Violence against women is strongly associated with suicide attempts: Evidence from the WHO multi-country study on women’s health and domestic violence against women
Highlights
► We present data on prevalence and predictors of suicidal behaviour among women from 13 low and middle income settings. ► Prevalence of lifetime suicide attempts ranged from 0.8 to 12.0%. ► Experience of violence predicted suicide attempts across settings, even after accounting for common mental disorders.
Introduction
Durkheim, the original suicide theorist, famously postulated in the 1800s that women were less prone to suicide because they were inclined to reside in the protective domestic sphere and did not trifle in worldly affairs (Kushner & Sterk, 2005). Although subsequent research has challenged Durkheim’s thesis (Canetto and Lester, 1998, Girard, 1993, Kushner and Sterk, 2005, Stark and Flitcraft, 1979, Stark and Flitcraft, 1995), suicidal behaviour among women has received relatively limited attention as a public health concern.
Globally, men are more likely to complete suicide than women, although there is substantial regional variation. In North America and Europe, approximately 3.9 men die from suicide for every one woman, whereas in Asia, sex ratios are more similar at about 1.1 men for every woman (World Health Organization, 2004). In China, women are more likely to complete suicide than men (Phillips, Li, & Zhang, 2002). In contrast, in many settings non-fatal suicidal behaviours are more common among women than men (Beautrais, 2006, Bernal et al., 2007, Bertolote et al., 2005, Nock et al., 2008), but historically have received less attention than fatalities. Indeed, when both mortality and disability are taken into account, the extent of the health burden of suicidality among women becomes clear. Intentional self-inflicted injuries were the 4th leading cause of death and 7th leading cause of DALYS for women aged 15–44 globally in 2005, ranking higher than well-recognised public health issues such road traffic crashes and hearing loss (Ribeiro, Jacobsen, Mathers, & Garcia-Moreno, 2008).
Despite this substantial health burden, little is known about the extent of suicidal behaviour and potentially modifiable risk factors in low and middle income settings (Vijayakumar, John, Pirkis, & Whiteford, 2005). Several recent international studies, including the world mental health surveys (Borges et al., 2007, Gureje et al., 2007, Joe et al., 2008, Nock et al., 2008), WHO SUicide PREvention Multisite Intervention Study on Suicidal behaviours (SUPRE-MISS) (Bertolote et al., 2005, Tran Thi Thanh et al., 2006), along with various in-country secondary school-based adolescent health surveys (Blum et al., 2003, Muula et al., 2007, Rudatsikira et al., 2007a, Rudatsikira et al., 2007b) and other studies (Agoub et al., 2006, Alem et al., 2007b, Kebede and Alem, 2007), have found the reported prevalence of attempted suicide among women and girls to be approximately 1–8%. Unfortunately, most of these studies report only on the role of socio-demographic characteristics and/or mental disorders as risk factors for suicidal behaviour (Bertolote et al., 2005, Nock et al., 2008). Although there is evidence from North America and Europe, and recently from India, confirming that adverse childhood experiences (Dube et al., 2001, Fergusson et al., 2008) and partner violence (Ellsberg, Jansen, Heise, Watts, & Garcia-Moreno, 2008) are associated with suicidal behaviour, only a limited number of studies from low and middle income countries have explored the role of these risk factors (Ahmed et al., 2004, Alem et al., 2007b, Blum et al., 2003, Borges et al., 2008, Maselko and Patel, 2008, Naved and Akhtar, 2008, Pillai et al., 2008, Vizcarra et al., 2004). Early exposure to violence and/or trauma may increase subsequent feelings of depression and affect ability to cope with life stressors, and thus be related to suicidal outcomes (Brodsky & Stanley, 2008, Fergusson et al., 2008). Similarly, there is discussion in the literature about the role of having a dowry/bride price, control over choosing one’s husband, and being childless in marriage in increasing suicide risk, but evidence only from a handful of studies, mainly in Asian settings (Ahmed et al., 2004, Kumar, 2003, Yusuf et al., 2000). Each of these factors may result in poor mental health status directly, but also may be associated with restricted autonomy and loss of control, which can then in turn cause poor mental health status (Canetto & Lester, 1998). Having increased autonomy and social support available may buffer associations between poor mental health status with violence and gender norm variables by mitigating feelings of isolation and hopelessness (for example, De Silva, Huttly, Harpham & Kenward, 2007).
We hypothesized that early childhood and adult experiences of violence, more conservative gender norms and poor adult mental health status would predict increased levels of suicidal outcomes (Fig. 1). This paper uses data from the WHO multi-country study on women’s health and domestic violence against women, which included 20967 women from 9 mainly low and middle income countries. We describe prevalence of suicide outcomes, and assess common and consistent predictors of reported suicide attempts across settings.
Section snippets
Methods
The study methods have been described in detail elsewhere (Garcia-Moreno, Jansen, Heise, & Watts, 2005). Briefly, representative population-based surveys of women aged 15–49 years (aged 18–49 in Japan) were conducted between 2000–2003. In four countries, study sites were more rural (‘province’) and urban (‘city’) locations: Zona da Mata de Pernambuco and Sao Paulo, Brazil; Cusco and Lima, Peru; Nakhonsawan and Bangkok, Thailand; Mbeya and Dar es Salaam, Tanzania. In five countries the survey
Results
A detailed description of the demographic characteristics of the women interviewed is published elsewhere (Ellsberg et al., 2008, Garcia-Moreno et al., 2005). The percentage of women who had ever been in an intimate partnership ranged from 68.5% in Thailand city to 93.9% in Japan city. The most common form of violence reported in most sites was intimate partner violence (70.9% in Ethiopia province to 15.4% in Japan city of ever-partnered women, with 9 of 13 sites above 40%). Non-partner sexual
Discussion
These findings provide new information on the prevalence of suicidality among women and demonstrate a strong association with experiences of violence. There was a 15-fold variation in the prevalence of suicide attempts across sites, 4-fold variation in lifetime suicidal thoughts and a 7-fold variation in recent suicidal thoughts. These findings are consistent with SUPRE-MISS, which documented a 10–14-fold variation in rates of suicidal ideations and attempts in men and women (Bertolote et al.,
Conclusion
National suicide rates have been identified as key indicators of state progress on mental health, along with the existence of national mental health policies and adequate resource allocation (Lancet Global Mental Health Group, 2007). The high prevalence of suicidal thoughts and attempts in this study and the strong association with violence against women illustrates the necessity of prioritizing violence in suicide reduction strategies for women. The recognition of violence as a major risk
Acknowledgements
We gratefully acknowledge the participants in the WHO study, and anonymous reviewers for helpful comments.
References (61)
- et al.
Assessment of suicidality in a Moroccan metropolitan area
Journal of Affective Disorders
(2006) - et al.
Risk factors for suicidality in Europe: results from the ESEMED study
Journal of Affective Disorders
(2007) - et al.
Adverse childhood experiences and suicidal behaviour
Psychiatric Clinics of North America
(2008) - et al.
Social capital and mental health: a comparative analysis of four low income countries
Social Science & Medicine
(2007) - et al.
Intimate partner violence and women’s physical and mental health in the WHO multi-country study on women’s health and domestic violence: an observational study
Lancet
(2008) - et al.
Exposure to childhood sexual and physical abuse and adjustment in early adulthood
Child Abuse & Neglect
(2008) Dilemmas and opportunities for an appropriate health-service response to violence against women
Lancet
(2002)- et al.
Prevalence of intimate partner violence: findings from the WHO multi-country study on women’s health and domestic violence
Lancet
(2006) - et al.
Childhood physical and sexual abuse and lifetime number of suicide attempts: a persistent and theoretically important relationship
Behaviour Research and Therapy
(2007) Burnt wives-a study of suicides
Burns
(2003)
Suicide rates in China, 1995–1999
Lancet
Effect of a structural intervention for the prevention of intimate-partner violence and HIV in rural South Africa: a cluster randomised trial
Lancet
Priorities for women’s health from the global burden of disease study
International Journal of Gynecology & Obstetrics
Global Mental Health 2: resources for mental health: scarcity, inequity and inefficiency
Lancet
Injury-related deaths in women aged 10–50 years in Bangladesh, 1996–1997
Lancet
Violent deaths among women of reproductive age in rural Bangladesh
Social Science & Medicine
Awareness and attitudes of a rural Ethiopian community towards suicidal behaviour: a key informant study in Butajira, Ethiopia
Acta Psychiatrica Scandanavia
Suicide attempts among adults in Butajira, Ethiopia
Acta Psychiatrica Scandanavia
Child sexual abuse
Women and suicidal behavior
Crisis
Suicide attempts, plans, and ideation in culturally diverse sites: the WHO SUPRE-MISS community survey
Psychological Medicine
A user’s guide to the self-reporting questionnaire (SRQ)
Adolescent health in the Caribbean: risk and protective factors
American Journal of Public Health
Traumatic events and suicide-related outcomes among Mexico City adolescents
Journal of Child Psychology and Psychiatry
The epidemiology of suicide-related outcomes in Mexico
Suicide and Life-Threatening Behaviors
Gender, culture and suicidal behavior
Transcultural Psychiatry
Childhood abuse, household dysfunction, and the risk of attempted suicide throughout the life span. Findings from the adverse childhood experiences study
JAMA
WHO multi-country study on women’s health and domestic violence against women: Intial results on prevalence, health outcomes and women’s responses
Age, gender, and suicide: a cross-national analysis
American Sociological Review
The profile and risks of suicidal behaviours in the Nigerian survey of mental health and well-being
Psychological Medicine
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