Excessive masculinity is linked to a significantly increased risk for death by suicide in men, new research suggests.

In the first study to show this association, investigators found that men with high traditional masculinity (HTM) ― a set of norms that includes competitiveness, emotional restriction, and aggression ― were about two and half times more likely to die by suicide than their counterparts without HTM. The finding underscores the "central role" of gender in suicide death.

"We found that high-traditional-masculinity men were 2.4 times more likely to die by suicide than those who were not [of] high traditional masculinity. We feel this is a significant finding, and one that's very rare to have evidence for," study investigator Daniel Coleman, PhD, told Medscape Medical News.

"Our other findings are also important and interesting," added Coleman, associate professor of social service at Fordham University in New York City. "One was that high traditional masculinity was associated with a host of other significant risk factors for suicide death. So not only does high traditional masculinity add to the risk of suicide death, it also may have indirect effects through other variables, such as acting-out behavior."

The study was published online February 12 in JAMA Psychiatry.

First Look

In the United States, death by suicide is 3.5 times more common in men than in women. Several potential drivers may explain this phenomenon; one plausible factor may be high levels of what the investigators describe as "traditional masculinity."

Interestingly, previous studies suggest that HTM men experience suicidal thought to a greater degree than other persons. Nevertheless, the potential influence of HTM and suicide mortality has not been examined before now.

The study is a secondary analysis of the national longitudinal Add Health study, which began in 1995 and followed 20,745 adolescents through young adulthood. Not only did that study show a direct association between measures of HTM and death by suicide, but it also corroborated the connection between HTM and other risk factors for suicide revealed in earlier research.

To tease out this relationship, Coleman and colleagues used data from the nationally representative Add Health study. A previous study concluded that nine Add Health variables were associated with suicide. These included suicide by a family member; being expelled from school; running away from home; using a weapon; being of white race; a past history of smoking; being in a serious fight in the past year; delinquency; and fighting.

In the current study, the researchers hypothesized that HTM would be associated with these nine variables, in addition to suicide, depression, and gun access.

Add Health began in 1995 with 20,745 adolescents who were followed over time. In the current analysis, the researchers matched data from that study with death records from the National Death Index from 2014. Death by suicide was defined using National Death Index procedures.

The investigators then used an established procedure for scoring gender-typed attitudes and behaviors. As part of this, a single latent probability variable for identifying oneself as male was generated from 16 gender-discriminating variables.

Participants who were found to score at least a 73% probability of identifying as male (>1 standard deviation above the mean) were classified as HTM.

"There's been a lot of speculating about masculinity as a risk factor for male suicides," Coleman said. "But it's very difficult to study suicide death and something psychosocial like masculinity. So this was an attempt to fill that gap and test the hypothesis that's being discussed quite a bit."

A Relevant Risk Factor

Twenty-two deaths occurred among the Add Health participants. Of those participants, 21 were men (odds ratio [OR], 21.7; 95% confidence interval [CI], 2.9 – 161; P < .001).

The analysis showed that all nine risks for suicide that were highlighted in previous research were positively associated with HTM, with small to medium effect sizes. Of these, the most pronounced was family member suicide, with an OR of 1.89 (95% CI, 1.3 – 2.7).

Most tellingly, HTM men were 2.4 times more likely to commit suicide than men not defined as such (95% CI, 0.99 – 6.0; χ2 = 3.979; P < .046). Nevertheless, HTM men were also 1.45 times less likely to report suicidal ideation (OR, 0.69; 95% CI, 0.60 – 0.81; χ2 = 23.06; P < .001). There was no association between HTM and nonfatal suicide attempts.

Interestingly, HTM men were slightly more likely to report easy access to guns (OR, 1.1; 95% CI, 1.01 – 1.20; χ2 = 4.27; P < .04), but they had lower levels of depression (Cohen's d, 0.17; P < .001).

HTM not only has a direct association with suicide but also with a web of indirect effects as well, thanks to its association with all the other risks identified in the previous study by another group of investigators.

HTM may be an underlying influence in male suicide that increases the probability of externalizing such behavioral risk factors as anger, violence, gun access, and school problems.

The finding that almost all of the victims of suicide were men underscores the central role that gender plays in these tragedies. As such, the investigators hope that the study prompts more research, as well as intervention efforts aimed at the role of masculinity in suicide.

"There are already things going on around the world to try to address the risk factors of masculinity for suicide death. So even though we haven't had the evidence that it's a risk factor, people have been operating under that assumption anyway," said Coleman.

"Hopefully our research contributes to raising the profile that high traditional masculinity is a relevant risk factor that we can organize prevention and treatment around," he added.

An Important Contribution

Commenting on the findings for Medscape Medical News, Mark S. Kaplan, DrPH, said the study makes an important contribution to suicide research.

"Any study that tries to link a living sample with death data, as they did here, is important," said Kaplan, professor of social welfare at the Luskin School of Public Affairs of the University of California, Los Angeles.

"It's also important because it begins to scratch the surface of more proximal or distal factors that are associated with suicide, and masculinity is one of those factors," Kaplan added.

"In an incremental way, it begins to add to the puzzle of why men have a higher mortality rate than their female counterparts. Because when it comes to suicide, men and women really are apples and oranges."

Kaplan believes HTM is one of several traits that may lead men to take their own lives.

"There are all sorts of other issues. For example, masculinity might be interacting with some of the harsh socioeconomic conditions that many men face. I think all of this points to the real need to understand why men die from suicide," he said.

The Add Health study is funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, with cooperative funding from 23 other federal agencies and foundations. No direct support was received from the grant for the current study. Coleman and Kaplan have disclosed no relevant financial relationships.

JAMA Psychiatry. Published online February 12, 2020. Abstract

For more Medscape Psychiatry news, join us on Facebook and Twitter.