cultural studies on adolescent suicidal behavior can be regarded as experi- ... "what happens when we die; I just reflected over death-life-universe; I was.
Journal of Gender, Culture, and Health, Vol. 4, No. 3, 1999
Gender and Cultural Differences in the 12-Month Prevalence of Suicidal Thoughts and Attempts in Swedish and Turkish Adolescents Mehmet Eskin1,2
This study compared the prevalence rates of suicidal thoughts and attempts among 966 Swedish and 959 Turkish (N = 1925) high school students. Nearly equal percentages of Swedish (23.2%) and Turkish (25.7%) students reported having had thoughts of killing themselves during the past 12 months. Turkish students reported greater current suicidal ideation than their Swedish peers. Significantly more Turkish (4.6%) than Swedish (2.7%) students reported having made attempts to kill themselves during the past 12 months. The most common reasons for suicidal thoughts and attempts in both groups were psychological problems (feelings of depression, hopelessness, meaninglessness, and emptiness). KEY WORDS: adolescence; suicidal ideation; suicidal attempt; Sweden; Turkey.
INTRODUCTION Suicide among young people is a serious mental health problem. For instance, it is the second leading cause of death among adolescents in the United States (Felner, Adan, & Silverman, 1992), and the rate of suicide has increased approximately 200% since 1960. (Gould, Shaffer, Fisher, Kleinman, & Morishima, 1992). It causes not only loss of life, but also a heavy emotional burden to those bereaved by suicide. Empirical evidence shows that suicidal morality rates increase sharply during adolescence (Aro, Marttunen, & Ldnnqvist, 1993) and that suicidal thoughts and attempts are 1
Department of Psychology, Stockholm University, Stockholm, Sweden. Correspondence should be addressed to Mehmet Eskin, Department of Psychology, Stockholm University, S-106 91 Stockholm, Sweden.
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common among adolescents. In their study with U.S. high school students, Smith and Crawford (1986) found that 62.5% had reported some degree of suicidal ideation or action, including 8.4% who had actually attempted suicide. According to Garland and Zigler (1993), lifetime prevalence of suicide attempts during adolescence ranges from 6% to 13%. Research has shown that suicidal adolescents and young adults suffer from a number of psychological and psychosocial problems. One of the psychological problems which is strongly related to adolescents as well as adult suicide is the presence of psychiatric signs or disturbances (Marttunen, Aro, & Lonnqvist, 1993). Suicidal behavior among adolescents is associated with mood disorders (Kandel, Raveis, & Davies, 1991). For instance, Brent, Perper, Goldstein, Kolko, Allan, Allman, and Zelenak (1988) documented the presence of affective disorders in 82% of the psychiatric inpatient sample of suicidal adolescents. Feelings of hopelessness in suicidal children are also found to be strongly related to suicidal intent (Kazdin, French, Unis, Esveldt-dawson, & Sherick, 1983). Moreover, substance abuse (Rossow & Wichstrom, 1994) and conduct disorder problems (Apter, Bleich, Plutchik, Mendelsohn, & Tyano, 1988) were also found to be related to adolescent suicide. Suicidal adolescents experience intrafamilial problems to a greater extent than nonsuicidal ones. Poor communication with parents is found to be related to adolescent suicidal behavior (Gould, Fisher, Parides, Flory, & Shaffer, 1996). A family history of psychiatric disorders is often found to be a powerful predisposing factor to suicidality. Garfinkel, Froese, and Hood (1982) reported a family history of psychiatric disorders among 50% of suicidal adolescents and children compared to 16% in the nonsuicidal control group. Further, Gould et al. (1992) reported that 40% of the adolescent suicide completers had a first-degree relative who had previously attempted or committed suicide. Moreover, feelings of social isolation, loneliness, and insufficient social support are more common in suicidal than nonsuicidal adolescents (Cole, Protinsky, & Cross, 1992; Wenz, 1979). Although the prevalence of youthful suicidal mortality varies widely (Barraclough, 1988), suicidological investigations have often failed to adopt a cross-cultural perspective. During the past 6 years I have compared different aspects of adolescent suicidal behavior in two socioculturally different countries: Sweden and Turkey. I found suicidal mortality rates to be higher in Sweden than in Turkey, but to have increased more rapidly in Turkey than in Sweden (Eskin, 1993). Despite rejecting attitudes toward suicide in Turkey, the prevalence of nonfatal suicidal behavior in Turkish adolescents was found to be similar to the prevalence in Swedish adolescents. In one of the comparative studies, the lifetime prevalence of suicidal attempts was found to be 9.4% in Swedish and 10.9% in Turkish adolescents (Eskin, 1995a). In another study, Turkish students reported greater suicidal ideation
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than Swedish students (Eskin, 1996). Studies usually indicate that women more often than men report having suicidal thoughts and attempting suicide, while men commit suicide more frequently than women (Moscicki, 1989). Previous comparative studies on adolescent suicidal behavior in Sweden and Turkey, however, documented contrasting patterns as regard to the gender differences. In the age range of 15-24 years, more males than females kill themselves in Sweden, while an equal number of males and females commit suicide in Turkey (Eskin, 1993). Eskin (1995a) found female gender to be a significant predictor of suicidal attempts in a Swedish but not in a Turkish sample of high school students. Further, another study found Swedish girls reporting more suicidal thoughts than boys, but there was no difference between Turkish girls and boys (Eskin, 1996). It is usually assumed that the rate of suicidal behavior is a function of societal attitudes toward suicide. Attitudes toward suicide are liberal/ permissive in Sweden, where secularization is a well-established norm, whereas these attitudes are rejecting/condemnatory in Turkey, where secular religion still plays a significant part in the lives of many people (Eskin, 1995b). Indeed suicide is strictly and explicitly prohibited in Islam (Ates, 1975). Since experimentally controlled studies on suicidal behavior are ruled out for practical and ethical reasons, an alternative approach is comparative investigations conducted in different sociocultural settings with differing suicidal mortality rates. The majority of studies on the adolescent suicide problem are usually based on the comparison of official suicide mortality statistics and hence do not reflect other aspects of suicidal behavior. Crosscultural studies on adolescent suicidal behavior can be regarded as experiments designed by nature and may reveal why some young people with a long life ahead kill themselves. Accordingly, the purpose of this study was comparatively to investigate the prevalence of and the reason for suicidal thoughts and attempts during the past 12 months in Swedish and Turkish adolescents. METHOD Subjects Subjects of the study were 966 Swedish (54.3% female) and 959 Turkish (56.1% female) (N = 1925) high school students. Mean age of the Swedish students was 17.2 years (SD = 1.0), with a range between 15 and 23 years, and the mean age of the Turkish sample was 16.1 years (SD = 1.0), with a range between 14 and 20 years. The age difference between the two groups reflects the time spent before high school education in the two
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countries. Nine years of education is required in Sweden to begin high school education, whereas it is 8 years in Turkey. Of the Swedish group, 38.7% were first-year, 32.0% second-year, and 29.4% third-year students. Of the Turkish group, 37.2% were first-year, 37.3% second-year, and 25.4% third-year students. Average years of school attendance for mothers of Swedish students was 13.3 years (SD = 3.3) and for fathers was 13.5 years (SD = 3.2). The average years of school attendance for mothers of Turkish students was 8.1 years (SD = 4.2) and for fathers was 10.0 years (SD = 4.1). Instrument The questionnaire that was used to collect data asked students whether or not they had thought about or attempted to kill themselves during the past 12 months. They were also asked to rate the frequency and the severity of their thoughts and attempts. Students rated the frequencies of their thoughts and attempts on a 4-point scale ranging from "Only once" (1) to "More than three times" (4). They rated the severities of their thoughts and attempts on a 5-point scale ranging from "Not at all serious" (1) to "Very serious" (5). A question asked adolescents about current suicidal ideation: "How likely is it that you will die by committing suicide?" Students responded to this question on a 5-point scale ranging from "Very unlikely" (1) to "Very likely" (5). Another question asked attempters whether or not they received any treatment because of their suicide attempts. Students were also asked to indicate the reasons for thinking about and attempting suicide. In addition to 13 reasons given in a list, an openended question asked students what other reasons they have had. Psychological reasons in the list were exemplified in a parenthesis by "feelings of depression, loneliness, hopelessness, meaninglessness, and emptiness." The first 13 reasons in Tables I and II are from the list and the rest were extracted from the responses to the open-ended question. Students could give more than one reason. The reasons given to the open-ended question were grouped into five categories. Reasons such as, "I was afraid of failing the university entrance exam; fear of failure; lessons are difficult; unable to cope with the demands of school and too much to do in the school; and school stress," were placed in the school stress category. Reasons such as, "what happens when we die; I just reflected over death-life-universe; I was curious about death and wanted to know how it would feel to be dead," were included under curiosity. "Problems and quarrels with sibling" were included under problems with sibling. Reasons such as, "to come out as homosexual; my sexual identity; and I thought I was homosexual," were
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included under problems with sexual identity. "My friend died, my friend attempted to kill him/herself," were placed in the friend's death and suicide attempt category. Finally, a question asked the method they used to attempt suicide. For the attempts, a list of seven methods were provided (see Table III). Use of alcohol/drugs was mentioned by a student in answer to an open-ended question. Students could check more than one method. The questionnaire also included questions about students' sex, age, grade, and parental education.
Procedure The questionnaire was first developed in Swedish and then translated into Turkish by the present author, whose mother tongue is Turkish. With permission from the Stockholm School Board, eight schools were contacted and asked for participation. Seven of them agreed to participate. One was a vocational high school and another was situated in an area where mostly immigrants lived. Similarly, after permission from the Ministry of Education, nine high schools were contacted in Istanbul. Two of them declined participation. Thus, the data were gathered from seven schools in Istanbul, too. One school was a vocational high school and two were private schools. Students filled in the questionnaire during the regular class hours for the study. Participation was totally voluntary and this was printed on the cover page of the questionnaire and was also verbally expressed either by the investigator or by the teacher at the time of data collection. Six Swedish and eight Turkish student's declined participation. Twenty-two Swedish and 19 Turkish questionnaires were discarded due to incomplete information.
Data Analysis The data were analyzed by using SPSS 6.1 for Macintosh. Chi-square tests were used to compare the groups on categorical variables. Students t-tests and analysis of variance (ANOVA) tests were used to compare the groups on continuous variables. Pearson product-moment correlation coefficients were computed between different components of suicidal behavior.
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RESULTS Suicidal Thoughts Past suicidal thoughts were as frequent among Swedish (n = 224; 23.2%) as they, were among Turkish students (n = 246; 25.7%). Past suicidal thoughts were more common among girls than among boys in both groups: Swedish, 29.0% versus 16.3%, x2(1) = 21.5, p < .000001; Turkish, 31.5% versus 18.2% x2(1) = 21.7, p < .000001. A 2 (country) X 2 (sex) analysis of variance (ANOVA) on current suicidal ideation yielded a significant main effect for country. Turkish students scored higher (M = 1.82) than the Swedish students (M = 1.71), F(l, 1751) = 4.0, p < .05. Separate 2 (country) x 2 (sex) ANOVAs on the frequency and severity of past suicidal thoughts produced two significant main effects for country. Swedish students reported having more frequent suicidal thoughts (M = 2.32) than did the Turkish students (M = 1.92), F(l, 298) = 8.6, p < .005. Turkish students rated their thoughts to be more serious (M = 3.24) than their Swedish counterparts (M = 2.29), F(l, 422) = 60.1, p < .0001. Table I presents the reasons for suicidal thoughts. In the Swedish group, more girls than boys reported problems with parents [33.8% vs. 20.8%, x2(1) = 3.9, p < .05], sexual abuse [4.1% vs. 0.0%, x2(1) = 3.0, p < .10], and problems with friends [25.0% vs. 12.5%, x2(1) = 4.6, p < .05]; Table I. The Reasons for Suicidal Thoughts Among Swedish and Turkish Adolescents Swedish Reason 1. 2. 3. 4. 5. 6. 7. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19.
Psychological problems Problems with parents Problems with girl/boyfriend Got lower grades than expected Problems with friends Broke with girl/boyfriend Financial problems in family Dissatisfied with physical appearance I was bullied My parents separated Alcohol/drug problems Someone in family died I was sexually abused School stress Problems with sibling Curiosity Friend's death and suicide attempt Problems with sexual identity
adf
= 1 for all.
N
%
150 68.2 65 29.5 35 15.9 23 10.5 46 20.9 18 8.2 11 5.0 36 16.4 9 4.1 2 0.9 6 2.7 14 6.4 6 2.7 5 2.3 1 0.5 10 4.5 2 0.9 3 1.4
Turkish
N
%
X2a
149 117 54 51 45 44 27 25 16 11 10 9 6 13 4 3 0 0
61.3 48.1 22.2 21.0 18.5 18.1 11.1 10.3
2.38 16.75 2.96 9.54 0.42 9.81 5.72 3.73 1.41 5.54 0.67 1.73 0.03 2.93 1.55 4.64 2.22 3,32
6.6 4.5 4.1 3.7 2.5 5.3 1.6 1.2 0.0 0.0
P NS
