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

DOI:10.1001/jamapsychiatry.2019.4702
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Daniel Coleman
Daniel Coleman
Daniel Coleman
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William Feigelman at Nassau County Community College
William Feigelman
Zohn Rosen at New York Medical College
Zohn Rosen
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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.
jamapsychiatry.com (Reprinted) JAMA Psychiatry Published online February 12, 2020 E1
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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.
Letters
E2 JAMA Psychiatry Published online February 12, 2020 (Reprinted) jamapsychiatry.com
© 2020 American Medical Association. All rights reserved.
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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;
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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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© 2020 American Medical Association. All rights reserved.
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... One prominent factor proposed to explain the demographic variation in the U.S. suicide rate is traditional masculinity, which suggests that men should be competitive and emotionally strong. This belief system has been associated with men's higher vulnerability to suicide in the U. S. (Coleman, 2015;Coleman et al., 2020). This cultural code is a significant characteristic of honor cultures in the southern U.S. states (Cohen andNisbett, 1994, Nisbett andCohen, 1996). ...
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... However, it remains less clear whether externalizing symptoms themselves (e.g., engaging in risky behavior) or underlying TMI increase men's risk for suicidality. For example, a study by Coleman et al. (2020) found men with strong TMI to be more than twice as likely to die by suicide than men with low TMI, while also being less likely to disclose suicidal ideation. Concordantly, found men with strong TMI who experienced status loss -status being a core dimension in many conceptualizations of TMI -to be about four times more likely to have attempted suicide in the past month. ...
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Broadening the Perspective on the Dynamics of Men's Suicide: Thought Suppression as a Mediator between Men's Self-Reliance and Suicidality
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  • Dec 2022
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Increase in Suicide Mortality in the United States, 1999-2018
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Full-text available
  • Apr 2020
Suicide is the 10th leading cause of death for all ages in the United States (1). Suicide is a major contributor to premature mortality as it ranks as the second leading cause of death for ages 10-34 and the fourth leading cause for ages 35-54 (1). Despite national goals to lower the suicide rate (2), several recent reports have documented a steady increase in suicide rates in recent years (3-6). This data brief uses final mortality data from the National Vital Statistics System (NVSS) to update trends in suicide rates from 1999 through 2018 and to describe differences by sex, age group, and urbanicity of county of residence.
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Masculinity and suicidal thinking
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PurposeMales feature prominently in suicide statistics, but relatively little work has been done to date to explore whether endorsement of dominant masculinity norms heightens the risk of or is protective against suicidal thinking. This paper aimed to further knowledge in this area. Methods We used baseline data from 13,884 men (aged 18–55) in the Australian Longitudinal Study on Male Health (Ten to Men) cohort. These men filled in self-complete questionnaires in 2013/14 which covered a range of topics, including conformity to dominant masculinity norms and suicidal thinking. We conducted logistic regression analyses to estimate the strength of association between these two variables. ResultsAfter controlling for other key predictors of suicidal thinking, one characteristic of dominant masculinity—self-reliance—stood out as a risk factor for suicidal thinking (AOR 1.34; 95% CI 1.26–1.43). Conclusions It suggests that one particular element of dominant masculinity—being self-reliant—may place men at increased risk of suicidal thinking. This finding resonates with current theories of how suicidal thinking develops and leads to action. It also has implications for the full gamut of suicide prevention approaches that target males in clinical settings and in the general population, and for our broader society. Further work is needed, however, to confirm the direction of the relationship between self-reliance and suicidality, and to unpack the means through which self-reliance may exert an influence.
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Investigating Correlates of Suicide Among Male Youth: Questioning the Close Affinity Between Suicide Attempts and Deaths
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This study was based on a sample of male high school students who completed National Longitudinal Adolescent Health Surveys in 1994, 1995, and 2001. We studied these students prospectively, comparing those who later died by suicide (n = 21) with those who were still living (n = 10,101). We employed chi-square and analysis of variance tests for statistical significance between suicide decedents and living respondents. Results showed suicide decedents were more likely to have experienced the suicide loss of another family member, to have been expelled from school, to have engaged in more delinquent actions including fighting, and to have greater involvement with the criminal justice system. Although one might have expected suicide casualties to have exhibited a greater amount of suicidal thoughts, attempts, and higher incidences of suicidality among their friends, our analyses did not find that these factors were associated with actual suicides. Should these findings be replicated, this would point to a need to refine youth suicide risk assessments. Collecting life histories, as well as identifying patterns of delinquency and fighting, may serve as more potentially fruitful means for assessing genuine suicide risk than some traditional risk assessment methods.z. © 2015 The American Association of Suicidology.
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The Salience of “Hegemonic Masculinity”
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This article argues that the concept of “hegemonic masculinity” remains highly salient to critical masculinities studies. The author outlines Raewyn Connell's initial formulation of the concept, how that initial model of hegemonic masculinity has been historically misinterpreted, the reformulation of the concept by Connell and Messerschmidt, and the recent scholarly amplification of the concept. The author concludes that Connell’s original emphasis on the legitimation of unequal gender relations remains essential to both the concept and to the field of critical masculinities studies.
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Traditional Masculinity as a Risk Factor for Suicidal Ideation: Cross-Sectional and Prospective Evidence from a Study of Young Adults
Article
  • Nov 2014
Objectives: Traditional masculinity is hypothesized to be associated with suicidal ideation, and traditional masculinity is predicted to interact with stressors, intensifying suicidal ideation. Methods: Cross-sectional and prospective data from a study of 2431 young adults was analyzed using hierarchical regression main effects and interaction models. Results: Traditional masculinity was associated with suicidal ideation, second only in strength to depression, including when controlling for other risk factors. Prospective effects were substantially weaker. There was mixed evidence for traditional masculinity by stress interactions. Conclusion: The results provide preliminary support for the role of traditional masculinity in suicidal ideation, but the relationship should be tested in studies of suicide attempts and mortality. Implications for prevention and intervention are explored.
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