Association of High Traditional Masculinity and Risk of Suicide Death

Abstract

This cohort study explores the association between high traditional masculinity and suicide death among US men using data from 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 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.

Add Health is a nationally representative study of adolescents into adulthood. Feigelman and colleagues⁵ 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.

Figure. Forest Plots of Factors Associated With Suicide Death and High Traditional Masculinity (HTM).

A and B, Feigelman et al⁵ risk factors for suicide death. C and D, Association of HTM with risk factors. All tests, P <.05. OR indicates odds ratio.

Methods

Add Health began with 20 745 adolescents in 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 participants. 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 procedures. 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 latent probability variable 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: χ² and odds ratios (ORs) and t tests and Cohen d. Stata, version 14 (StataCorp), was used for all data analyses and the criterion P value was set at P < .05.

Results

Of the 22 suicide deaths, 21 were men (OR, 21.7; 95% CI; 2.9-161; χ² = 18.8; P < .001). All subsequent analyses include men only. High–traditional masculinity men were 2.4 times more likely to die by suicide than non-HTM men (χ² = 3.979; P < .046; Table) but were 1.45 times less likely to report SI (χ² = 23.06; P < .001). There was no association between HTM and suicide attempts. High–traditional masculinity men were slightly more likely to report easy gun access (OR, 1.1; 95% CI, 1.01-1.20; χ² = 4.27; P < .04) and had modestly lower depression levels (Cohen d, 0.17; P < .001).

Table. χ² and t Test of Factors Associated With High Traditional Masculinity Among Male Respondents.

Measures	HTM, No. (%)		Total, %	OR (95% CI)	χ2 (df)	P Value
	Yes	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 thoughtsa
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 attempta
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.

^aDuring the past year.

All 9 risks for suicide from Feigelman et al⁵ were positively associated with HTM (Figure, C and D), with small to small-medium effect sizes.

Discussion

To our knowledge, this is the first study to show that HTM is associated with subsequent suicide among men. In addition to a direct association with suicide death, the association of HTM with all other risks suggests a web of indirect effects. In male suicide death, HTM may be an underlying influence increasing the probability of externalizing behavior 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 method⁶ and the 16 gender-discriminating variables are consistent 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 multivariate analyses and Add Health has no coding of gender identity other than male or female. This study should catalyze research, prevention, and intervention attention to the role of masculinity in suicide.