New Insights on Cultural Patterns of Suicide in the United States: The Role of Honor Culture

Abstract

Cultural differences in suicide can be indicative of varying social pressures placed on individuals. High suicide rates in U.S. honor cultures have been proposed to reflect pressures associated with maintaining one’s reputation. We extend this argument by highlighting that honor concerns differentially impact individuals based on gender, ethnicity, and age. Controlling for relevant confounds, we show that suicide rates were highest among older European American men from honor cultures, presumably because aging may render these men less capable of conforming to cultural ideals of masculinity. We discuss the need for process-focused and subgroup analyses when examining the effects of culture on suicide.

Keywords

suicide honor culture ethnicity gender aging

Suicide rates are highest in the Southern and Western United States. Whereas the Northeastern and Midwestern United States have suicide rates of 10.7 and 13.4 per 100,000 inhabitants, respectively, the corresponding rates for the south and west are 13.9 and 14.7 (Centers for Disease Control and Prevention [CDC], 2014). Recently, scholars have suggested that this is symptomatic of a culture of honor (Crowder & Kemmelmeier, 2014; Osterman & Brown, 2011). The southern states in particular have long been known as a culture of violence based on findings that members are more likely to use aggression in response to threats to personal honor (Cohen, Nisbett, Bowdle, & Schwarz, 1996; Cross, Uskul, Gercek-Swing, Alözkan, & Ataca, 2013; Gastil, 1971). Osterman and Brown (2011) argued that the high suicide rates are indicative, at their heart, of culturally sanctioned violence turned against the self. Thus, it is thought that if individuals are unable to defend their honor via interpersonal aggression, they may instead choose to end their lives.

The present research seeks to expand this argument by examining the extent to which cultural patterns of suicide vary across demographic groups, as the pressure to maintain one’s honor likely varies across different societal groups. To the extent that certain groups are much more likely to be the “carriers” of honor cultures, suicides among such group members should be more likely to reveal the imprint of cultural demands. That is, suicide should be more likely to occur when such individuals are unable to fulfill cultural expectations. With gender roles being contingent on culture (Eagly & Wood, 1999), we argue that honor cultures place higher and more rigid expectations on men compared with women, with especially older men being less able to meet such expectations than younger men. Also, given the history of honor cultures in the United States being tied to immigration from certain parts of Europe, we expect honor culture to predict suicide rates among European Americans, but not necessarily among members of other ethnic groups.

U.S. Honor Culture

The defining characteristic of honor culture is its emphasis on the link between social reputation and individual self-worth (Nisbett & Cohen, 1996; Üskül, Cross, Sunbay, Gercek-Swing, & Ataca, 2012). Being contingent on one’s social interactions and the favorable evaluation of one’s behavior by others, honor is inherently unstable. Everyday challenges, large and small, can undermine an individual’s status and reputation, thus rendering his or her honor malleable and uncertain (Cohen & Nisbett, 1994).

Some scholars locate the origins of U.S. Southern honor culture to the early influx of settlers from the herding cultures of the British Isles. With a limited presence of law enforcement, herders had to ensure that their property, and ultimately their livelihood, would not be stolen (Henry, 2009; Nisbett, 1993). To cope, men had to acquire a reputation of being potential aggressors, which enabled them to deter potential thieves. A resulting sense of honor became intimately connected with one’s ability and willingness to defend one’s property. Settlers who eventually began moving westward faced similar obstacles rendering them dependent upon similar strategies to ward off these threats (Brown, 2016; cf. Kitayama, Conway, Pietromonaco, Park, & Plaut, 2010). Thus, the Southern and Western states are often considered “honor states” due to their similar histories in this regard (Cohen, 1998).

In honor cultures, to be seen as an honorable member of society, individuals must actively work to maintain their honor by publicly adhering to cultural norms and expectations (Mesquita & Frijda, 1992). These include abiding by strict gender norms. Men’s honor is contingent upon their ability to serve as the protectors and breadwinners. When one’s honor is threatened, one must respond in a manner that reaffirms one’s masculinity (Bosson & Vandello, 2011). Given the history of the Southern United States, men often demonstrate their willingness and ability to defend their honor with aggressive or violent means (cf. Rodriguez Mosquera, Manstead, & Fischer, 2002).

Aggression does not establish, and may even challenge, a woman’s honor. In honor societies, women must show that they are demure, modest, and chaste (Nisbett & Cohen, 1996). These expectations reveal the patriarchal aspect of honor culture of which men are in charge of maintaining and protecting their property and family. As a result, a woman’s untoward behavior may reflect unfavorably upon the men in her family. Sexual explicitness on the part of a woman may especially signal that a man is unable to maintain a woman’s loyalty or restrain her behavior (e.g., Vandello & Cohen, 2003). With women’s behavior reflecting on men’s status, women’s honor is dependent upon their ability to avoid undermining the honor of their male family members (cf. Osterman & Brown, 2011).

Although lawlessness is no longer a characteristic of the South, men and women alike still recognize the link between social reputation and aggression. Not only are Southerners more likely than non-Southerners to own firearms and to endorse the use of violence to protect their property (Cohen & Nisbett, 1994, 1997; Nisbett, 1993), they are also more likely to respond aggressively to provocation (Cohen et al., 1996; Cohen, Vandello, Puente, & Rantilla, 1999). Furthermore, it has been demonstrated that the higher homicide rates in the South are primarily driven by argument-related homicide, suggesting that interpersonal provocation was more likely to result in murder in the South compared with the other regions of the United States (Nisbett, 1993).

Honor Culture and Suicide

As mentioned, the Southern and Western United States, both considered cultures of honor, have higher suicide rates than the rest of the United States. Similar to Osterman and Brown (2011), we hypothesize that the tight link between one’s perceived reputation and one’s sense of self-worth renders members of honor states susceptible to depression and suicide. When individuals cannot live up to the stringent cultural standards, they are likely at risk of experiencing a sense of alienation and failure (cf. Rosenblatt, Greenberg, Solomon, Pyszczynski, & Lyon, 1989; Tov & Diener, 2007). Moreover, when individuals believe that their reputation has been irreparably harmed, they may choose to end their lives to escape this predicament (cf. Pridmore, 2009; Pridmore & McArther, 2008).

This argument aligns with the interpersonal theory of suicide (Van Orden et al., 2010). According to this theory, people are likely to end their lives when their sense of belonging is undermined and when they come to feel that they are a burden to others. Brown (2016) argued that an individual is likely to experience both when he or she loses his or her honor. As mentioned, a loss of honor signals a loss of social repute, which may trigger a sense of isolation or disconnectedness. Yet, often honor is shared, such as when the loss of a woman’s honor has implication for her entire family (Vandello & Cohen, 2003; Vandello, Cohen, Grandon, & Franiuk, 2009). Under these circumstances, an individual may also feel as though he or she is a burden to others. Brown also highlights that people are more likely to commit suicide when they have become desensitized to self-harm. In such cultures, where exposure to violence is relatively common, individuals may have a higher tolerance for pain or perceptions of danger. These factors may contribute to the higher suicide rates in honor cultures to some degree.

Another factor contributing to the higher suicide rates in U.S. honor culture is a hesitance to seek help when psychologically distressed. In a series of studies, Brown, Imura, and Mayeux (2014) showed that individuals who strongly endorse honor-related beliefs were more likely to think that seeking out mental health support was evidence of personal weakness and would harm their social reputation. Crowder and Kemmelmeier (2014) also demonstrated that, although depression rates are equal across regions of the United States, rates of antidepressant prescriptions are considerably lower in the South and West than in the Northeast and Midwest. This difference explained, in part, the higher suicide rates in the former regions. These findings are consistent with the notion that for members of U.S. honor cultures, depression may pose a greater suicide risk than for members of nonhonor culture. It is plausible to assume that loss of status associated with help-seeking may be seen as acknowledging further weakness.

This argument alludes to “honor suicides” that exist in other honor cultures around the world. For instance, seppuku in Japanese culture refers to a ritualized suicide done as a means to restore one’s honor after a great shame. Even though seppuku is no longer a practice in Japan, similar redemptive suicides still occur. This is especially true during times of social upheaval such as economic recessions when many lose their jobs (Russel, Metraux, & Tohen, 2016). Historically, the link between shame and suicide in the United States has not been as explicit as it has been in Japan or other honor cultures, although evidence is emerging (Crowder & Kemmelmeier, 2017). Although we argue that a sense of shame in response to dishonor is a contributing factor to suicide in the U.S. honor culture, as our focus is on overall suicide rates, without being able to identify reasons for specific instances of suicide, we refrain from referring to suicide in the Southern United States as “honor suicides.”

Honor, Suicide, and Gender

Given that honor places different cultural demands on men and women, we argue that men in particular are at risk of suicide when they cannot meet gender role expectations. For a man, honor implies that he display a certain level of masculine strength, such as a willingness to aggress, which signals his status and ability to protect his family, and livelihood (Henry, 2009; Nisbett & Cohen, 1996). Simply put, men are expected to be protectors and providers in society. We argue that this places older men at greater risk of not meeting these cultural expectations, as they are likely to find it more difficult to project an image of virility, let alone display the physical strength necessary to deter aggression against their person.

As people age, personal success, and the social status associated with it, is not assured. Job loss, bankruptcy, a disabling disease, divorce, or other life circumstances may threaten one’s social standing. Given the stringent expectations as to what it means to be a man of honor, it may be more difficult for older men to overcome these obstacles. As they become aware that they are unable to fulfill expectations of manhood, they may feel alienated from or burdensome to their families and their communities. Surely, some of these issues occur among men of all ages. However, we argue that they are disproportionately likely to impact older men, thus putting them at an increased risk of suicide in honor cultures. Younger men, who can be more focused on future opportunities than older men, may be more likely entertain hope after such severe disruptions. As they get older and they begin to shift their attention to their limited time, they may begin to view such life events as setbacks that are impossible to overcome within their remaining span of life (cf. Strough et al., 2016). Although this is likely a phenomenon that occurs equally for men and women, we argue it is more consequential for men as their status as honorable member of society is contingent on their societal success. Moreover, scheduled transitions into a new phase of one’s life, such as retirement, may put especially men at risk of seeing their social status disrupted.

Women in honor cultures also face their own sense of gender-specific expectations such as portraying an image of chastity, loyalty, devotion to family, and modesty (Brown, 2016; Osterman & Brown, 2011). Although research on women in honor culture is limited, we argue that not being able to abide by their own set of role expectations may also put woman at risk of rejection and alienation. We speculate that for women, the aging process may undermine perceived attractiveness. Even though this may not occur differentially in honor and nonhonor societies, women from honor cultures may view aging as a barrier to signaling their purity and ultimately their social value in a male-dominated society. To our knowledge, the present study is the first to examine whether honor culture is related to women’s suicide rates across different age groups.

Ethnicity and Honor Culture

The herders who settled the Southern United States during the 17th and 18th centuries were largely Scots-Irish (e.g., Brown, 2016; Fischer, 1989); thus, the U.S. Southern honor culture centers on European immigrants. One may expect to observe that honor culture may be shared by all demographic groups within U.S. honor states. However, given that many regions of the United States remain fairly segregated (Wilson, 2011), different racial–ethnic groups have different cultural values (Coon & Kemmelmeier, 2001; Vargas & Kemmelmeier, 2012). For instance, although some African American communities may have established their own subculture of violence as a means of survival (cf. Wolfgang & Ferracuti, 1967), it is a distinct system of norms and values than the southern culture of honor described in this study. Even though African Americans and other minority groups may have been exposed to the honor culture in the South, they may not have adopted it as their own. Furthermore, evidence suggests that White males are more likely to endorse violent tendencies than African Americans (Cao, Adams, & Jensen, 1997). Thus, we expect that southern European Americans are the main carriers of honor cultures. Indeed, the suicide rates for European Americans are much higher than the suicide rates among African Americans (e.g., Oquendo et al., 2001); therefore, we expect that the above patterns hypothesized for suicides in men and women might be most pronounced in European Americans compared with African Americans.

The Present Study

The purpose of the present study is to examine how the association between U.S. state honor culture and suicide varies across certain demographic groups. We assume that cultural values have separate consequences for different types of people. Using Gastil’s (1971) Southernness Index and available suicide rates provided for 10 age categories, both genders, and European Americans and African Americans, we expect the relationship between honor culture, or “Southernness,” and suicide to be strongest for older European American men in Southern states than for any other demographic group examined.

A critical concern of the present work was to control for a number of confounding variables. Confident conclusions about the possible influence of honor culture can only be drawn if contaminating factors are controlled, such as population, access to mental health care, and so on. We also control for two important cultural confounds, collectivism and gun ownership rates (see Table 1). Southernness and collectivism are positively correlated, with some authors even referring to honor culture as a type of collectivism (Üskül, Oyserman, & Schwarz, 2010). Yet, higher collectivism is known to be linked to lower suicide rates whereas Southernness has been shown to be linked to higher suicide rates (Crowder & Kemmelmeier, 2014). Rates of gun ownership are also an established predictor suicide rates (cf. Harvard Injury Control Research Center, 2016), with firearms being more prevalent in honor states (Brown, 2016; Cohen & Nisbett, 1994; Felson & Pare, 2010). Clearly, as we examined the link between Southernness and suicide, it was necessary to separate the net effects of honor culture from the possible net effects of additional confounding factors.

Table 1.

Correlations Among State-Level Variables (N = 50).

Variable Name	(2)	(3)	(4)	(5)	(6)	(7)	(8)	(9)
(1) Southernness	.28^†	.47***	.003	−.30*	.42**	.28*	.62***	.59***
(2) Gun Ownership		−.31*	.35*	.24^†	.43**	−.75***	.29*	−.08
(3) Collectivism			−.39**	−.40**	.08	.23	.16	.49***
(4) Depression				.53***	−.05	−.21	.18	−.22
(5) Antidepressant Prescriptions					−.11	.02	.12	−.18
(6) HPSA						−.33*	.49***	.31*
(7) Population Density							−.23	.03
(8) Economic Deprivation								.38**
(9) July Climate

Note. HPSA = Health Processional Shortage Area.

†

p < .10. *p ≤ .05. **p ≤ .01. ***p ≤ .001.

Method

Suicide

From the U.S. CDC (2012), we obtained nonadjusted suicide rates (per 100,000 population) for men and women, 10 age groups, and two ethnic groups (European American and African American), which were aggregated across 2005 through 2009. Due to the positively skewed nature of suicide rates, we applied a natural log transformation. Suicide rates were available for these age groups: 10 to 14 years, 15 to 19 years, 20 to 24 years, 25 to 34 years, 35 to 44 years, 45 to 54 years, 55 to 64 years, 65 to 74 years, 75 to 84 years, and 85 and older. Because there were few data points at the youngest and oldest ages for African Americans, we collapsed the two youngest age groups (10-14 years and 15-19 years), as well as the two oldest age groups (75-84 years and 85 and older). There were no suicide data for African American women aged 65 and older.¹

Culture of honor

We used Gastil’s (1971) Southernness Index (centered), which was based on migration patterns of Southern populations to various U.S. states. Each state was assigned a Southernness score ranging from 5 (least Southern) to 30 (most Southern).²

Individualism–collectivism

We relied on Vandello and Cohen’s (1999) Collectivism Index (centered) with score ranging from 31 (least collectivist/most individualist) to 91 (most collectivist/least individualist).

Depression

Statewide levels of antidepressant drug prescriptions (ADPs) per capita (centered) were obtained for 2006 and 2007 (Mark, Shern, Bagalman, & Cao, 2007). Average percentage of adults who reported experiencing at least one major depressive episode (MDE; centered) for each state were obtained for the years 2005 to 2009 (Substance Abuse and Mental Health Services Administration, Office of Applied Studies, National Survey on Drug Use and Health, n.d.). These estimates reflect responses from in-person interviews of which individuals indicated whether they experienced any symptoms of MDE described in the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994). Respondents who reported at least five of the nine symptoms presented in the DSM-IV were considered having experienced MDE.

Gun ownership

Self-reported gun ownership percentages (centered) were available for 2001, 2002, and 2004 from the Behavioral Risk Factor Surveillance System (CDC, 2013). These estimates were based on those who responded “yes” to the question, “Are any firearms kept in or around your home?”

Covariates

Following Crowder and Kemmelmeier (2014), we controlled for additional state-level factors that may contribute to suicide. We obtained data from the Health Resources and Services Administration (HRSA; 2012) on the estimated state populations living in primary Health Processional Shortage Areas (HPSAs) to examine the effect of access to health care. Data regarding state population density (per one tenth of a square mile) were retrieved for 2004 through 2009 (Morgan & Morgan, 2006-2010). Our Economic Deprivation Index was based on data obtained for the years 2004 through 2009, which we computed by aggregating standardized statewide poverty rates (U.S. Census Bureau [USCB], 2013c), state unemployment rates (U.S. Department of Labor, Bureau of Labor Statistics, 2013), median household income (reverse scored; USCB, 2013d), and the percentage of the population that had received a high school diploma or more (reverse scored; 2004 through 2006; Current Population Survey [USCB], 2013b; 2007 through 2009 American Community Survey [USCB], 2013a). We also examined extreme temperatures using average January (coldest month) and July temperatures (warmest month) for each state. Estimates were obtained for the years 2004 through 2009 from the National Oceanic and Atmospheric Administration (NOAA; n.d.). We used data from the Current Results Nexus (2013) for Alaska and Hawaii because their information was unavailable. We then subtracted 72 degree Fahrenheit (temperate climate; equivalent to 22°C) from each state’s average January and July temperatures (Van de Vliert, 2007). However, because of multicollinearity, only July deviations from temperate climate were included in the analyses.

Results

To account for the fact that different age and ethnic groups were nested within states, we adopted a multilevel approach that allowed for correct parameter estimates and standard errors (Sadler & Judd, 2008). We generated separate models for men and women because the much lower levels of suicide among women did not permit direct gender comparisons for all age groups.

In a first step, we examined the effects of the two within-states predictors (age, ethnicity) and their interaction (Model 1). In a second step, we added the between-states main effects for predictors: Southernness, Collectivism, Gun Ownership, ADP, and depression levels and the covariates (Model 2). In a third step, we modeled cross-level interactions, such that each within-state effects (main effects and interaction) were allowed to interact with each of the three between-states predictors (Southernness, Collectivism, and Gun Ownership; Model 3), while controlling for the state-level covariates.³ As previous research has shown that the relationship between suicide rates and Southernness varies across levels of ADP and depression (Crowder & Kemmelmeier, 2014), we also include all interactions between Southernness, ADP, and depression in the model. Each successive expansion of the model explained additional variance and produced theoretically relevant results. We report pertinent results from each modeling step, but only the final model (Model 3) is reported in full (see the appendix).

Prior to each analysis, we removed outliers whose residuals were greater than three standard deviations away from the mean. Residuals were based on the third, full model for men and women separately. After identifying and removing the outliers (8 data points pertaining to men, 2 data points pertaining to women), we proceeded to test the three models mentioned previously.

Men’s Suicide Rates

The null model indicated that a substantial proportion of variance in suicide rates occurred between states, intraclass correlation coefficient (ICC) = .25, p < .001. Compared with the null, the within-state effects model (Model 1) explained 84.2% of the variance within states (31.1% of the variance between states), Model 2 explained 89.6% of the variance between states (84.2% within states). We specified the random slopes for age (τ = .003, p = .06) and ethnicity (τ = .004, p = .02) for the full model (Model 3).

Within-state effects (Model 1)

Examining the within-state effects model showed that on average European American men were more likely to commit suicide than African American men (28.18 vs. 14.69 per 100,000 persons, respectively), F(1, 587.00) = 1,446.38, p < .001; yet, a two-way interaction between ethnicity and age group, F(7, 575.61) = 36.22, p < .001, revealed that this difference between ethnicities was most pronounced in the oldest age groups (75+ years), b = −1.046, p < .001, 95% confidence interval (CI) = [−1.182, −0.911], than the youngest age groups (10-19 years), b = −0.531, p < .001, 95% CI = [−0.628, −0.434], with coefficients for other age groups falling in between.

Between-states effects (Model 2)

States with higher depression rates tended to have higher suicide rates, F(1, 55.08) = 21.00, p < .001, b = 0.125, 95% CI = [0.070, 0.180], whereas states with higher ADPs had lower suicide rates, F(1, 54.63) = 13.67, p = .001, b = −0.470, 95% CI = [−0.725, −0.215].

There was also a main effect of gun ownership, F(1, 54.19) = 7.95, p = .01. Examining this effect for men in the middle-age group (35-44 years old) and across the average effect of ethnicity revealed that state gun ownership rates were positively associated with state suicide rates, b = 0.006, p = .01, 95% CI = [0.002, 0.011]. Main effects of state Southernness, F(1, 53.01) = 3.39, p = .07, and state collectivism, F(1, 57.69) = 3.11, p = .08, were not significant. With the exception of population density, F(1, 56.19) = 7.65, p = .01, b = −0.003, 95% CI = [−0.005, −0.001], all other covariates were not statistically significant, ps > .10.⁴

Cross-level interactions (Model 3)

The effect of age and ethnicity varied across states’ levels of Southernness and rates of Gun Ownership. The results regarding the significant three-way interaction with ethnicity, age, and Southernness, F(7, 402.45) = 3.27, p = .002, as summarized in Figure 1, indicated that in states of high and low Southernness (±1 SD of the distribution mean), European Americans’ suicide rates increased across the life span, whereas this was not the case for African Americans. Generally, Southernness was only linked to higher suicide rates among European Americans, not African Americans, though there was a great deal of variability across the life span. At the youngest age (ages of 10-19), Southernness did not predict suicide rates among European Americans, b = 0.002, p = .72, 95% CI = [−0.008, 0.012], nor African Americans, b = 0.004, p = .62, 95% CI = [−0.011, 0.018]. However, Southernness was positively associated with suicide rates among European Americans in the oldest age group (75 years or older), b = 0.026, p < .001, 95% CI = [0.017, 0.034], but negatively linked to suicide rates for African Americans in the same age category, b = −0.023, p = .04, 95% CI = [−0.045, −0.002]. This pattern is consistent with our prediction that a state’s honor culture, here measured via Southernness, would be more critical in predicting suicide rates among older European American men than older African American men, for whom the relationship was unexpectedly reversed.

Figure 1.

Average suicide rates for men by age group, ethnicity, and state Southernness (±1 SD).

The three-way interaction among ethnicity, age group, and gun ownership, F(7, 389.60) = 2.91, p = .006, showed that the statistical effect of gun ownership remained relatively constant across the life span for both African American and European American men. However, it increased in the older age group for African American men (ages 75 and older) but decreased in the same age group for European American men (see Figure 2). For the youngest category of males (aged 10-19), the positive relationship between gun ownership and suicide is similar for European Americans, b = 0.168, p < .001, 95% CI = [0.010, 0.023], and African Americans, b = 0.173, p < .001, 95% CI = [0.008, 0.026]. However, at the ages of 75 and older, the relationship between gun ownership and suicide remained positive for African American men, b = 0.024, p < .001, 95% CI = [0.011, 0.037], but was no longer predictive of suicide for European American men, b = 0.003, p = .33, 95% CI = [−0.003, 0.009].

Figure 2.

Average suicide rates (retransformed) for men by age group, ethnicity, and state gun ownership (±1 SD).

A significant two-way interaction also emerged involving ethnicity and state collectivism, F(1, 74.20) = 9.89, p = .002, with the relationship between state collectivism and suicide rates being negative for African American men, but not for European American men. For instance, among those aged between 35 and 44, collectivism was linked to lower suicide rates among African Americans, b_Age35-44 = −0.012, p = .01, 95% CI = [−0.021, −0.003], but not among European Americans, b_Age35-44 = −0.001, p = .66, 95% CI = [−0.008, 0.005]. This suggests that collectivism may provide a buffering effect for African American, but not for European American, men. Furthermore, the present model did not replicate a Depression by ADP interaction previously reported by Crowder and Kemmelmeier (2014) and Osterman and Brown (2011), F(1, 58.52) = 0.01, p = .94, and again state population density, F(1, 55.97) = 4.57, p = .04, b = −0.002, 95% CI = [−0.005, −0.0002], was the only significant covariate, ps > .09.

Women’s Suicide Rates

Because there were no suicide data for African American women aged 14 and younger as well as 65 and older, and there were only three suicides reported for African American women between the ages 55 and 64, we only examined women’s suicide rates between the ages 15 and 54. The null model indicated a substantial proportion of variance in suicide rates occurred between states, ICC = .23, p < .001. Compared with the null, the within-state effects model (Model 1) explained 80.6% of the variance within states (30.8% of the variance between states), Model 2 explained 85.2% of the variance between states (82.2% within states). We specified the random slopes for age (τ = .011, p = .02) and ethnicity (τ = .006, p = .08) for the full model (Model 3).

Within-state effects (Model 1)

Similar to men’s suicide rates, results showed a significant two-way interaction between ethnicity and age group, F(4, 216.73) = 30.71, p < .001. European American women had higher suicide rates than African American women, and this difference was largest in the older age groups (45+ years), b = −1.119, p < .001, 95% CI = [−1.267, −0.971], than the younger age groups (15-19 years), b = −0.152, p = .20, 95% CI = [−0.385, 0.082].

Between-states effects (Model 2)

As was the case for men, women in states with higher depression rates tended to have higher suicide rates, F(1, 58.69) = 24.99, p < .001, b = 0.190, 95% CI = [0.114, 0.267], whereas states with higher ADPs tended to have lower suicide rates, F(1, 58.47) = 13.03, p = .001, b = −0.636, 95% CI = [−0.988, −0.283]. The main effects of Southernness, gun ownership, and collectivism, were not statistically significant, ps > .32. With regard to the control variables, our climate variable, F(1, 53.74) = 6.69, p = .01, b = −0.017, 95% CI = [−0.031, −0.004], state HPSA, F(1, 39.37) = 4.68, p = .04, b = 0.006, 95% CI = [0.0004, 0.013], and population density, F(1, 44.89) = 13.44, p = .001, b = −0.005, 95% CI = [−0.008, −0.002], were significant predictors of women’s suicide rates; other p = .99.⁵

Cross-level interactions (Model 3)

Although the two interactions between age and ethnicity did not vary as a function of our cultural variables, ps > .13, the effect of age and the effect of ethnicity were each qualified by cultural characteristics. For instance, the difference in suicide rates between European American and African American women varied as a function of state Southernness, F(1, 47.62) = 20.08, p < .001, such that the relationship between Southernness and suicide was positive for European American women, b = 0.022, p < .001, 95% CI = [0.011, 0.033], but not significant for African American women, b = −0.013, p = .19, 95% CI = [−0.035, 0.007].

The statistical effect of Southernness also varied across age groups, F(4, 155.85) = 2.65, p = .040. Similar to men, the positive effect of Southernness was stronger for older women (45-54 years old), b = 0.022, p < .001, 95% CI = [0.011, 0.034], than younger women (15-19 years old), b = 0.010, p = .12, 95% CI = [−0.003, 0.022], ranging from b_Age35-44 = 0.016, p = .006, 95% CI = [0.005, 0.028] to b_Age25 = 0.008, p = .17, 95% CI = [−0.003, 0.020], in between. Taken together, it seems that suicide rates among women showed a similar pattern to those of men such that Southernness was associated with higher suicide rates among European American women compared with African American women although this relationship did not vary as a function of age. Furthermore, the relationship between Southernness and suicide tended to also increase across the life span for women, but this did not differ between ethnic categories.

The manner in which collectivism predicted suicide rates of women varied weakly by age group, F(4, 158.40) = 2.85, p = .051. As expected, the negative association between collectivism and suicide rates materialized among women aged 15 to 19, b = −0.015, p = .07, 95% CI = [−0.031, 0.001], though this association reversed slightly older women aged 20 to 24, b = 0.030, p = .06, 95% CI = [−0.001, 0.062], but there was no relationship for all other age groups, ps > .32. None of the control variables were statistically significant, ps > .07.

Discussion

Our study showed that within the United States, older European American men in honor states are at a particularly high risk for suicide compared with other populations. This finding supports our argument that as men in honor cultures age, they may find it increasingly difficult to maintain their honor. As honor and self-worth are tightly linked in honor cultures, the loss of virility and a higher likelihood of experiencing a negative life event pose greater threats to one’s status and reputation. This may lower older men’s sense of self-worth, which may put these men at greater risk of depression and alienation, and, in more severe cases, thoughts of suicide. The pattern highlights how culture, particularly Southern honor culture, places different demands on different sociodemographic groups, which has very real consequences on their suicide rates.

The results of this study also add to the increasing awareness that culture plays a role for Joiner’s (2005) interpersonal theory of suicide (cf. Brown, 2016; Caulkins, 2014; Wong, Koo, Tran, Chiu, & Mok, 2011). According to this theory, perceived burdensomeness, thwarted belongingness, and acquired capability of self-harm all contribute to suicidal ideation and behavior (Ribeiro & Joiner, 2009). Research has shown that not being able to meet cultural standards puts individuals at risk of feeling burdensome to others. For instance, Imura (2015) showed that people who strongly endorse honor values felt a sense of burdensomeness if they did not perceive themselves as living up to those ideals. Coupled with the fact that as people age, they tend to feel more isolated from others (Van Orden & Conwell, 2011); we argue that as men from honor cultures age and it becomes more difficult to live up to the cultural ideals of manhood, they are at particular risk for suicide.

This suicide risk of middle-aged men is further heightened by the fact that honor societies are often somewhat more violent than nonhonor societies (Doucet, D’Antonio-Del Rio, & Chauvin, 2014; Henry, 2009; Nisbett, 1993), with firearms being more widespread as well. In line with Ribeiro and Joiner (2009), exposure to self-harm or even others’ pain can increase one’s capability for suicide. Thus, men in honor cultures are not only more likely to have access to the means to successfully commit suicide but are also desensitized to violence, which may lower barriers against self-harm. In other words, U.S. honor cultures place older European American men at particular risk for experiencing all three factors of the interpersonal theory of suicide, a particularly lethal combination in provoking thoughts of suicide.

We also found that, although women were far less likely to commit suicide than men, even in honor states, European American women were more likely to end their own lives than African American women. This difference was greater in honor states than nonhonor states, and further supports the notion that the traditions and beliefs associated with the early European herders’ are likely to have persisted to some degree today (Henry, 2009; Nisbett, 1993) and that especially Southern European Americans may have internalized these values to a greater degree than other groups. Although other groups may have had exposure to these cultural ideals, they may be less likely to have internalized them. African Americans have had a very different history in the South than European Americans and, as a result, likely hold distinct cultural beliefs. As such, it is likely that the types of events that are viewed as precipitators of suicide vary between European Americans and African Americans.

When examining state levels of gun ownership, we found that they only predicted suicide rates for men. Research has long shown that men are more likely to use guns as a means for suicide than women, which may be one reason why men have higher suicide rates than women (cf. Callanan & Davis, 2012). Extending previous research, we show that this relationship is relatively constant across the life span for both European Americans and African Americans although state gun ownership no longer had an effect for older European American men but increased sharply among older African American men aged 75 years and older. Thus, for older European American men, the availability of guns seems irrelevant in the decision to commit suicide whereas this was not the case for older African American men. We can only speculate as to the reasons behind this finding. One reason may be that African Americans are less likely to own guns than European Americans (Morin, 2014). Although gun ownership has been linked to higher suicide rates (Harvard Injury Control Research Center, 2016), European Americans who have entertained suicide late in life and who have easy access to a means to commit suicide may not appear in the oldest age category simply because such individuals may have terminate their life already. But it is equally possible to assume that the risk of suicide among older European American men is already at such a high level, that additional risk factors, such as the presence of a gun in the home, no longer increase the risk. Conversely, among older African American men, the presence of a gun seems to have a marked influence on suicide risk.

State collectivism seemed to have a protective effect for African American men and younger women. The literature on culture and suicide has long shown that collectivism and strong social networks buffer against suicide (Crowder & Kemmelmeier, 2014; Rudmin, Ferrada-Noli, & Skolbekken, 2003). The effect of collectivism may have emerged for African American men because European American communities tend to be more individualistic than African American communities (Gaines et al., 1997; but see Vargas & Kemmelmeier, 2012). Women are not nearly as at risk for suicide as men; yet, state collectivism buffered against suicide among those between 20 and 24 years of age. Since women also tend to be more interdependent and socially integrated than men (e.g., Cross & Madson, 1997), the effect in this age group may highlight the importance of social connections and embedded in women’s transition to adulthood.

Limitations

One of the major limitations of this and other archival studies is their inability to trace important processes. Although our findings support the hypothesis that the association between honor culture and suicide is strongest among older European American men, we cannot demonstrate which specific factors are contributing to this link. Although our research is consistent with the notion that this may be due to difficulties meeting social demands associated with masculinity, a more nuanced analysis of the link between honor culture the decision to commit suicide is needed.

Extending this argument, there is no clear conceptualization of state gun ownership rates and their relationship to suicide rates. Greater access to firearms in a society does increase the risk of a successful suicide (Shenassa, Catlin, & Buka, 2003). But even though this may be true (Siegel & Rothman, 2016), research linking state gun ownership rate with state suicide rates does not show whether or not it is gun owners who are committing suicide, or whether gun ownership reflects a separate cultural construct that facilitates suicide (see Kposowa, 2013; Namkug et al., 2011). Clearly, additional investigation is needed to understand this association.

Concluding Remarks

Culture is often discussed as a shared belief system that is internalized by all members of society. Yet, what is often overlooked is that such a shared belief system can have very different consequences across various groups. Our findings underscore the importance of considering the differential associations between culture and suicide across the life span for men compared with women, and for European Americans compared with African Americans. Although archival data cannot directly tap into the underlying processes assumed to give rise to the cultural variations in suicide rates, our findings certainly help pinpoint the location of where or, better, for whom honor culture increases the likelihood of suicide.

Whereas such insights may appear of primary relevance to scholars interested in the intersection between culture and suicide, our findings also have potentially important implications for suicide prevention. For instance, organizations dedicated to the prevention of suicide provide a range of measures aimed at helping others to identify people who are at risk for committing suicide (e.g., American Foundation for Suicide Prevention). Whereas other organizations make clear that older European American men are not typically viewed as an at-risk population, our study shows that, when it comes to suicide in the Southern and Western United States, they very much are. As we have argued, older European American men in these regions of the United States are likely to have internalized the association between honor and masculinity. To the extent that these causal dynamic holds, efforts to reduce stigma and pressures associated with upholding a certain type of masculinity may be particularly beneficial in reducing suicide in these regions.

Footnotes

Appendix

Parameter estimates for the null and full models (Model 3) for men’s and women’s suicide rates.

Predictors	Men				Women
	Null		Full		Null		Full
	b	SE	b	SE	b	SE	b	SE
Intercept	3.121***	0.044	3.722***	0.052	1.745***	0.052	2.320***	0.071
Demographics
Age
75^†			Reference
65			−0.453***	0.028
55			−0.412***	0.028
45			−0.248***	0.028			Reference
35			−0.365***	0.028			−0.144***	0.034
25			−0.546***	0.028			−0.571***	0.035
20			−0.582***	0.028			−0.883***	0.035
15			−1.106***	0.029			−1.121***	0.037
Ethnicity (Reference: European American)			−0.928**	0.068			−1.200***	0.078
Demographic interactions
Age × Ethnicity
75^†			Reference
65			0.026	0.089			—	—
55			−0.087	0.086			—	—
45			−0.005	0.076			Reference
35			0.272***	0.075			0.087	0.090
25			0.554***	0.075			0.757***	0.093
20			0.661***	0.076			0.319	0.201
15			0.514***	0.077			1.141***	0.127
State characteristics
Climate			−0.0003	0.004			−0.005	0.005
Economic deprivation			−0.048^†	0.028			−0.061	0.036
Population density			−0.002	0.001			−0.003^†	0.001
HPSA			0.002	0.002			0.003	0.003
Depression			0.106***	0.028			0.187***	0.037
ADP			−0.442**	0.138			−0.606**	0.175
Gun ownership			0.003	0.003			>−0.001	0.004
Southernness			0.026***	0.004			0.022***	0.006
Collectivism			−0.008**	0.003			0.001	0.004
Two-way interactions (Level 1 by Level 2)
Age × Gun Ownership
75^†			Reference
65			0.006*	0.003			—	—
55			0.002	0.003			—	—
45			0.003	0.003			Reference
35			0.006*	0.003			0.011***	0.003
25			0.012***	0.003			0.011***	0.003
20			0.009***	0.003			0.001	0.004
15			0.014***	0.003			0.001	0.004
Ethnicity × Gun Ownership			0.021***	0.006			−0.010	0.007
Age × Southernness
75^†			Reference
65			−0.010*	0.004			—	—
55			−0.016***	0.004			—	—
45			−0.018***	0.004			Reference
35			−0.019***	0.004			−0.006	0.005
25			−0.020***	0.004			−0.014*	0.005
20			−0.018***	0.004			−0.007	0.005
15			−0.024***	0.004			−0.012*	0.006
Ethnicity × Southernness			−0.049***	0.011			−0.036***	0.010
Age × Collectivism
75^†			Reference
65			0.009**	0.003			—	—
55			0.010**	0.003			—	—
45			0.011***	0.003			Reference
35			0.007*	0.003			0.002	0.004
25			0.005	0.003			0.008^†	0.004
20			0.005	0.003			−0.003	0.004
15			0.003	0.004			−0.004	0.005
Ethnicity × Collectivism			0.006	0.013			−0.004	0.011
ADP × Depression			0.009	0.120			−0.047	0.166
ADP × Southernness			−0.130	0.016			−0.031	0.021
Depression × Southernness			0.001	0.004			−0.001	0.006
Three-way interactions
Age × Ethnicity × Gun Ownership
75^†			Reference
65			−0.017*	0.008			—	—
55			−0.021**	0.008			—	—
45			−0.018**	0.007			Reference
35			−0.023***	0.007			0.0002	0.008
25			−0.030***	0.007			0.017*	0.008
20			−0.025***	0.007			−0.011	0.012
15			−0.021**	0.007			0.013	0.011
Age × Ethnicity × Southernness
75^†			Reference
65			0.046***	0.013			—	—
55			0.041**	0.013			—	—
45			0.067**	0.012			Reference
35			0.041***	0.012			0.001	0.012
25			0.052***	0.012			−0.006	0.008
20			0.037**	0.012			0.027	0.022
15			0.051***	0.012			−0.012	0.012
Age × Ethnicity × Collectivism
75^†			Reference
65			−0.021	0.014			—	—
55			−0.012	0.014			—	—
45			−0.026*	0.013			Reference
35			−0.016	0.013			0.008	0.013
25			−0.018	0.013			−0.002	0.013
20			−0.011	0.013			0.069*	0.032
15			−0.026	0.014			−0.018	0.017
ADP × Depression × Southernness			−0.019	0.019			−0.018	0.024
Random effects
Residual	0.235***	0.014	0.021***	0.002	0.263***	0.025	0.014***	0.004
Intercept	0.077***	0.020	0.006**	0.002	0.079***	0.027	0.006	0.004
Age			0.003^†	0.002			0.011*	0.005
Ethnicity			0.004*	0.002			0.006^†	0.004
−2 LL	950.15		−458.67		442.47		−158.93
AIC	956.15		−302.67		448.47		−50.93
BIC	969.46		43.47		459.19		142.18

Note. HPSA = Health Processional Shortage Area; ADP = antidepressant drug prescription; LL = Log Likelihood; AIC = Akaike information criterion; BIC = Bayesian information criterion.

†

p < .10. *p ≤ .05. **p ≤ .01. ***p ≤ .001.

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) received no financial support for the research, authorship, and/or publication of this article.

Notes

Author Biographies

Marisa K. Crowder is presently a doctoral candidate in the Interdisciplinary Social Psychology PhD Program at the University of Nevada, Reno. Her research examines cross-cultural differences in self-conscious emotions and the link between socioemotional competence and academic outcomes.

Markus Kemmelmeier received his PhD in social psychology from the University of Michigan in 2001. He is currently a professor in the Interdisciplinary Social Psychology PhD Program and the Department of Sociology at the University of Nevada, Reno. His research interests focus on cultural psychology, political psychology, intergroup relations, and social science methods.

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