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Over the last century, those who study adolescent suicide have documented a consistent pattern they call suicide’s “gender paradox”: While teen girls are more likely to have suicidal thoughts and to attempt suicide, males are significantly more likely to die by it. Theories attempting to explain this paradox have incorporated, among other factors, males’ tendency toward more lethal means of suicide, such as firearms or hanging, and a greater propensity toward drug and alcohol abuse, which are considered risk factors.
A new study finds that while teen boys in the United States are still dying by suicide at higher rates than their female counterparts, the gap has narrowed significantly over the past decade. The trend appears to be driven primarily by a shift toward more violent means of suicide among girls, and is most pronounced among younger girls between the ages of 10 and 14. The findings, though disturbing, are critical for understanding the mental health challenges faced by today’s youths, the study’s authors argue. They highlight the need for more proactive strategies for suicide prevention and treatment for youths at risk—strategies that would, ideally, be tailored more closely to developmental level, gender, and restricted access to the most lethal means.
The study, published in JAMA Network Open, was inspired by data from the CDC reporting that rates of suicide among teen girls have risen especially dramatically over the past decade, says lead author Donna Ruch, a post-doctoral researcher at the Center for Suicide Prevention and Research at Nationwide Children’s Hospital. In order to understand the driving forces behind the increase, and whether it significantly altered the ratio between male and female suicides among teens, Ruch and her co-authors examined data for 85,051 adolescent suicide deaths that occurred between 1975 and 2016. Of the 40-year total, approximately 80 percent were male and 20 percent were female; male suicide rates remained higher across demographics for the duration of the study period. Following peaks in the early ’90s for all genders and age groups, teen suicide rates decreased steadily until 2007.
When the overall suicide rate began to increase again after 2007, however, the increase was most significant for younger teen girls; from 2007 to 2016, suicide rates for girls between the ages of 10 and 14 increased an average of nearly 13 percent each year, while male rates among the same age group increased an average of 7 percent—shrinking the ratio of male to female suicides from 3.1-to-1 to 1.8-to-1. Among youth between the ages of 15 and 19, the trend was similar but slightly less strong; the suicide rate among older teen girls increased an average of approximately 8 percent each year, compared to an annual increase of less than 4 percent for older boys. The ratio among older teens dropped from a peak of 4.6-to-1 to 3.3-to-1.
In both age groups—but most notably in the younger group—the change was driven mainly by an increase in deaths by hanging or suffocation among girls; by contrast, the ratio of boys vs. girls who died by firearms actually increased among older teens over the same period, and the ratios of suicides by other means remained steady across age groups.
“There’s a specific, disproportionate increase in the methods,” Ruch says. Though the study was unable to identify the reasons for the shift based on the data available, more frequent attempts among girls—as well as a documented increase in the number of girls who have considered suicide over the same timespan—make the trend especially troubling, she says.
Unlike firearms—for which straightforward, though politically complicated, restriction strategies exist—it’s difficult to restrict suicidal teens’ access to means of hanging or suffocation, says Cheryl King, a psychologist who researches suicide prevention at the University of Michigan. “But what this [study] tells us is that we have to keep in mind that girls use very lethal methods, too,” says King, who was not involved in the research. “Because more girls report suicidal thoughts and make suicide attempts than boys, sometimes providers may not take their risk [of dying by suicide] as seriously.” Chronic suicidal thoughts or repeated, non-lethal attempts can be seen in girls as more common or as less risky of ultimate completion, she adds. “But the method that [a suicidal person] uses tends to become more lethal across time”—meaning that someone who first chose a less lethal method may attempt a different one the next time if their suicidal ideation is not recognized and treated. When a teen girl shows warning signs of suicide—such as depressive symptoms, non-suicidal self-injury, or unhealthy alcohol and drug use—”we want to take every indication of that risk seriously,” King says.
Means prevention is just one piece of a complex suicide-prevention puzzle. “Trying to prevent a suicide at the point when it’s just a matter of keeping them away from something to do it—that’s not where we want to be,” King says. Though steps should be taken whenever possible to restrict access, she argues, “what this [study] suggests is that we need to be thinking of younger ages for some of our proactive screening efforts.” Emergency rooms, for instance, typically don’t screen for suicidal thoughts in children who are 10 or 11. “Instead of screening just 12 and up, we should at least give consideration to begin screening a little earlier.”
Mental health education, particularly that with a suicide prevention focus, has typically targeted high schools, Ruch says. “But now we’re seeing that we need to tailor these interventions a little bit differently; now we know that we need to be hitting middle school kids and even younger.” Developmentally appropriate prevention programs tend to focus more on positive growth and reducing stigma than on suicide itself, King says. “During the younger years, like elementary school, more of the focus is on helping kids to be healthy or to have better coping skills,” as well as teaching them to feel comfortable discussing mental health and promoting supportive peer relationships. Parents of younger children, too, can be targeted with education programs that help them identify warning signs and locate treatment resources. “Parents need to know that there’s help available and that what their children are struggling with is treatable,” she adds. “The earlier we recognize mental health concerns, the more effective our treatments are.”
The gender piece of the puzzle, though important, is more complicated to address, Ruch says, particularly because the study was unable to identify why girls are experiencing such rapidly increasing rates of suicide. But part of the problem could be related to stereotypes that girls are more willing to seek help for depression or suicidal thoughts, she says. The rise of mental health challenges among younger girls, she adds, suggests that perhaps developmental factors—like earlier puberty—could be contributing to increases in depressed mood.
King adds that one of the most effective therapies for reducing the risk of suicide—dialectical behavioral therapy, or DBT—has been shown to be particularly effective in girls, though part of that is because they’re disproportionately represented in trials assessing its efficacy. “Most of what we know about the effects of DBT is with girls,” she says. “But it’s a treatment that is evidence-based and fairly widely disseminated.” She points to a randomized controlled trial of DBT, published in JAMA Psychiatry last year, that concluded that the treatment was effective in reducing repeat suicide attempts among highly suicidal adolescents.
Though the more rapidly rising suicide rate among girls is concerning, it’s also critical to keep in mind that the rate among boys is still much higher and continuing to rise, King says. “It’s distressing that the rate is going up for boys and girls,” she says.
Parents who are concerned about their teen’s mental health should know that it’s okay to ask about suicidal thoughts, Ruch says—contrary to popular belief, evidence does not support the idea that talking about suicide will put a child at greater risk by “putting the idea in their head.” “There’s this myth that if you talk to your children about suicide, it will influence their behavior,” she says. “We try to guide people differently. It’s okay to talk to your child.”
If a teen is thought to be at risk, she adds, “there are so many resources available at the national and local level”—including the National Suicide Prevention Lifeline, the Suicide Prevention Resource Center, or the Crisis Text Line—that can help parents understand changes in behavior or mood or get help in a crisis. “You’re better off talking to them about these things,” she says. “It’s okay to talk about this stuff, as painful as it is.”
If you or someone you know is exhibiting warning signs of suicide, call the U.S. National Suicide Prevention Lifeline at 800-273-TALK (8255), contact the Crisis Text Line by texting HOME to 741741, or seek help from a medical or mental health professional. To locate a mental health professional near you, visit the Psychology Today Therapy Directory.
