journal of Counseling & Development, 85, 370–377. Forbes, N., & Van der Hyde, V. (1988). Suicide in Alaska from 1978 to 1985: Updated data from state files. Native American & Alaska Native Mental Health Research, 1, 36–55. Garland, A. F., & Zigler, E. (1993). Adolescent suicide prevention: Current research and social policy implications. American Psychologist, 48, 169–182. Herring, R. D. (1997). Counseling indigenous American youth. In C. C. Lee (Ed.) Multicultural issues in counhseling (pp. 53–70). Alexandria, VA: American Counseling Association. Hirayama, K. K. (1990). Death and dying in Japanese culture. In J. K. Parry (Ed.), Social work practice with the terminally ill: A transcultural perspective (pp. 159–174). Springfield, IL: Charles C Thomas. Johnson, D. (1994). Stress, depression, substance abuse, and racism. Native American & Alaska Native Mental Health Research, 6, 29–33. Kachur, S. P., Potter, L. B., James, S. P., & Powell, K. E. (1995). Suicide in the United States, 1980–1992. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention. Kalish, R. A. (1968). Suicide: An ethnic comparison in Hawaii. Bulletin of Suicidology, December, 37–43. Kettl, P., & Bixler, E. O. (1991). Suicide in Alaska Natives, 1979–1984. Psychiatry, 54, 55–63. Kettl, P., & Bixler, E. O. (1993). Alcohol and suicide in Alaska Natives. Native American & Alaska Native Mental Health Research, 54, 34–45. Kirk, A. R., & Zucker, R. A. (1979). Some sociopsychological factors in attempted suicide among urban black males. Suicide & Life-Threatening Behavior, 9, 76–86. Leach, M. M. (2006). Cultural diversity and suicide: Ethnic, religious, gender, and sexual orientation perspectives. Binghamton, NY: Haworth. Leong, F. T. L., & M. M. Leach, M. M. (Eds.) (2008). Suicide among racial and ethnic minority groups. New York: Routledge. Leong, F. T. L., Leach, M. M., & Gupta, A. (2008). Suicide among Asian Americans. In F. T. L. Leong & M. M. Leach (Eds.), Suicide among racial and ethnic minority groups (pp. 117–141). New York: Routledge. Lester, D. (1994). Differences in the epidemiology of suicide in Asian Americans by nation of origin. Omega, 29, 89–93. Lester, D. (1997). Suicide in American Indians. Commack, NY: Nova Science. Lester, D. (1998). Suicide in African Americans. Commack, NY: Nova Science. Levy, J. E. (1988). The effects of labeling of health behavior and treatment programs among North American Indians. American Indian & Native Alaska Native Mental Health Research, 1, Monograph 1, 211–231.

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Lewinsohn, P. M., Rhode, P., & Seeley, J. R. (1996). Adolescent suicidal ideation and attempts: Prevalence, risk factors, and clinical implications. Clinical Psychology: Science & Practice, 3, 25–46. May, P. A., Van Wilkle, N. W., Williams, M. B., McFeeley, P. J., Debruyn, L. M., & Serna, P. (2002). Alcohol and suicide death among American Indians of New Mexico: 1980–1998. Suicide & Life-Threatening Behavior, 32, 240–255. McIntosh, J. L. & Drapeau, C. W. (for the American Association of Suicidology). (2012). U.S.A. suicide 2010: Official final data. Washington, DC: American Association of Suicidology, dated November 28, 2012, downloaded from: www .suicidology.org. Mirowsky, J., & Ross, C. E. (1984). Mexican culture and its emotional contradictions. Journal of Health & Social Behavior, 25, 2–13. Neukrug, E. (2007). The world of the counselor: An introduction to the counseling profession (3rd ed.). Belmont, CA: Brooks/Cole. Oquendo, M. A., Ellis, S. P., Greenwald, S., Malone, K. M., Weissman, M. M., & Mann, J. J. (2001). Ethnic and sex differences in suicide rates relative to major depression in the United States. American Journal of Psychiatry, 158, 1652–1658. Paniagua, F. A. (2005). Assessing and treating culturally diverse clients: A practical guide (2nd ed.). Thousand Oaks, CA: Sage. Pastore, D. R., Fisher, M., & Friedman, S. B. (1996). Violence and mental health problems among urban high school students. Journal of Adolescent Health, 18, 320– 324. Rowell, K. L., Green, B. L., Guidry, J., & Eddy, J. (2008). Factors associated with suicide among African American adult men. Journal of Men’s Health, 5, 274–281. Ryan, A. S. (1985). Cultural factors in casework with Chinese-Americans. Social Casework, 66, 333–340. Shiang, J., Blinn, R., Bonger, B., Stephens, B., Allison, D., & Schatzberg, A. (1997). Suicide in San Francisco, CA: A comparison of Caucasian and Asian groups, 1987-1994. Suicide & Life-Threatening Behavior, 27, 80–91. Stack, S. (1996). The effect of marital integration on African American suicide. Suicide & Life-Threatening Behavior, 26, 405–414. Stack, S., & Wasserman, I. (1995). The effect of marriage, family, and religious ties on African American suicide ideology. Journal of Marriage & the Family, 57, 215– 223. Thomason, T. (1991). Counseling Native Americans: An introduction for non-Native American counselors. Journal of Counseling & Development, 69, 321–327. Utsey, S. O., Standard, P., & Hook, J.N. (2008). Understanding the role of cultural factors in relation to suicide among African Americans. In F. T. L. Leong & M. M. Leach (Eds.), Suicide among racial and ethnic minority groups (pp. 57–79). New York: Routledge. Valle, R. (1986). Hispanic social networks and prevention. In R. L. Hough, P. A. Gongla, V. B. Brown, & S. E. Goldston (Eds.), Psychiatric epidemiology and prevention: The possibilities (pp. 131–157). Los Angeles, CA: UCLA Neuropsychiatric Institute.

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Watt, T. T., & Sharp, S. F. (2002). Race differences in strains associated with suicidal behavior among adolescents. Youth & Society, 34, 232–256.

Part III

MEN IN OTHER CULTURES

Chapter 16 MALE SUICIDE IN CHINA J IE ZHANG en are at higher risk of suicide than women across the world except in China. The gender (male to female) ratio of the Chinese suicide rates is different from those found in the rest of the world. None of the other societies with known suicide data has had female suicide rates higher than those for the males. In this chapter we try to examine some social and cultural variables in rural Chinese youths in order to identify the factors that account for the relatively low suicide rate for men and relatively high suicide rate for women. We conducted a study in rural China, where we sampled 392 suicides aged 14 to 35 years of age from 16 counties in three provinces and compared them with 416 community living controls of the same age range and from the same locations, using a case-control psychological autopsy method for the data collection. It was found that believing in Confucianism and being married are both protective factors for rural young men, while the two same variables are either risk factors or nonprotective factors for rural young women. Social structure and culture play an important role determining a society’s suicide rates, as well as the gender ratios. This chapter discusses the details of our study, the findings, and the implications. The relationship between gender and suicide has been extensively researched by suicidologists, as well as sociologists, given that men die much more often by suicide than do women, although reported suicide attempts are about three times more common among women than men (WHO, 2009). The incidence of completed suicide is higher among men than women in all age groups in most of the world. In Western societies, the male to female ratio varies between 3:1 to 10:1 (Hee Ahn, Park, Ha, Choi, & Hong, 2012). On the other hand, the gender ratio for the Chinese suicide rates has been

M

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different from those found in the rest of the world. It used to be 0.80, while in recent years it has been 1.10 (Phillips, Li, & Zhang, 2002; Wang, Li, Chi, Xiao, Ozanne-Smith, Stevenson, & Phillips, 2008; Zhang, Jing, Wu, Sun, & Wang, 2011). No society with documented suicide rates, besides mainland China, has had female suicide rates higher than male suicide rates. It is commonly believed that suicide, as a violent act against humans, is a masculine act and that is why it happens more in men than in women. Therefore, men are more likely to end their lives through effective violent means (such as guns, jumping and hanging), while women use primarily less violent methods such as overdosing on medications (Callanan & Davis 2012). This choice-of-method theory has been proposed as an explanation for the high gender ratio for suicide rates in the world. Researchers have also ascribed the disparity to inherent differences in male/female psychology. Greater social stigma against male depression and a lack of social networks of support and help for depression are often identified as key reasons for men’s disproportionately higher rate of suicide, since suicide as a “cry for help” is not seen by men as an equally viable option as it is for women (Canetto & Sakinofsky, 1998). The unique gender ratios found for Chinese suicide rates might be understood using the Chinese culture context. We have been asking why Chinese women are at such a high risk of suicide, but at the same time, why Chinese men are sometimes less likely than women to kill themselves by suicide? Is the unique gender ratio in Chinese suicide rates mainly contributed by more female suicides, by fewer male suicides, or by both? The present study examined several social, cultural and psychological variables in rural Chinese youths in order to identify protective factors in rural young men suicides that might account for the lower risk of suicide for Chinese young men. As the foundation of Chinese traditional culture, Confucianism and the Confucian ideology of family is an ethnic-religious tradition that has been rooted in Chinese daily life (de Bary, 1988). Familial relationships have been strictly regulated by the Confucian ideology (Tu, Heitmanek, & Wachman, 1992). Even during the reform era, more and more Chinese have been returning to traditional family roles, as the communist state has continuously enforced Confucian ideology, especially filial piety and harmony as a core family virtue, in order to compensate for the lack of social welfare and public services in the post-socialist era (Ikels, 2004; Jacka, 1997; Rofel, 1999). All traditional Chinese virtues are subordinated to the Confucian ideology, modified by it, defined in terms of it, or even eliminated by it (Hsu, 1998). Confucianism consists of three core sets of ethics and values: (1) filial piety, (2) harmony, and (3) female subordination (Hsu, 1998; Hwang, 1999). Filial piety (veneration of the elderly in the family) has been conceived as a pre-

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eminent virtue of Confucianism and has become the most powerful social dictate. Specifically, filial piety demands that Chinese persons: (1) venerate parents; (2) care for one’s own body (the body and the limbs, the hair and the skin, are given to us by our parents, and no injury should come to them); and (3) not die before parents (the white hairs should not go to the funeral of the black hairs; a son should not die before his parents). The principle of harmony is the touchstone for all interpersonal behavior (King & Bond, 1985). As a social theory, the foremost purpose of Confucianism is to achieve a harmonious society in which each individual acts towards others in a proper way (propriety) so that the social order can be established and maintained (Fingarette, 1972; King & Bond, 1985). The ethics and values of harmony stress: (1) being harmonious (happy family and nice neighborhood); (2) self-discipline (denying self and returning to propriety); and (3) endurance (restraining oneself for long-run goals). The Confucian principle of harmony reflects that being human is conditional on a person being obedient to social norms in daily interactions (Bauman, 1976). Thus, the focus of harmony is not fixed on any particular individual, but on the particular nature of the relationships among individuals who interact with one another (Solomon, 1971). Confucianism also imposes strict requirements on women. As a result of male chauvinism, women are relegated to a lower status in the Confucian family and society (Tu, Hejtmanek, & Wachman, 1992; Yang, 1959). Both the father and the husband are the ultimate disciplinarian in the traditional Confucian family (Slote, 1998). Even though the mother may have authority over her son, the oldest son takes over the authority in the family after her husband dies. In addition, the principle of sex segregation makes it imperative that brothers and sisters do not associate with each other closely and, when authority is in question, the male is always the dominant party (Ikels, 2004). The Confucian expectation of a good woman is illustrated in the Three Obediences and the Four Virtues. A woman in a very traditional Confucian family is discouraged from participating in social activities, cultivating talents, and receiving more education than her husband. She must accept arranged marriage by her parents, bear a son to carry on her husband’s family heritage, and serve the elderly and take care of her husband at home. In sum, in a Confucian society, men and women have different expectations in terms of life goals, work ethics, morality, family roles, and interpersonal relations. A Confucian society is a “man’s world,” where men’s ambitions, success and achievements are encouraged and valued more than those of women. This suppression of women, coupled with the gender equalitarian ideology of modern societies, is likely to bring about psychological frustration in women who value the traditional gender roles, but appreciate the

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equalitarianism in modern societies at the same time (Zhang, Wieczorek, Conwell, & Tu, 2011). China is not alone in the low gender ratio of suicide rates. There are several societies in which the male to female gender ratio for suicide rates is close to one. For example, the male/female suicide rate ratio was 1.1 for Hong Kong, 1.3 for Singapore, 1.8 for Japan (Canetto & Sakinofsky, 1998), 1.5 for Taiwan, 1.4 for India, 1.5 for the Philippines, and 2.2 for South Korea (WHO, 2009). It is not difficult to notice that most of these countries and regions are Confucian societies. Confucian gender ideology that plays down the role of women might have played an important part increasing the female suicide risk. Thus, it is hypothesized that, for Chinese rural young males, the more they value Confucianism regulations for men, the lower the suicide risk is for them and, for Chinese rural young women, the more they value Confucianism’s degraded role for women, the higher the suicide risk is for them. Thus, Confucianism in China can be a protective factor for Chinese men, but a risk factor for Chinese women.

Method Data Collection The data for this research were from a large psychological autopsy and case control study conducted in rural China. Rural young men and women aged 15 to 34 years who died by suicide were examined, and community living controls of the same age range and gender distribution were randomly sampled from the same areas. The psychological autopsy has been proven to be reliable and valid in Chinese social and cultural environments (Zhang, Wieczorek, Jiang, Zhou, Jia, Sun, Jin, & Conwell, 2002). Three provinces were selected in China for the study. Liaoning is an industrial province located in Northeast China, Hunan an agricultural province in Central South China, and Shandong a province with economic prosperity in both industry and agriculture that is on the east coast of China, midway between Liaoning and Hunan. The suicides came from 16 counties (6 from Liaoning, 5 from Hunan, and 5 from Shandong). In each of the 16 counties, suicides aged 15–34 were consecutively recruited from October 2005 through June 2008. After successful interviews with informants of the suicides and community living controls, a total of 392 suicides and 416 controls were collected for study. Two informants were interviewed for each suicide. However, it is recognized that the type of informants, rather than the number of informants used in psychological autopsy studies, is an extremely important consideration

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(Kraemer, Measelle, Ablow, Essex, Boyce, & Kupfer, 2003). The informants were selected based on the context or environment (how people observe the target individual, for example, home versus nonhome setting). This way, each informant was carefully obtained to optimize the information available for each case: (1) suicide informants were selected with recommendations from the village head and the village doctor. However, we tried to avoid as much as possible husbands and the in-laws of those female suicides triggered by family problems. Interviewing these people could result in very biased reports if marital infidelity and family oppression were possible causes of suicide, (2) suicides could be as young as 15 years of age, but informants had to be 18 years of age or older, and (3) for suicides, informant #1 was always a parent, spouse or another important family member, and informant #2 was always a friend, coworker, or a neighbor. Based on the above considerations, different responses from the two informants for the same suicide were integrated based on previous experiences (Kraemer et al., 2003). For demographic information, the answers by the informant who had the best access to the information were relied on. For example, a family member should know the suicide’s age and birth date more accurately than would a friend. To determine a psychiatric diagnosis, positive symptoms were selected because the other informant might not have had an opportunity to observe the specific characteristic or behavior of the suicide. Informants were first approached by the local doctor or the village administration with a personal visit. Upon their agreement on the written informed consent form, the interview schedule was arranged between two and six months after the suicide. Each informant was interviewed separately by a trained interviewer, in a private place in a hospital or in the informant’s home without interruption. The informants for the controls were also interviewed about the same time. The average time for each interview was 2.5 hours. This study was approved by the IRBs of all the universities involved in this study, in both the United States and China. The research nature of the interview and the background of the research project were explicitly explained to each interviewee. Before each face-to-face interview, an informed consent form that detailed the rights of the interviewee was read and signed. If distress was present during the interview and the participant wished to stop or discontinue, the interview was ended, and another replacement informant chosen.

Measures The case-control status (suicides versus living controls) was the dependent variable. Both age and education were measured in the number of years. The

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family annual income was measured with Chinese Renminbi (RMB), with the exchange rate of $1.00 to 7.00 RMB at the time of data collection. Marital status was dichotomized as “0=never married” and “1=ever married” with the latter including those who were currently married and living together, currently married but separated because of work, remarried, divorced, widowed and those nonmarried couples who lived together. Religion was categorized to “1=believer” (Muslim, Christian, Catholic Buddhism, Daoism) and “0=atheist.” The variables of “Confucianism for men” and “Confucianism for women” were assessed by two separate scales with a number of items tapping the level of agreement on each of the Confucian expectations that may modify an individual’s behavior and may be related to our dependent variable. There are seven items in the Confucianism scale for men, in which four are designed to tap filial piety. Respondents (informants) were asked to indicate how strongly the target person agreed or disagreed with the following statements: (1) filial piety to parents; (2) closeness to parents; (3) body and hairs are given by parents and no hurt should be brought to them; and (4) not die earlier than parents. Another aspect for Chinese men’s expectations is the value of harmony, which consists of three items: (1) being harmonious with family and friends; (2) self-discipline; and (3) endurance. Respondents (or informants) were asked to indicate how strongly the target person agreed or disagreed with these statements. The seven items tapping filial piety and harmony were summed so that higher scores indicate the target person’s stronger agreement with the Confucian ethics for men. The scale for Confucianism for women includes eight items: (1) women should stay at home, (2) caring for her husband and kids, (3) bearing a son, (4) keeping marriage without divorce, (5) three obediences, (6) no social activities, (7) women working at home only, and (8) a woman is less important than a man. The sum of the eight items indicates the score of Confucianism for women, and the higher the score, the stronger their agreement with the statements.

Findings The results are presented in Table 16.1. The comparisons were made separately for men and women. The male suicides were a little older than the male controls, but there was no difference for women. The male suicides had fewer years of education than the male controls, and again this difference was not found for the women. The community living controls were better off in family income than the suicides, and this was true for both men and women. The ever-married men and women were not necessarily at lower

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risk of suicide than the never-married groups of men and women. Believers in religion tended to be suicides more often than did the nonbelievers, and this was true for both rural young men and rural young women. Table 16.1 also compares the suicides and controls for their Confucian values. For the rural young men, the living controls scored significantly higher than the suicides on the measure of Confucianism for men. For the rural young women, the suicides scored significantly higher than the controls on the measure of Confucianism for women. Logistic multiple regressions were performed separately for males and females. Table 16.2 presents the findings from the two regression models. For men, both age and believing in a religion were risk factors for suicide. Education and marriage, as well as the Confucian values, were protective factors. For women, family annual income was a protective factor, but religion and Confucian values were risk factors. CONCLUSIONS The study described in this chapter, using the data collected from a largescale psychological autopsy project in rural China, examined the social psychological and cultural factors that are related to the Chinese rural suicide in order to identify the various risk and protective factors that distinguish male and female suicides in rural China, and to answer the question why the suicide rates are so similar for men and women in China. It was found that holding Confucian values may be the key to the answer. Confucianism is a buffer for men but a hazard for women for the risk of suicide in rural China. That religion is not a protective factor against suicide is in contrast to a large literature based in the West (Stack & Kposowa, 2011). Since the religious population constitutes only a small percentage in modern China, this finding might be anticipated. For example, Durkheim (1951) found that, where Catholics were a minority in the population in some European nations and cities, they actually had a higher rate of suicide than Protestants. According to the moral community view of Durkheim, religion best protects against suicide when the whole population is of one faith. In China, the vast majority of the population has no religion. In this context, the vast majority of the population is atheist and is less apt to support the beliefs of the religious minority. The relative lack of support from a moral community weakens the influence of religion on small religious groups (Eskin, 2004; Neeleman, Wessely, & Lewis, 1998; Stack & Kposowa, 2011). Another unique finding was that marriage was a protective factor for suicide only for men, but not for women in rural China. Specifically, in com-

71 (35.1) 131 (64.9) 182 (90.1) 20 (9.9) 28.59 (3.3)

161 (75.2) 53 (24.8) 27.02 (3.8)

25.47 (6.1) 9.36 (2.4) 21100 (20212)

93 (43.5) 121 (56.5)

26.95 (6.6) 7.40 (2.6) 14700 (30023)

15.871 -4.383

3.004

2.362 –7.910 –2.453