David Lester. Handbook of Death and Dying. Editor: Clifton D Bryant. Volume 1. Thousand Oaks, CA: Sage Reference, 2003.
Culture provides a set of rules and standards that are shared by members of a society. These rules and standards shape and determine the range of behaviors that are considered appropriate under prescribed conditions. Such cultural artifacts influence the behaviors of persons of different nationalities and ethnicities as well as other subgroups within a nation. In looking at cultural influences on behavior, one important difference across cultures that comes immediately to light is the difference in rates of suicide.
One of the most interesting phenomena in suicidology is the national variation found in suicide rates. As the data displayed in Table 1 show, suicide rates for males around the world vary from a high of 73.8 per 100,000 per year in Lithuania to a low of 1.1 per 100,000 in Azerbaijan. For females, the rates range from 14.8 in Hungary to 0.2 in Azerbaijan. Our current knowledge of worldwide trends in suicide is somewhat limited because many African, Middle Eastern, and Central and South American countries do not report their suicide rates to the World Health Organization.
For all but one of the nations shown in Table 1, the male suicide rate is higher than the female suicide rate. The lone exception is China, where women have a higher suicide rate than men; in the period 1990-94, the rate for women in China was 33.6 per 100,000 per year versus 24.2 for men (Phillips, Liu, and Zhang 1999). However, the Chinese government documents suicide fatalities only in selected regions of the nation, so the reported suicide rates are not completely valid.
The differences observed in national suicide rates are large and generally stable over time, as the data displayed in Table 2 demonstrate. Although the rates have fluctuated over the years shown, within each of the nations listed the rates in one year are positively associated with the rates in other years.
Although some observers have raised questions about the accuracy of official suicide rates in various nations—given, for example, the different evaluation and recording procedures of coroners and medical examiners in different countries (e.g., Douglas 1967)—research has shown the suicide rates of immigrant groups in both the United States and Australia to be strongly associated with the suicide rates in the immigrants’ home nations (Sainsbury and Barraclough 1968). For example, in 1959, Ireland’s suicide rate was relatively low, 2.5 per 100,000; in that same year, Irish immigrants to the United States, who encountered the same medical examiners as did members of other immigrant groups, also had the lowest suicide rate of all immigrant groups from European countries, only 9.8 (Dublin 1963).
Male suicide rates increase with age in most nations of the world, whereas for females, the distribution of suicide rates by age varies with the level of economic development of the nation (Girard 1993). In wealthy nations, such as the United States and Sweden, female suicide rates tend to peak in middle age. In poorer nations, such as Venezuela, suicide rates are higher for elderly women, and in the poorest nations, such as Thailand, the peak shifts to young adult women (Girard 1993).
Explaining National Differences in Suicide
Conklin and Simpson (1987) used factor analysis to examine the association of sociodemographic and economic variables with national suicide rates. These researchers identified two clusters of variables that appear to be associated with national suicide rates: One cluster was made up of variables concerning religion (these had the highest loading from Islamic countries), and the second cluster was made up of variables concerning economic development. Conklin and Simpson found that predominantly Muslim nations with low levels of economic development had the lowest rates of suicide.
In my own similar study of suicide rates in 72 countries, I identified 13 independent orthogonal factors for the social variables, only one of which, economic development, was associated with suicide rates (Lester 1996). This factor had high loadings from such social variables as low population growth and high gross domestic product per capita.
One possible explanation for differences in national suicide rates is that people of different nationalities differ in their physiology. For example, there are clear differences in the frequencies of particular genes in individuals from the different nations of Europe (Menozzi, Piazza, and Cavalli-Sforza 1978). Thus the people in different nations and cultures may differ in their genetic structures. In addition, recent research on identical twins and adopted children has shown that the likelihood that particular individuals will develop certain psychiatric disorders has a strong genetic basis. Differences in inherited tendencies to develop psychiatric disorders, particularly affective disorders, or to develop brain concentrations of serotonin, the neurotransmitter believed to be responsible for depression, may be partially responsible for differences in the suicide rates of nations and cultures.
Few researchers have explored how physiological differences may account for national differences in suicide rates, but one study that examined the association between physiological factors and cross-national suicide rates found that the suicide rates of nations were associated with the proportions of their populations with blood types O, A, B, and AB. The higher the proportion of people in a nation with type O blood, the lower the suicide rate (Lester 1987a).
The major psychological factors that have been found to be associated with suicidal behavior are depression, especially hopelessness, and psychological disturbance, such as neuroticism, anxiety, or emotional instability. Psychiatric disorders appear to increase the risk of suicide, with affective disorders and alcohol and drug abuse leading the list. Nations may differ in the prevalence of these conditions among their populations, and such differences could help to account for differences in suicide rates. For example, the people of different nations clearly do differ in their rates of consumption of alcohol (Adrian 1984), as well as in levels of depression generally (Weissman and Klerman 1977).
Moksony (1990) suggests that one simple explanation for national differences in suicide rates is that national populations differ in the proportions of people within them who are at risk for suicide. For example, in developed nations, suicide rates are typically highest among the elderly, especially elderly males. Therefore, those developed nations that have high proportions of elderly males will have comparatively high suicide rates.
The most popular explanations for differences in suicide rates between nations focus on social variables, which may be viewed in two ways: (a) as direct causal agents of the suicidal behavior or (b) as indices of broad social characteristics that differ between nations.
Émile Durkheim ( 1951) hypothesized that suicide is related to social integration, or the degree to which the people are bound together in social networks, and social regulation, defined as the degree to which people’s desires and emotions are regulated by societal norms and customs. According to Durkheim, egoistic and anomic suicides result from too little social integration and too little social regulation, respectively, whereas altruistic and fatalistic suicides result from too much social integration and too much social regulation, respectively. Sociologists since Durkheim’s time have argued that altruistic and fatalistic suicides are rare in modern societies; that is, suicide rarely results from excessive social integration or regulation. Rather, suicides increase in modern societies as social integration and social regulation decrease (see, e.g., Johnson 1965).
Some international studies have found suicide rates to be associated with such variables as low church attendance, amount of immigration and interregional migration, and divorce (e.g., Stack 1983). Some scholars view these associations as suggesting a positive relationship between broken relationships and suicidal behavior. For example, divorce may be associated with suicide at the societal level because divorced people have higher suicide rates than do married, widowed, or single people.
Other investigators have suggested that divorce and immigration are indicators of a broader and more basic social characteristic that plays a causal role in suicidal behavior (Moksony 1990). In the United States, interstate migration, divorce, church nonattendance, and alcohol consumption all intercorrelate highly, supporting the proposition that “social disorganization” is useful for explaining suicide rates. In this case, regions of the world with high rates of divorce may have high rates of suicide for those in all marital statuses. This has been found to be true in the United States, where states with higher divorce rates also have higher suicide rates across all marital statuses—single, married, divorced, and widowed (Lester 1995).
Cultural Influences on Motives for Suicidal Behavior
Suicidal behavior is differently determined and has different meanings in different cultures, as Hendin’s (1964) study of suicide in Scandinavian countries has demonstrated. Hendin found that Danish mothers used guilt arousal as a primary disciplinary technique to control aggression in their sons, and this resulted in a strong dependency need in the sons. This marked dependency was the root of depression and suicidality after adult experiences of loss or separation. Hendin found that fantasies about reuniting with these lost loved ones were common in those who committed suicide.
Hendin found that Swedish parents placed strong emphasis on performance and success, which resulted in ambitious children for whom work was central. Suicide in Hendin’s Swedish sample typically followed failure in performance and was linked to damage to the individuals’ self-esteem.
At the time Hendin conducted his study, the suicide rate in Norway was much lower than that in Denmark. Although Hendin found strong dependence on mothers among the sons in his samples in both countries, he found that Norwegian children were less passive and more aggressive than Danish children. Alcohol abuse was more common among the Norwegians, and Norwegian men were more open about their feelings—able to laugh at themselves and to cry more openly. Norwegian boys strove to please their mothers by causing no trouble, and they did not worry unduly about failure, typically blaming others for their personal failures and retreating into alcohol abuse.
Counts (1988) illustrates the ways in which a culture can determine the meaning of the suicidal act in her account of suicide among females in Papua New Guinea. In Papua New Guinea, female suicide is a culturally recognized way of imposing social sanctions. Suicide also holds political implications for the surviving kin and for those held responsible for the events leading a woman to commit suicide. In one such instance, the suicide of a rejected fiancée led to the imposition of sanctions on the family that had rejected her. Counts describes this woman’s suicide as a political act that symbolically transformed her from a position of powerlessness to one of power.
Cultures also differ in the degree to which they condemn suicide. It has been argued that one explanation for the low suicide rate among African Americans is that African Americans in general consider suicide to be unacceptable behavior (Early 1992). Murder rates are much higher for African Americans than they are for other racial/ethnic groups in the United States; African Americans are both murderers and murder victims at rates disproportionate to African Americans’ representation in the population at large. It has been noted that a large proportion of murders involving African American victims are precipitated by the victims; that is, the victims play some role, conscious or unconscious, in bringing about their own demise (Wolfgang 1957). It is possible that African American culture views death through victim-precipitated murder as more acceptable than suicide (Gibbs 1988).
Ethnic Differences in Suicide Rates
Within a nation, different ethnic groups often differ in their suicide rates. In the United States, whites have higher suicide rates than blacks (13.0 per 100,000 vs. 6.8 in 1992); the same is true in those African nations that report suicide rates, such as Zimbabwe (17.6 vs. 6.9 in 1983-86) and South Africa (18.4 vs. 3.0 in 1984) (Lester 1998). In the United States, whites and Native Americans have higher suicide rates (13.2 and 13.3, respectively, in 1980) than do Filipino Americans (3.5); the suicide rates of African Americans (6.1), Chinese Americans (8.3) and Japanese Americans (9.1) fall in between these extremes (Lester 1998). The suicide rates of the various Asian ethnic groups in the United States parallel the rates in the groups’ nations of origin.
Some aspects of ethnic and national differences in suicide are culturally invariant, whereas other aspects vary widely. For example, the suicide rates of Chinese populations in different regions of the world—such as mainland China, Hong Kong, Singapore, Taiwan, and the United States—show striking differences. The suicide rate in Taiwan in 1984 was 10.9; in Hong Kong, 9.2; and for the Chinese in Singapore, 14.6. The methods Chinese people use to commit suicide also vary by location, with poisoning the most common method in Taiwan, jumping and hanging most common in Hong Kong, and jumping used most often in Singapore. However, suicide rates for males and females have been found to be almost identical in these different Chinese populations—1.4 (Lester 1994).
Choices of Suicide Methods
The methods of committing suicide that people choose also tend to differ from culture to culture. DeCatanzaro (1981) has documented several culturally unique methods of suicide, such as the method of hanging used in Tikopia, in which the individual ties a noose around his or her neck, secures the end of the rope, and then runs to another part of the house. Firth (1961) has written about the traditional method of suicide in Tikopia, which is to swim out to sea and drown, timing the act so as to minimize, maximize, or leave to chance the prospects of rescue. Two other culturally distinct suicide methods, each of which has its own culturally determined motive, are suttee, an ancient Indian custom in which a widow commits suicide by throwing herself on her husband’s funeral pyre (motivated by grief), and seppuku, a Japanese form of ritual disembowelment (motivated by shame).
The use of firearms is currently the most common method of suicide in the United States and Canada, whereas in Switzerland, where residents typically own firearms as part of their participation in the civilian militia, hanging is the most common method of suicide. Despite the case of Switzerland, research indicates that increased availability of a method for suicide is associated with an increase in its use for suicide. For example, Killias, van Kesteren, and Rindlisbacher (2001) found that in nations where large proportions of the population own guns, higher numbers of suicide are committed with guns. However, they also found that rates of gun ownership have no association with total suicide rates. This suggests that if guns are not freely available, people who want to commit suicide will use guns less often and other methods—such as poisons, hanging, stabbing, jumping, and drowning—more often. Burvill and his colleagues (1983) found that immigrants who committed suicide in Australia shifted over time from using the most common methods of suicide in their home nations to using those most common in Australia.
Sometimes a particular method of suicide is so widely used that it comes to symbolize the act of suicide in general. For example, in England in the early 20th century, the expression “to take the pipe” came to mean committing suicide by any method. The expression came from the most common method of suicide at the time in England, which was by inhaling toxic domestic gas fumes; the gas, used for lighting and heating homes, was brought into houses by means of pipes. This method remained the most commonly used in England until the 1960s, when a switch from coal gas to natural gas made the gas piped into homes less toxic.
Effects of Cultural Conflicts
Another important issue in the study of suicide across cultures in recent years has been the effect of the influence of Western culture on suicidal behaviors in less modern cultures. Van Winkle and May (1986) examined suicide rates among three Native American groups in New Mexico—the Apache, the Pueblo, and the Navajo—and concluded that the high suicide rate among the Apache was associated with Apaches’ low social integration and high acculturation into mainstream U.S. society. The Navajo, who had the greatest geographic and social isolation from whites, also had the lowest suicide rate. Among the Pueblo, Van Winkle and May found that the most acculturated individuals had the highest suicide rates. In Taiwan, Lee, Chang, and Cheng (2002) found that aboriginal groups with lower levels of assimilation had higher suicide rates than did those groups that were more assimilated into the mainstream culture. These studies indicate that when people from different cultures encounter each other, the problems of acculturation can result in stress and its consequences, including increased rates of suicidal behavior, especially in less dominant cultural groups.
The Assumption of Cultural Invariability
It is important also for scholars to replicate research findings about suicide in cultures other than those in which particular results have first been observed. For example, Stack (1992) found that divorce had a deleterious effect on the suicide rates in Sweden and Denmark, but not in Japan. Stack offers four possible reasons for this finding: The divorce rate in Japan may be too low to affect the suicide rate, Japanese family support may be strong enough to counteract the loss of a spouse, ties between couples may be weak in Japan, and the cultural emphasis on conformity in Japan may suppress suicidal behavior.
In a comparison of depression and suicide among psychiatric patients in mainland China and the United States, Chiles and his colleagues (1989) found that suicidal intent was predicted better by depression for psychiatric patients in China and better by hopelessness for psychiatric patients in the United States. Compared with the Chinese patients, the American patients had considered suicide at earlier ages, made more prior suicide attempts, more often communicated their suicidal intent, and more often viewed suicide as an effective solution.
Wolfgang and Ferracuti (1967) examined the role that a subculture of violence plays in producing high murder and assault rates, and Gastil (1971) has argued that such a subculture of violence pervades the southern portion of the United States. Marks and Stokes (1976) refer to this subculture as an explanation for the greater use of firearms in suicides in the South compared with the rest of the United States.
Platt (1985) examined electoral wards in Edinburgh, Scotland, which differed in their rates of attempted suicide, to see whether they had different norms for suicidal behavior—that is, if they differed in their subcultures of suicide. Those living in wards with the highest suicide rates had more intimate contact with suicidal individuals and held different life values than did those in other wards; for example, they had a greater expectation that married couples would quarrel and that men would fight in public. However, Platt was unable to find to his satisfaction that the wards differed in their subcultures of suicide.
A study of the subcultural factors in teenage suicide documented several suicides in a group of adolescents, all of whom had poor relationships with their parents, poor self-images, a fascination with heavy metal music and the fantasies engendered by that music, and histories of heavy drug use (Lester 1987b).
There are large differences between cultures in the incidence of suicidal behavior, and culture influences the methods used for committing suicide and the reasons for doing so. Although the differences in suicide rates across nations and cultures may be explained in part by physiological differences between different groups of people, the more plausible explanations involve psychological and social variables, such as the abuse of alcohol and levels of social integration and social regulation. When competing cultures interact, members of the less dominant culture may experience increased stress (and, as a result, may commit suicide at increased rates).
It should be noted also that in culturally heterogeneous societies such as the United States, Canada, and Australia, we cannot assume that suicides are similar in rates, methods, motives, and precipitating factors across different subcultural groups. Those working to prevent suicide in such societies must take cultural influences into account (Sue and Sue 1990; Zimmerman and Zayas 1993).