Association of High Traditional Masculinity and Risk of Suicide Death: Secondary Analysis of 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.

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.

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).

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.

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.

Corresponding Author: Daniel Coleman, PhD, Graduate School of Social Service, Fordham University, 113 W 60th St, 7th Floor, New York, NY 10023 (dcoleman11@fordham.edu).

Published Online: February 12, 2020. doi:10.1001/jamapsychiatry.2019.4702

Author Contributions: Dr Feigelman had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Coleman, Feigelman

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Coleman, Rosen.

Critical revision of the manuscript for important intellectual content: Coleman, Feigelman.

Statistical analysis: All authors.

Supervision: Feigelman.

Conflict of Interest Disclosures: None reported.

Funding/Support: This research uses data from Add Health, a program project directed by Kathleen Mullan Harris and designed by J. Richard Udry, Peter S. Bearman, and Kathleen Mullan Harris at the University of North Carolina at Chapel Hill, and is funded by grant P01-HD31921 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, with cooperative funding from 23 other federal agencies and foundations. No direct support was received from grant P01-HD31921 for this analysis.

Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Information: Information on how to obtain the Add Health data files is available on the Add Health website (http://www.cpc.unc.edu/addhealth).