» Back to Table of Contents

Research Highlight

Tailoring Suicide Prevention for Women Veterans

Although women Veterans die by suicide at a lower rate than men, several trends have raised concerns over whether suicide prevention efforts are meeting the needs of women Veterans; these include sharp increases in the suicide rate among women Veterans in recent years, the higher rate of women Veterans attempting suicide than men, and the excess risk of suicide among women Veterans as compared to non-Veteran women. Indeed, much of the evidence in suicide prevention among Veterans reflects research with men-dominated samples. This is not surprising given the relatively small proportion of the Veteran population comprising women (11 percent), though at best this body of research is “gender-neutral” or, at worst, speaks primarily to our understanding of suicide risk and prevention among Veterans who are men.

Examining the potential need to tailor suicide prevention efforts for women Veterans requires a purposeful effort to design studies that enroll a sufficient proportion of women to allow for gender comparisons in suicide prevention-related topic areas, such as risk and protective factors, ideation, and recovery from nonfatal suicide attempts. The HSR&D-funded study (IIR 17-131), “Advancing Suicide Prevention for Female Veterans” began in 2018 and sought to address this gap through qualitative interviews and a subsequent longitudinal survey of approximately equal numbers of women-identifying and men-identifying Veterans who had recently attempted suicide.

Qualitative interviews with 25 women and 25 men provided the backbone for an understanding of how suicidal behavior develops, rooted in the experiences of Veterans who had attempted suicide within the prior six months. Across the 50 interviews, many similarities emerged in the lives, cognitions, and healthcare experiences of participants. Several gender differences were also readily apparent. Self-concept, social power, relationships, coping, and stress were the focal points of narratives that differentiated women from men in the development of suicidal behavior.¹ Women held less social power, experienced significant harm from relationships, were met with rejection when they sought out family and friends for support, and had been taught to second-guess themselves, which exacerbated their struggle to determine the best path forward.

The starkest difference observed between women and men was their internalization and externalization, respectively, of the challenges they had experienced. When women spoke about what they were thinking when they attempted suicide, they felt like “a throw away” of a person, and said, for example, “I felt like maybe it’s time for me to just leave this place because I’m shameful…I suck.

In that moment, I wanted to die,” and, “my mind is telling me, ‘you don’t deserve to be here, you don’t deserve to be anything.’” Meanwhile, men also felt a debilitating sense of failure, but expressed frustration with the world, which they perceived as having thwarted their attempts to succeed. They thought, “this is enough garbage, I’m done. I’m done fighting this fight, this is just exhausting and pointless,” and said, “I feel like at that point, I was like, ‘screw this,’” and “I felt like it was just not worth it.”

Consistent with the differences we observed between women and men in the development of suicidal behavior, women expressed different preferences and goals for treatment, or recovery, from their suicide attempt than did men.² First, women wanted to foster positive relationships with others, preferably other women, who could relate to their experiences. Importantly, they wanted to make connections with people for reasons other than shared health concerns, and they wanted to feel as though the relationship was mutually beneficial. Second, women wanted to improve their self-worth and confidence. This included a desire to increase their self-knowledge of why they think or do the things they do. Men, on the other hand, expressed wanting to live up to what they believed to be their ‘ideal self’ and to feel needed by others. Both women and men desired a stronger sense of purpose in life. Finally, we observed small differences in how women and men spoke about healthcare engagement; most importantly, our findings pointed toward a need for better access to trauma-informed care and women-only spaces to increase engagement in mental healthcare among women.

Findings from the interviews served to inform construct selection for the subsequent longitudinal survey of 1,000 Veterans (57 percent women-identifying) with a recent suicide attempt, enhancing the ecological validity of the survey and allowing for quantitative tests of relationships among concepts identified in the qualitative interviews. Veterans completed follow up surveys six and twelve months after completing a baseline survey. The main analysis focused on negative childhood and adult experiences, psychological distress, institutional betrayal, coping styles, self-compassion, financial satisfaction, social rejection, hope, autonomy, and suicidal ideation. At baseline, we identified cross-sectional gender differences; women reported a higher tendency to engage in negative coping strategies (i.e., avoidant behaviors such as substance use, social withdrawal, rumination), stronger feelings of institutional betrayal, and more commonly felt rejected by family and friends than men.³ Men had higher scores on constructs typically thought of as protective factors: self-compassion (i.e., the ability to treat oneself with kindness and understanding) and autonomy (i.e., a proxy for social power – a sense of independence and self-control over one’s life). Men also had higher scores on suicidal ideation. We observed no differences in the relationships among the concepts studied. Longitudinal analysis is ongoing.

Together, findings point toward a need to consider how societal forces and relationship experiences harm women’s self-perceptions, shaping both thoughts of suicide and perceived confidence in enacting self-determined behavior. The latter may exacerbate challenges observed in this study, and others, with engaging and retaining women Veterans in VA mental healthcare. These findings suggest that increasing confidence and self-knowledge of health conditions – together with increased trauma-informed care – may improve women Veterans’ engagement in care. Developing novel approaches that address healthy relationships, and advancing policy to reduce incidence of military sexual trauma are both critical avenues for suicide prevention.

Finally, these findings also suggest potentially beneficial alterations in the modes of care delivery, including ways to fine-tune treatment to address both women’s treatment goals and their internalization of harmful life experiences.

References

1. Denneson LM, et al. “Gender Differences in the Develop-ment of Suicidal Behavior among United States Military Veterans: A National Qualitative Study,” Social Science & Medicine 2020 September;260:113178
2. Denneson LM, et al. “Gender Differences in Recovery Needs after a Suicide Attempt: A National Qualitative Study of US Military Veterans,” Medical Care 2021 February 1;59:S65-S69.
3. Smolenski DJ, et al. “Informing Measurement of Gender Differences in Suicide Risk and Resilience: A National Study of United States Military Veterans,” Journal of Clinical Psychology 2023 May;79(5):1371-1385.