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. Author manuscript; available in PMC: 2022 Apr 1.
Published in final edited form as: Int J Ment Health Addict. 2019 Apr 17;19(2):438–446. doi: 10.1007/s11469-019-00078-1

Gender Characteristics in Methods of Chinese Rural Young Suicides

Xiaomei Xu 1, Jie Zhang 2,3, Qin Zhou 4, Long Sun 5
PMCID: PMC8209688  NIHMSID: NIHMS1527284  PMID: 34149330

Abstract

Suicidal men and women tend to use different means for suicide, but there has been a lack of studies on how Chinese male and female suicides are distributed on the various lethal methods. We studied 392 suicides (214 males and 178 females) consecutively sampled from selected rural areas of China, with the psychological autopsy (PA) design. It was found that majority of the Chinese rural young suicides died of swallowing pesticides or other farming chemicals (73.5%), and there was not much difference between men and women in all the suicide means as expected. Contrary to the findings in the United States, firearm was not available to Chinese civilians and was not the number one suicide means for the Chinese male suicides. In rural China, suicides with less violent methods outweighed those with violent methods in numbers, with more females chose less violent suicide methods than males. However, results of logistic regression showed that there was no significant association between gender and suicide methods in rural China. Mental disorders and impulsivity were also not associated with violent or less violent suicide methods. Our findings indicated that access to suicide means might be most important explanation of suicide methods. These findings may have certain implications on suicide prevention, and researchers and policy makers should take into consideration of the contexts of the people at risks of suicide.

Keywords: Gender, suicide, means of suicide, China, pesticides

As the 15th leading cause of death worldwide (WHO, 2014), suicide is a major public health issue all over the world. In China, suicide accounted for 287,000 deaths every year (Phillips, 2002). Suicide in China demonstrated unique characteristics. Rural suicide rate was 3 times higher than that in urban area, while in western countries no significant difference was found between rural and urban suicide rates (Yip et al., 2005; Wang et al., 2008). In China, suicide rate in females was higher than that in males, while more suicides were found among males than among females in western countries (Yip et al., 2005; Wang et al., 2008). The age pattern of suicide in China presented a bimodal distribution, with 2 peaks in youths aged 15–34 years and elderly people aged 60 and above (Phillips, 2002).

Research on suicide methods is an area of suicidology to better understand the contexts of the suicide, it also can recommend some prevention measures. The observations showed that more than half of suicides used firearms in US (Centers for Disease Control and Prevention 2010). However, swallowing farming pesticides or other chemicals was the main method of suicides in China (Phillips et al. 2002; Zhang et al. 2002a). Those might be explained by context differences between the cultures. Therefore, the methods used for suicidal behaviors are of relevance both for sociological research and for practical significance.

Suicide methods also vary by gender (Värnik et al., 2009), and the study of gender differences in suicide methods is of both cultural and practical importance. Previous studies have revealed gendered patterns of suicide means. However, few researches have addressed the disparities in the suicide methods between Chinese men and women. This study is aimed to fill the gap.

A review of Western studies on the gender differences in methods of suicide has presented some consistent patterns. To identify the most frequent gender-specific suicide methods in Europe, researchers studied 16 countries and found that hanging was the most prevalent suicide method among both males (54.3%) and females (35.6%). For males, hanging was followed by firearms (9.7%) and poisoning by drugs (8.6%); for females, by poisoning by drugs (24.7%) and jumping from a high place (14.5%) (Värnik et al. 2008). One reason why female suicides are less likely to use firearms than male suicides maybe that women who intend to die by suicide are more likely than men to avoid facial disfiguration (Callanan and Davis 2011). Another explanation for that women use poisoning or overdosed drugs, which are less lethal than firearms, to kill themselves is the fact that they are less intent on dying than the suicidal men (Callanan and Davis 2012; Denning et al. 2000).

In Asian regions, poisoning by pesticide was a common method among suicides (Ajdacic-Gross V et al., 2008). In China, pesticide poisoning was the most frequently used suicide method, and there was a drastic increase from 2004 to 2006 (Zhang et al., 2008). In Sri Lanka, restrictions on the import and sales of pesticide coincided with reductions in suicide in both men and women of all ages (Gunnell et al., 2007). There researches implied that China could also benefit from strict regulations on lethal pesticide.

In a study to investigate whether women use less lethal methods for suicide than men, researchers studied an American sample in California with original death certificates of 643 suicide victims obtained from records of a County Coroner. They found that women were over 73% less likely to use firearms than men, but there were no gender differentials in hanging. Female victims were over 4 times more likely to die from drug poisoning than male victims (Kposowa and McElvain 2006).

In another study conducted in Illinois, 10,287 suicides were examined for the means used for the act. Researchers found that firearms were the most lethal suicide method, and episodes involving firearms were 2.6 times more lethal than those involving suffocation, which was the second most lethal suicide method. The study suggests that preventing access to firearms can reduce the proportion of fatal firearms related suicides by 32% among minors, and 6.5% among adults (Shenassa, Catlin and Buka 2003). In China, few studies were focused on the gender differences of suicide methods. Li and colleagues collected 548 suicide cases and revealed that males involved more than females in suicides by mechanical methods (Li et al., 2016).

What can be the most prevalent means of suicide if firearms are less accessible to civilians? One study in Switzerland examined whether children and adolescents are drawn to other methods of suicide than adults. Of the 12,226 suicides which took place in a 10-year period, 333 were by children and adolescents (226 males, 107 females). It was found that the most prevalent methods of suicide in children and adolescents 0–19 years were hanging, jumping from heights and railway-suicides (both genders), intoxication (females) and firearms (males). Compared to adults, railway-suicides were over-represented in young males and females, and jumping from heights was over-represented in young males. Thus, availability has an important effect on methods of suicide chosen by children and adolescents. The researchers suggested that restricting access to most favored methods of suicide might be an important strategy in suicide prevention (Hepp et al. 2012).

In an effort to assess the distribution of suicide means in China, we went through 479 journal articles published on Chinese suicide, and found that the most prevalent means of suicide for Chinese people were poisons including pesticides, sleeping pills, etc. This method accounted for about 83% of the total suicides we had studied. The second most prevalent method was hanging, but claiming only 7.8% of the suicides. The following means were drowning (5.7%), self-cutting (1.5%), jumping from heights (1.3%), railway tracks (0.1%), and firearms (0.1%), and etc. (Zhang et al. 2002a).

The current information and statistics on the means of Chinese suicide are more than 10 years old and basically out of date due to the fast growing economy and social change in China. Further, few studies, if any, have addressed the differences in the suicide methods between Chinese men and women. The purpose of this study is to identify the gender differences in the means used for the Chinese rural suicides. We aimed to study China and Chinese society from a sociological and cultural perspective and recommend prevention measures based on the scientific research.

Method

Study Sampling

Data from 392 suicides aged 15–34 years were consecutively collected in three provinces of China: Liaoning, Shandong, and Hunan. Sixteen rural counties were randomly selected from the three provinces (six from Liaoning, five from Hunan, and five from Shandong). Information about suicide victims was collected with the psychological autopsy (PA) method. Psychological autopsy, as a procedure for the reconstruction of suicidal death through interviews with survivors (Beskow, Runeson, & Asgard, 1990), was widely used in studies on risk factors for suicide in US and western countries (Cavanagh et al. 2003). The aim of this method was to assess the suicides’ mental health status as well as other life experience before death through the information provided by the informants. PA has been tested to be reliable with good validity in Chinese social and cultural environments (Zhang et al. 2002b; Zhang et al. 2003; Phillips et al. 2002).

Procedures

Interview schedule was arranged between one and six months after a suicide event, with the assistance from the county level CDCs, who had consecutive records of suicide deaths in their county and was able to connect the research team with the households in villages. Two informants were selected for each suicide case: one as a next kin and the other as a friend or neighbor who was familiar with the victim. After getting their agreement with a written informed consent, our trained interviewers began the interview. The interview place was either the home of interviewees or the village clinic without interruption by others. The average time for each interview was about 2.5 hours.

Measures

The same questionnaire was interviewed with two informants for each suicide. In the questionnaire, the contents included demographic factors, mental health status, psychological factors, and characteristics related to suicide.

Demographic factors included age, gender, education years, marriage status (never married: single and no dating; ever married: married, widowed, divorced, remarried and single but dating with others), and religion (no: atheist; yes: Taoism, Islam, Protestantism, Catholicism, Buddhism, other).

Mental illnesses were diagnosed by using the Chinese version of the Structured Clinical Interview for the DSM-III-R (SCID) (Spitzer et al. 1988), which is an adequate instrument for Chinese populations (Zhang et al. 2003). The SCID helped us identify individuals who had had axis I disorders such as alcohol abuse and dependence, anxiety (post-traumatic stress disorder and panic disorder), affective disorders (dysthymia, unipolar major depression, and bipolar affective disorder), organic mood disorders, and primary psychoses (schizophrenia).

Instruments also included Beck Hopelessness Scale (BHS) (Beck et al. 1974) with 20 5-Likert responses from 1 (completely fit me) to 5 (completely opposite to me), the total score can range from 20 to 100. The 23-item Dickman Impulsivity Inventory (DII) (Gao, Zhang and Jia 2011) was designed to assess the personality trait of impulsiveness which includes two sub-scales: Dysfunctional Impulsivity Scales and Functional Impulsivity Scales. The former is the tendency to act with relatively little forethought when this causes problems and the latter is the tendency to act with relatively little forethought when this is optimal.

The 64-item revised version of Interview for Recent Life Events (IRLE) including 19 culturally (Chinese) specific items added by our research team was used to measure the number of life evens that happened in the past 12 months before suicide incidence (Paykel, Prusoff and Uhlenhuth 1971). The Chinese version of IRLE has been tested in previous study with a sound validation (Zhang and Ma 2012).

According to classification of violent and less-violent methods by previous suicide studies (Lin et al. 2008), in this study, suicide deaths with pesticide and other poisons and overdose, gases, and suffocation were classified into less-violent group. Suicide deaths with hanging, drowning, jumping from high place, wrist cutting, electric shock, and run over by train were classified into violent group.

Information Incorporation from Different Sources

For each suicide and control, we had two informants providing information for them. For different responses from the two informants for the same target, data were integrated according to the variables based on previous experiences (Kraemer et al. 2003). Though the control him/herself was also interviewed during the survey, we used information provided by the informants. For the demographic information, that provided by the informant who should better know it was employed. For example, to the target person’s age and birth date, information provided by family member was more accurate than that of friends or others. To determine a diagnosis with the SCID, the positive response was selected, because the other informant might not have had an opportunity to observe the specific behavior.

Statistical Analysis

Descriptive analyses, t-tests, and chi-square tests were carried out to describe and compare the demographic characteristics of suicides by gender. Multiple logistic regression models were used to analyze related factors to violent methods of suicides. All statistical analyses were carried out with the Statistical Package for Social Sciences (SPSS for Windows, version 21.0). The levels of significance for inclusion in the model and for determination of statistical significance were all 0.05 in this study.

Results

The study sample from the three provinces consisted of 392 suicides (178 females and 214 males). They were all from rural China and aged between 15 and 34 years at the time of death or interview. There were no significant gender differences in age, religion and education years. Female suicides were more likely than male suicides to be married. The present study suggests males were more likely to use violent means and females more likely to use less violent means (p=0.04). We compared violent suicide methods and less-violent suicide methods separately for males and females by gender on their socio-demographic and personal characteristics. (See Table 1).

Table 1.

Descriptions of the sample for major variables and gender comparisons

Variables All subjects (N= 392) Males (n = 214) Females (N= 178) χ2/t p
Mean / f SD / % Mean / f SD / % Mean / f SD / %
Age 26.84 6.37 26.95 6.6 26.7 6.09 20.62 0.61
Marital status 23.76 <0.001
 Never married 129 32.9 93 43.5 36 20.2
 Ever married 263 67.1 121 56.5 142 79.8
 Religion 0.12 0.73
 No 361 92.1 198 92.5 163 91.6
 Yes 31 7.9 16 7.5 15 8.4
Education years 7.38 2.77 7.40 2.63 7.38 2.92 12.63 0.76
Suicide methods 5.97 0.04
 Violent Methods 70 17.9 42 19.6 28 15.7 3.81 0.80
  Hanging 41 10.5 25 11.7 16 9.0
  Drowning 19 4.8 11 5.1 8 4.5
  Jumping 7 1.8 3 1.4 4 2.2
  Wrist cutting 1 0.3 1 0.5 0 0
  Electronic shock 1 0.3 1 0.5 0 0
  Run over by train 1 0.3 1 0.5 0 0
 Less Violent Methods 303 77.3 157 73.4 146 82.0 3.72 0.29
  Pesticides/Poison 288 73.5 151 70.6 137 77.0
  Overdose 12 3.1 4 1.9 8 4.5
  Gas 1 0.3 1 0.5 0 0
  Suffocation 2 0.5 1 0.5 1 0.6
 Methods unknown 19 4.8 15 7.0 4 2.2
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In this study, the most common method was ingesting pesticides or other poisons (73.5%, 288) used by suicide victims. Then 41 (10.5%) died by hanging, 19 (4.8%) died by drowning, 12 (3.1%) died by overdose of sleeping pills, and 7 (1.8%) died by jumping from a high place. The remainder (4.8%, 19) died of unknown methods. All deaths were confirmed to be suicide by consensus from the family members, village doctors, local medical agencies, and the police. Out of 392 suicide death, 70 (17.9%) were classified into the violent group and 303 (77.3%) cases were classified into the less violent group. Suicides with less violent methods outweighed those with violent methods in amount.

It was not a surprising finding that pesticide was the main suicide means in China. This might be due to the fact that China is an agricultural country and pesticide is quite common in rural China (Phillips et al. 2002b). This finding is consistent to previous suicide studies conducted in China (Centers for Disease Control and Prevention 2002), and similar pattern was also found in other Asian countries where agriculture is an important component of their national economy (Ajdacic-Gross et al. 2008; Gunnell et al. 2007; Gunnell 2007b).

Though males were more likely to use violent means than females, there were no significant difference within violent (p=0.80) and less violent (p=0.29) suicide methods group between male and female. Men and women in rural suicide sample used similar suicide means at different frequencies. The most frequent method used by male victims was pesticides or other poisons (151), followed by hanging (25), and drowning (11). For the female victims, the most frequent method was pesticides or other poisons (137), followed by hanging (16), overdose (8) and drowning (8).

Subsequent analyses were made separately for violent and less violent suicide methods by gender. In these analyses, we compared the characteristics and mental health status between males and females using violent and non-violent suicide methods. Results of distribution and single-variable analyses are showed in Table 2. There were significant gender differences only in the less violent suicide methods group. Religious belief (p<0.001), mental disorder (p<0.001), hopelessness (p=0.002) and life evens (p=0.04) demonstrated significant difference by gender.

Table 2.

Gender comparisons in using violent and less violent suicide methods

Variables Violent Mean Group (n = 70) Less Violent Mean Group (n = 303)
Male (n = 42) [n (%)/mean(s.d.)] Female (n = 28) [n (%)/mean(s.d.)] P Male (n= 157) [n (%)/mean(s.d.)] Female (n= 146) [n (%)/mean(s.d.)] p
Age 26.71±6.60 28.90±5.25 0.14 27.07±6.70 26.27±6.11 0.28
Education years 7.69±3.20 7.86±3.51 0.83 7.37±2.41 7.34±2.75 0.91
Married 29 (69.0) 23 (82.1) 0.34 83 (52.9) 117 (80.7) 0.53
Belief in Religion 4 (9.5) 2 (6.9) 0.70 11 (7.0) 13 (9.0) <0.001
Mental disorder 24 (57.1) 19 (65.5) 0.49 82 (52.2) 48 (33.1) <0.001
Hopelessness 73.28±14.89 71.14±13.34 0.54 70.75±13.01 66.06±12.73 0.002
Impulsivity 10.55±3.86 8.79±4.00 0.07 10.68±3.69 9.86±3.81 0.06
Life event 3.86±2.49 3.21±2.65 0.30 3.60±2.65 3.02±2.06 0.04
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The following comparisons were made separately for violent and less violent suicide methods in the samples. We examined the risk (odds) of suicide by a method group (violent or less violent) as a function of gender. All the other covariates were controlled for the model which included gender, age, education years, religions, marital status, hopelessness, impulsivity, life events, and mental disorders. The results of logistic regression analysis were shown in Table 3, which indicated that gender was not significantly associated with violent or less violent suicide methods (OR=1.37, 95% CI: 0.76–2.44).

Table 3.

Logistic regression estimates of risk factors for using violent methods of suicide

Variables OR (95% CI) P
Female 1.45 (0.84–2.53) 0.19
Age 1.01 (0.96–1.06) 0.70
Education years 1.06 (0.96–1.17) 0.24
Believe in Religion 1.00 (0.39–2.57) 0.99
Married 0.69 (0.34–1.42) 0.31
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Discussions

In current study, we analyzed the demographic and means of suicide by gender. The major findings are several: (1) the leading method of suicide in rural China was ingesting pesticides or other poison, and the violent suicide methods included hanging and drowning; (2) in rural China, completed suicides with less violent methods outweighed those with violent methods in amount; (3) male and female suicides were all choosing pesticide or other poison methods at the most frequency; (4) gender, mental disorders, and impulsivity were not associated with violent or less violent suicide methods.

In this consecutively selected suicide sample, there are too many subjects who died by pesticide or other poisons. It is different from the Western countries, where firearms and other more violent methods are often used for suicide (Callanan and Davis 2012). In the United States, males are more likely to use more lethal means than females, partially accounting for the different pattern for suicide deaths and attempts (Kann et al. 2016). However, firearms as a violent method are not available for Chinese suicides, and therefore, there is hardly a difference between Chinese men and women in violent methods for suicide. Another study conducted in China also supported this observation (Sun et al. 2011). Further, in a study in Norway to investigate gender differences in the communicative aspect of nonfatal suicidal behavior, no gender differences were found either (Hjelmeland, Knizek and Nordvik 2002).

Previous studies indicated that people with mental disorders were more likely to commit suicide using firearms (Swanson et al., 2015), and unplanned suicide behaviors were more likely to be engaged in swallowing medications (Jeon et al., 2010). However, in our study, mental disorders and impulsivity were not associated with violent or less violent suicide methods. This could be due to the fact that firearms were forbidden in China and pesticides were the most common suicide means within reach.

Ingesting pesticide or other poison is the most common method for suicide, especially in rural China (Phillips and Yang 2004). That self-poisoning forms a bulk of the total suicide mortalities is attributed to a general belief that poisoning kills with minimal suffering. These imply that the pesticide availability prompt suicide more frequently, and a ban of lethal pesticides in rural areas may be a method for suicide prevention which was also found in previous studies (Hawton and van Heeringen 2009).

There are some limitations which should be addressed when interpreting these results. First, concerning that psychological autopsy is a retrospective method, and the subjects were interviewed in one to six months after the suicide incident, the recalling bias can be a problem for the accuracy of the data. Second, when the responses of the two informants were different on mental disorders, we followed the literature’s suggestion and took presence of mental disorders. Therefore, the prevalence of mental disorders in the sample might be overestimated. Third, as a cross-sectional study, we are not able to infer any causal relationship based on the results. Fourth, sample of this research is relatively limited and some results may not be qualified to extrapolate to the whole population. Therefore, more representative and prospective longitudinal programs need to be done in the future for confirmation of certain unclear areas in order to identify different intervention strategies in preventing suicide behavior in the population.

Nevertheless, findings in this study revealed that pesticides were the mostly used suicide means in both males and female, in people with and without mental disorders, and in people with high and low impulsivity. The findings suggest that in the prevention and intervention of suicide, cultural aspects of local region and restriction of access to suicide means should be considered. In China, especially the rural areas, strengthened regulation on pesticides and other poisons or medication are warranted to reduce the suicide rate.

Acknowledgement:

The research was supported by the United States National Institute of Mental Health (NIMH): R01 MH068560.

Footnotes

Publisher's Disclaimer: This Author Accepted Manuscript is a PDF file of a an unedited peer-reviewed manuscript that has been accepted for publication but has not been copyedited or corrected. The official version of record that is published in the journal is kept up to date and so may therefore differ from this version.

Contributor Information

Xiaomei Xu, Shandong University School of Public Health Center for Suicide Prevention Research, China

Jie Zhang, Shandong University School of Public Health Center for Suicide Prevention Research, China State University of New York Buffalo State Department of Sociology, USA.

Qin Zhou, School of Public Administration, University of International Business and Economics, China

Long Sun, Shandong University School of Public Health Center for Suicide Prevention Research, China

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