Suicide and Self-Harm: Facts and Statistics
Suicide ResearchMost of the information presented here is taken from studies of the general population. To our knowledge, there haven't been specific studies done on inclination toward suicide and chosen methods used by the transgender community. We do know that almost half of trans folks have racked up at least one attempt on their own lives before they hit age 20. Aside from that, you should keep in mind when reviewing these facts and statistics that, for trans people, dysphoria can figure in. While these facts discuss co-morbidity of other conditions, be aware that dysphoria is, by itself, not uncommon as the sole reason behind a suicide attempt or an act of self-harm.
The Language of SuicideOne of the key issues surrounding global reporting of and response to suicide behavior is that there is no set language to describe feelings or actions. There isn't solid, universal diagnostic terminology that is consistently used to represent specific thoughts or behaviors. While we will use the definitions below for the purposes of training and discussion, be aware that these terms may mean different things to different people. When watching for a potential crisis or talking to someone in crisis, be aware of the intent behind what they say and never hesitate to ask for clarification.
- Self-Harm: this describes intentionally harmful acts such as poisoning that are undertaken without the intent to die.
- Self-Injury: this describes any deliberate injury to bodily tissue, such as cutting, scraping, or choking, undertaken without the intent to die.
- Attempt: an attempt is any deliberate action taken for the express purpose of ending one's own life.
- Completed Suicide: as implied, a completed suicide refers to a deliberate act with intent to die that results in death.
- Threat: any act, spoken or otherwise, indicating the person will make an attempt at suicide.
- Suicidal: the state of viewing suicide favorably, as a valid or appropriate response to current circumstances, with or without intent to act upon it.
- Passively Suicidal: the state of wanting to die without viewing suicide favorably; passively suicidal people often take risks with no concern for their safety.
The StatisticsWhile these statistics were generated by reviewing multiple worldwide reports, it's worth noting that more than half of the medical examiners surveyed in the US say that suicide is under-reported by between ten and 50%. These figures vary wildly, as acceptance of suicide as cause of death can have serious religious or cultural repercussions. As well, many cases reported as "death by misadventure" may well have been suicides without enough situational evidence to confidently declare the death intentional.
A particularly interesting fact is that across all studies surveyed, the majority of those who died by suicide had communicated their intent to family or friends and sought help from a professional in the year leading up to their deaths. Between 25% and 33% of those who died by suicide had been in contact with the mental health profession in some way during that time.
Suicidal behaviors have been shown to be repetitive. One study that followed 302 people who had attempted suicide found that, within five years of their first attempt, 37% went on to attempt again and 6.7% went on to complete suicide. Statistically, a prior suicide attempt is the best indicator of future attempts. It also follows that the more attempts a person has made, the higher the risk that they will complete suicide in the future.
Suicide is the tenth leading cause of death worldwide. Statistics specific to the transgender community aren't available, but given what we know of the likelihood that trans people will attempt, it's safe to assume that suicide ranks higher than tenth as a cause of death within the trans population.
While misclassification of death happens more often in children and the elderly, there being many other possible ways to explain deaths in those demographics, it is also widely underreported based on cultural norms or religious beliefs. In places where suicide is illegal, for example, or locations where the prevailing religion views it particularly unfavorably, cause of death may be declared an accident or natural causes even if evidence pointing to suicide exists.
Methods vary by culture and religion as well. Around 60% of completed suicides in the US involve firearms, whereas many Asian countries - most notably China and Sri Lanka - see the ingestion of pesticide as the most common suicide method. In Hong Kong, charcoal burning is gaining popularity as a means for suicide. Availability plays a large role in determining the "trending" methods, and it should be noted that the old adage "where there's a will, there's a way" certainly holds true in suicidal crisis. If one is determined to end one's life, methods will be substituted if the preferred means is inaccessible.
56 countries shared their suicide statistics. Worldwide, methods are broken down as follows:
Note that the likelihood of either gender to use any particular method will vary within the trans community. Even without the presence of hormone therapy, the lines are blurred. We should expect people to consider any method they might have access to, and never treat a threat as less serious based on the likelihood of one's target or birth sex to use that method.
Ethnic differences, including ethnic attitudes among transplanted immigrant populations, may also influence both the inclination toward suicide and the means chosen to attempt. Universally, however, the risk of suicide generally increases within a population by age. Given the sheer number of people in each age group, however, you may see higher absolute numbers of suicides in younger age groups.
Risk and Protective FactorsProtective factors are circumstances that may dissuade someone from attempting suicide. These include marriage - single, divorced, or widowed people are more likely to attempt than those who are married. Dependent children are also a protective factor in the family category.
Cultural ties to religion, family, and one's social circle can also stand as protective factors. While we should avoid manipulating the existence of these factors in a way that causes someone in crisis to feel guilty about being suicidal, any or all of them can absolutely be put forward as valid reasons to stay alive.
Conversely, socio-economic situations may be indicators of risk. Suicide attempts generally rise with the unemployment rate, and those who struggle with finding and maintaining jobs are more likely candidates to attempt suicide. Politically, more attempts are usually seen during more conservative regimes, while the rate tends to be reduced as things become more liberal.
Time of year as an influencing factor is a myth. Studies have shown, time and again, that temporal factors don't apply to the rate of suicide attempts. The idea that more suicides or attempts happen around family-oriented holidays or birthdays, for example, has consistently been proven false in the research. Anecdotally, we may see emotions running high at certain times of the year, but that alone doesn't translate to increased risk of suicide attempts.
Psychological FactorsWhile dysphoria itself can be enough to prompt a suicide attempt, there is a wide range of co-morbid conditions and other psychological factors that can contribute to a suicidal crisis.
Common personality traits observed in those who have attempted suicide include neuroticism, psychoticism, introversion, sensitivity, dependency, and cynicism. Two of the most widely studied traits observed are impulsivity and perfectionism. (It should be noted that merely having these traits isn't a red flag indicating a suicidal state of mind. We should simply be aware that they can and often do exacerbate existing depressive feelings and suicidal tendencies.)
Impulsivity is not well defined in the psychiatric profession, but the indication is that impulsive people are more likely to act in response to triggers such as stress, substance abuse, or depression. Similarly, self-critical perfectionism, while only studied in Western cultures, has been shown to prompt people to act. The line of thinking in a suicidal person generally flows from "I didn't do well at this particular thing" to "I'm such a failure" to a suicide attempt.
Along with personality traits, several cognitive variables - that is to say, patterns of thought - can contribute to suicidality. Commonly seen variables include feeling hopeless, having an autobiographical memory (replaying memories linked to negative emotions), feeling like a burden, rumination (constant dwelling on negative emotions), "black and white" thinking and rigidity of thought, and poor problem-solving skills.
Further, biology can influence one's inclination toward suicide. A growing body of evidence shows that predisposition towards suicide is partly heritable, though research has yet to identify specific genes responsible.
Finally, mental illness - either on its own or co-morbid with dysphoria - plays a large part in the decision of many people to attempt suicide. In more than 90% of attempted or completed suicides studied in Western countries, the subject was found to have at least one mental disorder. In Asian countries, between 60% and 90%, depending on the reporting region, had been so diagnosed.
Interestingly, the type of disorder diagnosed varies by location. In developed countries, for example, more than two-thirds of those studied who attempted or completed suicide had been diagnosed with a depressive disorder. In developing countries, that number is less than 40%, with other disorders diagnosed more frequently than in Western culture.
It has also been shown that negative early childhood experiences, most notably sexual and physical abuse, alter the chemistry of the brain, making one more biologically inclined toward suicide behavior.
Be aware, but do not share, that psychiatric in-patients are particularly vulnerable to suicide attempts and other harmful behaviors. As crisis counselors, we must advocate hospitalization for those who are committed to the idea of harming or killing themselves. Treatment of any kind in a supervised, safe location is often required to help people move past a crisis episode. This is especially true of those experiencing psychotic symptoms. We should be aware of this fact so we can gently prepare those in crisis for their in-patient stay; always frame it as a positive move, even if the person in crisis points out pitfalls of hospitalization locally.
Self-Harm and Suicidal BehaviorPrevious episodes of self-harm are second only to previous suicide attempts as statistical indications that someone is at high risk for an attempt. Those who have self-injured repeatedly are at even higher risk. Studies have found that those who were hospitalized for self-harm were between 300% and 2000% more likely than others without a history of self-harm to attempt suicide within the year following their treatment.
The primary reported risk factors for self-injurious behavior are consistent internationally. In general, female patients who have mental disorders and who do not have higher education are most at risk to self-harm, however these risk factors are not exclusive and don't, by themselves, indicate that someone is at risk for self-harm. The World Health Organization reports that self-injury is most common in females aged 15-24 and males aged 25-29, though there is significant under-representation in those figures as they were obtained by analyzing only the cases that resulted in hospital treatment.
The common theory that early-life abuse, particularly sexual abuse, is at all responsible for self-harm later in life is a myth. It has been debunked in numerous studies. In cases where early-life trauma does happen to be a factor, low memory specificity translates to lower risk of repetitive harmful behavior.
The prevalence of self-harm, on average, varies by age. In adolescents, approximately 8.9% of the female population and 2.6% of the male population engage in some form of harmful behavior. Over the course of a lifetime, those numbers increase to 13.5% and 4.3%, respectively. Of those treated in hospital, the following trends were observed:
- 15 - 16% repeated self-harm severely enough to be hospitalized within a year of the first treatment.
- 20 - 25% repeated self-harm severely enough to be hospitalized more than a year after the first treatment.
- Two percent completed suicide within one year of their hospital treatment.
- Seven percent completed suicide within ten years of their hospital treatment.
Depression and Suicide BehaviorIt's important to note that while suicidal behavior is rare in those who don't have a mental disorder, it is not caused directly by any one mental disorder. In addition to diagnosed conditions, personality traits, psychosocial conditions, and cultural components also play a part in one's inclination toward suicidal behavior.
Generally speaking, people with Bipolar II disorder are more likely to engage in suicidal behavior than those with Bipolar I disorder. Those diagnosed with unipolar depression are the least likely of the three to attempt self-harm or suicide. This is because "agitated" depression - depression that manifests with restlessness or anger - has been shown to lead to suicide attempts, and is more common in bipolar patients than those with unipolar depression.
Psychotic Disorders and Suicide BehaviorPsychosis presents some interesting challenges in regard to suicide and self-injurious behavior. Of all the antipsychotic medications on the market, clozapine is the only one proven in a peer-reviewed, placebo-controlled study to reduce suicide risk in those diagnosed with psychotic disorders. Overall, a 4.9% completed suicide rate has been observed in those with psychotic disorders.
There is some evidence that transgender people undergoing hormone replacement therapy who have a psychotic disorder blur the lines in typical gender statistics for self-harm and suicide behavior. That is to say, they fall between the genders where statistical likelihood for attempts and preference of method are concerned.
Other differences in those with psychotic disorders are just as interesting. Marriage, while normally a protective factor against suicide behavior, is not at all a risk indicator for those with psychotic disorders. Neither is unemployment a particular risk, where it would increase the likelihood of an attempt for others. For people with psychotic conditions, higher education translates to a higher predisposition toward suicide behavior.
Negative symptoms - that is, the absence of feelings or thoughts - associated with psychotic disorders seem to indicate a lower risk of suicide behavior. However, it's unclear whether this is because negative symptoms are a protective factor in and of themselves or because they result in an inability to make and act on plans to attempt. Conversely, it has been shown that active psychosis is linked to higher risk of suicide behavior on a corresponding scale - the more severe the psychosis, the higher the risk.
Other Psychological NotesThose diagnosed with mental disorders may show higher risk of attempting suicide as they become aware of their lost potential versus their pre-morbid state. For those whose conditions set in later in life, they may reflect often on how much better they could be or how much more they could achieve if they hadn't gotten the illness they have, and the more potential they view as lost the more likely they are to make an attempt.
Other risk factors include lack of impulse control - specifically of the kind associated with Cluster B personality disorders: antisocial, borderline, histrionic, and narcissistic - and substance abuse. Substance abuse represents a marginal risk increase for those with chronic psychotic disorders as well.
Also shown to contribute to suicidal behavior are poor economic or social status, obsessive or intrusive thoughts, bullying, and binge drinking. Those who actively self-harm have been shown to have poor decision-making skills, something that is not true of those who have harmed themselves in the past but no longer do. Be careful not to make assumptions, however; the fact that a person is engaging in injurious or suicidal behavior is not, by itself, an accurate indicator of problem-solving or decision-making skills.
Insight into one's mental disorder and its consequences also represents a risk factor. The more a patient knows about the need for ongoing treatment and the consequences of doing without that treatment, the more likely that patient is to engage in suicide behavior.
Overall, depressive symptoms of any disorder represent the highest risk factor. And, of course, all risks are amplified when the person isn't compliant with prescribed medications and other treatment regimens.
Personality Disorders and Suicide BehaviorBy far the biggest area of concern in this category is Borderline Personality Disorder. Its hallmark symptoms - mood instability, impulsive behaviors, and unstable relationships - are all, by themselves, indicators of high risk toward suicide behavior. Put together, the risk becomes even greater. BPD patients are prone to harmful behaviors, most commonly cutting and overdosing, followed by immediate requests for attention. The majority of completed suicides among those diagnosed with BPD happen after many years of unsuccessful treatment.
For BPD patients who threaten to engage in harmful or suicidal behavior, hospitalization is generally considered the best recommendation. However, repeated hospitalization can lead to regressive thinking and reinforcement that threats and harmful behavior result in the attention the patient seeks. This interferes directly with any outpatient treatment the patient is receiving, as ongoing treatment for BPD often involves conditioning against and encouragement to avoid attention-seeking behavior. Where outpatient therapy is concerned, DBT has been shown to be the most effective method for BPD patients. DBT-A is an adapted form of DBT aimed at adolescent patients.
Prevention StagesThere are multiple ways we can act to prevent suicide attempts or self-injurious behavior before the crisis point is reached. It's important to note two methods the psychiatric field recommended at one point but has realized are actually harmful. Minimizing the importance of a diagnosed mental disorder has been shown to discourage compliance with treatment, which as we saw above is a significant risk factor for suicide behavior. In addition, it was at one point suggested that suicide be acknowledged as an "understandable" response to stressors or other triggers. This is not the case - saying we understand someone's desire to end their life will more often than not be perceived as tacit permission to make an attempt.
The most powerful tools in the prevention arsenal follow common sense responses most closely. Refuse to allow any stigma surrounding mental illness or suicide to creep into your conversations. Address it in a frank, matter-of-fact way, encouraging open discussions about thoughts and feelings related to the illness, the person's circumstances, and suicide itself. In addition, counsel people who mention suicide to limit or remove access to lethal means. Never suggest a means of suicide a person has not already mentioned to you. If someone says they're tempted to grab a gun and end it, by all means encourage them to have a friend hold on to their firearms until they feel better. Don't advise them to have someone control their medications as well; if overdose hasn't occurred to them yet, we don't want to be the ones to plant the idea in their heads.
Gatekeeping is the watchword for those in frequent contact with people who may be inclined toward self-harm or suicide behavior. Keep an eye out for signs of distress and address them immediately. Often, allowing someone to vent is sufficient to diffuse the risk in the moment. Actively teaching and reinforcing good coping skills at all times, not just when someone is in crisis, will also serve us well.