COMMONWEALTH OF AUSTRALIA

Copyright Regulations 1969

WARNIN"G

This material has been reproduced and communicated to you by or on behalf of Charles Sturt UTI:iversity pursuant to Part VB of the Copyright Act 1968 (the Act).

The material in this communication may be subject to copyright lUlder the Act. Any further reproduction or communication of this material by you may be

subj ect of copyright protection under the Act.

Do not remove tbis notice.

< I !

. I' ",

I I

This article was downloaded by: [Charles Sturt University] On: 10 April 2014, At: 21: 12 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1 T 3JH, UK

International Journal of Culture and Mental Health Publication details, including instructions for authors and subscription information: http: //www.tandfonline.com/lollrccm20

Women and suicide: beyond the gender paradox Kathy McKa/, Allison MHnerb

& Myfanwy Maplea

a CRN for Mental Health and Well-Being in Rural and Regional Communities, University of New England, Armidale, Australia

b The McCaughey Centre: VicHealth Centre for the Promotion of Mental Health & Community Wellbeing, Melbourne School of Population Health, University of Melbourne, Australia Published online: 18 Feb 2013.

To cite this article: Kathy McKay, Allison Milner & Myfanwy Maple (2014) Women and suicide: beyond the gender paradox, International Journal of Culture and Mental Health, 7:2, 168-178, 001 : 10.1080/17542863.2013.765495

To link to this article: http://dx.doLorg/1 0.1 080/17542863.2013.765495

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the information (the "Content") contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content.

This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub- licensing, systematic supply, or distribution in any form to anyone is expressly forbidden . Terms &

....... ;..... 0.. «

o

Conditions of access and use can be found at http://www.tandfonline.com/page/terms­and-conditions

International Journal of Culture and Mental Health, 2014 Vol. 7, No.2, 168- 178, http://dx.doi.org/1O.10801l7542863.2013.765495

Women and suicide: beyond the gender paradox

Kathy McKaya*, Allison Milnerb and Myfanwy Maplea

Cl CRN for Mental Health and Well-Being in Rural and Regional Communities, University of New England, Armidale, Australia; bThe McCaughey Centre: VicHealth Centre for the Promotion of Mental Health & Community Wellbeing, Melbourne School of Population Health, University of Melbourne, Australia

(Received 20 June 2012; final version received 20 December 2012)

Traditionally, suicide research has focused on male mortality, with little attention paid to the female experience of suicide. This means there has been a lack of research examining how female suicide rates and behaviours have changed over time and between countries. Through an exploration of the World Health Organisation Statistical Information System (WHOSIS) data, this paper aims to analyse changes in the trends of female suicide across the period 1950 to 2009 in 106 countries. Observed changes in female suicidal behaviours are discussed in the context of 12 geographical and cultural areas of the world: Africa, Anglo-Saxon countries, the Western Pacific, the Baltic States, Central and Eastern Europe, Eastern Mediterranean countries, Scandinavia, South America, South East Asia, Southern Europe and Western Europe. By seeking understanding as to how suicidal behaviours are gendered within specific cultures and societies and by unpacking the Gender Paradox using Cultural Scripts Theory, this paper explores some possible culturally relevant explanations for female suicide rates and behaviours worthy of future research attention. Analysing the data and its limitations, and acknowledging its place within social and cultural constructs, allows for better understanding of the fatal female suicidal behaviour.

Keywords: female suicide; gender paradox; WHOSIS; cultural scripts

Background

Traditionally, empirical descriptions of fatal suicidal behaviours have mainly focused on the male experience, largely neglecting trends and patterns of female suicide mortality over time and between countries. This is likely due to the fact that men are more vulnerable to dying by suicide. Indeed, this is the case in developed countries where a majority of the literature originates. In contrast, females are recorded as being more likely to engage in non-fatal intentional self-harm (Beautrais, 2006; Cannetto, 2009). This morbidity- and mortality-focused statistical reporting, while useful in determining in-country or within-region male-to-female suicide ratios, leads to analysis focused on differences between sexes, rather than extending the discussion of gendered behaviours. For example, while masculine behaviours and methods are often considered lethal, violent and aggressive, feminine behaviours and methods are conceptualised as non-lethal, non-violent and passive (Canetto & Sakinofsky, 1998; Jaworski, 2003). This has further been constructed into presumptions of intention -

*Corresponding author. Email: kmckay8@une.edu.au

© 2013 Taylor & Francis

International Journal of Culture and M ental Health 169

by their method choice and performance, men are seen to possess a stronger intention to die than women (Canetto and Sakinofsky, 1998; Jaworski, 2003). However, it is also argued that more women perform self-harm and non-fatal suicidal behaviours simply because the normalised (and gendered) behaviours culturally prescribed to them are predominantly non-lethal, non-violent and passive (Canetto, 2009, 2008; Canetto & Lester, 1998; Canetto & Sakinofsky, 1998; Jaworski, 2003). Similarly, the cultural norms prescribed to men tend to lead to fatal outcomes. Consequently, surviving an attempt on one's life does not necessarily demonstrate a lack of intention to die, nor is death always necessarily intended (Denning, Conwell, King, & Cox, 2000; Nordentoft & Branner, 2008).

A general concentration on suicide as a male 'problem' has meant that there is a lack of epidemiological studies on female suicide. If investigations have been made specific to female suicidal behaviours, research has predominantly focused on suicide attempts, method choice and cultural contexts, for example in relation to women in Sri Lanka and India (Bertolote et aI. , 2010; Guzder, 2011). Some attention has also been drawn to the large number of women dying due to suicide in China (Phillips, Li, & Zhang, 1999; Yip, Liu, Hu, & Song, 2005; Zhang, Li, Tu, Xiao, & Jia, 2011) and in Japan, where the suicide rate among women aged 50-64 years is around 20 per 100,000 (Odagiri, Uchida, & Nakano, 2011). Attention has also been given to Indigenous groups in colonised nations, where female suicide rates are significantly higher compared to the broader female population, as is the case among Australian Aboriginal and New Zealand Maori groups (Beautrais & Fergusson, 2006; De Leo, Sveticic, & Milner, 2011 ; Silburn, Glaskin, Henry, & Drew, 2010; Silburn, Glaskin, Henry, & Drew, 2010).

Yet, these findings have rarely translated into deeper understandings of how the cultures in which women live influence their suicidal performance in terms of intent, self-directed aggression and method choice. It has only been in recent years that the transposition of the Gender Paradox within different countries and cultures has been argued to demonstrate that 'men and women will tend to adopt the self-destructive behaviours that are congruent with the gender scripts of their cultures' (Canetto & Sakinofsky, 1998, p. 17). This posits that researchers must investigate the ways in which female suicidal behaviours and deaths occur within different countries and cultural settings, quite apart from male behaviours, to better understand the phenomenon of female suicide. However, the Gender Paradox alone is not enough, it must be unpacked using Cultural Scripts theory in order to better understand the female experience of fatal suicide. Cultural Scripts Theory can assist in this debate through its focus on seeking to understand the 'tacit " rules" that tell us how to be a person among other persons - that is, how to think, how to feel, how to want (and how to act upon our wants), how to seek or impart knowledge, and, perhaps most importantly, how to speak to other people' (Wierbicka, 1993, p. 221). Cultural Scripts can link how a person perceives and articulates an experience to how they act upon it.

At a global level, the lack of research on the epidemiology of female suicide has meant that there has been limited attention to how rates (deaths per 100,000) of female suicide have increased or decreased over time. While female adolescent suicide rates have undergone periods of significant increases in Ireland and Norway (Mittendorfer Rutz & Wasserman, 2004), less is known about rates in other countries. However, as demonstrated in some of the research cited above, the description of female fatal suicidal behaviours differs markedly around the world. This gap in knowledge also highlights the likely variation between the numbers of females to

·c .<-o

N .......

170 K. McKay et al.

males dying by suicide within different regions of world and among varying cultural groups. Therefore, the aim of this paper is to provide a description of the burden of female suicide over time and across countries of the world reporting data to the World Health Organization (WHO). This is significant because of its specific focus on female suicide, especially in terms of its fluctuations over time within different geographical areas of the world. A focus specifically on female suicide also assists in the development of a dialogue aimed at understanding the gendered nature of suicide.

Methods

Data on suicide was obtained from the WHO Statistical Information System (WHOSIS) and checked against the 'country report charts' available on suicide mortality (WHO, 2011). Data was recorded for as many countries and periods of time as was available. Countries such as Canada have a long time period for which data was reported to the WHO, while data in other areas of the world may only be available for a single year, such as Jamaica, Iran or Zimbabwe (Table 1). This notable limitation in the availability of data is an issue we discuss throughout the paper and is a constant reminder of the likely challenges individual countries face in accurately reporting suicide data to the WHO.

Areas were grouped according to geographical regions of the world based on the classifications used in WHOSIS (Table 1). However, due to a large number of countries included in the region, Europe was further subdivided into Eastern-Central Europe, Southern Europe, Western Europe, Scandinavia and the Baltic States to provide a clearer picture of the suicide data from regions within Europe. The UK, Canada, Australia, New Zealand and the USA were combined into the category 'Anglo-Saxon' origin, following the conventions of past research and to acknowledge the comparability of suicide in deaths in each of these countries (De Leo & Evans, 2004). Data is displayed as age-standardised suicide rates (Ahmad et aI., 2001). Differences in suicide rates between regions and over time were presented in scatter plot graphs (Figure 1 and 2) and summary statistics (Table 1).

Results

Descriptive data by region can be seen in Table 1. This includes the average female suicide rates for the total time period reported to WHO, the minimum and maximum female rates and the median and standard deviation of suicide rates over time. Table 1 also shows the years of data available on suicide mortality.

Regions with the highest rates of death were the Baltic States (12.73 per 100,000) and Asia (Western Pacific) (10.32 per 100,000). The high rates in the Asian region was likely driven by suicide in countries such as China, which had an average rate of 27.2 per 100,000 in rural areas over the time reported to the WHO. Also in Asia, Japan had a relatively high average of suicide rates (13.3 per 100,000). Countries such as Estonia (12.6 per 100,000), Latvia (12.6 per 100,000) and Lithuania (13 per 100,000) are likely responsible for the high suicide rates in the Baltic States region.

The African region and South America had the lowest female suicide rates. One of the largest countries in the first of these regions was South Africa, which reported female suicide rates of 0.03 over the observed time frame of this study. In South America, Haiti (0.03 per 100,000) and Grenada (0.63 per 100,000) had some of the lowest suicide rates and contributed to the overall low rate of suicide in this region.

~

.......

o N

........

. . t:

: <

o N

.......

N ~

~

.@

Q) ;::- .~

:J

1:: .a C

/J V)

Q) ~

...c: ~

;>,

..0

'"

0

Q)

'"0

'" o --a ~

o Q

Tab

le I

. S

uici

de d

ata

repo

rted

to

the

WH

O,

by c

ount

ry a

nd r

egio

n, d

escr

ipti

ve s

tati

stic

s (p

er 1

00,0

00).

Yea

rs o

f N

um

ber

of

suic

ide

data

A

vera

ge f

emal

e R

egio

n co

untr

ies

avai

labl

e su

icid

e ra

te

Min

imum

M

axim

um

Afr

ican

reg

ion

5 19

55

2008

4.

15

0.00

11

.00

Ang

lo-s

axon

6

1950

20

09

5.16

1.

20

10.8

0 A

sia

(Wes

tern

Pac

ific

) 8

1950

20

09

10.3

2 0.

30

32.3

0 B

alti

c S

tate

s 3

1980

20

09

12.7

3 6.

50

17.9

0 C

entr

al a

nd E

aste

rn E

urop

e 23

19

55

2009

6.

99

0.20

28

.70

Sou

th A

mer

ica

30

1955

20

09

2.01

0.

00

7.10

E

aste

rn M

edit

erra

nean

7

1950

20

09

9.11

2.

00

22.3

0 S

cand

inav

ia

5 19

50

2009

2.

72

0.00

18

.00

Sou

th E

ast

Asi

a 4

1950

20

09

8.63

0.

00

23.9

0 S

outh

ern

Eur

ope

5 19

50

2009

2.

82

0.00

6.

10

Wes

tern

Eur

ope

9 19

50

2009

9.

46

2.80

16

.80

Ave

rage

mal

e/

~

fem

ale

suic

ide

Min

imum

M

axim

um

~

--.:

;::s

3.14

0.

00

7.75

~ S·

3.46

1.

40

7.08

;::s

1.

75

0.72

3.

00

e.. 4.

41

2.43

6.

16

~

3.74

l.

38

7.43

~

--.:

2.97

0.

50

18.7

5 ;::s

e.. 2.

90

1.35

6.

09

~

4.23

0.

53

14.7

5 2.

06

l.04

4.

00

Q

3.31

1.

67

8.00

- E'

2.66

1.

30

5.03

--.:

<"

';) ~

;::s ~ ~ ;::s

§. ~ ~ :::;

:-;::,

-.

>-'

-.

.l

>-'

·c 0.. -< o

172 K. McKay et al.

However, the reliability and representativeness of data in these areas may be limited, considering that these areas are among the poorest in the world and may lack the resources necessary for the establishment of suicide registries or have gaps in their formal reporting mechanisms.

Figure 1 demonstrates changes in the female suicide rate (death per 100,000) by year in 11 geo-cultural areas of the world. The horizontal axis represents the years during which suicide deaths were recoded and the vertical axis represents the overall suicide rate (death per 100,000). Anglo-Saxon countries, the Eastern Mediterranean region, Scandinavia, Southern Europe and Western Europe, had the most stable rates of female suicide over time, as can be seen in limited change in the pattern of suicide by year in these regions (Figure 1). Other areas showed greater variations in suicide, including areas in the African region, Asia (Western Pacific), the Baltic States, Central and Eastern Europe and Scandinavia. This is demonstrated in greater variation in suicide rates over time seen in Figure 1. There were also vast differences in South America, which may be due to particularly high rates in Suriname, as well as in South-East Asia. Regions with the highest rates of female suicide were the Western Pacific, Central and Eastern Europe and South-East Asia.

There was also considerable variation in the gender ratio of male to female suicide rates (i.e., male suicide/female suicide) between regions over time (Figure 2). As with Figure 1, the horizontal axis of this graph represents the years during which suicide deaths were recorded and the vertical axis indicates the total suicide rate (death per 100,000). Areas with markedly higher rates of males dying as to females (more than three males to one female) included countries in the African region, Central and Eastern Europe, South America, the South-East Asia region and

African

..... • • ·t~ ... ,. ..

Central&. EastemElJtape

•• • ••

••• •••••

SOUth East Asia

i

1940 1960 1980 2000 20:20 1940

• • •

•••• ••

•• • .... : . ..a·· ..... · I·- .1· ...... -.' . ~mEurope

.: ...• _­

.• :th . . ... :.- .

Figure 1. Age-standardised female suicide rates (death per 100,000) by region and year.

••• • •• • ~ttI-•

.......... .. ".~

International Journal of Culture and Mental Health 173

; ..........

• ~ .

•

. ' ~ ..... .. ', ...

• ·-Ut:.M

..........

... M' ....

Figure 2. Gender ratio of male-to-female suicide rates by country and year.

Southern and Western Europe. The Western Pacific had the lowest gender ratio, which implies a similar rate of males to females dying by suicide in this region. Aside from differences in the overall description, it is worth noting that the ratio of males to females dying by suicide was relatively stable in some regions, but changed over time in other regions. In particular, this refers to the African region, the Eastern Mediterranean region and South America.

Discussion

The results of this paper demonstrate the vast spatial and temporal differences in the rates of women dying by suicide over time. The most obvious limitation is that the data from the different countries examined was not available over a consistent or lengthy time period. As stated earlier, some countries had data that covered lengthy time periods. Yet other countries, such as Iran or Jamaica, only had data from much shorter periods of time. These differences impacted the overall suicide rates in the regions examined in this paper and influences the ability to accurate assess female suicide rates by regions over time. Data appears to have been little reported in some areas of the world, which shortens the length of time in which female suicide rates can be studied and compared. The lack of countries reporting suicide data prior to 1980 hinders the interpretation of time-trends in some areas.

All suicide deaths face vulnerability to misclassification or under-reporting, which, in some areas, may be due to legal ramifications or cultural stigma - as argued previously, female suicide deaths may be more vulnerable than male deaths. Indeed, Douglas (1967) originally cautioned that female suicides could be subject to

174 K. McKay et al.

stigma as they could imply an unbearable family life - a wife and mother chose death rather than live with her husband and children. This bound construction may still contain some relevance for more culturally conservative countries. Further, methods commonly used in female suicides, such as drug overdoses, can be more easily misclassified (Canetto & Lester, 1995; Cantor, Leenaars, & Lester, 1997; Jaworski, 2010).

We must also acknowledge that this study has not discussed non-fatal suicidal behaviours, which occur in far greater numbers than suicide deaths in many areas of the world (Canetto, 2009). The main reason for this is the lack of available data on suicide attempts across the world. Unlike suicide deaths, which are usually reported in vital statistics registers, few areas of the world regularly collect information on suicide attempts. Further exacerbating under-reporting is the fact that those who attempt suicide may not seek any help from healthcare facilities.

Regardless of these limitations, this paper was still able to reveal variation in the patterns and trends of female suicide deaths within different geographical regions of the world over time. The descriptive results presented in this paper provides the basis from which public health researchers can commence a discussion on the importance of single gendered analysis of suicide death to add to, and complement, the existing gendered comparison data that dominates the literature.

One of the notable findings was the increase in female suicide rates in those countries experiencing the most political, economic or social turmoil and transition in past decades, such as those in Eastern Europe, the Baltic States, the Western Pacific and South-East Asia. The ways in which contextual financial and social shifts impact both male and female suicide have previously been noted in several other studies (Barth, Sogner, Gnambs, Kundi, & Winker, 2011; Bogdanovika et aI., 2011; Ceccherini-Nelli & Priebe, 2010; Chang, Gunnell, Sterne, Lu, & Cheng, 2009; Gunnell, Platt, & Hawton, 2009; Makinen, 2006) and suggest that females are as likely to be at risk from macro-economic, political and social change as men. This research contradicts Durkheim's (189711952) hypothesis that females are immune to changes in the social environment because they are more 'protected' through their roles in the domestic sphere of family life (see also Canetto, 2008; Kushner, 1993; Kushner & Sterk, 2005; Lehmann, 1990, 1995).

There were also relatively high female suicide rates in Scandinavia and Western Europe. While not undergoing the same observable political and economic shifts as the areas discussed above, these regions of the world have undoubtedly experienced change over the past few decades. To name a few previously found to be associated with female suicide, these may include cultural shifts towards 'individualism' (Webster Rudmin, Ferrada-Noli & Skolbekken, 2003) and the increase in female participation in the workplace (Fernquist, 1999; Mayer, 2000). While these social shifts have brought about greater gender equality and liberalisation, the perceived need for women to successfully engage in both domestic and work life has resulted in work-family overspill, burnout, depression and psychological distress (Allen, Herst, Bruck, & Sutton, 2000); all of which may increase the risk of suicide in women. Considering this, it would not be surprising to find that these factors are also be related to an increased suicide risk.

We must also consider other possible explanations for higher female suicide rates in these areas, such as genetic differences, cultural variation in the acceptability of suicide, access to means, an increasing use of lethal means or the availability of appropriate healthcare and suicide-prevention services (Bogdanovika, Jiang, Lohr,

....... ..... I-< 0.. « o .......

International Journal of Culture and Mental Health 175

Schmidtke, & Mittendorfer-Rutz, 2011; Canetto, 2008; Jaworski, 2007). Interestingly, it is worth noting that those areas with moderate to high suicide rates were also the best resourced in terms of healthcare. This raises the question as to whether the resources available are appropriate to the needs of suicidal women and to the overarching culture in which they sit.

Thus far in suicide research, there is disproportional interest in the epidemiology, motivation and social determinants of male suicide, while comparatively little attention has been focused on female suicide. However, as we have shown in the descriptive analyses above, there are many areas of the world where female suicidal behaviours are above the global average. These findings emphasise the need for further attention from both policy makers and researchers into the unique factors underpinning female suicidal behavior.

Another significant finding of this study was the vast differences in the gender ratio of suicidal behaviours between regions of the world. Several areas have a relatively equal number of males dying to females in the world, particularly in the Western Pacific and South-East Asia. This closer number of females to males dying by suicide has begun to be noted (e.g. , De Leo, Milner, & Wang, 2009) and contradicts universal assumptions that men are always at greater risk of suicide than women. It is also worth noting that the gender ratio of suicide has increased over time in Central and Eastern Europe, South America, South-East Asia, and (to some extent) Southern Europe.

In the absence of clear explanatory data or mature discussion within the suicidology field, the findings from this study could assist in commencing initial discussions in a gendered, yet not comparative, suicide debate. This study has unpacked the Gender Paradox of suicide using Cultural Scripts theory; a theory that deconstructs the ways in which all behaviours, including suicide, are perceived, articulated and then acted upon. Consequently, this can explain why, in some localities and during particular periods, women and men use different methods while at other times and places they do not, and why the mortality rates from the same method vary by gender (Canetto & Sakinofsky, 1998; Jaworski, 2010). In addition, the gender differences in reporting behaviours can be addressed, as family members and local authorities may be more likely to conceal female suicidal behaviours (see Douglas, 1967). Finally, Cultural Scripts Theory can account for the Gender Paradox of suicidal behaviour, as well as its exceptions, recorded around the world (Canetto & Lester, 1998; Canetto & Sakinofsky, 1998).

It is important that contextually-sensitive suicide research is initiated and prevention strategies developed in areas of the world for which there is little knowledge. It is clear that the proximal and distal determinants of suicide are likely to be influenced by the societies in which they occur; a recent paper demonstrated that the prevalence of suicide cases with classifiable mental disorders differed considerably across the world (Milner et aI., 2012). However, as has been demonstrated in the current study, culture, including religion and gendered norms, can also impact upon the ways in which suicide as a behaviour is perceived, researched and prevented.

Conclusion and implications

The findings presented in this paper demonstrate that female suicide deserves understanding in and of itself. While often lower than male rates, the female rates of

176 K. McKay et al.

suicide in countries such as Japan, Sri Lanka and Hungary are higher than the global average suicide rate. Consequently, there is a need for public health interventions to address this burden - these suicide rates need to be understood just as urgently as the male suicide rates. Further, gender ratios in some countries are decreasing which nullifies the presumption that male suicide rates are always considerably higher than female rates. Indeed, in rural China more women die by suicide than men, a phenomenon that has continued for over a decade now. The findings from this paper have opened a discourse around the placement of female suicide within suicidology -that it should no longer be predominantly comparative but is deserving of understanding on its own. Large numbers of women remain vulnerable to suicide in many countries around the world and it is vital to ensure that preventions and interventions are appropriate and effective to their needs. Analysing the rates and ratios of female suicide in different countries is only the start - the next necessary step is to better understand the cultural contexts in which the numbers sit. This is especially the case in countries experiencing social and economic crises as there is little understanding as to how these crises impact upon female wellbeing and suicidal behaviours because it appears that Durkheim's argument of domestic safety can no longer be presumed.

Notes on contributors Kathy McKay is a Postdoctoral Research Fellow in the Collaborative Research Network for Mental Health and Wellbeing in Rural Areas at the University of New England, New South Wales. Her research interests include the constructions of gender, culture and community within suicidology.

Allison Milner is a Research Fellow at the School of Population and Global Health, the University of Melbourne. Her main areas of research include suicidology, mental wellbeing, and work as a social determinant of health and illness.

Myfanwy Maple is an Associate Professor of Social Work in the School of Health and Collaborative Research Network for Mental Health and Wellbeing in Rural Areas at the University of New England, New South Wales. Her research interests include suicide, bereavement, trauma and resilience.

References Ahmad, 0. , Boschi-Pinto, c. , Lopez, A. D., Murray, C. 1. L. , Lozano, R. , & Inoue, M. (2001).

Age standardization of rates: A new WHO standard. Geneva: World Health Organization. Allen, T. D. , Herst, D. E. , Bruck, C. S., & Sutton, M. (2000). Consequences associated with

work-to-family conflict: A review and agenda for future research. Journal of Occupational Health and Psychology, 5, 278- 308. doi:1O.10371l076-8998.5.2.278

Beautrais, A. (2006). Women and suicidal behavior. Crisis, 2, 153-156. Beautrais, A., & Fergusson, D. M. (2006). Indigenous suicide in New Zealand. Archives of

Suicide Research, 10, 159- 168. doi: 10. 108011 381 1 110600556913 Bertolote, 1. M. , Fleischmann, A. , De Leo, D. , Phillips, M .R. , Botega, N.J. , Vijayakumar, L. ,

... Wasserman, D. (2010). Repetition of suicide attempts: Data from emergency care settings in five culturally different low- and middle-income countries participating in the WHO SUPRE-MISS Study. Crisis, 31 , 194- 201.

Barth, A. L. , Sogner, T., Gnambs, M ., Kundi, A. R. , & Winker, R . (2011). Socioeconomic factors and suicide: An analysis of 18 industrialized countries for the years 1983 through 2007. Journal of Occupational and Environmental M edicine, 53, 313- 317. doi:1O.l097/ JOM.Ob013e3l820d l6lc

International Journal of Culture and Mental Health 177

Bogdanovica, I., Jiang, G-X., Lohr, c., Schmidtke, A., & Mittendorfer-Rutz, E. (2011). Changes in rates, methods and characteristics of suicide attempters over a 15-year period: Comparison between Stockholm, Sweden, and Wurzberg, Germany. Social Psychiatry & Psychiatric Epidemiology, 46, 1103-1114. doi:1O.1007/s00127-01O-0282-3

Canetto, S. S. (2009). Prevention of suicidal behaviour in females: Opportunities and obstacles. In D. Wasserman & c. Wasserman, (Eds.), Oxford textbook of suicidology and suicide prevention: A global perspective (pp. 241-247). Oxford: Oxford University Press.

Canetto, S. S. (2008). Women and suicidal behaviour: A cultural analysis. American Journal of Orthopsychiatry, 78, 259-266. doi:1O.1037/a0013973

Canetto, S. S., & Lester, D. (1998). Gender, culture and suicidal behavior. Transcultural Psychiatry, 35,163-190. doi:1O.11771136346159803500201

Canetto, S. S., & Lester, D. (1995). The epidemiology of women's suicidal behavior. In S. S. Canetto & D. Lester, (Eds.), Women and suicidal behaviour (pp. 35-37). New York: Springer.

Canetto, S. S., & Sakinofsky, I. (1998). The gender paradox in suicide. Suicide & Life­Threatening Behavior, 28, 1- 23.

Cantor, C. H., Leenaars, A. A. , & Lester, D. (1997). Under-reporting of suicide in Ireland 1960-1989. Archives of Suicide Research, 3, 5- 12.

Ceccherini-Nelli, A., & Priebe, S. (2010). Economic factors and suicide rates: Associations over time in four countries. Social Psychiatry and Psychiatric Epidemiology, 46, 975-982. doi: 10.1007/s00127-01O-0275-2

Chang, S-S. , Gunnell, D. , Sterne, 1. A. c., Lu, T-H., & Cheng, A. T. A. (2009). Was the economic crisis 1997- 1998 responsible for rising suicide rates in east/southeast Asia? A time-trend analysis for Japan, Hong Kong, South Korea, Taiwan, Singapore and Thailand. Social Science & Medicine, 68, 1322-1331. doi:1O.1016/j.socscimed.2009.01.01O

De Leo, D., & Evans, R. (2004). International suicide rates and prevention strategies. Gottingen, Germany: Hogrefe & Hubar.

De Leo, D. , Milner, A., & Wang, X. (2009). Suicidal behavior in the Western Pacific region: Characteristics and trends. Suicide and Life-Threatening Behavior, 39, 72-8l. doi:10.15211 suli.2009.39.1 .72

De Leo, D., Sveticic, 1., & Milner, A. (2011). Suicide in Indigenous People in Queensland, Australia: Trends and methods, 1994-2007. Australian and New Zealand Journal of Psychiatry, 45(7), 532-538. doi: 10.3109/00048674.20 1l.570310

Denning, D. G. , Conwell, Y. D. , King, D. , & Cox, C. (2000). Method choice, intent and gender in completed suicide. Suicide and Life-Threatening Behavior, 30, 282- 288.

Douglas, 1. D. (1967). The social meanings of suicide. Princeton: Princeton University Press. Durkheim, E. (189711952). Suicide: A Study In Sociology. London: Routledge & Kegan Paul. Fernquist, R. M. (1999). Gender equality and the sex differential in suicide rates using gender-

age standardized data. Archives of Suicide Research, 5, 255- 260. Gunnell, D. , Platt, S., & Hawton, K. (2009). The economic crisis and suicide. BMf, 338,

1456-1457. doi:1O.1136/bmj.b1891 Guzder, 1. (2011). Women who jump into wells: Reflections on suicidality in women from

conflict regions of the Indian subcontinent. Transcultural Psychiatry, 48, 585- 603. doi:10.117711363461511425098

Jaworski, K. (2010). The gender-ing of suicide. Australian Feminist Studies, 25, 47-61. doi: 10.1080108164640903499752

Jaworski, K. (2007). The gender of suicide. School of Communication: Division of Education, Arts and Social Sciences. Adelaide: University of South Australia.

Jaworski, K. (2003). Suicide and gender: Reading suicide through Butler's notion of performativity. Journal of Australian Studies, 76, 137-146. doi:1O.1080114443050309387832

Kushner, H. I. (1993). Suicide, gender and the fear of modernity in nineteenth-century medical and social thought. Journal of Social History, 26,461-490. doi:1O.1353/jsh/26.3.461

Kushner, H. I., & Sterk, C. E. (2005). The limits of social capital: Durkheim, suicide and social cohesion. American Journal of Public Health, 95, 1139- 1145. doi:1O.2105/AJPH.2004. 053314

Lehmann, 1. M. (1995). Durkheim's theories of deviance and suicide: A feminist reconsidera­tion. American Journal of Sociology, 100, 904-930. doi: 10.1086/230604

Lehmann, 1. M. (1990). Durkheim's response to feminism: Prescriptions for women. Sociological Theory, 8,163- 187. doi:1O.23071202203

·c 0..

--< o

N ,......;

178 K McKay et al.

Makinen, I. H. (2006). Suicide mortality of Eastern Europe regions before and after the Communist period. Social Science & Medicine, 63, 307-319. doi:1O.1016/j.socscimed.2006. 01.002

Mayer, P. (2000). Development, gender equality and suicide rates. Psychological Reports, 87, 367-372.

Milner, A. , Sveticic, 1., & de Leo. (2012). Suicide in the absence of mental disorder? A review of psychological autopsy studies across countries. International Journal of Social Psychiatry. Published online 11 May 2012

Mittendorfer Rutz, E., & Wasserman, D. (2004). Trends in adolescent suicide mortality in the WHO European region. European Child and Adolescent Psychiatry, 13, 321-331. doi: 10.1007 Is00787 -004-0406-y

Nordentoft, M., & Branner, 1. (2008). Gender differences in suicidal intent and choice of method among suicide attempters. Crisis, 29, 209-212.

Odagiri, Y. , Uchida, H., & Nakano, M. (2011). Gender differences in age, period and birth­cohort effects on the suicide mortality rate in Japan, 1985-2006. Asia-Pacific Journal of Public Health , 23,581-587. doi:10.117711010539509348242

Phillips, M. R. , Li , X., & Zhang, Y. (1999). Suicide rates in China, 1995- 1999. Lancet, 359, 835-840. doi:1O.1016/S0140-6736(02)07954-0

Webster Rudmin, F., Ferrada-Noli, M. , & Skolbekken, 1. A. (2003). Questions of culture, age and gender in the epidemiology of suicide. Scandinavian Journal of Psychology, 44, 373-381. doi:l0.111111467-9450.00357

Silburn, S. B. , Glaskin, D. , Henry, D. , & Drew, N. (2010). Preventing suicide among indigenous Australians. In N. Purdie, P. Dudgeon & R. Walker (Eds.), Working together: Aboriginal and Torres Strait Islander mental health and wellbeing principles and practice (pp. 91 - 104). Canberra: Commonwealth Department of Health and Ageing.

WHO. (2011). Mortality database. Retrieved from http://apps.who.int/whosis/database/mortl tablel.cfm

Wierbicka, A. (1993). A conceptual basis for cultural psychology. Ethos, 21, 205-231. doi: 10.1525/eth.1993.21.2.02a00040

Yip, P. S. F. , Liu, K. Y. , Hu, 1. , & Song, X. M. (2005). Suicide rates in China during a decade of rapid social changes. Social Psychiatry & Psychiatric Epidemiology, 40, 792-798. doi: 1O.1007/s00127-005-0952-8

Zhang, 1., Li , N. , Tu, X-M., Xiao, S. , & Jia, C. (2011). Risk factors for rural young suicide in China: A case-control study. Journal of Affective Disorders, 129, 244-251. doi: 1 0.10 161 j.jad.2010.09.008