Elsevier

Journal of Affective Disorders

Volume 243, 15 January 2019, Pages 297-304
Journal of Affective Disorders

Research paper
Gender inequality and suicide gender ratios in the world

https://doi.org/10.1016/j.jad.2018.09.032Get rights and content

Highlights

  • Global variations in suicide gender ratios were associated with gender inequality.

  • Male to female suicide rate ratios were higher in countries with more egalitarian gender norms; whereas lower suicide gender ratios were generally observed in countries with higher level of gender inequality.

  • Cultural-based indicator of gender inequality (i.e. natality inequality/son preference) was more sensitive than economic-based indicator (i.e. the GII).

  • Strategies to eliminate culturally embedded discrimination against women have the potentials to prevent suicides.

Abstract

Background

To assess whether gender inequality determines the patterns of suicide gender ratios.

Methods

Using suicide data obtained from the World Health Organization Statistical Information System, 2012, suicide gender ratios were calculated and a world map of the ratios constructed. Forest plots were utilized to assess whether gender inequality (indicated by the Gender Inequality Index [“GII”] and male to female sex ratios at birth) moderated the worldwide patterns of suicide gender ratios. Regression analyses were then performed to estimate the extent to which gender inequality affects suicide gender ratios before and after controlling for human development level (“HDI”).

Results

Gradient relationships of suicide gender ratios across 3 tertiles of GII were observed (ratios = 2.03, 2.54, 3.51, respectively for high, moderate and low GII, P = 0.03). High sex ratio at birth was significantly associated with lower suicide gender ratio (ratio = 1.64 vs. 2.75, P = 0.00). Regression analyses showed that highest tertile of GII and high sex ratios at birth were significantly associated with lower suicide gender ratios (P = 0.00 and P = 0.00, respectively). When the level of human development level was controlled, high sex ratio at birth remained to be a significant determinant of suicide gender ratios (P = 0.00), whereas the significance of GII disappeared (P = 0.19).

Limitations

The cross-sectional data do not allow for causal inferences.

Conclusions

Male to female suicide ratios were higher in countries with more egalitarian gender norms. Strategies to eliminate culturally embedded gender discrimination have the potentials to prevent suicides.

Introduction

It is well known that in most parts of the world, suicide rates in men are generally higher than in women (World Health Organization, 2017a). According to the global suicide report from the World Health Organization, the estimated overall male to female suicide rate ratio was 1.9 in 2012 (male:15.0 per 100,000; female: 8.0 per 100,000). In high-income countries however, the male to female ratio of age-standardized suicide rate was 3.5 (male:19.9 per 100,000; female: 5.7 per 100,000), whereas in low- and middle-income countries, the male-to-female ratio was 1.57 (male: 13.7 per 100,000, female: 8.7 per 100,000). The male to female suicide rate ratios, nonetheless, vary greatly between countries. Among the 172 Member States, male to female suicide rate ratios ranged between 0.5 and 12.5 in 2012 (World Health Organization, 2014). However, to the best of our knowledge, no previous studies have explored the underlying factors in the relation of global variations in suicide gender ratios.

Several studies pointed out that male to female suicide rate ratios in East Asian countries were lower than in the Western countries, as suicide rates in women in those regions were higher (Chen et al., 2017, Lester, 1982, Yip et al., 2000). Lower women's status may be a potential explanation for the high female suicide rates in East Asia (Chen et al., 2017, Phillips et al., 2002, Zhang et al., 2006,) as low women's status is related to violence against women, feminization of poverty and women's shortage of resources to deal with life predicament, lack of education and economic opportunities (Chant, 2008, Maselko and Patel, 2008). However, whether women's status is associated with the patterns of suicide gender ratios in the world has yet to be explored.

Recently, the United Nations Development Program (“UNDP”) compiled a new global index of gender inequality – Gender Inequality Index (“GII”), to capture women's disadvantage in the dimensions of empowerment, labor activity and reproductive health (Gaye et al., 2010, Permanyer, 2013). This composite index presents a summary of gender disparity in each country and provides a simple measure to examine the associations between global patterns of gender disparity and male to female suicide gender ratios. However, GII has been criticized to have put too much emphasis on the economic and material dimensions of the disadvantages in women, neglecting the inherited cultural aspects of gender inequality (Permanyer, 2013). In the current analyses, natality inequality, i.e., son preference (Sen, 2001), has been added to represent the cultural aspect of gender inequality. Without any deliberate human interruption, laws of nature revealed that for every 100 girls, about 102–106 boys were being born (UNFPA Asia and the Pacific Regional Office, 2012). Due to strong cultural attitude of son preference in some societies, especially in the low and middle income countries, owing to excess in female child mortality and sex-selective abortion, many girls went missing (Das Gupta et al., 2002; Sen, 2003). Son preference represents culturally rooted discrimination against women that women themselves internalize the practice, this kind of gender bias self-perpetuates with little need of direct reinforcement from the male world (Das Gupta et al., 2002, Kabeer, 1999). Combining GII and sex ratios at birth would be better able to capture gender inequality in a more comprehensive way, encompassing material, health, as well as cultural dimensions of gender inequality.

The aims of the current study are first, to provide descriptive analyses of suicide gender ratios in the world, and second, to examine whether egalitarian gender norms were negatively associated with male to female suicide rate ratios. As the level of human development may affect the associations between gender inequality and suicide gender ratios (Chen et al., 2017), it was controlled in the current study.

Section snippets

Data

The suicide mortality data in 2012 were obtained from the WHO mortality database (World Health Organization, 2017b), death records data from Taiwan's Department of Health (Ministry of Health and Welfare, 2017) and the Coroner's Court of Hong Kong (Coroner's Court of Hong Kong, 2013). Suicide mortality was identified using the International Classification of Diseases, 10th revision (“ICD-10′') code of X60-X84 (intentional self-harm). A total of 174 regions (172 WHO members plus Taiwan and Hong

Results

As can be seen from Fig. 1, suicide gender ratios varied markedly across different countries in the world. Overall, highest male to female suicide gender ratios were found in East European countries and the former Soviet Republics; lowest ratios however appeared in the Asian countries. A scatter plot of GII and suicide gender ratios stratified by HDI was presented in Fig. A1. A boxplot presenting the distribution of sex ratios at birth and suicide gender ratios was shown in Fig. A2.

Fig. 2

Main findings

The present results indicate that international variations in suicide gender ratios were associated with gender inequality. Male to female suicide rate ratios were higher in countries with more egalitarian gender norms; whereas lower suicide gender ratios were generally observed in countries with higher level of gender inequality. Cultural-based indicator of gender inequality i.e., natality inequality/son preference, was more sensitive than economic-based indicator, i.e., the GII. After

Conclusions

Gender inequality contributed to global variations in suicide gender ratios, lower ratios were found in places where gender-based discrimination was more prominent. It has long been known that even though women face a variety of social disadvantages, their suicide rates are lower than their male counterparts. How women develop strengths to survive hardships are areas that need in-depth exploration, and this kind of inquiry would complement suicide prevention in men.

Gender inequality is not a

Conflict of interest

The authors declare no conflicts of interest.

Ethics approval

No ethics approval is needed as it involves the open data sources.

Contributors

QS Chang: study design, data collection, data analysis, figures, data interpretation, writing of the first draft.

PSF Yip: study design, data collection, data analysis, data interpretation, critically revise the first draft of the manuscript.

YY Chen: literature search, study design, data collection, data interpretation, finalized the manuscript, supervised the study.

Role of the funding source

The current study is supported by Taiwan's Ministry of Science and Technology (MOST 105-2314-B-532-004-MY3), the Department of Health Taipei City Government (10701-62-007), and a Strategic Public Policy Research (SPPR) of the University Grant Council at the University of Hong Kong(SPPR-HKU-12).

The funders have no role in the study design; in the collection, analysis and interpretation of the data; in the writing of the report; and in the decision to submit the paper for publication.

Acknowledgements

None.

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