Suicide attempts among men with histories of child sexual abuse: Examining abuse severity, mental health, and masculine norms

Abstract

Objective

Men who were sexually abused during childhood are at risk for a variety of long-term mental health problems, including suicidality. However, little is known about which factors are related to recent suicide attempts for this vulnerable, under-researched population. The purpose of this study was to examine the relationship between abuse severity, mental health, masculine norms and recent suicide attempts among men with histories of child sexual abuse (CSA).

Methods

We analyzed survey data gathered from a purposive sample of 487 men who were sexually abused during childhood. The age of the sample ranged from 19 to 84 years (μ = 50.4 years). Recent suicide attempts served as the dependent variable in the study. Self-reported measures of sexual abuse severity, child physical abuse, mental health, masculine norms, and demographic information (age, race) represented the independent variables.

Results

The results from logistic regression modeling found that five variables – duration of the sexual abuse, use of force during the sexual abuse, high conformity to masculine norms, level of depressive symptoms, and suicidal ideation – increased the odds of a suicide attempt in the past 12 months.

Conclusion

To improve mental health services for men with histories of CSA, mental health practitioners should incorporate sexual abuse severity, current mental health, and adherence to masculine norms into assessment and treatment planning.

Introduction

Globally, approximately one million people die from suicide each year (World Health Organization [WHO], 2012a). Between 1999 and 2007, suicide ranked as one of the top ten leading causes of death in the United States for age groups between 15 and 64 (Centers for Disease Control and Prevention [CDC], n.d.). Yet, these statistics do not include suicide attempts, which are nearly 20 times more frequent than completed suicides (WHO, 2012a). During 2008–2009, approximately 1 million US adults reported making a suicide attempt (CDC, 2011). Because men are more likely to complete suicide than women (Mościcki, 1994, WHO, 2012b), understanding factors contributing to suicide attempts is critical to addressing the high rate of mortality among men.

A growing body of research has found that child sexual abuse (CSA) is a salient risk factor for later suicide attempts among adolescent and adult males and females (Bedi et al., 2011, Dube et al., 2005, Martin et al., 2004; see also meta-analysis by Paolucci, Genuis, & Violato, 2001). Although prevalence rates vary depending on methodological issues, studies have found that approximately 15% of adult men reported a history of CSA (Briere and Elliot, 2003, Dube et al., 2005, Lisak et al., 1996). Compared to men without histories of CSA, suicide attempts were 4–11 times higher for men with histories of CSA (Molnar, Berkman, & Buka, 2001). However, most studies that focused on the association between CSA and suicide attempts compared samples of individuals with and without histories of CSA. Consequently, little is known about which factors are associated with suicide attempts among adult survivors of CSA generally. Additionally, the majority of research on adult survivors of CSA has focused on females (Dhaliwal et al., 1996, Holmes and Slap, 1998, Spataro et al., 2001). Because men with histories of CSA are a vulnerable, under-researched group, the purpose of this study was to explore risk factors for suicide attempts within this population including characteristics of CSA, childhood physical abuse (CPA), gender norms, and mental health. The results of the current study will strengthen the knowledge base, provide directions for future research, and identify suggestions for clinical practice.

Adverse events experienced during childhood, which include CSA, have been linked with later suicide attempts (Afifi et al., 2008, Dube et al., 2001). After controlling for the effects of mental health disorders and other adverse childhood events in a nationally representative sample (N = 5,877; ages 15–54), Molnar et al. (2001) found that 8–12% of suicide attempts were independently attributed to CSA. Focusing on the effects of different types of child abuse, Joiner et al. (2007) found that childhood physical and violent sexual abuse imposed greater risk for future suicide attempts than molestation and verbal abuse. Andover, Zlotnick, and Miller (2007) found that individuals with a history of suicide attempts were more likely to report histories of CSA or CPA compared to individuals without a history of attempts. Brezo et al. (2008) found that young adults who experienced both CSA and CPA had 5–14 times greater risk of suicide attempts. Similarly, Fergusson, Boden, and Horwood (2008) found that both CSA and CPA were associated with suicidal ideation and attempts; however, the effects of CPA were weaker and less consistent.

These findings lend some support to the interpersonal theory of suicidal behavior (Joiner, 2005, Van Orden et al., 2010). The core idea behind this theory is that, in order to die by suicide, individuals must acquire the capability for suicide through a reduced fear associated with suicidal behaviors. The capability for suicidal behavior emerges through habituation in response to repeatedly painful and fearful experiences, and over time, an individual can tolerate increasingly painful and potentially lethal forms of self-harm (Van Orden et al., 2010). Experiences of childhood abuse, especially when severe, have the potential to be both fear-inducing and extremely physically painful (Joiner et al., 2007). In a sample of men with histories of CSA, O’Leary and Gould (2009) found that physical injuries and invasive sexual abuse (i.e., penetration) were positively correlated with both suicidal ideation and suicide attempts. Thus, according to the theory, types of childhood abuse that are more painful and more severe – such as physical and sexual abuse – are more salient risk factors for suicide than other, less physically painful, forms of abuse. In the current study we hypothesized that the use of physical force during CSA, the frequency of CSA, and having experienced CPA would be positively related to suicide attempts.

The experience of CSA can profoundly impact the gender identity of male survivors by causing identity confusion, self-blame, and shame (Holmes and Slap, 1998, Hunter, 1991, Lisak, 1994, Nasjleti, 1980). One reason for this is that CSA violates many socially sanctioned gender expectations in Western culture which include dominance, winning, heterosexuality, emotional control or stoicism, and pursuit of status (Mahalik et al., 2003). Male survivors who adhere to these expectations may believe that being a victim is wholly un-masculine (Lisak, 1993). Being abused by another male may heighten feelings of stigma, shame, and internalized homophobia (Heath et al., 1996, Mahalik et al., 2003, Spataro et al., 2001) and increase the survivor's fear that he won’t be believed or will be labeled a homosexual if he discloses the sexual abuse (Alaggia, 2005, Banyard et al., 2004). Men with histories of CSA often delay disclosure for years and even decades (Holmes and Slap, 1998, O’Leary and Barber, 2008, Spataro et al., 2001, Ullman and Filipas, 2005). Rather than attempting to understand, address, and reconcile the internal conflict over masculinity, some male survivors adopt a different approach: hegemonic masculinity or hyper-masculinity (Dorais, 2002, Lisak, 1994). In these cases, men guard the secret of CSA through behaviors designed to prove or reassert their masculinity according to stereotypical norms (i.e., excessive conformity).

A consistent pattern is emerging in the literature on male gender norms: conformity to traditional masculine norms is positively related to psychological distress. Mahalik et al. (2003) found that conformity to masculine norms predicted global psychological distress and that several types of traditional male norms (e.g., dominance, self-reliance, risk-taking) were related to specific mental health problems such as depression, somatization, hostility and anxiety. Theodore and Lloyd (2000) found that norms, such as emotional restrictiveness, were positively related to depression, anxiety, and stress and negatively related to well-being. Although our literature review identified some studies that focused on masculinity and suicidal thoughts (e.g., Hunt, Sweeting, Keoghan, & Platt, 2006), we did not identify any studies that examined the relationship between conformity to masculine norms and suicidality among men with histories of CSA. Men who adhere to traditional norms such as emotional control or restrictiveness may isolate themselves from others. Furthermore, norms such as risk-taking and violence may propel an individual to take drastic actions and transition from suicidal ideation to a suicide attempt. For these reasons, in the current study we hypothesized that high conformity to masculine norms will be related to an increased risk of a suicide attempt in the past year.

Among adults, having a depressive disorder has been cited as a risk factor for suicide attempts. Using data from the National Comorbidity Survey, Nock and Kessler (2006) found that risk factors for suicide attempts included being male and having a major depressive episode. Another study found that among individuals with a major depressive disorder, the recognition of having a mental health condition increased the risk of suicidal ideation and attempts (Gonzalez, 2008). A growing body of research has found that CSA is related to long-term mental health problems for men including depression (for reviews, see Holmes and Slap, 1998, Putnam, 2003, Spataro et al., 2001). In one study, O’Leary (2009) found that men with histories of CSA were up to 10 times more likely to be classified as meeting clinical thresholds for psychiatric complaints, including severe depression, than men from a comparison community sample. Thus, we hypothesized that the level of depressive symptoms would be related to an increased risk of a suicide attempt in the past year.

Suicide ideation has also been found to be related to suicidal behavior. The results of a cross-national study with data from 17 countries revealed the lifetime prevalence of suicidal ideation, suicide plans and suicide attempts to be 9.2%, 3.1% and 2.7%, respectively (Nock et al., 2008). The probability of a suicide attempt is greater for individuals who express suicidal ideation with a plan compared to those who express suicidal ideation without a plan (Nock et al., 2008). Because suicidal behavior often follows a progression from thoughts through attempts (van Heeringen, 2001), we hypothesized that suicidal ideation in the past year would be related to an increased risk of a suicide attempt in the past year.

As previously noted, few studies have concentrated on identifying risk factors for suicide attempts specifically within a sample of men with histories of CSA. Thus, the purpose of this study was to identify risk factors among this under-researched population. Using aspects from the interpersonal theory of suicide and previous empirical research to guide our selection of salient risk factors, we included characteristics of the sexual abuse, the presence of CPA, depressive symptoms, suicidal ideation, and masculinity. Research that identifies risk factors for suicide attempts for this population can inform suicide prevention and treatment services.