Abstract
Men aged 85 years and over have the highest rate of suicide of any age or gender group in Australia. However, little is known about their trajectory toward suicide. The objective of this study was to understand the role of masculine norms and other life factors in the suicidality of older men. Thirty-three men aged 80 years or more took part in a semistructured focus group or interview, and/or completed a survey. Participants were asked about the issues facing older men, well-being and aging, physical health challenges, social support, mental health and help-seeking, and suicide and suicide prevention. Five themes emerged: “finding out we’re not invincible,” “active and tough,” “strong silent types,” “decision makers,” and “right to die.” Participants spoke about masculine norms that had influenced their lives as providers and decision makers, and now influenced how they coped with aging and their journey toward death. For some participants, suicide was seen to be a rational alternative to dependence in their final years. Suicide prevention should adopt a gendered approach and be cognizant of the influence of gender roles and masculinity in older men’s lives. Further research and prevention efforts should be mindful of the impact of masculine norms of self-reliance and control on an older man’s decision to end his life. Suicide prevention efforts should work to reduce stigma around the challenges of aging, maximize opportunities for control, facilitate social connection, and improve residential aged care.
Keywords
The rate of suicide among men aged 85 years or more is the highest of any age or gender group in Australia and in many countries globally (Australian Bureau of Statistics, 2018; World Health Organization, 2018). In Australia, the standardized rate of suicide of these men is 32.8 per 100,000, which is six times higher than women of the same age and double that for males aged 60–84 years. The number of suicides among older people is likely to rise as the number of older people increases (Christensen et al., 2009).
The reason for the higher rate of suicide among men aged 85 years or more is unclear. Physical health problems have been identified as a contributor to suicide among older people, with suicide more likely when multiple health conditions coexist (Juurlink et al., 2004). Illnesses and disabilities that threaten independence, sense of usefulness, dignity, and pleasure in life increase risk of suicide (Erlangsen et al., 2015). Psychiatric disorders such as depression, anxiety, and substance abuse are prevalent in those who die by suicide and pose a strong risk to suicide in older people (De Leo et al., 2013). Social factors such as social exclusion, loneliness, and bereavement also interact with other risk factors to play an important role in suicide risk in older people (Conejero et al., 2018). The relevance of this research to people aged 85 years or more, and men in particular, is limited, as most studies include all people aged over 60 or 65 years, fail to report age-specific findings, are retrospective, and do not report findings by gender. Many of the identified risk factors are common to men and women across the life span (Van Orden et al., 2010), and many older people who experience these risk factors, including physical illness or disability, do not kill themselves (Canetto, 1992).
The higher rate of suicide among men of all ages has been attributed to a number of factors including the lethality of chosen means, externalizing of depression, increased substance use, and reduced social connectedness and help-seeking (Mergl et al., 2015; Player et al., 2015; Rice et al., 2014). These factors are influenced by masculinity—the socially constructed masculine norms that inform men’s behavior (Thompson et al., 1995). Hegemonic masculinity refers to a particular variety of masculinity to which other men, and women, are subordinated and that is maintained because of the benefits it affords most men. This masculinity is negotiated through a continuing process of mobilization, marginalization, contestation, and resistance. (Carrigan et al., 1985). In Australia, and in many Western countries, hegemonic masculinity endorses norms of stoicism, independence, invulnerability, and avoidance of many emotions (Connell, 2015). The masculinity of older men has been characterized by avoidance of weakness, the pursuit of respect and admiration, confidence and self-reliance, and a desire to never give up (Emslie et al., 2004; Thompson & Langendoerfer, 2016). However, this version of masculinity may be a key contributor to suicide by older men.
Many positive health behaviors such as self-care, expression of emotion, and help-seeking contrast sharply with masculine social norms (Addis & Mahalik, 2003). Men’s preference for self-reliance can also hinder the formation of meaningful social connections (beyondblue, 2014; Moller-Leimkuehler, 2002). The masculine norms of stoicism and self-reliance are associated with suicidal thinking and behavior in men (Coleman & Feigelman, 2020; Pirkis et al, 2017). The interplay between masculinity and suicidality may be amplified for older men who commonly experience challenges to their self-reliance as they age. Older men may also be less capable of flexible coping due to their socialization and developmental experiences and the influence of hegemonic masculinity scripts that promote self-reliance and autonomy (Canetto, 1992, 2017). Physical illness and disability may be particularly difficult for older men if they have not previously experienced challenges to their autonomy or limits to the benefits of masculinity (Canetto, 1992; Chandler, 2019).
In previous generations, growing older earned men status; however, in recent decades, ageism has led to the veneration of youth and increasing devaluing of older men. This emphasis on youthful masculinity has left older men with a “cultural vagueness” about how to do masculinity (Thompson & Langendoerfer, 2016, p136). Men who represent subjugated masculinities, such as older men who are unable to live up to hegemonic ideals, may be at higher risk of suicide, as they draw on prized attributes of masculinity to respond dramatically and fatally to marginalization (Chandler, 2019).
Despite the higher rate of suicide among older men and the established role that masculinity plays, studies of older people’s suicidality have rarely considered gender. Participants in a U.S. study spoke about how losses in economic means, relationships, and physical ability contributed to thoughts of suicide by older men (Apesoa-Varano et al., 2018). They viewed suicide either positively, as an opportunity to exercise control, or negatively as opposing their desire to never give up. The study did not specifically examine the experiences of men aged 85 years or more. There is a need to understand how masculinity interplays with suicidality as men age, particularly for those aged 85 years or more who demonstrate the highest rate of suicide.
Our research seeks to address the current gaps in knowledge by talking to groups of men aged 80 years or more to understand the role that masculinity plays in their views of living, dying, and suicide. The findings will improve our understanding about suicide by older men and inform suicide prevention efforts.
Method
An expert advisory group comprising specialists in suicide prevention and men’s health provided advice regarding study design, recruitment methods, and recruitment materials, and provided input into data analysis and interpretation of findings. Design was guided by the empirical and theoretical research published on older men and suicide, but given the inaccessibility of some of this literature and the sensitivity of the topic, we also consulted two men aged over 80 to assist with study design. This way we were able to ensure we could not only build on existing theory and research but also use an approach that was suitable for the population under study.
Participants
We included men aged 80 years or more in the study to increase the potential participant pool and gain insight into thoughts about suicide as men approached the high-risk age group of 85+ years. Recruitment took place between December 2017 and May 2018 through the Australian National Ageing Research Institute (NARI), Men’s Sheds (a community-based service that provides a space for men to work on meaningful projects in the company of other men) in three locations in Melbourne (in the state of Victoria), and the retiree association of a large Australian bank. Interested men were asked to contact the researchers. A research team member explained the details of the study via phone and screened participants for eligibility (aged 80 years or more, able to take part, and not at imminent risk of suicide or experiencing significant cognitive decline). Men identified at risk of suicide were contacted by a study psychologist. The psychologist’s phone number was given to all participants and the psychologist attended each focus group to provide support if needed. Focus group was our preferred method of data collection for its potential to generate discussion between members and provide access to shared social discourses. Other methods were available for participants who were unable to physically attend a focus group.
Forty-seven men aged 80 years or more expressed an interest in the study. Two participants were unable to undertake phone screening due to hearing difficulties. The remaining 45 participants undertook screening, and none were excluded. Of these, 26 took part in four focus groups, one completed a telephone interview, and six completed a questionnaire. Each participant provided written or verbal consent. Ethics approval was obtained from the university ethics committee (ID: 1749795.3).
Data Collection
Participants completed closed-ended questions regarding their demographics and health. Focus groups were semistructured with questions centered around eight key areas (shown in Table 1). The eight key areas were chosen based on previous research and in consultation with the advisory group. The areas represented factors that have been associated with older men’s suicide: the challenges of aging, coping with aging, and social connection. As suggested by members of the advisory group, questions were phrased to be direct and to prompt reflection on personal experiences and those of other men. This strategy for questioning was chosen to allow participants to speak impersonally if they chose, in recognition of the possibility that masculine values around autonomy and self-reliance might hamper men’s disclosures. If not raised naturally in the focus group, participants were prompted about differences between men and women to facilitate reflection on gender and its role in suicidality.
Broad Themes and Main Questions.
Focus groups had a maximum of eight participants, ran for 90 min, and were facilitated by two researchers (PF and KK or BD), except for one small group that was facilitated by one researcher (PF). One was held at NARI and three were held in Men’s Sheds. Phone interviews ranged from 30 min to an hour. Questionnaires were posted. Phone calls one week after participation provided an opportunity to share information that may have been withheld in the group or that arose since.
Data Analysis
We undertook thematic analysis of the focus group discussion, phone interviews, questionnaire responses, and follow-up phone calls considering all responses together. A summary of the key themes with supporting quotes was collated by two of the researchers (KK, PF). This summary was presented to the advisory group, which provided feedback regarding the key themes emerging. The three authors who had been involved in data collection (PF, KK, and BD) then collaboratively developed a coding framework that captured the full range of comments, and conducted a framework analysis to order the themes into an overarching framework to make sense of the emerging themes (Green & Thorogood, 2014). Two authors (PF and KK) independently coded one of the focus groups and determined the level of agreement on coding the data. The coding framework was further refined in collaboration with all authors to address areas of disagreement, and consensus was obtained regarding the final coding framework. One of the authors (PF) coded the remaining content, consulting with the other author (KK) when needed. Comments were coded to more than one theme where relevant. The final thematic framework is shown in Table 2.
Thematic Framework.
Results
As shown in Table 3, participants reported a mean age of 84 years, most were born in Australia, spoke English at home, and lived in their own home, either alone or with a partner. Over half reported a main occupation in the manager/administrator or professional categories. Despite many revealing health problems, none rated their health as “poor,” and many rated their health as “very good” or “excellent.”
Participant Characteristics (N = 33).
Note. *Major occupational categories as described in the ASCO = Australian Standard Classification of Occupations (Australian Bureau of Statistics, 1997).
Five broad themes emerged regarding older men’s lives: “finding out we’re not invincible”; “active and tough”; “strong, silent types”; “decision makers”; and “right to die.” Information about gendered life experiences and pressures around masculinity were raised spontaneously and early, often with a touch of self-deprecating humor. The researchers rarely asked for reflections about men compared to women, as they anticipated they might have to tease out these issues.
“Finding Out We’re Not Invincible”
Responses to the question about the biggest problems facing men aged over 80 were typified by one participant: “I think the answer to the question is: are old guys really invincible? of course we all say we are, until we get a bit older and we find out that we’re not.” Participants spoke about the experiences that challenged their invincibility as they aged. These responses speak to the concept of “thwarted privilege” wherein the expected rewards of masculinity—in this case, invincibility—is denied (Chandler, 2019). They spoke about frustration with loss of independence due to declining physical health, changes in the way they are regarded by others, financial difficulties, and difficulties with technology. Some men spoke about the strain of caring for partners who were unwell or dying.
Frustration With Loss of Independence due to Declining Physical Health
Participants experienced declining health, which led to frustration at no longer being able to do the things they used to do. They were apprehensive about threats to their independence, such as losing their driving license.
You can’t physically do it, so you’ve got to employ somebody to get the job done, which is frustrating because half the time they don’t do a good job anyway. If you took driving away from me it’d be like chopping my legs off, I’d be you know, I could possibly get a scooter or something, but no, I don’t know what I’d do.
The Regard in Which We are Held
Most participants were disappointed by negative attitudes toward older people. There was a perception that society no longer valued them.
I know some Asian people from Cambodia, they’re still a very, very close-knit family and they’re always there to help each other, which you’re not getting in the Western families these days like you used to.
“The regard in which we are held” can vary from patronizing to burdensome.
A few commented on positive attitudes toward them by others including doctors and medical staff.
It’s just dawned on me the respect that they pay to my wife and myself and it’s got to be the age factor, no other reason.
Fear of Running Out of Money
Participants spoke about the fear of running out of money and the difficulties of maintaining their lifestyle, independence, and health on a fixed income.
The cost of everything goes up, and the income I’m getting is staying more or less static, so you have to keep trimming what you can afford to do, and make sure that the money is going where it gives you the most return in terms of good diet, that’s difficult for many people on a reduced income. 60 years ago, life expectancy was 68–70 for a male. So, finances were expected to last up to 10 years beyond retirement, but now men live much longer. Now everything is going up but if they are on a pension, or their finances have run out.
Financial strain may be felt more acutely by older men than for women due to the male provider role (Carrigan et al., 1985). Participants frequently spoke about their role as male provider and how this shaped the men they had become.
Technology
Participants felt unable to keep up with technology and this struggle added to the feeling of isolation from society and losses in independence. Frustrations with technology contributed to reduced autonomy and a perception that they were devalued—both key aspects of masculinity and possible drivers of older men’s suicidality (Canetto, 1992).
Old codgers like me get left behind. You go to the bank, they say to send them an email; you want to make a payment, you have to go online. It’s just another nail in the coffin. But worst of all is the attitude that government in the wider sense just are not interested unless you have computer skills to reply to them.
Some Men Look After Their Wives
Some participants spoke about the difficulties of caring for wives who were unwell. This was a practical challenge, as they now had to do everything around the house, and an emotional challenge, as they witnessed the deterioration in their partner. This was one of the few occasions that participants spoke openly about their emotions.
My wife had Alzheimer’s for the last 10 years of her life. I looked after her at home until it became unmanageable. You cannot look after someone like that at home and remain sane yourself. It’s very, very difficult to find good care for people. This past 48 hours has been terrible, absolutely horrific from my point of view, because (of) her mind, she can’t gather her thoughts or converse in a normal manner. She’s referring to things which we haven’t been speaking of, and she worries about me.
The group listened quietly, but it was unclear whether it was usual for these men to discuss these experiences. Their disclosure runs counter to the “invisibility” of men’s emotional lives that is enforced by other men to maintain hegemonic masculinity (Schwab et al., 2016). Perhaps caring for wives is seen as an extension to the provider role such that these participants felt safe to disclose their struggles; alternatively, these men might be acting outside of hegemonic masculinity when they express their distress. This crisis may be acting as a catalyst for more open relationships with other men (McKenzie et al., 2018).
“Active and Tough”
Participants spoke passionately about the importance of keeping active to maintain good health and having a positive, tough mental attitude. They described a masculine way of living characterized by many of the key aspects of hegemonic masculinity—achievement-focused, self-reliant, and problem solver for other people.
Keeping Active
Staying active was exceptionally important with a lot of time spent on activities that were believed to prolong their lives. Death was the feared consequence of not keeping busy. Participants were involved in structured activities and clubs such as men’s sheds, hobby groups, church, sport, and classes.
You’ve got to be able to keep your mind working, that’s to me the most essential thing of them all. I have found that some friends have given up living because it is hard to keep active and so have died.
Participants spoke about the importance of having a purpose which gives them a “reason to get out of bed” in the morning. This was more strongly felt when it was directed at supporting others.
You’ve got a reason to get out of bed in the morning. Getting out of bed becomes more and more difficult as you get older. Doing things for yourself you know I won’t say it’s pointless, but I mean you don’t get as much enjoyment out of it as you do if you can do something for somebody else. And it’s the stimulation to get up, be able to do things for other people that keeps you going.
Positive and Tough Mental Attitude
Having a positive and tough mental attitude was important. Participants spoke about the need to be accepting of aging and to still find enjoyment, and of being “tough enough” to deal with challenges alone, get on with life, and not give into feelings of sorrow.
You’ve got to look at things positive, extremely positive, and if you get a bit of a change, you must not dwell on it, if you dwell on it you’ll go down sinking, so you’ve got to revert around and get yourself out, and there’s only one person that can help you. . . yourself. The ones who seem to be still surviving are those who when they think about their life they think only of the good things and they say oh I’ve been happy, I’ve had a wonderful life. Everyone has one or two traumas in their life and it’s just a matter of being big enough and tough enough to get through it.
“Strong Silent Types”
Participants spoke about the reluctance to talk about emotions and how, because of this, women are better at communicating and socializing. They spoke about masculine stereotypes such as the “strong silent type” and used clichés such as “bottled up.” Men keep things to themselves, keep it bottled up. No-one knows what his worries are. I think some men have got the theory they need to be strong silent types who don’t give in and don’t admit that they’ve got a sore toe or whatever it might be. Whereas women will chat about it and talk about it and pass on a recipe or whatever, they just do things differently.
Consistent with Carrigan et al.’s (1985) assertion that men’s inflexible coping may in part be a product of their socialization and developmental experiences, participants struggled to answer a question about who they would talk to if they were experiencing a personal or emotional problem. This seemed to be related to mental health literacy, as the question was asked in multiple ways using words such as “stress” or “worry,” but the participants were still largely unable to answer. Answers were often related to physical health problems. They valued long-standing relationships with their doctor.
If I had anything really, that was concerning me, I’d go to my GP, whom I have a good relationship with, and discuss it with him.
Contrary to hegemonic masculinity that discourages open expression of emotions, a few participants described how they talked about personal issues with men. As found in other research, and perhaps similarly to those who were caring for wives in this study, a crisis had enabled a deeper relationship with other men (McKenzie et al., 2018).
One mate in particular. . . I can always talk to him, any problem at all. I’ve got a couple of guys I know pretty well. . .because they’re a bit the same. One guy’s gone through a cancer problem recently and he freely discussed this with all of us at the golf club. . .he talked about his problems.
Men Don’t Have Best Friends
Participants highlighted the need to keep connected to people. They spoke warmly about partners, children, and grandchildren, and about the value of clubs. These relationships were highly valued and comments about “making up for lost time” revealed a change, or a desire for change, in their quality. Participants did not want the social self-sufficiency that characterizes hegemonic masculinity (McKenzie et al., 2018) Joining in activities is something personally I think older people should do, they tend to get in their little warren and stick at it. . .. you’ve got to mix with people. Five children are all married, five grandchildren, three are married, and five great grandchildren. . . and they keep me busy. Yeah after the job I did all my life they’re my bit of sanctuary.
Despite the value of relationships, they described themselves as being on the periphery of family and lacking in close friends. They had many acquaintances, but few relationships of depth. It was proclaimed that “men don’t have best friends.” I have 175 members here [at the Men’s Shed] and they’re all acquaintances. I know them all, I greet these blokes like I greet anybody, but a close friend is entirely different. Where a woman seems to have this all the time, and have closer communications than what we have. The women are fortunate that the children and the grandchildren, particularly the males, are very supportive of the matriarch. And there’s a lot of love there, and therefore in some cases they’re not going to experience the loneliness that the men might feel. Because men we tend to ask how are your finances to the grandchildren, but mum turns around to the grandchildren and she says how are you going, what are you doing – and it’s a different – and the women are happier in that environment. So therefore, they are quite happy in the emotional part of life.
The participants explained that their life roles had influenced the quality of their relationships, but they did not mention the influence of any pressures around masculinity. Friendships centered around work and many ended with retirement, after which it was difficult to initiate and maintain close relationships with other men.
We went to work and the women didn’t, and the women were home, so they had their own little social groups and so down the street, over the street, shopping, and they had their little bunch of friends right along the whole way and they sort of make friends easy, where we had a group of blokes at work and you’re stuck with them.
Women’s roles as mother and carer were maintained with aging, whereas men didn’t have the same “fatherly instinct” and were sometimes peripheral to the family.
Women tend to look after their children, not only children, their grandchildren and great grandchildren, like we have had our great, great grandchild for a couple of weeks . . . and my wife tends to look after her, so their motherly instincts stays with them, where a father he hasn’t got the same fatherly instinct, because he’s the head of the family. Women can cope with all sorts of hardship. . . And they’ve got family, often males are separated from their family.
In contrast, a few participants described close relationships with their family.
My son, although he lives in Queensland, I’m pretty close to him, he’s now 50 or so, so he’s old enough to discuss things with.
“Decision Makers”
In many instances, participants spontaneously described their life role as decision makers and providers and how this had impacted on their ability to cope with aging. They frequently mentioned how other people had policed this version of masculinity—family who had modeled gender roles and passed gendered expectations to them.
We Were Born to It
Participants described rigid gender roles which they were “born to” that had influenced their lives.
We were born to it, our parents were male dominated, I use that word not aggressively, but our dad used to bring home the money and mum looked after it, but dad made the decisions. Likewise, mum stayed home and looked after us, brought us up . . . In our life my wife stayed home, brought up two boys and I more or less made the decisions. And it’s just gone on and will go on because it’s in us to do it. It’s part of our DNA you know, ‘son you go out and if you take a lady on as your wife, well you make sure you look after her’. . . that was part of the deal.
Lonely and Worried Decision Makers
Participants largely did not question these gender roles for themselves, but some acknowledged the burden of this role at times and how it had created strong silent men.
By hell it was hard work those days, and because you were brought up to do that, you couldn’t really, you could share a little bit with your wife, but the actual decision-making process was with you all the time. Worrying about whether you made the right decisions, and you know that’s when you can get lonely and worried. . ..and the other thing is you don’t tend to share it, because you made the decisions all the time and you reckon well that’s my job, I’ve got to do it.
A few participants spoke about how they lived differently to these roles and how this had changed their views on life, but they acknowledged this was not “typical.” My wife was earning more money than me, I brought up the children, so I’m not your typical male, but I’m one of an increasing number of males that have experienced the other side of life, and I’ve lived these differences, we think differently
There was a tension between describing their gender role as unchangeable whilst also acknowledging change for younger men. There was hope that younger men would not experience some of the problems they had experienced.
This problem will probably disappear with the new [generation] coming through. They’re much more involved in that what you’re talking about, so they won’t be as lonely and separated when they get to our age because they will be used to doing all these things
Coping With Aging
Participants commented that women are generally better at coping with aging than men. The differences were perceived as stark and unchangeable. Consistent with other research, they described a more flexible coping style for women (Canetto, 2017).
I think wives often don’t complain even though they have a lot of problems, they put up with things – and you said women maybe don’t suicide as often as men, I think women are first of all perhaps more used to bearing pain and suffering, physical and mental, and many of them are more religious than men are, and their church gives them the sort of group contacts that men who are often not religious, I think there’s quite a distinct difference there, they don’t have the church. My wife says men always like to find a problem and solve it, and also, they like to be on top of things, and women are less competitive, they’re less wanting to be boss, they’re less wanting to go for the answer, they will feel around it, they approach it from different angles – it’s this business about women think with more of their brain than men do, and use intuition. So, men follow the straight line of the argument, the rationality, and the women work more emotionally. So, they have a different way of solving problems.
“Right to Die”
Some participants expressed strong views when asked about suicide. Attitudes toward suicide varied according to the life stage within which it occurred. Suicide by younger men was largely seen negatively, described as a “crime” or “a coward’s way out.” Some men described times when they had suicidal thoughts as a younger man in response to stressors such as marriage breakdowns, financial crises, and work or business problems. Suicide as an older person was not seen as “suicide,” rather it was a rational response to life that wasn’t worthwhile anymore.
When I was young, as you know suicide was a crime, if you tried to suicide and you recovered you went to jail, you know. I was brought up suicide was the cardinal sin you know, unforgiveable and all this sort of stuff. So, I’m not, can’t imagine myself ever wanting to do it, like suicide, unless you know I was in that much pain and so forth you know. Fortunately, now there’s euthanasia that hopefully would absolve you of having to do that.
Many participants did not object to suicide as an option for older men. Some mentioned assisted dying and saw it as an alternative and valid choice. Some saw suicide as their right to be able to choose the time and method of their death. This view could indicate that these men see suicide as way for men to enact “prized attributes” of masculinity (Corrigan et al., 2013).
I have a philosophical objection to this idea that somehow suicide is wrong and bad. I as an individual should be the only person with the right to decide when I die, how I die, where I die. When I’m ready to go, when I find that life is no longer worth living, I will take my own life and I don’t see why anyone has the right to stop me.
However, some men disagreed and said that they did not think they would choose to end their lives.
Reasons for Suicide
Being a burden to others, physically or financially, loneliness, suffering pain, and avoiding to go to a nursing home were among the strongest reasons mentioned for why older men would choose to take their own life—each of which has strong associations with hegemonic masculine ideals around independence and self-reliance. Participants spoke about their fear of dying in a hospital or nursing home, citing negative experiences of family members, and about not wanting to endure poor health, dependency, and abuse.
You might feel your family is better off without you, financially or physically. Just being a realist. Or if you suffer a lot of complaints – is life worth living? Now when you look at what we read in the papers now about elder abuse, about the poor standard of nursing homes nationally, who would want to go any other way than by their own means and their own time from choice.
Participants spoke about losing family and friends to death and how difficult it can be to make new contacts. Loneliness threatened their ability to stay alive.
And my belief is the main reason [why men die by suicide] is they’re lonely and they have no contact with anybody, and that’s the main reason.
A loss of a partner was mentioned as a potential trigger for suicide. Participants described how older men are often dependent on their wives for social contact and within the domestic context and struggled to manage without them.
Loneliness is the big one. You lose your partner and you’re dead. I can see changes in men when they lose their partner, dramatic changes sometimes because they’ve never done the laundry, they’ve never done their bed, so they’ve never cooked, sometimes they haven’t even driven, their wives do the driving. And all of a sudden, your partner’s gone and they’re lost, and you can actually see them going downhill. And sometimes they’d say this is enough, I can’t be bothered anymore.
It seems that, consistent with other research, when their partner (commonly a woman) dies these men lose their main, or sole, source of emotional support (McKenzie et al., 2018). They may also be less capable to cope with widowhood compared to women (Canetto, 1992).
Preventing Suicide
A few suggestions were made about things that could prevent suicides among older men. They suggested that improving care and more valuing from society would make a big difference.
Make nursing homes more attractive then they might be prepared to let themselves die in a nursing home rather than at home with their family, but nursing homes being in the state they are, I don’t think anyone wants to die in a nursing home, or in a hospital. If you can offer me a better alternative I would be happy not to commit suicide. But nobody at the moment offers me an alternative that I want. The government has to take old age seriously enough to provide adequately for us, at the moment they don’t.
Finally, many men commented on the positive influence of the social connection provided by Men’s Sheds, and how this could prevent suicides.
If I came down and had a yarn with the blokes at the Shed I’d probably be alright.
Discussion
Suicide by older men is a major health concern that is expected to increase with an aging population. This study provides insight into the attitudes toward living, dying, and suicide by men 80 years and older. It is the first Australian study that follows a gendered framework for researching suicide in men over 80 years.
Older men in our study were open about their views on living, dying, and suicide. None reported being distressed by the study or sought assistance from the psychologist. Consistent with the assertions of other researchers, this generation of men were largely living in keeping with hegemonic masculine practices of never showing weakness, seeking respect and power, projecting confidence and self-reliance, and never giving up (Thompson & Langendoerfer, 2016). They spoke about masculine norms that had influenced their life role as strong silent decision makers, which were now having negative impacts on their relationships and ability to cope with aging. These norms were also likely influencing their attitudes toward their death.
Participants spoke about frustrations with finding out they’re not “invincible” through loss of independence, disappointments with their perceived value by society; fear of running out of money; difficulties with technology; and for some, the strain of caring for unwell wives. It may be that these events are felt strongly as they are experienced as “thwarted privilege” wherein the expected, and thus far experienced, rewards of masculinity are now denied of them (Chandler, 2019).
Loneliness and fears of being a burden for others and entering nursing care were identified as potential triggers for suicide. Research by Oliffe et al. (2017) provides insight into why these challenges may be particularly difficult for older men. In their study of (younger) men’s suicidality, they noted a theme related to struggling with psychological trauma and injury. Failure to recover from these injuries constituted a failure to embody masculine ideals around control and self-reliance, which then played a role in suicidality. The older men in our study strongly embody these masculine ideals and are experiencing increasing aging-related injuries and threats. These men may experience aging-related challenges as exceptionally distressing and may see their future as hopeless, which may be compounded by a lack of alternative ways of living and coping available to them due to a lifetime of fixed gender roles and expectations around masculinity. The men spoke about how they were staying alive by keeping busy doing things that gave them a sense of purpose—activities that likely help them to restore the sense of self-reliance and control that they may be losing in other areas of their lives. It is easy to see how an older man’s well-being may plummet if he is no longer able to do the activities that maintain his sense of control and privilege associated with masculinity. Hegemonic masculinity encourages men to feel shame if they cannot live up to masculine ideals (Chandler, 2019), and indeed, many of the men equated a lack of (masculine) activity with death.
Family lives and partners were central to men’s well-being. However, many men lacked deeper relationships. They attributed this lack to the ways they had lived their lives, on the periphery of family life with social interactions limited to men they worked with, that had left them without the skills needed to form deeper relationships. It also likely speaks to the influence of masculinity. Connell notes that a resistance to intimacy between men hinders close relationships and is deeply entrenched in Australian masculinity (Connell, 2005). Seeking support and discussing emotions runs counter to expectations that emphasize strength and emotional restraint (Chandler, 2019). Shame can ensue if emotions and struggles are disclosed. Oliffe et al.’s (2017) study spoke about how men self-isolate as a protective strategy when they feel shame and stigma if they “visibly surrender to their challenges” (Oliffe et al., 2017, p. 896). This could be amplified for older men who, because of ageist attitudes that devalue older people, experience a masculinity characterized by diminishing social capital and a sense of emasculation (Thompson & Langendoerfer, 2016). For men who have lived their lives with strong values of self-reliance and stoicism and who are now experiencing frequent challenges to those values and their value in society, it could be that social isolation is a strategy to protect themselves from shame and stigma. These men would then likely experience a cycle of increasing distress and social isolation in response to further threats to their self-reliance. This cycle could be compounded by the loss of a partner. Many older men may have a limited range of interpersonal and coping skills due to socialization, and often rely on partners as their sole emotional support so they can maintain an “invisible” emotional life publicly and preserve their masculine persona (Canetto, 1992; McKenzie et al., 2018; Schwab et al., 2016). Thus, the loss of partner could leave men with few resources to cope with the challenge of aging.
Suicide was seen as a legitimate choice for older men. Strong themes of self-reliant and in-control masculinity were evident. As a younger man, self-reliance and control protected against suicide as they considered their duty to family, but now as an older man they were acting as drivers to suicidality through concerns about being a burden on others and a desire to maintain control over the end of their life, rather than enter nursing care. Masculine norms can be protective against suicide but self-reliance and stoicism may ultimately render suicide acceptable, and even compulsory, as a means to conceal and solve problems independently (Oliffe et al., 2011, 2017). Canetto (2017) supposes that older men of European descent (such as the men in our study) may have experienced lives that were relatively protected from challenges to status, autonomy, and control. Suicide can then be viewed as a reasoned choice that exemplifies masculine control, power, and determination in the face of such challenges (Canetto, 2017). A life marked by loss of masculine “honor” is not seen as worth living (Scourfield et al., 2012).
A gendered approach to suicide prevention is long overdue (Canetto & Sakinofsky, 1998; Robertson et al., 2015), and the findings here demonstrate that it is particularly needed for older men. Men’s gendered role experiences and the pressures of masculine norms play a clear role in older men’s ability to cope with aging and their attitudes toward suicide. To the best of our knowledge, these factors have not featured in older men’s suicide prevention despite the assertion of their importance over 20 years ago (Canetto, 1992). Concerningly, it also seems possible that future cohorts of older men may continue to experience a heightened risk for suicide given that many of the issues raised by men in our study have also been noted in studies with younger men (Cleary, 2012; McKenzie et al., 2018; Schwab et al., 2016). Therefore, it is critically important that a gendered approach to men’s suicide prevention is adopted for men of all ages. McKenzie et al. (2018) suggest that such a gendered approach to men’s mental health should deconstruct the hegemonic ideal of a man who is emotionally and socially self-sufficient and portray ways in which men can increase their social connection practice to pursue emotionally supportive relationships. Perhaps older men could play a pivotal role in these efforts by sharing their experiences with younger men.
Whilst many other researchers advocate for increased emotional openness and help-seeking for men as a way to combat suicidality (Oliffe et al., 2017), it seems that for older men, given the difficulties talking about emotional problems and their strong adherence to traditional masculine norms, psychological “talking therapies” may not be attractive. The men in our study spoke freely, but did so as a means of contributing to research and preventing suicides. The men were also not experiencing any current suicidality, which may have allowed them to speak without fear of judgment. Perhaps if psychological-based interventions are to be provided to older men, they should appeal to their desire to have purpose and be useful. Australian men are generally more comfortable providing help to others rather than seeking help for themselves (beyondblue, 2014).
Professionals should become more sensitive to older men’s experiences and the clues to suicidal intent in older men (Canetto, 1992). Our research indicates that a lack of activity or purpose may be key indicators of reduced well-being in older men. Consideration should also be given to the language used with older men. Consistent with the advice from our expert advisory group, the older men in our study responded well to direct language, but had trouble connecting with language around emotional well-being.
We need to be careful of ageist attitudes that presume a lack of capacity for change among older people. There were men in our study who were acting outside of traditional gender roles. Some spoke about emotionally close relationships with family members and friends. Many spoke about increased involvement in family life; some had taken on more domestic responsibilities and were caring for their wives. Previous studies with older men similarly indicate that they may be open to alternative masculine practices (Mackenzie et al., 2017). The men in our study demonstrated some insight into the possibility for a different and changing masculinity, when, in contrast to the fixed gender roles that they had lived, they acknowledged, and hoped, that things were different for younger men today. It is possible for new aspects, such as help-seeking and emotional expressiveness, to be incorporated into “traditional masculinity” and for some men to move toward more personally defined practices of masculinity (Emslie et al., 2006; Lomas et al., 2016). Perhaps the experiences of older men acting outside of fixed gender roles could be explored further to understand how these men are managing to act in ways contrary to the dominant masculinity of their peers. Increased awareness of other men’s emotional struggles may be the first step to change (King et al., 2018). If older men were made aware that other men are experiencing similar problems and challenges, they may be more open to other practices of masculinity that include more openness and deeper relationships, as the shame and stigma around their struggles reduces.
Assistance with meaningful social connections both within families and through structured social activities could be critical to suicide prevention among older men. The men in our study spoke about increasing social alienation, related to their historical position within families and the community, and their limited ability to initiate friendships and maintain meaningful connections. Men’s Sheds provide one opportunity for older men’s socialization, which was effective for the older men we spoke to, as it allowed them to socialize in a structured way and provided opportunities for new friendships in ways that overcome the difficulties these men expressed with relationships. This option may not be appealing or available to all older men and further research could be conducted with men who are not engaged with Men’s Sheds. Times of crisis could be harnessed as possible catalysts for closer relationships between men (McKenzie et al., 2018).
The intersection between suicide and voluntary assisted dying was raised. In Victoria, Australia, assisted dying is only available to those with a terminal disease, illness, or medical condition who are within 6 months of anticipated death (Parliamentary Library & Information Service, 2017). This legislation was enacted in June 2019 after our research was conducted. Whilst a full exploration of assisted dying was not within the scope of this study, it was clear that the impending availability of assisted dying was influencing some of the older men’s thoughts about the end of their life. Many of these older men did not see the voluntary death of an older person as “suicide”; rather, they saw it as a rational response to a life that was no longer deemed worthwhile. Some viewed it as a way to exercise control over their death. While past research has found that stigma around suicide has been protective against suicide by older men (Oliffe et al., 2011), it seems that voluntary-assisted dying removed that stigma for the men in our study. Future research should be mindful of the interplay between the masculine norms of self-reliance and control and the shame associated with loss in these domains, which may drive decisions to access assisted dying.
This study was limited by a lack of diversity in socioeconomic status and culture. Future research could seek to speak with a broader range of older men, such as men of diverse sexual orientation who are at higher risk of suicide (WHO, 2014), and men who are experiencing suicidality, such as suicide attempt survivors. Despite older people of diverse sexuality experiencing greater hardship in their lives related to marginalization, previous research suggests that sexual minority older people cope better with aging. Improved coping may be due acquired “crisis competence,” which is developed through a lifetime of adversity (Brown & Grossman, 2014), and possibly also because they do not experience the same “thwarted privilege” as they age like many other men do (Chandler, 2019).
Future research could also further explore coronial data related to older men. Few studies of coronial data related to older people have compared men and women, and none have compared those who have died by suicide with those who are alive or have died by other means. Preexisting relationships between some of the participants, due to shared involvement in Men’s Sheds, may have hindered personal disclosures. Negative reactions by men to emotional disclosures by other men are commonly experienced as a way to enforce hegemonic masculinity, and this could mean that men were not comfortable talking openly in the focus group (McKenzie et al., 2018). However, despite this, we witnessed some men openly disclosing personal challenges, acting contrary to masculine pressures.
Richman (1992) asserts that suicide among older people is not very different from that of younger people, in that it is a reaction to stress and various life events, which almost always involve other people. This study has highlighted the ways in which the masculinity of older men interplays with their reactions to the stress associated with aging and their relationships with others to create a situation where suicide may seem like the only way to maintain control. Suicide prevention efforts should adopt a gendered approach and be cognizant of the influence of masculinity in older men’s lives. Efforts should also work to reduce older men’s stigma around dealing with the challenges of aging, maximize opportunities for control, facilitate their social connection, and improve residential aged care.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was funded by The Ageing Hallmark Research Initiative at the University of Melbourne.
