Association of High Traditional Masculinity and Risk of Suicide Death: Secondary Analysis of the Add Health Study

Abstract

In the United States, men die by suicide at 3.5 times the rate of women.¹ One driver of this gender disparity may be high traditional masculinity (HTM), a set of norms that includes competitiveness, emotional restriction, and aggression.² Quantitative studies of HTM are interrelated with discourse on hegemonic masculinity.³ Using norm- and trait-based measures, HTM men were found to have higher suicidal ideation (SI),²,4 but to our knowledge, the association with suicide death has not been tested with a credible measure of HTM.

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Letters
RESEARCH LETTER
Association of High Traditional Masculinity
and Risk of Suicide Death: Secondary Analysis
of the Add Health Study
In the United States, men die by suicide at 3.5 times the rate
of women.
1
One driver of this gender disparity may be high tra-
ditional masculinity (HTM), a set of norms that includes com-
petitiveness, emotional restriction, and aggression.
2
Quan-
titative studies of HTM are interrelated with discourse on
hegemonic masculinity.
3
Using norm- and trait-based mea-
sures, HTM men were found to have higher suicidal ideation
(SI),
2,4
but to our knowledge, the association with suicide death
has not been tested with a credible measure of HTM.
Add Health is a nationally representative study of adolescents
into adulthood. Feigelmanand colleagues
5
found 9 Add Health
variables associated with suicide (Figure, A and B) and weak
nonsignificant effects for depression and gun access. This study
hypothesizes that HTM is associated with suicide, depression,
gun access, and the 9 variables previously noted. No prediction
was made for HTM regarding SI or suicide attempts.
Methods |Add Health began with 20 745 adolescentsin 1995 and
in 2014 was matched with death records using the National
Death Index. The details of the methods of Add Health can be
found at http://www.cpc.unc.edu/addhealth. The Add Health
study was reviewed and approved for human participant
issues at the University of North Carolina Chapel Hill. Under that
protocol, written informed consent was elicited from all par-
ticipants. The secondary analysis of this data was approved by
the institutional review board at Fordham University.
Death by suicide was defined by National Death Index pro-
cedures. Through the use of a method novel to suicide research,
an established procedure was replicated for scoring gender-typed
attitudes and behaviors in which a single latentprobability vari-
able of identifying as male was generated from 16 gender-
discriminating variables (including not crying, physically fit, not
moody,not emotional, liking yourself, fighting, and risk taking).
6
Participants scoring 73% probability or higher of identifying as
male (>1 SD above the mean) were coded as HTM. Details of
additional variables can be found in Feigelman et al.
5
Because
of the small number of suicides, the analysis was limited to
bivariate tests and effect sizes: χ
2
and odds ratios (ORs) and ttests
and Cohen d. Stata, version 14 (StataCorp),was used for all data
analyses and the criterion Pvalue was set at P< .05.
Results |Of the 22 suicide deaths, 21 were men (OR, 21.7;
95% CI; 2.9-161; χ
2
= 18.8; P< .001). All subsequent analyses
Figure. Forest Plots of FactorsAssociated With Suicide Death and High Traditional Masculinity (HTM)
Decreased
Suicide Risk
Increased
Suicide Risk
OR (95% CI) Log
Factor
Family member suicide
Expelled from school
Ran away from home
Used weapon
White
Smoking (past 30 d)
Serious fight (past year)
8.98 (2.1-39)
OR
(95% CI)
3.89 (1.4-10.6)
3.06 (1.1-8.4)
2.94 (1.1-8.1)
2.83 (1.0-7.8)
2.5 (1.1-5.9)
2.11 (1.3-3.6)
Feigelman et al,5 2016 categorical risk factors for suicide death
A
101 1000.1
Factor
Delinquency
Fighting
Feigelman et al,5 2016 continuous risk factors for suicide death
B
Decreased
HTM
Increased
HTM
Factor
Family member suicide
Expelled from school
Used weapon
Ran away from home
Serious fight (past year)
White
Smoking (past 30 d)
1.89 (1.3-2.7)
OR
(95% CI)
1.46 (1.3-1.7)
1.43 (1.3-1.7)
1.43 (1.3-1.7)
1.29 (1.2-1.4)
1.22 (1.1-1.3)
1.18 (1.1-1.3)
Association of HTM with categorical risk factors
C
Factor
Delinquency
Fighting
0.66 (0.23-1.09)
Cohen d
(95% CI)
0.47 (0.04-0.9)
0.17 (0.13-0.21)
Cohen d
(95% CI)
0.17 (0.13-0.21)
Association of HTM with continuous risk factors
D
0 1.51.0
Cohen d (95% CI)
0.5
0 32
OR (95% CI)
1
0.10 1.251.20
Cohen d (95% CI)
0.15
A and B, Feigelman et al
5
risk factors for suicide death. C and D, Association of HTM with risk factors. All tests, P<.05. OR indicates odds ratio.
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include men only. High–traditional masculinity men were
2.4 times more likely to die by suicide than non-HTM men
(χ
2
= 3.979; P< .046; Table) but were 1.45 times less likely to
report SI (χ
2
= 23.06; P< .001). There was no association
between HTM and suicide attempts. High–traditional mascu-
linity men were slightly more likely to report easy gun access
(OR, 1.1; 95% CI, 1.01-1.20; χ
2
=4.27;P< .04) and had mod-
estly lower depression levels (Cohen d,0.17;P< .001).
All 9 risks for suicide from Feigelman et al
5
were posi-
tively associated with HTM (Figure, C and D), with small to
small-medium effect sizes.
Discussion |To our knowledge, this is the first study to showthat
HTM is associated with subsequent suicide among men. In ad-
dition to a direct association with suicide death, the associa-
tion of HTM with all other risks suggests a web of indirect ef-
fects. In male suicide death, HTM may be an underlying
influence increasing the probability of externalizing behav-
ior risk factors, such as anger, violence, gun access, and school
problems. The finding that almost all suicide decedents were
men underlines the central role of gender in suicide death. The
protective or null association of HTM with nonfatal suicidal
behavior mirrors the gender differences in suicide death and
nonfatal attempts but conflicts with previous studies of HTM.
Relevant interpretive theories of these findings include the
Canetto cultural scripts theory and the Baumeister escape
suicide theory.
2
The measure of HTM is based on a well-established
method
6
and the 16 gender-discriminating variables are con-
sistent with US relevant masculinity theory and measures in
content, but its convergent validity with measures used in
previous suicide research is unknown. Other limitations
include that the small number of suicides precluded multi-
variate analyses and Add Health has no coding of gender
identity other than male or female. This study should cata-
lyze research, prevention, and intervention attention to the
role of masculinity in suicide.
Daniel Coleman, PhD
William Feigelman, PhD
Zohn Rosen, PhD
Author Affiliations: Graduate School of Social Service, Fordham University,
New York, New York (Coleman); Department of Sociology, Nassau Community
College, Jamaica, New York (Feigelman); Mailman School of Public Health,
Columbia University,New York, New York (Rosen).
Corresponding Author: Daniel Coleman, PhD, Graduate School of Social
Service, Fordham University, 113 W 60th St, 7th Floor, New York, NY 10023
(dcoleman11@fordham.edu).
Published Online: February 12, 2020.doi:10.1001/jamapsychiatry.2019.4702
Author Contributions: Dr Feigelman had full access to all of the data
in the study and takes responsibility for the integrity of the data and
the accuracy of the data analysis.
Concept and design: Coleman, Feigelman
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Coleman, Rosen.
Critical revision of the manuscript for important intellectual content:Coleman,
Feigelman.
Statistical analysis: All authors.
Supervision: Feigelman.
Conflict of Interest Disclosures: None reported.
Funding/Support: This research uses data from Add Health, a program project
directed by Kathleen Mullan Harris and designed by J. Richard Udry, Peter S.
Bearman, and Kathleen Mullan Harris at the University of North Carolina at
Chapel Hill, and is funded by grant P01-HD31921 from the Eunice Kennedy
Shriver National Institute of Child Health and Human Development, with
cooperative funding from 23 other federal agencies and foundations.
No direct support was received from grant P01-HD31921 for this analysis.
Role of the Funder/Sponsor:The funding organizations had no role in the
design and conduct of the study; collection, management, analysis, and
Table. χ
2
and tTest of Factors Associated With High TraditionalMasculinity Among Male Respondents
Measures
HTM, No. (%)
Total, % OR (95% CI) χ
2
(df)PValueYes No
Suicide death
Yes 10 (.3) 9 (.1) 0.19
2.4 (0.99-6.0) 3.979 (1) .046
No 3084 (99.7) 6747 (99.9) 99.8
Total, No. 3094 6756 9850
Suicidal thoughts
a
Yes 249 (8) 760 (11.1) 10.2
0.69 (0.60-0.81) 23.06 (1) <.001
No 2856 (92) 6048 (88.8) 89.8
Total, No. 3105 6808 9913
Suicide attempt
a
Yes 62 (2) 164 (2.4) 2.3
0.82 (0.61-1.1) 1.71 (1) .19
No 3076 (98) 6683 (97.6) 97.7
Total, No. 3138 6847 9985
Easy access to guns
Yes 1020 (32.5) 2085 (30.4) 31.1
1.1 (1.01-1.2) 4.27 (1) .04
No 2118 (67.5) 4764 (69.6) 68.9
Total, No. 3138 6894 9987
Depression Cohen d(95% CI) t(df)
Mean (SD) 9.59 (6.17) 10.73 (6.98) NA 0.17 (0.13-0.21) 7.81 (9936) <.001
Total sample size, No. 3121 6817 9938 NA NA NA
Abbreviations: HTM, high traditional
masculinity; NA, not applicable;
OR, odds ratio.
a
During the past year.
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interpretation of the data; preparation, review, or approvalof the manuscript;
and decision to submit the manuscript for publication.
Additional Information: Information on how to obtain the Add Health data
files is available on the Add Health website (http://www.cpc.unc.edu/
addhealth).
1. Hedegaard H, Curtin SC, Warner M. Suicide Mortality in the United States,
1999-2017. Atlanta, GA.: Centers for Disease Control and Prevention;
2018.
2. Coleman D. Traditional masculinity as a risk factor for suicidal ideation:
cross-sectional and prospective evidence from a study of young adults. Arch
Suicide Res. 2015;19(3):366-384.doi:10.1080/13811118.2014.957453
3. Messerschmidt JW. The salience of “hegemonic masculinity”. Men Masculinities.
2019;22(1):85-91. doi:10.1177/1097184X18805555
4. Pirkis J, Spittal MJ, Keogh L, Mousaferiadis T, Currier D. Masculinity and
suicidal thinking. Soc Psychiatry Psychiatr Epidemiol. 2017;52(3):319-327.
doi:10.1007/s00127-016-1324-2
5. Feigelman W, Joiner T, Rosen Z, Silva C. Investigating correlates of suicide
among male youth: questioning the close affinity between suicide attempts and
deaths. Suicide Life Threat Behav. 2016;46(2):191-205. doi:10.1111/sltb.12183
6. Cleveland HH, Udry JR, Chantala K. Environmental and genetic influences on
sex-typed behaviors and attitudes of male and female adolescents. Pers Soc
Psychol Bull. 2001;27(12):1587-1598.doi:10.1177/01461672012712003
Letters
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