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Gender Differences in the Development of Suicidal BehaviorHSR&D’s monthly publication Veterans’ Perspectives highlights research conducted by HSR&D and/or QUERI investigators, showcasing the importance of research for Veterans – and the importance of Veterans for research. In the October 2020 Issue:
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IntroductionVeterans are 1.5 times more likely to die by suicide than civilians, and women Veterans are 2.2 times more likely to die by suicide than women civilians. The suicide rate among women Veterans increased 61% between 2005 and 2017, while the suicide rate among men Veterans increased 43%.3 Suicide is a leading cause of death in the United States. Since 1999, suicide rates have risen by more than 30% in half of the states, with nearly 45,000 lives lost in 2016 alone.1 Currently, the COVID-19 pandemic is associated with elevated adverse mental health conditions among U.S. adults, as well as disproportionately worse mental health outcomes, increased substance use, and elevated suicidal ideation among younger adults, racial/ethnic minorities, essential workers, and unpaid adult caregivers, most of whom are women.2 Moreover, despite VA’s increased efforts over the past decade in implementing comprehensive Suicide Prevention Program initiatives, such as the Veterans Crisis Line, hiring Suicide Prevention Coordinators at every VA hospital, in addition to enhanced monitoring, Veteran suicide rates remain high. This issue of Veterans’ Perspectives highlights a national qualitative study – led by Dr. Lauren Denneson and funded by HSR&D (IIR 17-131) – which sought to better understand gender differences in the development of suicidal behaviors among U.S. Veterans, in order to inform future research and gender-tailored prevention efforts. Qualitative research may broaden our understanding of how suicidal behaviors develop by using an approach grounded in the experiences of those at risk for suicide; however, qualitative studies of Veterans at risk for suicide have been scant and primarily reflect the experiences of male Veterans. Thus, Denneson and colleagues interviewed 50 Veterans (25 men, 25 women) who had made a suicide attempt in the prior six months. Interviews were conducted between May 2018 and January 2019, and questions focused on both men and women Veterans’ experiences with military service, suicidal thoughts and attempts, and healthcare following their attempt. Study Participants Veterans were recruited from VA healthcare facilities across the U.S and the resulting study cohort was demographically and clinically diverse. Participants included men (n=25) and women (n=25) Veterans between the ages of 23 and 70 who had served in Vietnam (10%), post-Vietnam (28%), Persian Gulf War (28%), and in Operations Enduring Freedom, Iraqi Freedom, and New Dawn (60%). Participating Veterans experienced a range of mental health conditions, the most prevalent were: depression (84%), PTSD (54%), anxiety (46%), substance use disorders (40%), and schizophrenia/bipolar disorders (22%). Further, 46% had been diagnosed with chronic pain disorder and 34% with a sleep disorder. Study Findings This analysis revealed two gendered narratives of suicide attempts that incorporated the primary themes of self-concept, social power, relationships, coping, and stress. Women VeteransWhen discussing reasons for their suicide attempts, women described feelings of worthlessness. Women appeared to internalize negative experiences and evaluations from others into negative assessments of their worth (i.e., ‘I am bad’). Following are some of the individual comments that were given by women Veterans about their respective suicide attempts. “I’m just a… I’m less. I don’t want to be here anymore.” “I felt like maybe it’s time for me to just leave this place because I’m shameful. I haven’t done anything in my life. I suck… That moment, I wanted to die.” “I felt like such a failure…No relationship worked. I wasn’t productive. I wasn’t doing anything that was good. I was just non-existent in an existing world. My self-esteem was so low.” “…but my mind is telling me, ‘You don’t deserve to be here, you don’t deserve to be anything.’” “And at that point you’re picking apart your entire life and just seeing all the bad. You think, maybe you’re not worthy of having these good things in life.” “Being sexually assaulted [in the military], it made me feel super vulnerable and weak. In the beginning I told you I wanted to become a Marine for the discipline and the strength and all those things so the last thing I would ever want to feel was that I was weak or someone could make me do something that I didn’t want to do, and it happened so I deal with reminding myself that I’m not weak, but I feel weak.” Men VeteransIn contrast to women, men discussed feeling like the world had let them down and that they no longer had any fight left to obtain the life they want to live. Their feelings primarily reflected their interpretations of failed actions (i.e., ‘What I did was bad.’) rather than assessments of their worth. Following are some of the comments that were given by men Veterans about their respective suicide attempts. “Because you are about to go, ‘well we’re all going to die anyway, why am I putting up with this crap? This is enough garbage, I’m done. I’m done fighting the fight, this is just exhausting and pointless.’ I’ll fight a fight when there’s a point, but when it’s just basically masochism to keep putting up with it, it’s just like, ‘why is this— the f****** point again?’” “I don’t think I was planning it, I just did it. I just didn’t want to live. I had enough of—I’ve had enough. I’m still stressed out and I sit back and wonder, why am I still here? Why am I going through all of this? I was just tired of life. I just didn’t want to live. I get to a moment, to a point where I just can’t seem to deal with life anymore.” “I just thought I was going to be more centered, more responsible…Well I mean, I ended up in jail, I ended up doing drugs, and I ended up doing the same thing my dad does. The drinking, the partying, the drugs, the women, just the stupid decisions. Everything that I didn’t want to be is exactly what I became.” Different Perspective on Military CultureThere was also a difference in how men and women described being a man or woman in the military. When discussing their military experiences, some women described a culture that was hostile towards women and that relegated women into two possible roles, defined by their level of promiscuity: someone with many sexual partners or someone who refuses. “I got told in my A school, so my training after basic training, in the Navy you get to either be a bitch or a whore. Either you’re going to be someone that sleeps your way to the top, or going to be somebody that everyone sees as the ice queen.” –Woman Veteran In contrast, men Veterans in this study found it difficult to describe what it felt like to be a man in the military, which suggests that they were accustomed to the military being a largely male space, which can confer feelings of control and normalcy. Interviewer: “What was it like to be a man in the military?” Typical participant response: “I don’t know. Just to be a man in the military, or what? I guess I don’t understand the question.” –Man Veteran However, men Veterans acknowledged the extra effort women need to put in to be considered for career-related opportunities in the military – or to be perceived as being on equal footing with men. “Female Marines are looked down on, they’re kind of like second-rate citizens in the Marine Corps, generally the butt of any kind of joke. They have a whole bunch of derogatory nicknames for female Marines. I can’t imagine being a female Marine and having to deal with all that crap. I’m sure a lot of them don’t experience it to their face, but all this stuff is said behind their back. It’s pretty disgusting.” –Man Veteran When they transitioned to civilian life, men Veterans experienced a loss of social power. They talked about feeling out of control after their transition, and often tried to match what they had achieved in the military. Some talked about feeling like “less of a man” because they did not think they were fulfilling their stereotypical gender role. “And then on the other side, I’m not even able to support them without my wife working when she doesn’t want to work because she wants to take care of the kids, and I feel like a failure because of that.” –Man Veteran “It was probably the best experience of my life and I was always trying to match that I guess in civilian life. And I’ve never been able to so I’m always striving to achieve what I did in the military and I’ve been out over 10 years now, 14 years and I still can’t find it, I got four degrees, I’m working towards a PhD, it’s still not the same. I’ve tried everything.” –Man Veteran How Men and Women CopeBoth women and men spoke about the potential for friends and family to be a source of support when coping with life’s challenges, but their coping behaviors and experiences differed when it came to reaching out to others for help. While women wanted their family and friends to be supportive and looked to obtain emotional support from them, the women were often met with rejection and a lack of understanding. “It was breaking my heart, it was tearing me apart. If [my husband] had been more comforting and supportive…I feel like that [suicide attempt] would have never happened had I had that one person that I trusted the most to be there for me. And he was kind of like my last hope in that sense too because I was crying for help, I was screaming for help and he wasn’t there.” –Woman Veteran Men, on the other hand, received emotional support from family and friends, but were reluctant to ask for help. When speaking specifically about suicidal thoughts, most men said they would not reach out to others for help if they had decided to attempt suicide. “You’re not going to talk to anybody. You’re not going to reach out. Your decision is made…Because if I’m going to commit suicide, I’m going to kill myself. It’s not a cry for help. I don’t want people to feel sorry for me, or feel bad for me—no. If you’re actually trying to commit suicide, actually want to die, you’re just going to do it. Why the f*** would I want to talk to this guy? I’ve got shit going on. I’ve got to get myself dead.” –Man Veteran ImplicationsThese findings illustrate the importance of understanding gender differences in the context of suicide prevention. Although there were similarities in the constructs that emerged within both genders, the differences in the content and processes of how these constructs operated within each gender lead to considering different possible ‘best approaches’ for gender-tailored prevention within the four areas of the socio-ecological framework. Among women, it may be crucial to first address feelings of worthlessness that are rooted in self-blame. Individual-level approaches that seek to improve self-acceptance or self-compassion could be useful in this regard. Among men, individual-level approaches that increase their sense of purpose in life might be a critical step in prevention, as it may be a necessary platform on which to build their desire to continue to work through life’s challenges. For more information about this study, please contact Lauren Denneson, PhD, a core investigator with HSR&D’s Center to Improve Veteran Involvement in Care (CIVIC), Portland, OR, at Lauren.Denneson@va.gov . References
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