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 the identification of hundreds of risk factors and dozens of theories on cause. In addition, multiple suicide prevention initiatives have been tested.
While much has been learned, perhaps one of the most important aspects of study consistently present across the decades of research is what is commonly referred to as the gender paradox. More recently, the question of gender in suicidal behavior has expanded to include transgender and gender-diverse (TGD) individuals.
First: What Exactly Is the Gender Paradox of Suicide?
The traditional gender paradox of suicide is simple: Men die by suicide more often than women, but 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 are quite striking. CDC data1 demonstrates that men account for over 76% of suicide deaths in the United States each year. There are 3.3 male suicide deaths for every one 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.
Why Does the Gender Paradox Exist?
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. 2 3
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 over 80% 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.
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.
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 20134 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.
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, and 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. 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.
- Centers for Disease Control and Prevention, Suicide rising across the US. https://www.cdc.gov/vitalsigns/suicide/index.html
- 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
- Joiner, Ph.D., Thomas E., “Why Do People Die By Suicide” Lecture Video. https://www.youtube.com/watch?v=DESRIZtUIT4
- 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