To die or not to die: a qualitative study of men’s suicidality in Norway

In 1998, Canetto and Sakinovsky [1] described the gender paradox of suicidal behavior: “In most Western countries, females have higher rates of suicidal ideation and behavior than males, yet mortality from suicide is typically lower for females than for males”. This paradox has puzzled suicide researchers for decades. Thus, gender has increasingly been emphasized as crucial for understanding suicidal behavior [2]. This is, for instance, reflected in the following comprehensive publications: In 2012, Canetto and Cleary [2] edited a part special issue of Social Science & Medicine on Men, Masculinities and Suicidal Behavior. In the same year, the Samaritans [3] in the UK published the research report Men, Suicide and Society: Why Disadvantaged Men in Mid-Life Die by Suicide. This report provided an extensive overview of factors leading to men’s suicide. In 2014, Lester, Gunn III and Quinnett [4] published the anthology Suicide in Men: How Men Differ from Women in Expressing Their Distress, with chapters from many different socio-cultural contexts. The editors’ aim with this book was to start a discussion on men’s vulnerability.

It is, however, necessary to be cautious since gender is one of the most frequently used sociodemographic variables as well as one of the most oversimplified and misused concepts in epidemiological and risk factor suicide studies [5–7]. Consequently, Krysinska et al. [5] underlined that “… it remains a serious challenge for both researchers and clinicians to identify risk and protective factors which make “some men” vulnerable to suicide, while others remain resilient when faced with life adversity or psychopathology”.

From research conducted to date, we know some of the circumstances that may make some men vulnerable to suicidal behavior. Evans et al. [8] and Scourfield & Evans [9] have, for instance, pointed out that men are challenged more by changing gender roles than are women. They also maintain that marriage may be a more positive experience for men than for women, that the care of children has become culturally more important and expected for men, and that men do not employ their social network for support when experiencing emotional difficulties. Hence, marriage breakdown may have worse consequences for men than for women.

Cleary [6] interviewed young Irish men after a suicide attempt and found that they had high levels of emotional pain. In addition, they had fewer coping skills as they had problems recognizing their symptoms as well as disclosing their pain to others because of dominating masculine norms of being in control. Also others have found men to be less likely than women to express emotions [10], which again has been assumed to account for the report of higher psychological distress among women, but higher suicide rates in men [6, 11]. A consequence of the inability to disclose emotional distress is that relationship problems and breakups might carry different weight for men than for women. However, the financial and ideological context of severe relationship problems must be considered as mediating factors [8, 12, 13] as cultural condemnation of divorce or women’s financial dependency influence the effect of relationship breakup. In addition, one has to consider when in the life course the breakup happens as it carries different weight during different age groups. According to a systematic review by Evans et al. [14] middle-aged men appear to be more affected than women and younger men by a breakdown in their marital/romantic relationships since these relationships may be their main source of intimacy and their only possibility for sharing their vulnerable sides. In another review study Evans et al. [8] find “… no definitive evidence of a gender differential in suicidal behaviors following the breakdown of a relationship” as they do not find any clear trend that goes across age. Nor do they find consistent patterns across countries or regions.

Previous research has shown that men who adhere to traditional beliefs about masculinity seem to have increased health risks compared to those who do not aspire to traditional forms of masculinity [15]. This must be seen in relation to the fact that traditional masculine behavior underplays the role of emotion as the man is expected to be in total control of himself and the situation, and thus reluctant to report distress [16]. This, in turn, then allows stress to build up and a vulnerability to suicidal behavior may develop. However, the development of masculinity occurs in interplay with the actual and constantly changing context. The life of an 80-year old man has developed in a considerably different context than what is the case for a 20-year old man. From the existing research, some male risk factors like single marital status, unemployment, retirement and physical illness are identified [17], but they all must be seen in light of the actual social and normative context, the specific life history and age and what they mean for each man.

Historically, masculinity norms in Norway were influenced by harsh physical environment and being a fishing nation [18]. Dangerous and hard work was fundamental for being able to provide for the family and necessary periods of absence built the fundament for the women to take responsibility. According to Lease et al. [18] this created cultural values of self-sufficiency, independence, and courage of men, but lay also the foundation for egalitarianism between the genders. Men supported changes at home and working-place but they may have received incongruent messages about appropriate masculine behavior. The news featured Norwegian men who felt a devaluation of traditional masculine roles [19]. In addition, the Norwegian society is changing rapidly through immigration and masculine norms from other cultures are blended into society.

In a changing society like Norway, context sensitive research is needed and qualitative research comes to the fore. Such research is able to take more of the context and actual life situation of individuals into consideration in the analysis, compared to what quantitative risk factor research is able to [8, 20]. Qualitative research also allows us to focus on the individual and to highlight contextualized individual differences in circumstances related to suicidality. This is important in order to develop our understanding of what suicidality might mean to people who are suicidal, in their context, and beyond the common simplistic risk factor categories. Franklin et al.’s [21] recent meta-analysis of 50 years of risk factor research demonstrated the limited value of risk factors in terms of understanding suicidality and hence for suicide prevention. For example, “relationship problems” is a commonly found risk factor for suicidal behavior. In her comprehensive review study on Muslim women and suicide, Canetto [22], however, found that relationship problems can cover many, and very different issues for these women. There is no reason to believe that this would be any different for women in general, as well as for men. This will in turn have consequences for suicide prevention. The purpose of the present qualitative interview study was thus to investigate what men who have engaged in a suicidal act perceived as crucial for their decision to harm themselves or attempt to take their life. We analyze this in the context of their actual life situation, and hence look deeper into aspects that might be overlooked or not described in traditional quantitative risk factor research.

We conducted semi-structured qualitative in-depth interviews with men admitted to hospital following a suicidal act. Before the interview, we knew nothing about the participants other than the fact that they had harmed themselves sufficiently to require hospitalization. We chose this approach deliberately in order to be as open as possible to the men’s own descriptions of the circumstances around their suicidal act.

Two themes were developed through the analysis: Reasons or triggers for the suicidal act and Attributed responsibility for the suicidal act. They are described and substantiated by quotations in the following.

In this study, we interviewed men after a suicidal act medically serious enough to require hospitalization. One-third of the men expressed that they actually had not wanted to die, while the rest had decided that death was the best option in their life situation. We compared these two groups on the two themes developed in the analysis, namely what they perceived as the main reason or trigger for their suicidal act and to whom/what they attributed responsibility for the act. All the men who did not want to die and half of the men who had wanted to die emphasized relationship problems as the main reason/trigger for the suicidal act. The elevated risk of suicidal behavior and ideation after breakdowns in intimate relationships has been known for some time [26]. Krysinska [5] has emphasized a male vulnerability to negative life events, while Lester, Gunn and Quinett [4] emphasized men’s vulnerability specifically to relationship problems: “Men also appear to be more impacted by breakdowns in their marital and romantic relationships, perhaps because they benefit more from marriage and perhaps because men find it hard to meet the modern expectations for increased intimacy”. In their systematic review of research on relationship breakdown and suicide risk, Evans et al. [8, 14] found 17 studies with higher risk for men, six with a higher risk for women, and six with no gender difference. Van Orden et al. [27] pointed out that women in general value family and being loved higher than men and then in the absence of these “… suffer greater emotional pain than do men in the same situations”. This stands in contrast to Evans et al. [8, 9], who underline men’s larger vulnerability under relationship breakups and suggest as explanations “… men’s role inflexibility, the increasing importance of the care of the children, men’s desire for control in relationships, and men’s social network” [9].

In order to understand and target this vulnerability we need to know more about particularities, as we meet different reactions to problems based on men’s masculine identity. Three quarters of our participants described relationship problems as the main reason or trigger for their suicidal act, though they were related to different underlying feelings such as feeling betrayed, abandoned, ashamed, or being a failure in terms of inability to take responsibility for the wife. The individual emotional reactions must be understood on the background of their history and context and their relationship with those. Several publications and anthologies [2, 4, 28] have contributed significantly to the contextualized understanding of gendered suicide scripts, while suicide among men in the specific Norwegian context still is mainly unexplored. With the exception of Rasmussen et al. [29], who have contributed with their psychological autopsy study on suicide among young men, where they found suicides to be signature acts of compensatory masculinity, we still do not know much about the particularities among men in Norway.

In the present study, the main trigger for the suicidal act among our participants was in line with other countries a variety of problems related to close relationships. In fact, three quarters of them mentioned such problems that covered many different issues and the men also felt hurt in different ways as their actual background and context was different. In addition, the age range was from 20 to 76 years, contributing even more to the complexity of the situation as their situation and psychological make-up might have differed significantly. The relationship problems mentioned were connected to the men’s lived masculinity, ranging from shame, or tainted masculine honor, to taking responsibility as a man for the wife. Most of these problems could be interpreted in line with men’s desire for control in relationships as a consequence of the traditional Norwegian masculinity norms as independence and self-sufficiency. The two oldest men stated that they had not wanted to be a burden to their wives, which could be interpreted as role inflexibility [9]. In 2017, Canetto, in her article “Suicide: Why are older men so vulnerable?” [30] convincingly showed that illness may lead men to suicide in a much higher degree than women. Her explanation is “Rigidity in coping and in sense of self, consistent with hegemonic-masculinity scripts, emerged as individual-level clues”. The meanings and consequences of severe illness thus are highly dependent on gender values and the ideal of self-sufficiency and independence that traditionally were Norwegian masculine ideals. Except for this perceived burdensomeness, we could not find any trigger specific for the age groups (young adults, middle-aged, old).

Relationship problems and perceived burdensomeness draw the attention towards the Interpersonal Theory of Suicide (IPTS); a theory developed by Joiner [31] and further explicated by Van Orden and colleagues [27]. Judging from the recent systematic review and meta-analysis of the studies testing this theory to date conducted by Chu and colleagues [32], this theory currently seems to dominate the suicide research field. The IPTS posits that thwarted belongingness and perceived burdensomeness must be present simultaneously for a suicidal desire to emerge.

Certainly, some of the (relationship) problems found above may be interpreted as thwarted belongingness, but this does not seem to be accompanied by feelings of burdensomeness. The men who explicitly said that they felt like a burden (to their wives), expressed this in a context of long lasting, stable relationships, indicating that this had nothing to do with thwarted belongingness. In his book outlining the IPTS, Joiner [31] claims that this theory is able to explain suicidality “worldwide, across cultures” and in their meta-analysis of all the 122 studies testing the IPTS to date (all quantitative), Chu et al. [32] on the one hand claim that the findings support the theory, but on the other admit that the evidence is mixed, and that effect-sizes are small to medium, indicating huge variations. Qualitative studies like the present one, are able to present more nuanced and contextualized pictures of what lies behind suicidal behavior compared to what quantitative risk factor research is able to. In qualitative studies, some of the complexity and individual variability involved in suicidal behavior becomes apparent [20]. Such studies contribute to question the relevance of reductionist theories like the IPTS, which posits that suicide can be explained by three factors only (acquired capability to enact lethal self-harm in addition to thwarted belongingness and perceived burdensomeness). However, (masculine) identity always is contextual and dynamic, developed and maintained in an ongoing interplay with other people and the surrounding society. Consequently, the prominent approach to suicide prevention seems to require a dynamic and systemic perspective instead of a pure individualistic approach.

In keeping with Fleischer [33] and Staples & Widger [34], we found suicidality to be clearly relational. During the last 60 years this relational aspect of suicidality repeatedly has been described in communicative terms as ‘symbol’ [35], ‘appeal’ [36], ‘manipulation’ [37] or ‘cry for help’ [38], and hence defined suicide as a communicative act. Men’s hesitance to express distress and seek help might be an additional argument to study their suicidal behavior as their specific form for communication in order to understand why it seemed necessary to turn from verbal communication to suicidal acts. It might therefore be fruitful to view suicidal acts as relational, communicative acts and thus to interpret them within the framework of communication theory [33, 39].

In this study we found an interesting difference in attribution of responsibility between the “not to die” and “to die” group. Only one in the “not to die” group took full responsibility for the suicidal act, whereas all but one did the same in the “to die” group. The men who did not want to die described the suicidal act as involuntary because of either alcohol or blackout. This attribution of responsibility goes beyond classical attribution theory [40], as the men who renounced their own responsibility for the suicidal act, did not attribute it externally to someone else, but to forces that were beyond their power within themselves. For three men, the explanations seemed to offer a way of distancing themselves from the act without feelings of guilt or shame. This mechanism enabled them to sympathize with those close to them and create a shared project to deal with the problems. The other two participants who did not take responsibility, felt betrayed by their family and did not want to talk with them, and only reluctantly with health personnel. The denial thus did not create a constructive platform for these men. The only man in the “not to die” group taking full responsibility for his suicidal act was ashamed, did not want to talk to either family or professionals and just wanted to “pull himself together”.

In the “to die” group, all but one took full responsibility and the one not doing so described the suicidal act as a “failure”, as he was determined to die. His ashamed reaction to the ‘failed’ attempt can be understood in line with Canetto and others’ work on gendered cultural scripts of suicidal behavior [2, 4], as a failure of the masculine ideal of being in full control.

The differences in attribution of responsibility might indicate the level of determination or a way of ascribing meaning to the suicidal act at the same time as maintaining their masculinity. They described the suicidal act as a deliberate act; an act they had thought extensively about for a longer or shorter period of time. An important question might be whether their attribution of responsibility and thus level of determination and meaning-making might be an indicator of the prognosis for their future and their proneness to repeat the suicidal act, with or without lethal intent. This has implications for suicide prevention.

The diversity of the stories speaks heavily against standardized efforts, including categorizing patients in relation to the level of suicide risk. The time should rather be spent listening to patients’ stories. This is in line with comprehensive research, which shows that clinicians should stop categorizing patients in relation to the level of suicide risk, and that health authorities should withdraw guidelines that require this [41]. The diversity of stories and needs of the patients rather calls for time to build up strong meeting-points with health personnel [42, 43]. Professionals must be given space, time and trust to apply their health professional skills when meeting the individual patient [44]. This requires the health professionals to be provided with suicidological competence that far exceeds a biomedical understanding of suicidality [45]. Not taking responsibility for a suicidal act might for example be an important message for health professionals to explore why the men renounce responsibility and which psychological function this may have. This should be addressed in the follow-up of suicide attempts by men and should also be studied in depth in further context sensitive research.

Relationship problems were the main reason or trigger of the suicidal act for most participants, but in very different ways, mirroring lived masculinity. As relationship problems cover a vast variety of issues that are irrefutably intertwined with their specific history and context, standardized efforts in terms of suicide prevention might not be the way forward. Besides a variety of relationship problems, some men also described ennui and physical pain as main reason/trigger of the suicidal act. The most striking finding of our study, however, is the uniqueness of each story.