The Gender Paradox of Suicide: How Suicide Differs Between Men, Women, and Transgender/Gender Diverse Individuals

Over the last 50 years, research in field of suicidology (the science of why people die by suicide) has produced a large body of knowledge, including identifying hundreds of risk factors and dozens of theories on cause. Multiple suicide prevention initiatives have also been tested during this time.

And while we’ve learned a lot, perhaps one of the most important aspects of study consistently present across the decades of research on suicide is what is commonly referred to as the gender paradox, or why men account for more suicide deaths than women. More recently, the question of gender in suicidal behavior has expanded to include transgender and gender-diverse (TGD) individuals. Here’s a look at the role gender plays in suicide.

What is the Gender Paradox of Suicide?

The traditional gender paradox of suicide is simple: Men die by suicide more often than women, even though women report thoughts of suicide more often and make more non-fatal suicide attempts than men. In fact, the data from research on the subject is quite striking.

CDC data demonstrates that men account for over 76% of suicide deaths in the United States each year. The CDC also found that there are 3.3 male suicide deaths for every female suicide death. In contrast, in research studies, women are two to three times more likely to discuss thoughts of suicide than men, and there are approximately three female suicide attempts per every one male suicide attempt.

Although rates of suicide are different across age groups (e.g., middle-age and older adults die by suicide more than younger adults) and race/ethnicity (e.g., non-Hispanic White and Indigenous individuals die by suicide more than people of Hispanic ethnicity and/or Black racial identity), the gender paradox remains true across other demographics.

These data points demonstrate a simple truth: men die by suicide far more than women, but women experience thoughts of suicide and attempt suicide more than men. So why does this gender disparity persist when it comes to suicidal thoughts vs suicidal behavior?

Why Do More Men Commit Suicide Than Women?

Certainly, answering this question would provide meaningful information on the broad nature of suicide. However, the findings from this line of research are far more complicated than the paradox itself.

One potential reason that men die more by suicide than women is that men, compared to women, appear to be more fearless of death and able to tolerate more physical pain. As such, they may have a higher capability of a lethal suicide attempt if thoughts of suicide develop. This understanding is fairly intuitive. If people do not fear death and can feel confident they can tolerate the pain associated with suicide, they may be more likely to follow through on a plan to die by suicide. This concept is a central component of the Interpersonal Theory of Suicide, which provides clear hypotheses about how the desire and capability for suicide develops and has been researched for almost 15 years.

This fearlessness of death and tolerance of pain may also explain one key finding within the gender paradox of suicide. Compared to women, men generally use more violent methods for suicide, such as suicide by firearm. For example, approximately 60% of male suicides are by firearm, whereas just over 30% of female suicides include self-inflicted gun violence. This finding is important, since suicide attempts by firearm result in death in nearly 90% of cases. With other suicide methods such as overdose, suffocation/hanging, and self-piercing/burning, death is the result in less than 10% of these cases.

This means that for many men, their first attempt at suicide is fatal, whereas women are more likely to live through a first attempt. In fact, less than half of men who die by suicide have a documented history of one or more previous suicide attempts, whereas well over 50% of women who die by suicide have attempted before.

Why Do Women Attempt Suicide More Than Men?

According to the American Foundation for Suicide Prevetion (AFSP) women are 1.5 times more likely to attempt suicide than men. But why are suicide attempts so much higher in women while the mortality rate of suicide is 3 to 4 times higher in men? One potential answer lies in the different rates of deliberate self-harm (DSH) between men and women.

According to a Cambridge study on gender differences in suicide behavior, researchers found that DSH is more common in women. The study goes on to suggests that:

“Acts of DSH by females are more often based on non-suicidal motivation.” In females, the appeal function of DSH, whereby DSH is used to communicate distress or to modify the behavior and reactions of other people, seems more common. In males, DSH is more often associated with greater suicidal intent. It is interesting that in community samples, suicidal ideation is reported far more often by females than males and when DSH is found in men it more strongly correlates with suicide.”

Another important suicidal driver for women is major Depression. According to a Danish study, major depression is approximately “twice as common in females, and is known to underlie more than half of all suicides” which can potentially account for the increased rate of suicidal behaviours in women.

What About Transgender and Gender Diverse (TGD) People?

Although some of the above ideas may explain why the gender paradox of suicide exists, there is potentially a need to revise our understanding of the paradox as we begin to learn more about suicide in transgender and gender diverse (TGD) individuals. For the sake of terminology, the term TGD refers to individuals whose sex assigned at birth (“natal sex”) does not match their own feelings about their gender, or “gender identity.” In this way, people who were deemed to be a man at birth (male natal sex) but feel as though their gender is not male (a gender identity of female or neither male/female, etc.), would fit under the umbrella term of TGD.

Our field’s understanding of the gender paradox of suicide was developed when most scholars viewed gender as a male/female binary. It has only been since the late 2000s that scholars have investigated suicide in those whose gender identity do not match their sex assigned at birth.

What Do We Know About Suicide in TGD Individuals?

As with the “why does the gender paradox exist” question, the answer is not simple. Some research suggests that TGD individuals whose natal sex was female may be at slightly higher risk for thoughts of suicide compared to those who were assigned male at birth, while other research has found the opposite relationship. More consistently, suicidal thoughts appear to be more prevalent in those TGD individuals who perceive their gender as neither male nor female (sometimes referred to as “non-binary”) compared to transgender men and transgender women (TGD individuals who view themselves as the male or female gender that is incongruent with their natal sex).

Like the relationship between suicidal thoughts and natal sex/gender, the relationships between suicide attempt history and the TGD aspects of gender are murky at best. For example, as mentioned above, in relationship to suicide attempts, some research has found higher lifetime rates of attempts in TGD individuals with a female natal sex as compared to male natal sex. A roughly equal number of studies have found no difference in attempts across TGD natal sex categories.

A similar lack of consistent findings has been seen in studies comparing suicide attempt histories in those who identify within and outside of the gender binary. Simply put, there currently is no consistent research regarding the relationship between suicide attempt history and both natal sex and current gender identity in TGD individuals.

Suicide Attempts vs. Suicide Deaths

As you may notice, the paragraphs above note relationships with suicidal thoughts and attempts, not death by suicide. In fact, a very clear lack of research regarding death by suicide in TGD individuals can be seen in the research literature. Why is this? This answer is fairly simple: National rates of suicide are most often calculated using death certificates filed in each state.

These death certificates are most commonly completed by coroners and other medical certifiers, many of whom may not know a deceased individual identified as TGD. Also, early versions of these certificates only allowed for binary male/female gender identification. Thus, we do not know how the gender paradox “plays out” in TGD individuals as it relates to death by suicide.

So what do we know about death by suicide in TGD individuals? First and foremost, we know it is prevalent – and likely more prevalent than suicide in those who identify with their natal sex (“cisgender”). A study of all veterans who were given a gender-related diagnosis in the Veterans Affairs healthcare system between the years 2000-2009 indicated that TGD veterans died by suicide at over two times the rate of the national average of veteran suicide, and over six times the rate of the general population.

This study published in the American Journal of Public Health in 2013 unfortunately did not contain additional information about natal sex or current gender identity and relied on healthcare providers having asked questions regarding a gender-related diagnosis in order to have a record of TGD status in patient charts. Scholars argue that, because of these limitations, the estimates for suicide in TGD veterans may be underestimated.

Gender and Suicide Conclusions

For years, the gender paradox was quite simple: women think about and attempt suicide more than men, but more men die by suicide. This has been and continues to be true in basically all age groups and races/ethnicities.

Complexity to the paradox has been added over the last decade or so for two reasons:

  1. Scholars wanted to identify why this paradox existed
  2. Work with TGD individuals became more prominent.

It is likely that we will learn more over the next decades of research regarding why this paradox exists and if it can be extended to the understanding of suicide in TGD individuals.

Although it is simple in theory, the gender paradox is a great example of the complexity of why people die by suicide. There may be trends, risk factors, and consistencies across stories, but for those who die, there is great individual complexity in why and how. Although hundreds of risk factors play a role in predicting suicide, including natal sex and gender identity, the prevention of suicide in clinical settings will likely rely on far more than knowing basic demographic factors.

One’s own suicide story, reasons for living, reasons for dying, and visualized method of suicide are likely important and may only slightly be influenced by one’s natal sex/gender.

How CAMS Can Help

Clinical tools such as the Suicide Status Form (SSF), a critical component of the Collaborative Assessment and Management of Suicide (CAMS), exist to help providers and patients collaboratively determine one’s drivers for suicide that can be mitigated through intervention to reduce suicide risk. Regardless of a patient’s natal sex, gender, or even mental health diagnosis, the collaborative assessment of these individual factors may help clinicians and patients alike understand more about one’s suicide risk and how a future suicide attempt could be prevented.

Learn more about how you can become CAMS Trained™ and CAMS Certified™to provide an evidence-based suicide treatment framework with all of your patients, no matter their gender.

References:

  1. Centers for Disease Control and Prevention, Suicide rising across the US.
  2. National Center for Biotechnology Information, The interpersonal theory of suicide: A systematic review and meta-analysis of a decade of cross-national research. https://www.ncbi.nlm.nih.gov/pubmed/29072480
  3. Joiner, Ph.D., Thomas E., “Why Do People Die By Suicide” Lecture Video. https://www.youtube.com/watch?v=DESRIZtUIT4
  4. National Center for Biotechnology Information, Prevalence of gender identity disorder and suicide risk amount transgender veterans utilizing veterans health administration care. https://www.ncbi.nlm.nih.gov/pubmed/23947310

About Raymond P. Tucker Ph.D.

Raymond P. Tucker Ph.D.
Raymond is an Assistant Professor of Psychology at Louisiana State University (LSU) where he founded the Mitigation of Suicidal Behavior (MOSB) Laboratory in 2017. He also is a Clinical Assistant Professor of Psychiatry at Louisiana State University Health Sciences Center /Our Lady of the Lake Medical Center. He finished his Ph.D. in clinical psychology from Oklahoma State University in 2017 following his clinical internship at VA Puget Sound. Raymond's research broadly focuses on the enhancement of theoretical models of suicide and suicide risk assessment tools, particularly in underserved populations (e.g., Veterans, Transgender and Gender Diverse adults). Raymond began his tenure as a CAMS consultant in 2019 after receiving a state-level grant to implement CAMS across the Our Lady of the Lake Regional Medical Center in Baton Rouge L.A. He is a former board member of the American Association of Suicidology and is a current faculty member at the National Suicidology Training Center.

6 Risk Factors for Transgender & Gender Diverse Suicide

Our understanding of how gender affects suicidality was developed when most scholars viewed gender as a male/female binary. However, over the last decade, scholars have begun investigating suicide in those whose gender identity does not match their sex assigned at birth.

Recent studies have shown that transgender/gender-diverse (TGD) adults share many risk factors for suicide with the general population, such as mental health concerns, substance abuse, and life stressors. However, unique risk factors for TGD individuals are also becoming more apparent through recent research. This research attempts to understand the factors that relate differently to suicidal thoughts (such as symptoms of depression) and suicidal behaviors (such as access to a firearm). This way of understanding suicide is often referred to as the ideation-to-action framework. By understanding the unique risk factors for suicide in TGD individuals, we can develop more effective prevention strategies and interventions to support this vulnerable population.

Why do Transgender People Die by Suicide?

The following are six risk factors that providers should be aware of and assess in order to better understand suicide risk in their TGD patients.

Risk Factor #1:  External minority stress

Studies have identified various factors that contribute to suicide and suicidal ideation in transgender individuals. These factors include different forms of violence, discrimination, harassment, and rejection based on one’s minority gender identity. These factors are consistently associated with increased suicidal ideation but have a weaker link to suicidal behavior. The factors that are most highly related to suicidal ideation include harassment, discrimination, social stressors such as rejection, and non-affirmation in one’s identity. On the other hand, experiences of physical and sexual violence are related to both suicidal ideation and behavior. By understanding and addressing these risk factors, we can work towards developing effective prevention strategies and interventions to support the mental health and well-being of transgender individuals.

Risk Factor #2:  Internal minority stress

Transgender/gender-diverse (TGD) individuals face unique risk factors for suicide and suicidal ideation that are experienced more internally compared to external discrimination or violence. These risk factors include internalized stigma and transphobia, which can lead to shame about being transgender. Other factors include concealment of identity and nondisclosure, expectations of social rejection, an inability to express gender, negative self-concept, and an unclear gender identity. These internal factors are particularly associated with the vulnerability for suicidal ideation, but they have a weaker link to suicidal behavior once suicidal ideation has developed. By addressing these internal risk factors through therapy, support, and affirmation of identity, we can reduce the risk of suicidal ideation and improve the mental health and well-being of TGD individuals.

Risk Factor #3:  Psychiatric morbidity

As with the general population, mental health problems are linked to an increased risk of suicide and suicidal ideation among transgender individuals. Common mental health issues that contribute to suicidal thoughts and behaviors include depression, loneliness and isolation, emotional instability, anxiety, PTSD, alcohol and drug abuse, physical and mental disabilities, and learning disabilities. Some risk factors are more closely related to suicidal behavior than others, such as substance abuse and PTSD. However, internal factors like loneliness and social isolation can also contribute to suicidal ideation. By addressing mental health issues through therapy and support, we can help transgender individuals manage these risk factors and reduce the likelihood of suicide and suicidal ideation.

Risk Factor #4:  Transition and healthcare

Gender transition is a unique and personal experience for transgender individuals, and the steps involved in the process can vary widely. These steps can range from social transition, such as dressing in one’s gender, to medical interventions like hormone therapy or surgery. However, there are certain risk factors related to the transition process and healthcare that are associated with an increased risk of suicidal thoughts and behaviors in TGD adults. These factors include not completing hormone therapy, a lack of medical interventions such as breast or genital surgery, living as one’s birth gender, identity documents that do not align with one’s gender identity, limited healthcare coverage for gender-related interventions, a lack of psychotherapy for gender dysphoria, and visual nonconformity. By addressing these factors and providing access to appropriate healthcare and support, we can help reduce the risk of suicidal ideation and improve the overall well-being of transgender individuals.

Risk Factor #5:  Reasons for living

There are certain factors that can serve as protective measures against suicidal thoughts and behaviors among transgender individuals. These include reasons for living, such as religiosity, optimism, survival coping beliefs, concerns about how loved ones would react to their suicide, fear of suicide, fear of social disapproval if one attempts suicide, and moral objections to suicide. By focusing on and strengthening these protective factors, we can help reduce the risk of suicidal ideation and behavior in transgender individuals. Additionally, providing support and resources to individuals who may be struggling with suicidal thoughts can also be helpful in preventing suicide and improving overall mental health.

Risk Factor #6:  Demographics

Certain demographic and static risk factors have been identified in studies related to suicide and suicidal ideation among transgender individuals. These include assigned female sex at birth, gender self-identification as male, and childhood gender nonconformity. Additionally, factors such as younger age, racial or ethnic minority status, education, income, employment, socioeconomic status, and sexual orientation as gay, lesbian, bisexual, or unsure have also been linked to suicidal thoughts and behaviors in this population. By taking these risk factors into consideration during patient assessments and suicide prevention efforts, healthcare providers can work to improve outcomes for transgender individuals and decrease the risk of suicide.

References:

 

1https://www.apa.org/topics/lgbt/transgender.pdf

2https://www2.psych.ubc.ca/~klonsky/publications/ita.pdf

For more information

To learn more about how gender and gender identification affects suicidality, read “The Gender Paradox of Suicide: How Suicide Differs Between Men, Women, and Transgender/Gender Diverse Individuals” by Dr. Raymond P. Tucker, and “Correlates of suicide ideation and behaviors among transgender people: A systematic review guided by ideation-to-action theory” by Dr. Caitlin Wolford-Clevenger.

About Raymond P. Tucker Ph.D.

Raymond P. Tucker Ph.D.
Raymond is an Assistant Professor of Psychology at Louisiana State University (LSU) where he founded the Mitigation of Suicidal Behavior (MOSB) Laboratory in 2017. He also is a Clinical Assistant Professor of Psychiatry at Louisiana State University Health Sciences Center /Our Lady of the Lake Medical Center. He finished his Ph.D. in clinical psychology from Oklahoma State University in 2017 following his clinical internship at VA Puget Sound. Raymond's research broadly focuses on the enhancement of theoretical models of suicide and suicide risk assessment tools, particularly in underserved populations (e.g., Veterans, Transgender and Gender Diverse adults). Raymond began his tenure as a CAMS consultant in 2019 after receiving a state-level grant to implement CAMS across the Our Lady of the Lake Regional Medical Center in Baton Rouge L.A. He is a former board member of the American Association of Suicidology and is a current faculty member at the National Suicidology Training Center.

About Alix Aboussouan

Alix Aboussouan
Alix Aboussouan is a second year PhD student in clinical psychology at Louisiana State University. As a member of the Mitigation of Suicidal Behavior (MOSB) research lab there, she studies risk and resilience factors for suicide in TGD adults. She is also a CAMS-trained therapist and delivers the intervention to at-risk adults at Our Lady of the Lake Regional Medical Center.

Gun Safety and Suicide Prevention

Perhaps you’ve personally known someone, or treated someone, who attempted suicide using a firearm. Chances are, it was a man – and chances are, the attempt was fatal.

Guns and Suicide in the United States

Studies show that 76% of those who die by suicide in the U.S. are men, and 60% of male suicides are by firearm. Tragically, death is the result of over 80% of firearm suicide attempts. Since men are more likely to use firearms in suicide attempts, and since using a firearm results in a higher likelihood of death than other methods (such as overdose or suffocation/hanging), overall more men than women die as a result of suicide. For instance, approximately 77% of those who die by suicide during their first attempt are men and most of these deaths are by firearm.1

Addressing the Intersection of Firearms and Suicide:

Regardless of the gender of suicide-by-firearm victims, increased awareness of firearm safety can go a long way in preventing gun deaths and reducing suicide rates. Here are some ways that we can help to prevent suicide by firearms in our communities:

Access to Firearms for At-Risk Individuals: Trigger Locks, Gun Safes & More

While most gun owners feel that guns make them safer2, this is likely not true if a person in the household is suicidal. In fact, studies show that access to a firearm increases the risk of death by suicide by as much as three times for everyone in the household.3

One major action that can help save lives is to provide information about removing firearms, or installing trigger locks, firearms safes, and other methods of securing to not only individuals at risk for suicide but also to their loved ones.

Provide Counseling on Firearm Safety

CAMS-care, which uses an evidence-based therapeutic framework for suicide-specific assessment and treatment of a patient’s suicidal risk, recommends a collaborative discussion between a healthcare provider and patient (and ideally the patient’s family or other support network) about how to stay safe. The CAMS-care assessment includes questions about access to firearms as well as personalized discussion of how to be safe with them. Recommendations for safety are not prescriptive; they are decisions made via collaborative problem solving. For some, the solution may be to remove firearms from the house altogether. For others, it may mean securing firearms in a gun safe with ammunition stored separately, and for others putting a picture of a loved one by the firearm is the only agreed upon deterrent.

Increase Public Awareness of Firearm Safety to Prevent Suicide

They say “it takes a village to raise a child,” and the same could be said of preventing suicide. Public awareness campaigns about firearms safety in suicide prevention can reduce the number of deaths by suicide in our communities.

Campaigns launched by law enforcement, medical professionals, and gun shop owners can also help prevent suicide. For example:

  • Police and other law enforcement agencies can expand existing gun licensing and safety training requirements for new or prospective gun owners to include suicide prevention information.
  • Firearms dealers, gun range owners, or retailers can offer suicide prevention-specific information in sponsored gun safety courses.
  • Physicians and other medical professionals can discuss firearms safety and suicide risk with patients.

The Role of Gun Control Laws

Grass-roots efforts by concerned citizens to raise awareness of firearms safety and suicide prevention can also help make our communities safer. However, it’s important to recognize that individual efforts are most effective when complemented by comprehensive gun control laws that address firearm accessibility and ownership. Implementing stricter gun regulations and background checks can serve as pivotal measures in preventing impulsive acts of self-harm. By combining the power of community-driven initiatives with formal legislation, we create a more comprehensive approach for addressing gun deaths.

How Gun Safety Can Promote Suicide Prevention

The road to preventing firearm suicides through gun safety is not a straight path, but by embracing responsible firearm ownership, education, and community collaboration, we can collectively move towards a safer society. By fostering open discussions, advocating for gun safety policies, and promoting mental health awareness, we can help reduce firearm suicides in the U.S.

Over half of the adults in America know someone who has died by suicide.4 Perhaps with greater awareness of the role that firearms safety can play in suicide prevention, our loved ones and patients will have a better chance of surviving a suicide attempt, or even ultimately avoiding suicidal behavior altogether.

 

References:

1 Bostwick, J. M., Pabbati, C., Geske, J. R., & McKean, A. J. (2016). Suicide attempt as a risk factor for completed suicide: even more lethal than we knew. American journal of psychiatry173(11), 1094-1100.

2 Igielnik R, Brown A. Key takeaways on Americans’ views of guns and gun ownership. Pew Research Center. June 22, 2017. https://pewrsr.ch/2sZzPjv.

3 Anglemyer A, Horvath T, Rutherford G. The accessibility of firearms and risk for suicide and homicide victimization among household members: A systematic review and meta-analysis. Annals of Internal Medicine. 2014; 160: 101–110.

4  http://www.rasmussenreports.com/public_content/lifestyle/general_lifestyle/september_2017/ more_than_half_of_americans_know_someone_who_committed_suicide

For more information

To learn more about how gender and gender identification affects suicidality, read “The Gender Paradox of Suicide: How Suicide Differs Between Men, Women, and Transgender/Gender Diverse Individuals” by Dr. Raymond P. Tucker.

About Raymond P. Tucker Ph.D.

Raymond P. Tucker Ph.D.
Raymond is an Assistant Professor of Psychology at Louisiana State University (LSU) where he founded the Mitigation of Suicidal Behavior (MOSB) Laboratory in 2017. He also is a Clinical Assistant Professor of Psychiatry at Louisiana State University Health Sciences Center /Our Lady of the Lake Medical Center. He finished his Ph.D. in clinical psychology from Oklahoma State University in 2017 following his clinical internship at VA Puget Sound. Raymond's research broadly focuses on the enhancement of theoretical models of suicide and suicide risk assessment tools, particularly in underserved populations (e.g., Veterans, Transgender and Gender Diverse adults). Raymond began his tenure as a CAMS consultant in 2019 after receiving a state-level grant to implement CAMS across the Our Lady of the Lake Regional Medical Center in Baton Rouge L.A. He is a former board member of the American Association of Suicidology and is a current faculty member at the National Suicidology Training Center.