Suicidal Behavior of Adolescent Girls: Profile and Meaning
Joseph, Hanna Bar, Reznik, Ilya, Mester, Roberto, The Israel Journal of Psychiatry and Related Sciences
Abstract: In the last two decades the incidence of adolescent suicides has been very high (though it has been on the decrease in the U.S. A. over the last four years), giving rise to a multitude of empirical and theoretical studies. The extensive knowledge that has accumulated regarding adolescent suicidal behavior has led to a more differentiated attitude. Many studies try to clarify specific needs, motivations and the conceptualization of death and suicide in various adolescent subgroups (minorities, females, homosexuals), thereby enabling more specific and exact methods of evaluation, prevention and intervention. Adolescent girls' suicidal behavior is different in many aspects from boys' suicidal behavior: Girls mortality rate from suicide is a 3-5 times lower rate than boys, but their attempted suicide rate is four to hundreds time higher. Girls suicide mainly by drugs and their suicide is mainly in reaction to interpersonal difficulties. Their motivation is often a cry for help. The comorbidity of suicide and depression is much higher for adolescent girls than boys. These differences generate a different understanding and separate treatment strategies. Two theoretical approaches that may explain the profile which characterizes suicidal girls will be presented. One has a psychological developmental context, and the other a social cultural context. Implications for specific prevention measures include legal action on pack sizes of analgesics, compulsory registration of attempted suicide and more gender specific treatment and prevention programs.
This paper presents a multi-factorial analysis of the specific characteristics of suicide in adolescent girls, and looks for the reasons that would explain the low rates of fatal suicide and the very high rates of attempted suicide among them.
Suicide of Adolescent Girls
The suicide profile of adolescents from the point of view of gender is homogenous over time (several decades) and place (most Industrialized Western countries). While adolescent boys have a 3-5 times higher rate of mortality from suicide than adolescent girls, adolescent girls have a 3 times higher rate of suicide attempts. Most of these differences are not observed in the suicide rates of children or the elderly (the elderly have the highest fatal but not attempted male to female suicide ratio) (1-3). According to current surveys and studies, the ratio between suicidal attempts and fatal suicide varies between ten to one (non-fatal vs. fatal attempts) (4) and hundreds to one (5, 6).
Farbrow (7), in a summarizing article, presents suicide rates for a representative sample of the Industrial countries - United States of America, Japan, Canada, Australia, England and countries in Europe. The summary relates to the years 1960-1980. In most of these countries, a noticeable rise in the number of suicides was observed towards the '80, and in all these countries the ratio of fatal suicide in girls and boys of one to four was present.
In the ' 80s there was a certain decrease in suicide rates, but this tendency did not continue for long, and in the last two decades there has been another increase. In the US, a further decrease over the last four years has been detected. In a study carried out in Oregon in 1990-1992, the rate of adolescent suicide was found to have increased six-fold. The rate of suicide in this state had been higher than the all-American average, even prior to this study (8) and, as a result, a law had been passed obliging the hospitals to report to the authorities on adolescents who were referred to them after attempting suicide, and to refer these adolescents to counseling. In a scrupulous study following the legislation, the suicide rate of 15-17-year-old adolescent girls was 5.7:100,000 and the rate of boys 4 times that, 20.2: 100,000. This ratio of 1:4 corresponds with the ratio in all the Western countries. The gender ratio for younger adolescents aged 9-13 is 2:1. In an all American summary, which was done by Mclntosh (9) on behalf of the American Association for Suicide Prevention, a ratio of 1:4 was also observed, i.e., for every 4 boys who committed suicide, there was one girl. The same was observed in Canada (10). The rate of suicide for 15-19-year-old boys is 19.9 per 100,000, while the rates of girls committing suicide of the equivalent age is 5.5.
In young Canadians aged between 20-24, for every adolescent girl who commits suicide there are 6 adolescent boys. In a recent comprehensive paper (11) a ratio of 1:5 for American youth was concluded from many surveys and research studies.
In Israel the finding of four fatal suicidal attempts for adolescent boys to every one fatal suicidal attempt for adolescent girls is repeated both in the age group 15-19 and in that of 20-24, according to the report of Health Information Department (12). In a study done by Kohn et al. ( 13), similar findings are observed among Israeli adolescents. The last published official Israeli statistics, referring to the year 1997, reports that 66 adolescent boys and 8 adolescent girls committed suicide (12). The last WHO survey (2001) records suicide rates of 108 countries, and in all of these countries, similar rates of suicide has been observed for both sexes with only three exceptions to these results (14).
Suicide Attempts Among Adolescent Girls
In the second half of the last century, research of adolescent suicide focused mainly on fatal suicidal attempts, since these were more distinct, easier to diagnose, and better registered than non-fatal attempts, thus enabling a multi-dimensional analysis. Non-fatal suicidal attempts are difficult to define, and therefore difficult to quantify (15). They also allow for different interpretations (such as the incident being an accident, a mistake in taking medication, etc.), thus reducing the number of observed suicidal attempts in female adolescents.
A substantial amount of research in the field of suicidal attempts was carried out with adolescents hospitalized following a suicidal attempt. However, hospitalized suicidal adolescents constitute only a fraction of the total number of adolescents attempting suicide, and therefore provide only a partial picture.
Suicidal attempts are relatively more common among adolescent girls than among adolescent boys. The rates given in professional literature vary widely, depending on the quality and the type of study. In epidemiological studies, which study "serious" suicidal attempts needing hospitalization, it was found that the rate of girls who attempted suicide was 2-4 times more than that of boys (8, 9, 16, 17).
In Israel the recording of suicidal attempts is significantly lacking. Unlike countries in Europe and some states in the US, there have hardly been any systematic surveys done within the community, other than a survey done in Holon - Bat-Yam in 1999 (18). The rates available are those obtained from the emergency rooms of the hospitals, which do not report every case. The ratio of girls to boys who were hospitalized after attempting suicide in the age group of 10-19 is 3:1, 25.2% of the attempts are made by boys, and 74.8% by girls. The same ratio was found in another Israeli survey (19). Currently, we do not have data on adolescents who attempt suicide and are seen by private doctors, psychologists and community advisors.
In surveys and studies carried out within communities, and in prospective studies, the rates of suicide attempts of adolescent girls are much higher. In the official statistical report of the US government, 100-200 suicide attempts are counted for every fatal suicidal attempt (7). In Wichstrom's study (20), which examined 10,000 Norwegian adolescents, most of whom were girls, it was observed that 2.7% of the subjects reported attempting suicide during the previous year (a rate of 2,700:100,000). Similar results (3%) were observed in refugees in Canada (21). Garfinkel (5) also reported a high ratio of non-fatal suicidal attempts to every fatal suicide attempt (350:1). Girls made most of the non-fatal attempts in this study. Herman and Jobes's article (15) cites several studies done on the basis of adolescents' self report. According to their findings, 8%-9% of adolescents reported having attempted suicide. Girls carried out the majority of suicide attempts in these self-report studies. It is possible that these results represent only the tip of the iceberg.
Comorbidity and Adolescent Girls Suicide
Depression increases the probability of suicide. Adolescent suicide is frequently comorbid with depression and other disturbances. However, even the comorbidity is different for boys and girls. Depressive disorder is more frequent in females of all ages. Studies show a ratio of 4:1 of depressed adolescent girls to boys (22, 23). Post-menarcheal girls had higher depression scores than did the same age pre-menarcheal girls (24).
In a study done by Lewinson et al. (17), the rate of girls who suffered from depression was also found to be significantly higher than that of boys. In this study it may be seen that while with the 19-24 year old subjects, the sex differences between boys and girls attempting suicide got smaller, the difference in the rates of depression stayed the same.
Depression increases the probability of suicidal ideation and attempts (25). Mazza and Reynolds (26) report, in a follow-up study on 374 high-school students, that more girls were found to be depressed, and had more suicidal ideation than boys. In the study done in Uppsala, Sweden (22), a follow-up study was carried out for over a year. Depression was found to be one of the two predictive factors for suicidal ideation in girls, but not so in boys. Major depression was found to increase the risk of suicide 20-fold in adolescent girls (11).
Systematic differences of comorbidity between boys and girls (suicidal boys are more often found to use drugs and alcohol, and are more often diagnosed with Conduct Disorder) raise again the question as to whether suicide of adolescent girls is essentially different to that of boys. Since depression is more common in women and adolescent girls, and since these have a higher rate of recurring depressive episodes, we would expect a higher rate of fatal suicidal attempts in this group. However, girls figure much more in the non-fatal suicide group. Moscicki (27) raises an interesting hypothesis: more women who are depressed turn to treatment than do men who are depressed, and this treatment moderates the severity of their depression and prevents fatal suicide attempts. This explanation does not explain the high rates of non-fatal suicidal attempts and suicidal ideation, which characterizes the women who were not helped enough by the treatment. And it does not hold for the case of non-fatal suicidal behavior of adolescents, who are often reluctant to try treatment.
Sexual abuse has been associated with increased risk for suicidal ideation and behavior during adolescence. Recent research confirms this connection even after taking into account environmental and family risk factors (28). The majority of studies compared sexually abused to non-abused adolescent girls, and found a significant increase in suicidal ideation and attempts in the sexually abused group. (29-32). Some studies examined abused and non-abused adolescent boys and girls without making any gender differentiation and came to the same conclusion (33-35). A few studies differentiating adolescents according to sex found no significant difference in rate of suicide attempts between sexually abused adolescent boys and girls (36-38).
Adolescent girls with eating disorders are also at high risk of enacting suicidal behavior (39). The relationship between anorexia, depression and suicide is unclear, although, at face value, the self-destructive tendency of anorexia is clear. The wish to lose weight might be an expression of the wish to die (40). In a follow-up carried out on hundreds of patients who had eating disorders, Patton (41) also observed a high rate of suicidal tendencies.
Methods of Suicide
The method of suicide chosen by female adolescents is important for the understanding of suicidal behavior that characterizes adolescents, and for the understanding of its special "female" characteristics.
Although the methods of suicide are measurable and comparable, the issue is complex, on account of the method being related to the suicidal intent. The basic assumption that the more serious the intent to die the more fatal the method isn't always correct (42,43). Occasionally, those who do not intend to die use fatal methods, and occasionally, those who intend to die, use non-fatal methods.
In the choice of the method, accessibility is also an important factor, as is familiarity with the agent chosen (firearms, medications), and, apparently, also, cultural and social symbolic meanings. Both adolescent boys and girls often choose firearms, but the rates differ significantly. While 77% of adolescent boys use firearms to commit suicide, only 33% of girls choose to do so (4, 15). The picture drawn by prospective studies is similar. For example, a follow-up study done for 15 years in the US (44) indicates that a third of the girls committed suicide by consuming medications, but only 9% of the boys committed suicide in this way. This ratio is repeated in a summing-up survey done by the Center for Disease Control (6). Close to 70% of male suicides are committed by firearms, as compared to close to 12% of female adolescents.
In New Mexico (45) the finding that 70% of male adolescent suicides choose firearms is replicated, though in this study 50% of female adolescent suicides also chose this method. It is important to mention that, in recent times, there is a rise in the tendency of adolescent girls to use firearms, although the wide difference between the rate of adolescent boys using firearms as a method and that of girls is maintained (12).
In Israel, the tendency is similar although reports are lacking. Among those between the ages of 15-24 who committed suicide in 1996, close to 50% of the boys used guns or explosives, whereas these methods were used by only 30% of the girls. In other cultural groups, such as Chinese in China and in the US, the suicide profile differs between girls and boys, and the ratio is nearing 1:1 in China. There is also a difference between the genders in the methods chosen. Suicidal attempts among Chinese girls are characterized mostly by overdoses. The non-fatal methods raise once more the question of which proceeds what, the egg or the chicken? Does the choice of drugs reflect socio-cultural needs and scripts and thus helps to avoid a fatal outcome, or, do the girls attempting suicide not intend to die to begin with, and therefore choose less destructive methods? Moscicki (27) suggests regarding suicidal attempts as "signs of distress" which conceal fantasies of being rescued, rather than wishes to die. In her opinion, in fatal suicidal attempts there is a surrendering of this fantasy. Therefore, it is necessary to beware of interpreting the factors causing the suicidal attempts. Each suicidal attempt increases the risk factor that the following attempt will be "more successful," and therefore requires understanding and attention.
Triggers and Incentives
Beside similarities in triggers of suicide between boys and girls, there are systematic and consistent differences. According to Brent et al. (46), use of medication, intoxication, broken homes, accessibility of weapons and conduct disorder are triggers for suicide in boys.
Girls cite interpersonal problems, familial problems and a need for emotional relief as causes for the suicide attempt, while boys indicate problems such as disappointing school performance (6, 47). Experts constructing a guide for adolescents' suicidal behavior assessment state that "It is very likely that serious family disturbances increase the risk for attempted suicide" (11). Gould et al., stressing the psychosocial factors in adolescent suicide, found that poor parent child communication is associated more with suicidal risk in girls than in boys (25).
In a comprehensive study on adolescents carried out in Hong Kong (48), the predicting factor of suicidal ideation for girls was the feeling that parents did not care, or the presence of family conflicts. There was no such correlation found for suicidal ideation in boys, in which less interpersonal factors, such as studies and success, were indicated (4, 43). However, in following studies that tried to determine whether adolescent boys in effect do tend to attempt suicide more often for intrapsychic reasons than girls, no significant differences between the genders was found.
In a comprehensive multi-national study (42) the incentive for suicide was examined: 55% of the subjects reported their wish to die, 55% mentioned escape, 57% mentioned a need for relief (42). In this study no difference was found between countries or gender. It is important to mention that 80% of the subjects in this study were girls (42). This finding does not correspond with the incentives found in most of the other studies. It might be correct that the need to die is related to the fact that the adolescent girls included in the study were ones whose suicide attempt was serious enough to require hospitalization. Less fatal attempts by adolescent girls probably fit more into the group of adolescents who attempt suicide because of intrapsychic factors.
By reviewing the updated professional literature we may draw a profile of the adolescent girl with suicidal behavior. She is in the second half of the adolescent years (15-19 years), she tends more towards non-fatal suicidal behavior, tends to use drugs as a method for suicide rather than firearms or other weapons. A suicidal girl tends to be more depressed and to regard the suicidal attempt as a cry for help or as a message within an interpersonal context.
What contributes to this particular profile and from where do the differences between adolescent girls and boys and between adolescent girls and women of other ages originate?
In the last two decades, various theoretical and research studies have tackled these issues. Most of those studies point to two different main approaches to the gender specific profile. The first is related to adolescent girls' specific developmental and maturational processes, and the second emphasizes social and cultural factors.
A: Developmental approaches
For many centuries, researchers have emphasized the difference between the maturational process of girls and that of boys (49). The process of separation from the parents involves friction, and a stage of mourning for the loss of parental object (50). This process is often different for girls, who are educated for continuous dependence on the parents, than for boys, who, from childhood on, are directed towards independence.
In a study conducted on close to 1,000 adolescents in Hong Kong it was found that the predictors of suicidal ideation in girls were low levels of caring on the part of parents and high level of conflict (48).
In a national longitudinal study carried out in Norway it was found that it was possible to predict future suicidal attempts by: prior attempts, gender (girls) and the examination of early sexual development. Early physical changes interfere with a gradual separation process and may intensify the feelings of maternal withdrawal and abandonment (20).
According to Erikson (51), an identity crisis is inevitable in the process of adolescent development. Identity formation on the other hand may serve as a barrier to suicidal ideation and behavior (52). Because of longstanding conflicting cultural messages and scripts, girls' identity crystallization takes longer, moves back and forth and is ridden with inner conflict (49). Because of the differences between the ways boys and girls process and perceive things at this stage, the risk of suicidal attempts for girls rises, when there is identity diffusion, family discord and/or an ever widening gap between physical and psychological growth.
Another aspect of the same process, which is often mentioned as contributing to the different profiles of suicide, is that of the physical development of girls which may, and often does, lead to discomfort and low self-esteem resulting in depression. Surprisingly enough studies (15) reveal that feelings of intellectual inferiority also characterize adolescent girls' development.
Berman and Jobes (15) mention low self-esteem, negative attitudes towards the self and anhedonia as risk factors for adolescent girls' suicide. Tomori (53) found more depression and lower self-esteem in suicidal girls. Self and body image become a source of doubt and self-deprecation. Probably, this led Berman and Jobes to support a questionable explanation - that the reason girls use mainly drugs when attempting suicide is to avoid disfiguration.
B: Socio-cultural approaches
Suicide may have different significance for the genders at adolescence. Farbstein found that a suicide attempt at age 16-17 did not affect Israeli girls' performance and adaptation to military service two years later, but did affect performance and adaptation for boys (54). Stillion (55) observed that non-fatal suicidal behavior was considered by non-suicidal subjects as "suitable" for young women, who are more sympathy provoking, than for men or older women. The attitude of adolescent girls towards youngsters attempting suicide was found to be much less critical and less avoiding of those who attempted suicide than that of boys of similar age (56, 57).
Although in current studies adolescents declare their wish to die and their need to stop the pain and their feelings of hopelessness, the suicidal attempt of girls is still understood as a cry for help, or in other words, as an interpersonal manipulation. The expectation that the suicidal motivation of girls is dependency-related is usually consistent with this expectation in our culture.
Contrary to the "acceptance" of girls' non-fatal suicidal attempts, fatal suicidal attempts are considered "unacceptable." In the study of Lewis and Shepherd, women who committed suicide were considered as having been less capable of adjusting, and less normal than men who killed themselves. Women who died by suicide, in comparison to men, were seen in a more negative light and as being more foolish, weak and unacceptable, irrespective of the immediate cause of the suicide (58).
Adopting behaviors that are considered feminine raises the risk for non-fatal suicidal attempts. This behavior is partially understandable in the light of beliefs and attitudes that link gender and suicidal behavior. Girls' inclination to share, and to lean on their wide social support networks may change fatal suicides into non-fatal ones, thus offering an alternative explanation to their high attempted suicide rate. This reliance is also socio-cultural in nature.
The sex role is shaped as part of adolescent development. This component of the sexual development is culture dependent, and the acceptable stereotypes of femininity and masculinity see women as weak, dependant, with nurturing relationships and with a need for giving expression to their pain and difficulties. It was observed that boys who hadn't conformed to their gender role, i.e., boys who had behaved in their childhood like girls, showed a higher tendency for suicidal attempts than girls, who hadn't conformed to their gender role, and who had behaved in their childhood more like boys (56).
Androgynous subjects, i.e., subjects with a wide concept of gender which include masculine and feminine components show less suicidal behavior than the undifferentiated group, i.e., subjects with an unclear non-defined concept of their gender.
While the gender approach, in many studies of suicidal tendencies, claims that there is a significant, salient and continuous influence of social scripts which influence the method and the fatality of the suicidal act (59,60), it is important to pay attention to the studies which show that adolescent girls' distress may be more a result of a lack of a clear gender identification.
In a study carried out on Israeli adolescents, a negative correlation was found between psychological sex role and suicidal behavior. However, the decisive factor was uncertain identification with their gender. Both girls who scored high on the "femininity" scales and those who scored high on the "masculinity" scales had a high inverted correlation with suicidal behavior. The girls in the suicidal activity group were found to be significantly lower in "femininity" than the girls in the control group, in other words, a lack of definition or commitment, a lack of a clear and solid message confuses the adolescent and disturbs the development of the gender. The less the gender is clear to the adolescent girl, the higher the risk for depression and suicidal behavior.
Elevated rates of suicidal behavior are found among homosexual youth. Yet there is no study available, which shows that gay, lesbian or bisexual youth have elevated rates of fatal suicide (61). Attempted suicide in this group is between two and eight times greater than in other-mainly male - subjects (62). This suggests that the frequent harassment and pressures on these adolescents, cause reactions that find expression in "feminine" culturally-approved ways namely suicidal behavior. Thus, the relationship between the organization of the gender identity in the adolescent years and suicidal tendencies may also partially explain the high rates of suicidal activity among homosexual adolescents.
In the days of Durkheim consideration was already given to the fact that women react differently than men to social stress, and that they will be more likely to attempt suicide when facing problems in interpersonal relationships, and less when facing problems of status. Although more than a century has since passed, and there is much more equality between men and women, apparently in the field of suicidal behavior the differences between the sexes remain constant
It is possible to summarize that the rate of girls with non-fatal suicidal attempts continues to be high. This behavior is related, in girls more than in boys, to depression, anorexia, interpersonal problems and family discord, and to the use of less lethal instruments.
Two approaches to the understanding of these findings give partial explanations. The gender social-cultural approach tries to relate the adolescent girl's specific suicidal profile to cultural influences which are based, on the one hand, on traditional feminine stereotypes, and on the other, on modern social pressures (to be thin = to be desirable). To some extent, there is support for this approach in some of the studies presented above, and therefore it is possible to presume that the expectations (the stereotypes) represent a social-cultural message in the socialization process, that affects girls' suicidal behavior. All of the above leads us to the hypothesis that gender plays a role in youngster's decision regarding suicidal behavior. It is even possible that the stigma connected to fatal suicide of girls actually acts as a deterrent.
These cultural factors could provide a partial explanation, since they affect women of all ages. Even so, young girls and older women have different suicidal profiles than those of adolescent girls.
The developmental approach completes that which is lacking in the social-cultural approach. The emotional separation from parent figures, the tendency for depression, the heightened concerns about body image and intellectual capacities, and the anxiety over lack of a definite identity, push the adolescent girl to temporary over-reliance on social and cultural scripts. This latter also determines what is right and what is wrong behavior in the field of suicide.
The suicidal behavior of adolescents is multi-factorial. Some of the motives, triggers, methods and explanations are common to both boys and girls. In this article we have only discussed the dimensions that are not common to the two sexes. These dimensions are of importance for the care-takers during the stage of evaluating suicidal risk, and during the stage of therapeutic intervention. Special therapeutic attention should be paid to problems found in the process of separation-individuation; and to doubts in the identity formation process of adolescent girl patients. Over and above this, it is essential when working in the field of prevention to pay attention to gender-related differences in suicidal behavior. Most of the internet sites for suicide prevention recommend sharing of pain, telling somebody, and generally communicating the distress. Adolescent girls, even suicidal ones, share a lot and need different specific measures of intervention - like family counseling. In light of the attention given to the prevention of adolescent suicide in modern health policy, specific attention must be paid to the special characteristics of adolescent girls' suicide behavior, in planning and implementing prevention programs. We already witness primary efforts in this direction-more accurate and forced registration of attempted suicide (legislation in Oregon ), legislation on pack sizes of analgesics (63) the comprehensive suicide prevention bill (SB405) passed in California, may all add to a differential approach to girls' suicide behavior
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Hanna Bar Joseph, PhD,1 Ilya Reznik, MD,2,3 and Roberta Mester, MD2,3
1 District Outpatient Mental Health Clinic, Rehovot, Israel
2 Ness Ziona Mental Health Center, Ness Ziona, Israel
3 Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
Address for Correspondence: Dr. Hanna Bar Joseph, District Outpatient Mental Health Clinic, 80 Remez Street, Rehovot, Israel. E-mail: firstname.lastname@example.org…
Questia, a part of Gale, Cengage Learning. www.questia.com
Publication information: Article title: Suicidal Behavior of Adolescent Girls: Profile and Meaning. Contributors: Joseph, Hanna Bar - Author, Reznik, Ilya - Author, Mester, Roberto - Author. Journal title: The Israel Journal of Psychiatry and Related Sciences. Volume: 40. Issue: 3 Publication date: July 1, 2003. Page number: 209+. © Gefen Publishing House Ltd. 2008. Provided by ProQuest LLC. All Rights Reserved.
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