Sex-related differences in methods of and reasons for suicide in Turkey between 1990 and 2010

Abstract

Objective

To analyse suicides occurring in Turkey between 1990 and 2010 according to sex, age, reason and method.

Methods

Data concerning suicides occurring in Turkey between 1990 and 2010 were obtained from annual records published by the Turkish Statistical Institute. Data were analysed according to sex, age, reason for suicide and suicide method.

Results

The crude suicide rate was 2.42 per 100 000 population in 1990 and 4.02 per 100 000 population in 2010. The highest number of suicides was seen in those aged 15–24 years. In this age group, the number of suicides in females was significantly higher than in males. The most common suicide method in Turkey was hanging. Men used firearms more frequently than women. All the reasons for suicide occurred in a higher number of males than females; however, the difference between males and females was more significant for economic problems, relationship problems and educational failure. The leading reason for suicide in females was relationship problems.

Conclusion

Detecting population subgroups with a high suicide risk and obtaining regional demographic data are of great importance for future studies on suicide prevention.

Keywords

Completed suicide sex age suicide methods suicide reasons

Introduction

Suicide is a conscious act of self violence, and is defined as ending one’s life deliberately and voluntarily;^1,2 it is viewed across all societies as a complex human behaviour. Suicide is among the top 10 leading causes of death worldwide and is the fifth leading cause of death in China.^2,3 In some countries, suicide has been reported to be the third leading cause of death for 15–44-year-olds and the second leading cause of death in 10–24-year-olds.^2–6 According to the World Health Organization, suicide rates have increased by 60% worldwide over the last 45 years.⁷

Suicidal behaviour may be associated with mental or physical illness, alcohol or drug abuse, chronic physical illness, stressful life events, emotional or communication problems, conflicts within the family, divorce, failure in school, exposure to trauma or violence, or large and sudden changes in an individual’s life, such as alienation and compliance problems induced by modernization.⁶ People may attempt suicide because of biological, genetic, psychological, social, environmental and economic factors, as well as cultural and situational factors including job or financial loss, low socio-economic status, family history of suicide, previous suicide attempts, lack of social support, cultural and religious beliefs, death or loss of a loved one, and the presentation of suicide by the media as a solution.^8–11 Mental disorders such as depression or alcohol use are significant suicide risk factors, particularly in Europe and North America, whereas the most important risk factor in Asian countries is impulsivity.⁷

A variety of people attempt suicide, ranging from healthy people reacting to stressful life conditions, to patients with severe mental disorders. Moreover, suicide can affect many people beyond the individual attempting suicide; it also has significant short- and long-term effects on spouses, parents, children, other family members, friends, colleagues and peers.^1,2,12,13 Suicide rates can differ between various demographics and populations, and even between different regions of the same country.^14–19 Although suicide rates are highest among adult males, the increasing rate among young people of both sexes has become a major problem in both developed and developing countries.⁷ Studies have shown that suicide methods differ among age groups, highlighting the importance of identifying subgroups at high risk of suicide.^1,4,16,20

The collection of statistics related to suicide, which is considered to be an indicator of community health and socio- economic structures, has provided important information about the frequency and methods of suicide and the reasons behind it. In the present study, suicides occurring in Turkey between 1990 and 2010 were analysed according to sex, age, reason and method.

Methods

Data collection

Suicide data for the period between 1990 and 2010 were obtained from annual records published by the State Institute of Statistics, which was renamed the Turkish Statistical Institute in 2005.^21–23 These data come from information gathered by the police and gendarmerie, who are required to report every suicide occurring in residential areas using a Suicide Statistics Form. This form includes the following information: age, sex, marital status, place of residence, education level and economic status of the individual; method of suicide; estimated number of people the suicide victim was obliged to look after; possible reason for the suicide. Possible reasons listed are: illness (psychiatric or physical illness are not differentiated); family problems; emotional issues; being jilted by a loved one; economic problems; business failure; educational failure; other reasons; unknown reasons. In the present study, family problems, emotional issues and being jilted by a loved one were categorised as ‘relationship problems’. Other reasons and unknown reasons were categorised as ‘other reasons’.

Statistical analyses

Suicides were analysed according to sex, age, reason for suicide and suicide method. All statistical comparisons were made using crude suicide rates or frequencies. Comparisons according to year, sex and age were performed using general log-linear analysis. A P-value < 0.05 was considered to be statistically significant. All statistical analyses were performed using SPSS® software, version 20 (IBM, Somers, NY, USA).

Results

There were 44 596 suicides in Turkey between 1990 and 2010. The numbers of suicides and the crude suicide rates at 5-year intervals are shown in Table 1. The crude suicide rate varied between 2.42 per 100 000 population to 4.02 per 100 000 population, with the lowest and highest rates occurring in the years 1990 and 2010, respectively. This represents an increase of 67% between these two years.

Table 1.

Crude suicide rates in 5-year intervals in Turkey between 1990 and 2010.

Year	Estimated mid-year population, × 1000	Completed suicides, n	Crude suicide rate per 100 000 population
1990	56 136	1357	2.42
1995	60 611	1460	2.41
2000	65 311	1802	2.76
2005	68 566	2703	3.94
2010	73 003	2933	4.02

Of the 44 596 individuals who committed suicide in Turkey between the 1990 and 2010, 28 347 (63.6%) were male and 16 249 (36.4%) were female.

Data concerning the distribution of suicides in Turkey between 1990 and 2010 according to sex and age are given in Table 2. Sex and age were analysed using ‘male’ and ‘>75 years’, respectively, as the base categories. The highest number of suicides occurred in those aged 15–24 years (z = 21.11, parameter estimate [PE] = 2.02, P < 0.001, 95% confidence intervals [CI] 1.85, 2.22). The number of suicides in females was significantly higher than in males, both in those <15 years old (z = 14.90, PE = −0.46, P < 0.001, 95% CI −1.24, −0.96) and in those aged 15–24 years (z = −15.68, PE = −0.88, P < 0.001, 95% CI − 0.98, −0.76).

Table 2.

Distribution of suicides in Turkey between 1990 and 2010 according to sex and age.

	< 15 years			15–24 years			25–34 years			35–44 years			45–54 years			55–64 years			65–74 years			≥ 75 years
Year	Male	Female	Total	Male	Female	Total	Male	Female	Total	Male	Female	Total	Male	Female	Total	Male	Female	Total	Male	Female	Total	Male	Female	Total
Total	677	846	1523	6812	6843	13 655	6333	3411	9744	5046	1825	6871	3995	1244	5239	2526	916	3442	1708	660	2368	1250	504	1754
1990	30	18	48	225	198	423	190	106	296	162	47	209	95	53	148	83	29	112	37	20	57	43	21	64
1991	25	17	42	195	170	365	180	88	268	126	65	191	93	41	134	79	35	114	47	17	64	33	17	50
1992	32	22	54	183	204	387	160	81	241	129	33	162	83	35	130	84	34	118	32	22	54	23	10	33
1993	30	40	70	190	211	401	161	93	254	133	57	190	78	35	113	51	29	80	43	19	62	46	13	59
1994	21	35	56	253	242	495	204	121	325	172	64	236	110	44	139	96	40	136	59	18	77	34	23	57
1995	21	31	52	242	258	500	213	107	320	156	64	220	112	27	139	65	29	94	64	26	90	34	11	45
1996	30	38	68	318	335	653	260	130	390	182	70	252	134	47	181	98	34	132	66	19	85	34	20	54
1997	56	73	129	320	380	700	266	186	452	183	80	263	117	39	156	109	31	140	68	27	95	37	18	55
1998	22	44	66	306	355	661	263	155	418	221	85	306	139	54	193	69	31	100	65	27	92	40	14	54
1999	17	27	44	306	298	604	260	192	452	202	89	291	134	51	185	87	30	117	69	39	108	36	16	52
2000	25	32	57	307	314	621	262	137	399	183	80	263	149	37	186	98	37	135	64	32	96	26	19	45
2001	27	33	60	423	418	841	407	187	594	318	100	418	229	55	284	132	50	182	97	46	143	44	18	62
2002	30	43	73	332	414	746	328	201	529	274	105	379	205	70	275	107	31	138	74	27	101	42	18	60
2003	32	48	80	416	506	922	333	241	574	270	112	382	219	82	301	133	58	191	102	51	153	69	33	102
2004	38	44	82	446	451	897	373	206	579	285	128	413	230	78	308	140	52	192	91	42	133	78	25	103
2005	38	40	78	408	398	806	389	217	606	279	101	380	277	80	357	151	62	213	115	32	147	83	33	116
2006	40	42	82	394	438	832	397	218	615	317	126	443	284	82	366	162	67	229	101	35	136	87	39	126
2007	36	63	99	375	364	739	434	211	645	334	107	441	274	97	371	154	58	212	103	45	148	98	40	138
2008	29	51	80	407	350	757	372	198	570	351	115	466	302	69	371	188	42	230	155	32	187	120	35	155
2009	49	46	95	354	252	606	437	155	592	392	91	483	385	92	477	236	68	304	135	46	181	123	37	160
2010	49	59	108	412	287	699	444	181	625	377	106	483	346	76	422	204	69	273	121	38	159	120	44	164

Data presented as n victims.

Data concerning sex and suicide method in Turkey between 1990 and 2010 are given in Table 3. Sex and suicide method were analysed using ‘male’ and ‘other’, respectively, as the base categories. The two most common suicide methods were hanging (z = 22.63, PE = 2.50, P < 0.001, 95% CI 2.29, 2.72) and use of firearms (z = 16.38, PE = 1.87, P < 0.001, 95% CI 1.65, 2.09). The number using firearms was significantly higher in males than in females (z = −5.33, PE = −1.03, P < 0.001, 95% CI −1.46, −0.67). The method of suicide showed a significant difference over the years of study (χ²= 1114.12, P < 0.001).

Table 3.

Suicide methods in Turkey between 1990 and 2010 according to sex.

	Hanging			Firearms			Drugs or chemicals			Jumping from high place			Drowning			Other
Year	Male	Female	Total	Male	Female	Total	Male	Female	Total	Male	Female	Total	Male	Female	Total	Male	Female	Total
Total	14 132	7112	21 244	7374	2304	9678	2419	3888	6307	2490	1952	4442	662	396	1058	1270	597	1867
1990	489	242	731	124	39	163	101	126	227	74	48	122	33	24	57	44	13	57
1991	419	214	633	117	34	151	95	112	207	72	54	126	36	21	57	39	15	54
1992	361	237	598	125	36	161	86	94	180	84	52	136	21	15	36	49	7	56
1993	391	246	637	133	50	183	64	110	174	88	66	154	28	15	43	28	10	38
1994	507	301	808	188	64	252	90	116	206	100	71	171	29	20	49	35	15	50
1995	497	252	749	180	67	247	51	117	168	111	83	194	20	17	37	48	17	65
1996	585	315	900	262	120	382	92	154	246	94	70	164	30	24	54	59	10	69
1997	576	341	917	304	152	456	85	212	297	118	94	212	29	14	43	44	21	65
1998	508	280	788	333	153	486	94	207	301	115	86	201	35	20	55	40	19	59
1999	504	306	810	313	119	432	94	169	263	123	112	235	20	17	37	57	19	76
2000	504	273	777	305	105	410	112	181	293	114	84	198	14	11	25	65	34	99
2001	811	339	1150	410	131	541	178	271	449	158	124	282	41	17	58	79	25	104
2002	675	347	1022	313	104	417	169	292	461	130	114	244	22	17	39	83	35	118
2003	784	461	1245	420	140	560	153	324	477	118	122	240	29	35	64	70	49	119
2004	774	420	1194	482	146	628	166	271	437	139	122	261	42	20	62	78	47	125
2005	813	387	1200	509	147	656	157	261	418	151	111	262	33	20	53	77	37	114
2006	872	411	1283	530	137	667	141	303	444	140	114	254	39	26	65	60	56	116
2007	888	437	1325	542	137	679	156	255	411	127	89	216	29	22	51	66	45	111
2008	973	419	1392	583	171	754	122	155	277	121	96	217	39	14	53	86	37	123
2009	112	436	1557	627	133	760	110	57	167	136	117	253	42	11	53	75	33	108
2010	1080	448	1528	574	119	693	103	101	204	177	123	300	51	16	67	88	53	141

Data presented as n victims.

Data concerning sex and the reason for suicide in Turkey between 1990 and 2010 are given in Table 4. Sex and reasons for suicide were analysed using ‘male’ and ‘other’, respectively, as the base categories. All reasons for suicide occurred in a higher number of males than females; however, the difference between the sexes was more significant for economic problems (z = 13.88, PE = −3.21, P < 0.001, 95% CI −3.66, −2.75), relationship problems (z = −12.85, PE = −1.23, P < 0.001, 95% CI −1.42, −1.04) and educational failure (z = 11.67, PE = −4.03, P < 0.001, 95% CI −4.72, −3.36). The leading reason in females was relationship problems (z = 8.52, PE = 1.98, P < 0.001, 95% CI 1.47, 2.38).

Table 4.

Reasons for suicide in Turkey between 1990 and 2010 according to sex.

	Illness			Relationship problems			Economic problems			Business failure			Educational failure			Other^a
Year	Male	Female	Total	Male	Female	Total	Male	Female	Total	Male	Female	Total	Male	Female	Total	Male	Female	Total
Total	7588	4771	12 359	6523	6211	12 734	4636	694	5330	1555	54	1609	663	522	1185	7382	3997	11 379
1990	289	163	452	278	249	527	103	12	115	45	0	45	38	10	48	112	58	170
1991	281	155	436	241	238	479	122	15	137	39	0	39	27	15	42	68	27	95
1992	261	172	433	196	186	382	110	15	125	41	2	43	28	11	39	90	55	145
1993	299	165	464	205	245	450	111	27	138	37	0	37	30	37	67	50	23	73
1994	350	190	540	281	287	568	163	38	201	50	0	50	38	36	74	67	36	103
1995	332	203	535	294	250	544	159	42	201	47	1	48	36	28	64	39	29	68
1996	405	259	664	366	308	674	199	55	254	57	2	59	42	34	76	53	35	88
1997	381	249	630	352	485	837	235	31	266	88	4	92	47	26	73	53	39	92
1998	348	249	597	338	411	749	238	39	277	114	0	114	39	40	79	48	26	74
1999	352	249	601	334	398	732	245	34	279	97	5	102	43	37	80	40	19	59
2000	306	194	500	303	344	647	287	36	323	81	3	84	42	28	70	95	83	178
2001	456	287	743	488	470	958	453	72	525	146	2	148	33	26	59	101	50	151
2002	512	383	895	394	338	732	267	60	327	82	9	91	41	47	88	96	72	168
2003	545	473	1018	389	457	846	330	55	385	134	13	147	50	45	95	126	88	214
2004	298	184	482	321	277	598	163	31	194	57	3	60	35	34	69	807	497	1304
2005	288	186	474	282	257	539	190	35	225	61	2	63	17	14	31	902	469	1371
2006	322	190	512	269	258	527	193	22	215	54	2	6	19	14	33	925	561	1486
2007	357	224	581	312	257	569	240	23	263	58	2	60	16	11	27	825	468	1293
2008	436	212	648	325	230	555	269	20	289	117	2	119	17	17	34	760	411	1171
2009	386	173	559	263	126	389	305	13	318	89	1	90	11	4	15	1057	470	1527
2010	384	211	595	292	140	432	254	19	273	61	1	112	14	8	22	1068	481	1549

Data presented as n victims.

Includes being sent to jail, being a migrant, being questioned by police, being dismissed from a job, and any other reasons.

Discussion

In the present study, the crude suicide rate in Turkey was 2.42 per 100 000 population in 1990 and 4.02 per 100 000 population in 2010. The crude suicide rate has been reported to be ∼ 40 per 100 000 population in Northern and Eastern European countries and less than two per 100 000 population in South Africa and Asian countries. According to the World Health Organization, the global crude suicide rate was approximately 16 per 100 000 population in 2000,⁷ whereas the crude suicide rate was 2.76 per 100 000 population in Turkey, in the same year. In a multicentre study including Turkey, the rate of both attempted and completed suicides was found to be lower in Ankara than in other European cities in 1998.²⁴ Despite being lower than the global average, the present study showed that the crude suicide rate in Turkey increased by 67% from 1990 to 2010. In addition, it has been reported that the crude suicide rate in Turkey increased by 295% for males and 245% for females over the 33-year period between 1974 and 2006.^1,2,22 These increases therefore seem to be persistent and noteworthy.

Suicide rates across all age groups are three to four times higher in males than in females in the USA and European countries, and suicide rates in all age groups are nearly two times higher in males than in females in some Asian countries.²⁵ In the present study of suicides occurring over a 21-year period, 63.6% of the victims were male and 36.4% were female, with suicide being ∼ 1.75 times more frequent in males than in females. The higher number of suicides among males can be attributed to higher rates of poverty, business and economic problems, fragmented family structures, globalization, rapid modernization, changes in social values, effects of communication devices including the media, ease in obtaining weapons and the increase of drug use and substance addiction.²

Suicide is the third most common cause of death globally among those aged 15–44 years, of both sexes.^7,13 It has been noted that these are the most economically productive years of life.²⁶ In the present study, suicide rates were highest among those aged 15–24 years, followed by those aged 25–34 years and those aged 35–44 years. Moreover, there were more suicides in females than in males in those aged <15 years and those aged 15–24 years. It is known that, in general, men are more likely to complete suicide than women.^24,27,28 However, similar to our findings, successful suicide has been reported to be more common among females aged 15–44 years in Sri Lanka, El Salvador, Cuba, Ecuador, China, and the Eastern Mediterranean Coast, compared with other population groups.^{10,17,29–33} Ji et al.³¹ reported that female suicide rates were 25% higher than male suicide rates, attributing the difference to Eastern culture. Two studies in Turkey reported that 72% and 62.9%, respectively, of completed suicides in people <19 years of age occurred in females.^27,28 The major reasons for adolescent suicide include social factors such as inability to participate in social activities and decreased social support, chronic and damaging emotional life events such as parental divorce and termination of an emotional relationship, failure in school, mental disorders such as cognitive immaturity, age-related impulsivity and depression, or a combination of these factors.³⁴

In the present study, the highest number of suicides in females occurred in those aged 15–24 years. The greater number of female suicides under the age of 24 years is thought to be related to migration from rural to urban regions, rapid social changes, low literacy rates, patriarchy, unwanted and usually religious marriages at an early age, and the inability to tolerate the realities of life when compared with the ideal family life portrayed by mass media.²⁰ Several cultural factors in Turkey affect the prevalence of female suicide. Turkish society tends to place women under the control of men, who are entrusted to protect them, but many women are exposed to forced marriages and various forms of domestic violence.² Suicide rates in different age groups vary in different parts of Turkey, with rates in those aged <24 years in the Eastern and South-eastern Anatolia regions being higher than in other regions of the country.¹⁶ In a psychological autopsy study covering suicides between 1995 and 2000 in the Batman Province of Eastern Turkey, it was reported that 75% of the reported suicides occurred in females and that the majority of these women were illiterate, young, of low socio-economic status and had migrated from rural to urban areas.²

There is great variation in the most commonly used suicide methods reported in different countries.^16,35,36 In the present study, the two most commonly used suicide methods in Turkey from 1990 to 2010 were hanging and use of firearms. Use of firearms as a method of suicide in women has gradually increased over the last 20 years.^4,37 In the present study, the number of firearm suicides was significantly higher in males than in females. In the study of Oner et al.,¹ which covered suicides in Turkey between 1990 and 2000, the proportion of victims using drugs or chemicals was higher in females than in males. Comparison of results suggests that suicide methods used by females have changed over time, with suicide using drugs or chemicals having decreased in females and firearm suicides having increased 4.6-fold in males and 5.1-fold in females.² Another study from Turkey in 2004 reported that the use of firearms was the most common suicide method for those aged <19 years.²⁷ Following a change in law in 1990, obtaining a gun license and carrying guns became easier in Turkey. Although the authors concluded that this increase may not be directly related to the ease of obtaining weapons, they noted the association between an increase in the use of firearms as a method of suicide and an increase in the number of people obtaining gun licenses and carrying guns. It was also noted that psychological assessments are not required before obtaining a gun.²⁷ In the USA, suicide rates are lower in states where firearm usage is more tightly regulated, with several studies reporting increased suicide rates in adolescent populations with increased access to weapons.^4,38,39

The study of Oner et al.¹ reported that between 1990 and 2000, relationship problems was the most common reason for suicide in females, whereas illness was the most common reason for suicide in males. In the present study, which covered 1990–2010, reasons for suicide showing the greatest significant differences according to sex were economic problems, relationship problems and educational failure. According to another study from Turkey that evaluated suicide notes, economic problems and relationship problems were the most common reason for suicide in males and females, respectively.^40,41 Oner et al.¹ reported that the main reason for suicide in males between 1990 and 2000 was illness; in the present study, economic problems was the reason for suicide that showed the greatest significant between-sex difference. Previous studies have suggested that having a job can help alleviate the risk of suicide, especially for young males.²¹ Unemployment is a known risk factor for suicide, with suicide rates being higher in unemployed individuals.²¹ Suicide rates have been shown to increase during times of economic crisis^17,21 and to decrease concomitantly with decreasing economic problems.²⁶ In addition, an association between psychiatric disorders and unemployment has been reported.²¹ In the present study, the most common reason for suicide in females between 1990 and 2010 was relationship problems. It has been suggested that young people are particularly vulnerable to psychosocial stressors and are increasingly unable to cope with problems and deteriorating relationships, resulting in an increased suicide risk.⁹ In addition, many adolescents who attempted or completed suicide reported having problems related to family, school/the workplace and/or a boyfriend/girlfriend.²⁴ A major limitation of the present study was that the Turkish Statistical Institute does not hold detailed data on the reasons for suicide.

In the present study, significant differences were found between males and females in both the reasons for suicide and the methods used. Suicides due to economic problems were significantly more frequent among males, whereas suicides due to relationship problems showed no significant difference according to sex. Importantly, the use of firearms to carry out suicide was more common among males, although the use of use more violent suicide methods may be increasing in women. The present study results should be taken into account when designing programmes to reduce and/or prevent suicide.

Footnotes

Declaration of conflicting interest

The authors declare that there are no conflict of interest.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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