Why Are More Women Dying by Suicide?

Every day for nearly six months after Natalie* turned 45, she thought about taking the turn on her way to work so sharply that she would overshoot the road, go airborne and land in the river. She imagined it all happening quickly: the sensation of flying, the huge splash as the car hit the water, then the water surrounding her, as the car descended to the river bottom.

Natalie imagined herself not holding her breath, not panicking, not trying to escape as the car filled with water, but rather breathing the same as if she were above the water. She imagined the air in her lungs being displaced with water and then losing consciousness. A Catholic, Natalie imagined herself saying an Act of Contrition and praying for forgiveness, but mostly she imagined a peaceful death.

Simone*, 57, had been taking anti-anxiety medication for nearly two years for stress before she got into a hot bath with a half-full bottle of pills, a bottle of wine and a razor blade.

Chloe*, 22, wasn’t even sure what she was doing when she knotted the scarves together, tied them to the bars of the headboard of her bed, lay down and then slipped the noose around her neck. She’d read that hanging was the easiest and least painful method of suicide and she was ready to die.

Bianca*, 31, had bought the gun a year earlier. She told her family and friends that she had bought a gun “for protection.” In a note she left, she said she had slept with the gun under her pillow every night for 13 months and 17 days and it made her feel safe. Then, like 51 percent of suicides, Bianca used the gun she’d bought to kill herself.

According to the National Institute of Mental Health and the American Foundation for Suicide Prevention, on average 123 people commit suicide in the U.S. every day. For every suicide, 25 more attempt it. More men are die by suicide than women, largely due to the methods they choose—guns, single car accidents and hanging.

Yet more women attempt suicide than men. In most Western countries there is a “gender paradox” for suicide: Women have more suicidal ideation than men and attempt suicide three to four times as often as men, but men are three and a half times more likely to kill themselves.

In 2014, an estimated 2.7 million Americans made a plan to commit suicide. A plan is the final step prior to suicide—like Natalie plotting out exactly how she would speed up her car and drive it into the river. According to suicide prevention programs, having a plan, the means to carry it out and the intention means someone is at greatest risk of attempting suicide. When Bianca bought the gun, she had already been devising a plan. Once she had the gun—the means she had chosen for her suicide—it would have taken another person knowing she was planning her own death to intervene for that tragedy to be averted.

Bianca did not survive. Her body was found in her car in a wooded area near her family home. There were a series of notes on the seat next to her. While the majority of suicide attempts are not completed, nearly 90 percent of suicides using guns result in death.

Natalie, Simone, and Chloe did survive their suicide attempts, but they are among a new and alarming statistic: According to a report from the Centers for Disease Control (CDC), the rate of suicide among women overall increased exponentially between 1999 and 2014, with a steady increase annually since 2006.

The numbers are startling: suicides among women have increased overall by 24 percent—the highest rate ever reported, according to the CDC study on suicide. The report indicates among white women, that increase was 60 percent as opposed to 28 percent in men. Certain groups of women are most at risk. Tragically, the number of suicides among Native American women has nearly doubled: It is 89 percent higher than in 1999. In March 2018, the CDC reported that American Indian/Alaska Natives (AI/AN) have the highest rate of suicide of any racial or ethnic group. What’s more, the rise in suicides among women appears to be a global phenomenon, with reports in the U.K., Australia, South Africa, Canada, and Scandinavia, recording similar trends to that in the United States.

This 30-year high the CDC tracked with their data saw increases in every age group and among men as well as women. But the rise in suicides was higher for women and worst for middle-aged women, those the CDC places in the 35 to 64 age group. Women aged 45 to 64 already have the highest rate of suicide of all age groups.

The resounding question is: Why would women at the peak of their lives be most likely to kill themselves?

The answers are surprisingly simple: Women are overburdened with work both at their jobs and at home and at both the expectations are far higher for women than for men. At work, women are expected to work harder than men and to accede to standards not applied to men.

At home, women are the moms and daughters that both children and parents demand.

These stressors are leading to addictions to alcohol and pills, mental illnesses like depression and anxiety and even bouts of PTSD.

The day Natalie had chosen to drive into the river, she swerved her car at the last minute. She ran up on the grassy verge of the river bank and sat, sobbing, for several minutes. It was, she said, like a scene out of a movie.

Natalie said she began “thinking of suicide as an option” after her mother died suddenly and the stress of caring for her father, who had Alzheimer’s, while raising two teenagers on her own and working full-time became “oppressive. Each day it just seemed more impossible to keep doing what I was doing.”

What pushed Natalie to the ER instead of suicide was, in fact, her children. She said her older daughter came into her room one night, sat down on her bed and simply said, “Mom, don’t leave us.”

“I wasn’t sure why she was saying this to me. I had never threatened to leave my kids or even hinted that I was depressed—at least that’s what I thought. But the next day, I got my best friend to take care of the kids and I went to the hospital and they said I was in crisis.” Natalie chokes back tears as she says she can’t believe how close she came to leaving her children motherless.

Yet as disturbing as Natalie’s story is, it is far from unique.

Dr. Kathryn Abel, professor of psychological medicine at the Center for Women’s Mental Health at the University of Manchester, U.K. says these stories are more and more prevalent.

In addition to the increase in suicides among women, Abel told the Daily Mail U.K. in an interview, “We are seeing an increase in the rates of common mental disorders in middle-aged women, especially in the 45 to 55 age bracket.”

According to Abel, this is a distinctly female issue.

“This is not the same for men, who seem to be keeping a steady rate. We are seeing the highest rates in decades among women and we need to understand what is happening.” Suicide may be the end result for some women, but Abel says that many women are having depression, anxiety and breakdowns.

“The levels of common mental disorders, such as breakdowns, in middle-aged women are steadily increasing. In 1993 it was at 12 percent, but has risen to 20 percent and is still rising. We can put a lot of it down to lifestyle,” Abel explained.

By “lifestyle,” Abel means women having babies later in life, with concomitant careers, and the compounded burden of caring for aging parents and/or in-laws.

That was the case for Simone. Her children had graduated from college and were finally situated in jobs where they no longer required her financial help. She had just put her mother in a nursing home. Simone’s husband of 30 years had promised to seek help for his addiction to painkillers, which had “snuck up on him” after knee-replacement surgery two years earlier. His addiction had threatened to derail their family.

Simone said when she chose suicide, it was because she felt she was “finally free to leave” following a decade of what she called “head-slamming, bone-crushing, heart-squeezing” stress. Suicide, she said, had begun to feel like a gift she was giving to herself, like other women might save up for a spa day. “It was what I was giving myself after getting everyone where they needed to be.”

It was, she said, why she lit candles around the bathtub and took the wine with her along with the pills and razor blade. She relaxed in the tub first, she said, drinking the wine, but not taking the pills, yet.

Likely suffering from untreated depression while she was dealing with constant familial crises and a high-stress job, Simone said she had no idea how deeply depressed she was, or for how long, until she started screaming after she cut one of her wrists and watched the water in the bathtub start to turn red. She said it was as if the sound of her own screaming “woke me up from this long, terrible dream I’d been in.” It was in that moment she knew she really did not want to die.

According to the New York Academy of Medicine, more than 42 million American women are doing what Natalie and Simone were doing: raising children, caring for aging and/or infirm parents while trying to maintain careers—often as the main income source for their families.

These women, dubbed “the sandwich generation,” are predominantly between the ages of 35 and 54. The AARP and the National Alliance for Caregiving report that women serve as the main caregivers, even if the elderly or ill parent being cared for is that of their male spouse.

In December 2015, Ann Case and Angus Deaton wrote a ground-breaking paper on the rising number of deaths among middle-class white people due to the rising rate of suicide, alcohol use and opioid addiction. No other racial or ethnic group had seen the same rise—all other racial groups saw a continued drop in death rates. White women had even higher rates of death than men.

The reasons: stress related to finances, children, marriage, and elderly parents. According to the authors of the study, opioid overdoses, suicides and diseases related to alcoholism are all often “deaths of despair.”

According to Deaton, “We think of opioids as something that’s thrown petrol on the flames and made things infinitely worse, but the underlying deep malaise would be there even without the opioids.”

As it was for Natalie.

As identifiably stressful as the circumstances Natalie and Simone faced are, and although the numbers indicate middle-aged women are among the most likely to commit suicide, there are other factors present for women who commit or attempt suicide. Chloe was in her first year of graduate school and said she had spent her entire four years as an undergraduate feeling an “inordinate pressure to achieve, to be the best, to make my family proud, to be the first at this, that and everything.”

The eldest child of Caribbean immigrants, Chloe said she felt “constant conflict between my family, my various identities and what I wanted to achieve for myself, the things that drove me to be me.”

Chloe explained she also felt pressure from her parents to be a role model for her younger siblings by getting good grades, working, not dating, not drinking. Not only did Chloe find these demands unrealistic, she didn’t want her siblings to feel the same pressures to conform that she did. “By the time senior year hit, I felt like I was leading a double life and it was suffocating. Later I realized I’d chosen the most metaphoric way to try and kill myself.”

Chloe said she had sought counseling at student health several times during her junior and senior years of college, but had left the clinic before following through with the visit. She’d even looked up free services for mental-health help in New York, but had never gone to any of them or even called any of the numbers she’d found online.

“I was just lost. I knew I was in trouble, but I just would drink on the weekends and pass out and then go back to class on Monday. I did that for like two years. I held down a job and stayed on the dean’s list and had friends and looked normal. And then I graduated and nothing was different. That’s when I tried to kill myself.”

Suffocation, usually by hanging, is the third most common form of suicide after guns and poisoning, according to the CDC. It is also increasingly more common in women. Chloe slid off the bed after putting the noose around her neck. She remembers the sharp pain of the noose against her larynx, the feeling of choking and then blacking out. The emergency room physician who treated her after the EMTs brought her in, emphasized that she came very close to dying.  Her larynx was so badly bruised she had trouble speaking for several weeks. She also had difficulty swallowing. She was admitted to the hospital psychiatric ward for a 72 hour hold which turned into a week and was transferred to a mandatory psychiatric outpatient program after she was released.

“I must have really wanted to live,” she says, tears still coming at the memory of how close she came to losing her life. “Thankfully, I didn’t die.”

According to the National Institute of Mental Health, more than 50 percent of people who commit suicide suffer from depression. That number jumps to 75 percent if alcohol-based depression is factored in.

Opioid addiction can be another contributing factor and is on the rise among women. Simone said she was over-using her anxiety medication even though her husband was fighting his own addiction and had also begun taking a sleeping pill. Simone also revealed that nearly every one of her women friends was taking pills of some sort “just to get through the days.”

In March 2018, Dr. Monica Bharel who heads the Massachusetts Department of Public Health, told NPR that many overdoses are in fact intentional suicides that aren’t being registered as such. Massachusetts began tracking overdose deaths in May 2017 to determine which were suicides. Bharel noted that the “tremendous amount of stigma surrounding both overdose deaths and suicide sometimes makes it extremely challenging to piece everything together and figure out unintentional and intentional.”

Simone had originally planned her suicide to be pills, which the CDC reports is the choice of 34 percent of women.

Dr. Maria Oquendo, past president of the American Psychiatric Association, told NPR that between 25 and 45 percent of overdoses might be suicides.

Several large studies indicate women addicted to opioids are at increased risk of suicide. In one study, women addicted to opioids were eight times as likely to commit suicide as men. Since women are twice as likely to suffer from depression as men, these co-factors for suicide—everything from familial problems to alcohol or pill addiction—are alarming. The reasons are complex: The Mayo Clinic cites a long list, from hormonal fluctuations that begin at puberty to an inherited predisposition to depression, to situations and circumstances like those faced by Natalie, Simone, and Chloe. According to the Mayo Clinic, hormonal differences contribute to the length of time women are susceptible to depression because girls tend to begin puberty earlier than boys, hormones fluctuate for post-pubescent girls due to menstruation, and this susceptibility to depression lasts straight through menopause, peaking at both puberty and menopause. Those peaks add support to the reasons why teenage girls and peri- and menopausal women are the most likely suicides among females. Additional hormonal risks for suicide include pregnancy, miscarriage, abortion, and postpartum depression which can also morph into postpartum psychosis for some women. Untreated, postpartum depression can actually last a lifetime.

Some women aren’t diagnosed with postpartum depression until their 50s and even later.

There is another factor as well. According to a 2015 paper on female suicide by Dr. Lakshmi Vijayakumar, who founded Sneha, the premiere suicide prevention program in India, no one factors in the sexist dismissal of suicidal ideation in women. Vijayakumar writes that while male threats of suicide and/or other suicidal ideation is taken seriously, women’s threats of suicide are often dismissed as manipulation and attention seeking.

She writes, “Remarkably few studies have focused upon suicidal behavior in women or attempted to explore the complex relationships between gender and suicidal behavior. One reason for the lack of investment in female suicidal behavior may be that there has been a tendency to view suicidal behavior in women as manipulative and nonserious (despite evidence of intent, lethality, and hospitalization), to describe their attempts as “unsuccessful,” “failed,” or attention-seeking, and generally to imply that women’s suicidal behavior is inept or incompetent.”

Vijayakumar says because suicide attempts are not tracked, the sheer weight of women’s suicidal ideation and what prompts them to attempt suicide is largely unknown and unremarked.

This epidemic of suicide attempts by women doesn’t include what doctors are now calling “slow suicide,” which is described as a prolonged period of abuse, self-harm and eventual suicide using a variety of means. Yet the CDC cites suicide and “self-inflicted injury” as separate events, suggesting a clear recognition of the differences between intentional acts of suicide and prolonged behaviors that might result in death.

Among the latter are drug and alcohol addiction. While the opioid crisis has been the main headline, a study released in September 2017 from the Journal of the American Medical Association (JAMA) found alcohol abuse on the rise and the drug of choice among women, racial and ethnic minorities, and poor people. Chloe said she had been abusing alcohol for over a year prior to her attempted suicide and said she had often been “blackout drunk” on the weekends.

Binge drinking is on the rise among women and alcohol abuse contributes to depression. Simone said she used alcohol as a coping mechanism while she was dealing with the worst of her familial crises but never considered herself addicted the way her husband was to painkillers. Yet when she decided to kill herself, she had a bottle of wine with her. And her anti-anxiety medication.

The World Health Organization says the efforts must be made to both identify suicide as a problem and create serious prevention programs to stop it. The CDC urges education in prevention as well as promoting information on warning signs of suicide.

In an interview with CNN when the CDC study was released, Dr. Christine Moutier, chief medical officer of the American Foundation for Suicide Prevention, a nonprofit organization that funds suicide research, said, “Our nation has not made the level of investment on a federal level that can have the positive effect on suicide that has happened for the other leading causes of death,” such as heart disease and cancer. As a consequence, she explained, suicide was continuing to rise each year. “Access to lethal means is one of the most significant risk factors for an individual to die by suicide,” Moutier added. Such as guns and pills.

Recognizing the warning signs of suicide is vital to prevention. Bianca’s sister now believes her sister buying a gun and telling family and friends was a cry for help that was missed by everyone while Natalie wasn’t even aware she was throwing out warning signs until her daughter came to her.

The pressures on women have increased steadily over the years covered by the CDC study. But with women undergirding our society in both the workplace and on the homefront, it should not be shocking that women are turning to alcohol and even suicide in response to those pressures.

The question is: What are we doing to lessen the stress on women and keep them from taking their own lives?

Natalie, Simone, and Chloe each have said they felt so isolated due to the pressures they were under, there was no one to tell them self-care was essential. Natalie said therapy has helped her reset her priorities. Simone, who also entered therapy, said she had “just felt exhausted from requests,” that “everyone always needed something and there was never time for me to just breathe.”

Chloe said the best thing that had happened to her was being forced to address the lack of control she felt over her own life and the pressure to please others. “I think it took having doctors tell me I deserved to live my life for myself that was really key to my turning things around. I had always thought that was selfish, to put myself first. I was wrong. In the hospital, I realized I had to recapture my own life, that I had been given a second chance.”

Dr. Abel summed up the problem so many women have–they don’t feel they can say no and the stress becomes unbearable and something breaks. “The feeling of failing is a very typical way women resolve their distress,” she asserted. “They internalize it and take on the guilt. Women have to recognize when they need help, such as inability to sleep, a restless mind, lack of concentration and not enjoying things you’d normally enjoy. But the causes don’t matter—the solutions do.”

*Names of the women have been changed, as denoted, to protect their identities.