By far the biggest risk factor for suicide is being male

We should pay attention to disparities in suicide rates. Especially the biggest one.

Photo by Inzmam Khan

We are at the end of National Suicide Prevention Week. Reducing the tragic rates of suicide in the U.S. should be an overwhelming priority for policymakers. The devastating impact of a suicide on families, friends and communities is impossible to overstate.

• For some of the very best scholarly work in this space, see the research of Thomas Joiner.

• For a wrenching personal essay on losing a friend to suicide, see this from David Brooks in the New York Times.

• To do something, support the Movember Foundation or one of the many other non-profits working in this space.

Prevention requires awareness. We need to have a clear sight of who is at most risk of a death in order to marshal resources correctly. As the CDC notes:

A comprehensive approach to suicide prevention includes. . . . Using data to identify disproportionately affected populations with increased risk of suicide.

So it is very good that the CDC has a whole section of its website devoted to disparities in suicide.

But it is very bad that the CDC manages to completely ignore the biggest disparity of all: the one between men and women.

Here’s what the CDC says:

Some groups experience more negative conditions or factors related to suicide. While anyone can experience suicide risk, some populations experience more negative social conditions and other factors described above and have higher rates of suicide or suicide attempts than the general U.S. population. The excess burden of suicide in some populations are called health disparities.² Examples of groups experiencing suicide health disparities include veterans, people who live in rural areas, sexual and gender minorities, middle-aged adults, people of color, and tribal populations.

The CDC then drills down into a number of these disparities, as well as outlining the action that the Federal Government is taking on each. The full list of disparities are those by: Age; Lesbian, gay, or bisexual; Veterans; Race and ethnicity; People with disabilities; Industry and occupation; Geographic region. The CDC has produced an infographic to help raise awareness of these disparities. The front page gives a good summary of its content:

This is important work. But here’s the thing. None of these disparities in rates of death from suicide come anywhere close to the gender gap.

The chart below, prepared by our awesome summer intern Drew Collins-Burke, shows the relative suicide risk between some of the groups identified by the CDC, specifically over-75s v. under-75s; rural v. urban; Native American v. white, veterans v. non-veterans, and male v. female:

(This is also the first outing for the emerging chart style for the American Institute for Boys and Men, so feedback appreciated. Note that we show here only differences that can be shown using the same dataset, and in the same year. That’s why the data is for 2020, and why we do not show comparisons for some of the categories, including for LGBTQ populations, since these rely on different data sources and/or measures).

Of course, there are many troubling trends in terms of female mental health too, especially among teen girls. The CDC has correctly drawn lots of attention to these, especially to a 2021 self-report survey, the Youth Risk Behavior Survey (YRBS), with a press release, infographics and a media-focused webinar. This self-report survey shows high and rising rates of sadness and suicidal ideation among girls, for instance, even if the actual suicide rates for girls and women have not risen significantly, as they have for boys and men.

This is a good test of the ability of policymakers to think two thoughts at once. I just heard an excellent summary of the paradox of these statistics from Dr. Lisa Damour on a USA Today podcast. After citing the YRBS data, the interviewer asked Damour “Are girls and young women more in danger? And if so, why?” Damour said:

Girls are more likely to suffer from what we call internalizing disorders, anxiety and depression, and other ways that they collapse in on themselves, whereas boys, when they're in distress are more likely to suffer from what we call externalizing disorders, being hard on the people around them, getting in trouble, acting out. Interestingly, those were self-report survey data. I think they gave us a very helpful, if alarming, picture of what was happening for girls. Self-report data don't tend to ask about externalizing disorders or externalizing symptoms.

. . . I would say, I'm not sure that self-report data are the best way for us yet to get a sense of what's happening for boys. . . I worry terribly about the girls. I also worry about the boys, because when we actually look at suicide rates, boys outpace girls in suicide rates. So, girls may talk and think about suicide more, but we also know that boys, we use a terrible term, complete suicide more. So, this is to say we have a lot of alarming data and we may be better at detecting early signs of distress in girls than in boys. We want to make sure we're taking a good look at all teenagers and keeping a close eye on everyone.

Amen, Dr Damour. Effective prevention relies on accurate risk assessment. Policy makers, health professionals, community leaders and parents need to know which groups are, on average, at highest risk of losing their lives to suicide. The issue of male suicide is one that we’ve covered here before. And it will certainly be an important stand of work for the new American Institute for Boys and Men.

A nagging question here is: why? Why does the CDC downplay or even ignore the glaring gender gap in suicide risk, even in the context of highlighting disparities. I don’t know. Perhaps someone from the CDC would be willing to debate some of our concerns. Maybe we’re missing something. But it’s hard to avoid the conclusion that highlighting any gender gaps that disfavor boys or men is what Ezra Klein called, in his podcast with me, a “narrative violation”. It goes against the grain of certain assumptions about the shape and direction of inequality.

But when the stakes are as high as this, such neglect is just unacceptable, and from a public health perspective, a dereliction of duty.