Masculinities and suicide

Across the globe, suicide and parasuicide present an interesting paradox: while more women worldwide are involved in acts of parasuicide each year, there are more deaths from suicide among men than women (Stack, 2000). In the Western hemisphere, for instance, twice as many men complete suicide compared with women, and the figure may be higher in some countries, including the United States (Murphy, 1998). Nor are such trends recent phenomena: Emile Durkheim's (1897/1951) ground-breaking work on suicide trends in 19th century Europe highlighted a similar gap in completed suicide among women and men. This gap became more marked as we approached the new millennium (McClure, 2000).

Yet, most psychological explanations for men's higher suicidal mortality are unsatisfactory. Traditionally, there has been a tendency to focus on biological factors underpinning the suicide gap between women and men (e.g. hormonal differences), or a tendency to treat gender as a 'given'. Moreover, it is certainly true that the complexity of factors involved and the relative rarity of suicidal acts makes detailed examinations of the phenomenon difficult. This dearth of theoretical and empirical work, however, is also a reflection of the way in which psychologists and suicidologists have previously neglected factors associated with gender (Canetto, 1997; Payne, 2006). Until quite recently the relationship between suicidal behaviour and men's gender – or masculinities – has largely been taken for granted or marginalised.

Emerging evidence, however, suggests that a more comprehensive examination of gender offers a powerful means of understanding the gap in suicide between men and women (Hunt et al., 2006; Möller-Leimkühler, 2003; Payne et al., in press). More specifically, the construction of masculinities is believed to be one of the most important factors influencing the way in which suicide is discussed, contemplated and enacted by men (Hawton, 2000; Hunt et al., 2006). Elucidating these relationships may highlight ways of modifying gender-related influences on suicidal behaviour.

What is gender?

To begin with, we need to be clear about what is meant by 'gender' and 'masculinity,' – terms which have not always been used in a consistent manner by researchers in different fields. One tradition that remains popular within the psychological sciences theorises gender as singular female or male 'personalities' or 'schemas' – what Kimmel (1986) described as 'role containers'. This view of gender suggests that there are male or female gender-stereotypic traits, and an 'innate' need to fill appropriate roles. However, as various authors have pointed out, such a view is overly-simplistic and does not capture the multiple forms of masculinities and femininities that can be demonstrated, nor where the pressure to fulfil roles comes from (Connell, 1995; Courtenay, 2000; Kimmel, 1986).

More recent conceptualisations of gender take a lead from social constructionist and post-structuralist ideas. Theorists from these fields propose that gender, rather than being mere role containers, is something that is repeatedly and constantly 'done' (Pleck et al., 1994) – as West and Zimmerman (1987, p.126) write: 'Doing gender involves a complex set of socially guided perceptual, interactional, and micropolitical activities that cast particular pursuits as expressions of masculine and feminine "natures".'

In other words, understanding gender requires us to contemplate the way in which gender is dynamically enacted, especially in relation to other individuals (Crawford, 1995). For social constructionists and post-structuralists, then, all behaviours and cognitions that women and men exhibit can be informed by an understanding of gender. Whether in relation to conversation, work, sex or other everyday activities, the manner in which behaviours are enacted provides the key for understanding what men and women consider 'acceptable' masculine and feminine behaviour (e.g. Crawford, 1995; Messner & Sabo, 1994). Certainly it is possible to identify, within particular societies or cultures, clusters of behaviour that are considered enactments of 'dominant' masculinity or femininity. Moreover, social conventions and norms ensure that most individuals adopt and conform to such dominant gendered identities (Bohan, 1993).

In the West, for instance, men experience considerable social pressure to endorse dominant – or 'hegemonic' – gendered identities, such as being independent, strong and competitive, while also denying anxieties and insecurities (Golombok & Fivush, 1994). The link seems obvious: if all behaviours are an expression of gender, perhaps 'doing masculinity' puts men at higher risk for suicidal behaviours compared with women's 'doing femininity'.

Yet historically, the associations between suicide and masculinities have not generated a great deal of interest (Canetto, 1997; Kung et al., 2003), particularly among psychologists. Overturning this academic oversight is important, because an analysis of masculine identities offers a powerful means of understanding the excess in male suicides (Hunt et al., 2006). Thus, in a recent review of the literature on gender and suicide, Payne et al. (2007) documented a myriad of ways in which the construction of masculinities impacts on men's greater rates of completed suicide. In the following section, we consider some of these patterns.

Methods of suicide and substance misuse

An important difference in completed suicide between women and men relates to their method of choice (e.g., Beautrais, 2000; Denning et al., 2000; Kung et al., 2003). In general, men are more likely to die through suicide using violent methods with higher lethality, such as by using firearms and hanging. Indeed, Murphy (1998) has argued that the male–female gap in suicide mortality may partly be explained as result of the large numbers of women surviving suicide attempts because of the less lethal nature of the methods used. Some authors have suggested that this difference stems from the way in which suicidal behaviours are used to demonstrate gendered identities. In other words, differences in the methods used in suicide help to define oneself as a woman or a man (Canetto, 1997). Specifically, men may be more likely to use violent or lethal actions because such methods are congruent with dominant constructions of masculinity that prescribe aggression and strength (cf. Wannan & Fombonne, 1998).

In addition, while most societies tend to stigmatise suicidal behaviours, surviving a suicidal act is more likely to be perceived as something 'inappropriate' for men (White & Stillion, 1988). This is consistent with the idea that men experience greater social pressure than women to endorse stereotypes that they should be tough, robust and strong (Golombok & Fivush, 1994). In this sense, Möller-Leimkühler (2003) explains, lethal suicidal behaviours among men are concurrently a final demonstration of their masculinity and an attempt to avoid the 'negative' connotations of surviving a suicide attempt. 

Gendered identities also influence an individual's familiarity with different methods, which in turn explains gender differences in suicide methodology. Take, for instance, the use of firearms: in countries where gun ownership is legal, men are more likely to store and use firearms than women, perhaps partly because doing so is one way of endorsing masculine stereotypes of strength and toughness. Accordingly, men are more likely to be familiar with the use of firearms, and hence more likely to use firearms in suicidal behaviours (Denning et al., 2000). Social constructions of hegemonic masculinity, which include notions of emotional withdrawal and rigidity, also influence gender differences in suicidal behaviours in other ways. For instance, several studies and reviews of the literature have shown that male suicides are less likely than female suicides to have had contact with health services or to have been known to psychiatric services (e.g. Luoma et al., 2002). 

This finding reflects the fact that men are less likely than women to consult for most conditions (e.g. Courtenay, 1998), and for mental health and emotional problems specifically (Canetto & Sakinofsky, 1998). The reasons for this can be traced back to the way in which norms of masculinity are constructed to include a denial of pain, emotional sensitivity and anxiety. Thus, in much the same way as, say, some men store and use firearms as a demonstration of masculinity, others may dismiss their healthcare needs on the same grounds. Asking for help, even in the face of possible suicide, may be viewed as feminine behaviour, and if men are to live up to expectations of strength and independence, they are required to 'sort out' their mental and physical problems on their own (Courtenay, 2000).

Consider, for example, the way in which women and men relate to depression, which is known to be an important factor in suicidal behaviour. Because symptoms of mental illness are perceived as inconsistent with a masculine identity, men's response to depression often involves social withdrawal (including hiding symptoms from others), unwillingness to consult healthcare professionals, and a denial of symptoms (Canetto & Sakinofsky, 1998). As Warren (1983, p.151) explains, 'The linkage between depression and femininity may provide men with the strongest motivation to hide their depression from others.' Instead, men may rely on norm-congruent behaviour, including aggressiveness and alcohol or substance misuse, to reassert their masculine identities, rather than seek medical help (Canetto & Sakinofsky, 1998).

It should not come as a surprise, therefore, to find that alcohol and substance misuse occurs more frequently prior to suicide among men than among women (Groves & Sher, 2005). For instance, studies have shown that depression as a comorbid condition of alcohol consumption is higher among men who complete suicide than it is among the general population or among women (e.g. Murphy, 1998). Some commentators have highlighted the way in which alcohol consumption, in particular, is conceived as a gender-appropriate behaviour for men (Courtenay, 2000).

Social support and employment

As we noted above, an important aspect of hegemonic masculinities, at least in the West, includes limited modes of emotional expressiveness, a higher threshold for emotional sensitivity and a denial of weakness, especially because to do the opposite would imply a loss of status and control (Bohan, 1993). These gendered behaviours also influence more general suicide-related factors among men. For one thing, the risk of suicide in relation to being married is lower for men than it is for women – the widowed, divorced and separated and those living alone have higher suicide rates than married adults, but higher risks are experienced by non-married men compared to non-married women (Luoma & Pearson, 2002).

It is possible to trace this effect back to a prominent difference in the way women and men initiate and maintain social networks. Specifically, men who endorse stereotypes of masculinity that include attributes of independence and control are less likely to have large, supportive social networks. For these men, then, marriage acts as an important protective factor, in that it provides them with an important source of stability and emotional support. By contrast, in the face of a change to their marital status – for instance following the break-up of a marriage or death of a spouse – men become more vulnerable to suicide precisely because they are less socially connected than women (Burr et al., 1997).

In addition, Möller-Leimkühler (2003) has highlighted the psychological costs associated with dominant masculinities. She writes that, because the norm for masculinities includes many traits associated with success (e.g. being happy and optimistic), negative emotions, such as pessimism, disappointment and uncertainty, may have more negative psychological consequences for men. That is, because men experience pressure to always be happy and self-reliant, any personal setback or traumatic event (e.g. marital break-up, unemployment, disability) is likely to have a more damaging effect on their psychological well-being. This will particularly be true in those instances when men also lose other avenues of social support, such as the loss of the home and family, following a divorce (Kposowa, 2003).

Because norms of masculinity include attributes related to success and striving, loss of employment or a decline in socioeconomic status are likely to have a detrimental effect on men's well-being. Indeed, the available evidence supports this hypothesis in relation to suicidal behaviours: the relationship between unemployment and suicide (Qin et al., 2003), and socio-economic status and suicide (Sher, 2006), appears to be stronger for men than it is for women. Overall, then, men are more sensitive to negative changes in their socio-economic and employment status, and this may lead to higher risks for suicide.

When a gendered analysis is applied, it is not difficult to see why this might be the case. For men, unemployment is typically less accepted by society than women's unemployment, and so men who are unemployed may perceive themselves as transgressing social norms. In addition, the impact of job loss also implies a loss of status, routine and work support, all of which may be more detrimental for men than women, especially if men also perceive domestic roles (e.g. caring for children) as being incongruent with their masculine identities.

Challenging gendered constructions

The examples we have discussed above do not constitute an exhaustive list of the ways in which constructions of masculinities influence suicidal behaviours (Payne et al., 2007). Moreover, there may be certain aspects of the relationship between masculinities and suicide that do not follow the established pattern outlined above. For instance, Hunt et al. (2006) have presented some preliminary evidence suggesting that higher masculinity scores (as measured by Bem's 1981 Sex-Roles Inventory) are related to lower suicidal ideation. This may be because dominant stereotypes of masculinities value independence, assertiveness and dominance, which are related to self-mastery and feeling in control of one's life (Hunt et al., 2006).

Nor are we suggesting that the relationship between gender and suicide that we have outlined above is the same for all men. As we have stressed, while there is a dominant or hegemonic masculinity that men are encouraged to assimilate, a minority of men adopt 'alternative' masculinities that promote healthy behaviours and cognitions (although they may then experience significant distress as a result of being 'different'). It is also possible that some women adopt unhealthy behaviours and cognitions (e.g. unhealthy dieting) as a way of demonstrating femininities, and this may increase their risk of suicide.

Nevertheless, masculinities that predominantly promote healthy behaviours are relatively infrequent, and are certainly not the way most men learn to behave and think (Courtenay, 2000). A key question that arises, therefore, is: What should be done? From a purely academic point of view, we believe there is great merit for psychologists in refocusing research agendas to include more thorough investigations of gender differences in health-related behaviours and thoughts. Gender, particularly masculinities, clearly has an influence on the way in which suicidal behaviours are demonstrated, and psychologists will need to recognise the importance of this influence (cf. Hunt et al., 2006; Payne et al., 2007).

Such a goal may actually be much closer than expected. For instance, some cognitive models of suicide, such as Baumeister's (1990) escape theory of suicide, posit that suicidal behaviour is the end stage of a chain of events and decisions beginning with perceptions of failure to meet rigid self-strivings. Understanding the way in which gendered identities influence the events along those chains will no doubt yield a more thorough understanding of suicidal behaviour. More specifically, a gendered approach could be incorporated into contemporary suicide research, such as content analyses of suicide notes (e.g. Lester & Linn, 1997) or an examination of the way in which 'public' suicides are enacted (e.g. Lester, 2003).

Doing so will also aid healthcare practitioners in tailoring suicide prevention strategies that treat both women and men as agents articulating gendered experiences and beliefs. Consider the earlier example of depression: whilst the detection and treatment of depression is currently an important component of suicide prevention strategies, it is still quite rare for such strategies to incorporate a gendered approach. As we have seen, however, men are less likely to consult for depressive symptoms, which suggests that more active methods may be required to reach them.

More broadly, strategies that aim to reduce the number of male suicides will need to confront the way in which wider structures of power produce and reproduce inequalities between women and men. In most, if not all, contemporary societies, hegemonic masculinities not only have a detrimental effect on men's health (Stanistreet et al., 2005), but also involve the subordination of women (a central theme of the feminist criticisms of 'patriarchy'). Overcoming the gender gap in suicide and other health-related factors will, therefore, require societies to challenge hegemonic masculinities as well as the power structures that give rise to them. This will not be an easy task, especially when one considers the time and energy spent on maintaining gender inequalities, but the fruits of such labour will ultimately benefit both women and men.

- Viren Swami is in the Department of Psychology, University of Westminster
[email protected]

- Debbi Stanistreet is in the Division of Public Health, University of Liverpool

- Sarah Payne is in the School for Policy Studies, University of Bristol

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