Changing demographic characteristics and motives for suicide in rural China,1980

Abstract

Given the absence of a complete vital registration system in rural China, a unique large-scale ethnographic study was conducted to examine the incidents, trends, demographic characteristics and motives for suicide. This study was implemented in 55 villages from 23 prefectures in 11 provinces. Family members, relatives, friends, and neighbours of suicide victims, and key informants (cadres, village doctors, funeral/burial coordinators, and primary-school teachers) in a village were interviewed to obtain and verify the detailed life history of each suicide victim since the 1980s. Among 849 suicide victims we investigated, we found more female than male victims, which is reversed gender difference in traditional suicide literature. Both number of elderly suicide victims and suicide motives related to livelihood have dramatically increased in recent years. There were more middle-aged victims during the years 1995–9. This study suggests that suicide in rural China remains an urgent and enormous public health problem. Findings from this research cast doubt on the well-known sex disparity in China’s suicide victims and suggest a possible epidemic of elderly suicides in rural China. The shifting pattern of suicide motives tracks socio-cultural changes in rural China.

Keywords

suicide victim suicide motive rural China

Introduction

Suicide in China has been shown to be an alarming issue: about 30 per cent of all suicide incidents worldwide are found in China and India alone (Conner et al., 2007; Phillips et al., 2002a, 2002b; Zhang, 2010; Pearson et al., 2002; Yip et al., 2005; Bertolote and Fleischmann, 2002, 2015). Findings from different studies suggest that the majority of completed suicides in China are committed by rural residents, who have much higher suicide rates than their urban counterparts (Yip et al., 2005; Wang et al., 2014; Ji et al., 2001). During the years 1995–9, the overall suicide rate in rural China was estimated to be 27.1 per 100,000 people per year, about three times higher than that in urban areas (Phillips et al., 2002a). Besides the unusually high suicide rates, several distinct features of suicide in rural China have been suggested by existing studies. The most noteworthy one is probably the high female-to-male ratio of suicide victims in rural China, which makes China the only country with more female suicide victims than male in the world. Meanwhile, suicide incidents among the elderly appear to be on the increase in rural China (Li et al., 2009; Wang et al., 2014; Yip et al., 2005; Bertolote and Fleischmann, 2002). Finally, suicide in rural China is possibly driven by cultural-specific factors and social conditions (Zhang et al., 2004; Pritchard, 1996; Phillips et al., 1999).

Existing studies on suicide in China have investigated risk factors or proximate causes of suicide (Phillips et al., 2002b, 2007; Li et al., 2007; Law and Liu, 2008). For example, one pioneering study identifies eight risk factors of suicide in China (e.g. depression symptoms, previous suicide attempt, acute stress and low quality of life) and suggests that suicide incidents are associated with the exposure to multiple risk factors instead of a single risk factor (Phillips et al., 2002b). While these findings are valuable to the design of more effective suicide-prevention programs in China, researchers remain unclear about whether the exposure to different risk factors is possibly driven by more fundamental determinants of suicide and how such fundamental determinants, if any, correspond to the cultural tradition and social transformation in China (Fu and George, 2015; Link and Phelan, 1995; Zhang et al., 2010). For rural residents who were familiar with suicide victims, such as family members, relatives, friends and neighbours, previous studies did show that their explanations of suicide were seldom constructed upon proximate risk factors such as depression, stress or life dissatisfaction (Meng, 2002; Lee, 2014; Fei, 2005). Instead, these interviewees tried to explain whether they found the suicide incidents or the motives of suicide victims plausible. Therefore, we argue that the attention of researchers and policy-makers on suicide in rural China should be shifted from individual risk factors to socio-cultural origins that put these suicide victims at risk. Delineating the generic nature of motives for suicide will allow us to contextualize risk factors for suicide and better understand how social dynamics of China’s great transformation affected suicide in its vast rural areas from 1980 to 2009.

Yet, previous studies on these topics related to suicide in rural China have been hampered by data quality and availability (Yip and Liu, 2006; Yip et al., 2005; Phillips et al., 1999). Due to the rural-urban divide (Chan and Zhang, 1999; Fu and Ren, 2010), China’s vital population registration system and health facilities have inadequate coverage in rural areas. Meanwhile, deliberate misclassification of causes of death can also result from social stigma perceived by family members of the suicide victims (Lee et al., 2007). A large-scale ethnographic project was thus conducted to explore and verify all suicide victims from 55 villages in 11 provinces. Findings from this unique qualitative project not only advance our understanding of demographic characteristics of suicide victims and their motives in rural China but also help reveal underlying social dynamics of suicide that are unlikely to be captured by medical records and survey data.

Methods

Study design

This study is based on coded qualitative data retrieved from a collaborative ethnographic project. This large-scale project conducted in the years 2007–14 covered 55 villages from 23 prefectures (Qinhuangdao, Yuncheng, Huai’an, Shaoxing, Hefei, Bengbu, Xuancheng, Longyan, Ganzhou, Ji’an, Xinyang, Wuhan, Huangshi, Shiyan, Xiangfan, Jingmen, Xiaogan, Xianning, Enshi, Changsha, Yueyang, Changde, Chenzhou, and Hezhou) in 11 provinces (Hebei, Shanxi, Jiangsu, Zhejiang, Anhui, Fujian, Jiangxi, Henan, Hubei, Hunan, and Guangxi). Despite the qualitative nature of this project, the 11 provinces vary substantially in terms of demography, geography and economic development. It should be noted that researchers had no prior knowledge of suicide incidents in the selected villages before the project was implemented. The selection of 55 villages was determined by their accessibility to researchers. Due to the sensitivity of the research topic, the ethnographic interview cannot be conducted in a Chinese village without first notifying local officials and obtaining their consent. A collaboration network of researchers across China was developed to gain the support from local officials and carry out the fieldwork in these 11 provinces. Among all residents in a village (including rural migrants from this village), suicide victims aged 15 or above were thoroughly investigated in this retrospective project and the youngest suicide victim identified in this research was 17 years old. Only adults aged 18 or above were invited to participate in the interview. All the 55 villages investigated had a total of 71,733 residents (based on their household registration status) by the end of 2009, and the current study focuses on information about suicide victims since the 1980s. Among these villages, 849 suicide incidents from 1980 to 2009 were identified and investigated.

Data collection

While the flow of information within a village is often facilitated by its close-knit (family and kinship) network, the research team made several efforts to identify suicide victims, verify their socio-demographic profiles and explore the victims’ motives for suicide. The ethnographic interview was carried out at each of the 55 village in the following four steps. First, random interviews with peasants were conducted in public space, such as local grocery stores, sidewalks and resting areas; and the village cadre maintaining demographic records of a village was contacted. Second, key informants in a village, especially these related to health care and funeral/burial arrangements, were interviewed. These informants included primary-school teachers, village doctors and local funeral/burial coordinators. Third, family members of the victims were interviewed, and, if that was not possible, focus groups consisting of friends, neighbours and/or the relatives of the victims were conducted. Finally, the research team revisited the village cadre to verify and integrate information from all sources. A summary session was held every night to review existing materials and improve the quality of interviewing. Depending on the population size of a village and difficulty in recruiting various interviewees, the duration of fieldwork conducted at a specific village ranged from two weeks to a month. There were 145 interviewers involved in this study, which interviewed about 3100 respondents. The interview with each respondent lasted for approximately 3 to 3.5 hours. It should be noted that although the research team made extensive efforts to identify and validate all suicide incidents over the period of study, we do not claim that this study provides an exhaustive report of all possible incidents given that some suicide victims may be both socially and geographically isolated from others in the same village.

Measures

Four key variables pertaining to suicide victims were retrieved from the ethnographic reports and coded for analysis: sex, the calendar year of death, age at the time of death, and major motives for suicide. Sex of the same suicide victim reported by various interviewees tends to be consistent throughout the fieldwork. The temporal information related to the calendar year of death and age at the time of death were obtained and verified by asking interviewees to project their answers to major historical events in China and life-course events of the victims’ family members (e.g. birth, death, marriage and school enrolment). Although the use of these historical and life-course events helped participants to recall the age of suicide victims and their timing of death, it remains difficult for this retrospective project to obtain accurate temporal information of all suicide victims. We thus report the calendar year of death in 5-year groups and aggregate the age of suicide victims into three categories: youth (15–34 years old), the middle-aged (35–59 years old) and the elderly (60 years old and over).

Suicide incidents are categorized according to major motives for suicide. While a small proportion (about 10%) of suicide victims may possess more than one motive for suicide, the research team determined a major motive of each suicide victim by carefully examining ethnographic materials collected, and these incidents were not counted repeatedly. A major motive for suicide is viewed in this study as a motivation that prompts a victim to develop an inclination for suicide and, if left unabated, the persistence and intensification of such motivation ultimately account for suicide.

Based on the interview data collected in this project, seven general categories of major motives for suicide were identified. Subsistence-induced suicide is observed in victims who lack economic, human and social capital and cannot maintain a minimum standard of living that is adequate for survival. Illness-induced suicide happens when victims try to end illness-induced physical pain and psychological distress, especially the former. The first two types of motives are related to livelihood in rural China. Revenge suicide is adopted as a means to punish or threaten others, or defend oneself against false accusations. Altruistic suicide is viewed by victims as a way to reduce burdens assumed by others (usually family members). These suicide victims are often motivated by reducing economic burdens of their families, but burdens can also be physical, emotional or cultural. For example, when a person was confronted by his in-laws due to his extramarital affairs, his mother committed suicide in the hope that the son could be excused from physical punishment and humiliation from the in-laws. In some rare cases the elderly committed suicide in the belief that their own longevity would bring bad fortune to offspring. In comparison, some victims also choose to end their life as a way to avoid their own economic, social and cultural burdens (or to avoid their own obligations, as according to interviewees). These who are supposed to support the family and perform various duties in a village may find these tasks too demanding and resort to suicide. Despair-related suicide specifically refers to these cases where victims feel unable to fulfil their emotional needs, such as freedom of marriage, boy preference and filial piety. Finally, for the remaining victims, they did not have suicide plans and encountered an intense acute stressor before their impulsive suicide. This type of suicide is facilitated by the high availability of pesticide in rural China (Conner et al., 2007; Phillips et al., 2002a; Nock et al., 2008).

Results: Changing demographic characteristics and motives for suicide in rural China

The demographic characteristics of 849 suicide victims included in the ethnographic project are shown in Table 1. Except for the years 1990–94, the number (incidents) of suicide victims in the 55 villages interviewed shows a monotonic increase over the entire period of study. Consistent with the previous observation that China is possibly the only country with more female suicide victims than male ones (Phillips et al., 1999; Conner et al., 2007), there are more female victims (56.8%) than male victims in the sample. Yet, such sex disparity in suicide rates tends to diminish in more recent years, and we surprisingly observed that the suicide trend is returning to the normal in recent years. Therefore, the proportion (percentage) of female victims in the overall sample dropped from 73.4 per cent in the years 1990–4 to 41.9 per cent in the years 2005–9. For age differences in suicide rates, the number of young suicide victims decreased whereas the number of elderly suicide victims dramatically increased. From 1980 to 2009, there was a more than ten-fold increase in the number of elderly suicide victims (i.e. from 14 victims to 154 victims) and their share of overall suicide victims increased from 19.4 per cent to 77.8 per cent. For the middle-aged group, their suicide rate reached its peak in the years 1995–9, and then declined and fluctuated. In age-sex subgroups, suicide victims in the initial time period (the years 1980–4) were dominated by young women (43.1%) and young men (20.8%). With the substantial increase of elderly suicide victims, the majority of suicide victims in the most recent time period consisted of older men (46.0%) and older women (31.8%). The increase of older men in suicide victims is particularly striking: its contribution to the overall victims increased from 8.3% in the years 1980–4 to almost one half (46.0%) in the years 2005–9, which leads to a reversed sex difference in suicide victims over the period of study.

Table 1.

Number and percentage of suicide victims from 55 villages in 11 provinces of China, by Age and Sex, 1980–2009.

	Female		Male		Aged 15–34 yrs		Aged 35–59 yrs		Aged 60 yrs and over		Total
	Number	Percent	Number	Percent	Number	Percent	Number	Percent	Number	Percent	Number
1980–84	47	65.3%	25	34.7%	46	63.9%	12	16.7%	14	19.4%	72
1985–89	86	66.7%	43	33.3%	70	54.3%	19	14.7%	40	31.0%	129
1990–94	80	73.4%	29	26.6%	66	60.6%	17	15.6%	26	23.9%	109
1995–99	94	59.1%	65	40.9%	24	15.1%	44	27.7%	91	57.2%	159
2000–04	92	50.6%	90	49.5%	21	11.5%	23	12.6%	138	75.8%	182
2005–09	83	41.9%	115	58.1%	11	5.6%	33	16.7%	154	77.8%	198
Total	482	56.8%	367	43.2%	238	28.0%	148	17.4%	463	54.5%	849
	Female						Male
	Aged 15–34 yrs		Aged 35–59 yrs		Aged 60 yrs and over		Aged 15–34 yrs		Aged 35–59 yrs		Aged 60 yrs and over		Total
	Number	Percent	Number	Percent	Number	Percent	Number	Percent	Number	Percent	Number	Percent	Number
1980–84	31	43.1%	8	11.1%	8	11.1%	15	20.8%	4	5.6%	6	8.3%	72
1985–89	55	42.6%	10	7.8%	21	16.3%	15	11.6%	9	7.0%	19	14.7%	129
1990–94	57	52.3%	11	10.1%	12	11.0%	9	8.3%	6	5.5%	14	12.8%	109
1995–99	20	12.6%	25	15.7%	49	30.8%	4	2.5%	19	12.0%	42	26.4%	159
2000–04	11	6.0%	13	7.1%	68	37.4%	10	5.5%	10	5.5%	70	38.5%	182
2005–09	5	2.5%	15	7.6%	63	31.8%	6	3.0%	18	9.1%	91	46.0%	198
Total	179	21.1%	82	9.7%	221	26.0%	59	7.0%	66	7.8%	242	28.5%	849

Table 2 presents the number (incidents) and percentage of major motives for suicide. Motives related to subsistence, illness, revenge, impulsion, despair, avoidance and altruism account for 23.0 per cent, 19.0 per cent, 15.0 per cent, 13.7 per cent, 12.3 per cent, 11.7 per cent and 5.5 per cent of the overall sample respectively. Although the percentage of altruistic suicide stayed below 10 per cent from 1980 to 2009, the composition of other major motives changed substantially over time. Revenge, impulsion, despair and avoidance were the most frequent motives for suicide in the 1980s, but subsistence-induced suicide and illness-induced suicide became most prevalent in the 2000s. Meanwhile, the increasing number of suicide incidents was driven by the sharp rise of subsistence-induced and illness-induced suicide in more recent years. The incidents of altruistic suicide were also increasing, while the incidents of avoidance suicide roughly stayed at the same level. Suicide incidents related to revenge and impulsion reached their peaks around the 1990s and then declined.

Table 2.

Major motives for suicide retrieved from ethnographic reports on 55 villages in 11 provinces of China, by age and sex, 1980–2009.

	Subsistence		Illness		Revenge		Impulsion		Despair		Avoidance		Altruism		Total
All	Number	Percent	Number	Percent	Number	Percent	Number	Percent	Number	Percent	Number	Percent	Number	Percent	Number
1980–84	2	2.8%	5	6.9%	13	18.1%	16	22.2%	13	18.1%	18	25.0%	5	6.9%	72
1985–89	8	6.2%	18	14.0%	34	26.4%	20	15.5%	24	18.6%	20	15.5%	5	3.9%	129
1990–94	3	2.8%	17	15.6%	24	22.0%	35	32.1%	23	21.1%	5	4.6%	2	1.8%	109
1995–99	37	23.3%	26	16.4%	27	17.0%	25	15.7%	16	10.1%	18	11.3%	10	6.3%	159
2000–04	77	42.3%	51	28.0%	15	8.2%	4	2.2%	9	5.0%	17	9.3%	9	5.0%	182
2005–09	68	34.3%	44	22.2%	14	7.1%	16	8.1%	19	9.6%	21	10.6%	16	8.1%	198
Total	195	23.0%	161	19.0%	127	15.0%	116	13.7%	104	12.3%	99	11.7%	47	5.5%	849
	Subsistence		Illness		Revenge		Impulsion		Despair		Avoidance		Altruism		Total
Female	Number	Percent	Number	Percent	Number	Percent	Number	Number	Number	Percent	Number	Percent	Number	Percent	Number
1980–84	0	0.0%	3	6.4%	12	25.5%	10	21.3%	10	21.3%	10	21.3%	2	4.3%	47
1985–89	2	2.3%	9	10.5%	30	34.9%	14	16.3%	18	20.9%	8	9.3%	5	5.8%	86
1990–94	3	3.8%	10	12.5%	21	26.3%	25	31.3%	20	25.0%	1	1.3%	0	0.0%	80
1995–99	14	14.9%	12	12.8%	24	25.5%	19	20.2%	10	10.6%	8	8.5%	7	7.5%	94
2000–04	39	42.4%	24	26.1%	12	13.0%	2	2.2%	4	4.4%	5	5.4%	6	6.5%	92
2005–09	26	31.3%	16	19.3%	11	13.3%	8	9.6%	10	12.1%	6	7.2%	6	7.2%	83
Total	84	17.4%	74	15.4%	110	22.8%	78	16.2%	72	14.9%	38	7.9%	26	5.4%	482
	Subsistence		Illness		Revenge		Impulsion		Despair		Avoidance		Altruism		Total
Male	Number	Percent	Number	Percent	Number	Percent	Number	Number	Number	Percent	Number	Percent	Number	Percent	Number
1980–84	2	8.0%	2	8.0%	1	4.0%	6	24.0%	3	12.0%	8	32.0%	3	12.0%	25
1985–89	6	14.0%	9	20.9%	4	9.3%	6	14.0%	6	14.0%	12	27.9%	0	0.0%	43
1990–94	0	0.0%	7	24.1%	3	10.3%	10	34.5%	3	10.3%	4	13.8%	2	6.9%	29
1995–99	23	35.4%	14	21.5%	3	4.6%	6	9.2%	6	9.2%	10	15.4%	3	4.6%	65
2000–04	38	42.2%	27	30.0%	3	3.3%	2	2.2%	5	5.6%	12	13.3%	3	3.3%	90
2005–09	42	36.5%	28	24.4%	3	2.6%	8	7.0%	9	7.8%	15	13.0%	10	8.7%	115
Total	111	30.3%	87	23.7%	17	4.6%	38	10.4%	32	8.7%	61	16.6%	21	5.7%	367
	Subsistence		Illness		Revenge		Impulsion		Despair		Avoidance		Altruism		Total
Aged 15–34 yrs	Number	Percent	Number	Percent	Number	Percent	Number	Percent	Number	Percent	Number	Percent	Number	Percent	Number
1980–84	0	0.0%	0	0.0%	10	21.7%	12	26.1%	13	28.3%	10	21.7%	1	2.2%	46
1985–89	1	1.4%	3	4.3%	28	40.0%	11	15.7%	21	30.0%	6	8.6%	0	0.0%	70
1990–94	1	1.5%	3	4.6%	16	24.2%	24	36.4%	18	27.3%	4	6.1%	0	0.0%	66
1995–99	0	0.0%	0	0.0%	16	66.7%	6	25.0%	2	8.3%	0	0.0%	0	0.0%	24
2000–04	0	0.0%	2	9.5%	8	38.1%	1	4.8%	4	19.1%	5	23.8%	1	4.8%	21
2005–09	0	0.0%	1	9.1%	1	9.1%	2	18.2%	3	27.3%	4	36.4%	0	0.0%	11
Total	2	0.8%	9	3.8%	79	33.2%	56	23.5%	61	25.6%	29	12.2%	2	0.8%	238
	Subsistence		Illness		Revenge		Impulsion		Despair		Avoidance		Altruism		Total
Aged 35–59 yrs	Number	Percent	Number	Percent	Number	Percent	Number	Percent	Number	Percent	Number	Percent	Number	Percent	Number
1980–84	0	0.0%	1	8.3%	0	0.0%	2	16.7%	0	0.0%	8	66.7%	1	8.3%	12
1985–89	0	0.0%	2	10.5%	1	5.3%	4	21.1%	1	5.3%	10	52.6%	1	5.3%	19
1990–94	0	0.0%	4	23.5%	4	23.5%	7	41.2%	1	5.9%	1	5.9%	0	0.0%	17
1995–99	2	4.6%	11	25.0%	4	9.1%	8	18.2%	5	11.4%	14	31.8%	0	0.0%	44
2000–04	1	4.4%	7	30.4%	3	13.0%	0	0.0%	3	13.0%	8	34.8%	1	4.4%	23
2005–09	2	6.1%	8	24.2%	4	12.1%	1	3.0%	3	9.1%	12	36.4%	3	9.1%	33
Total	5	3.4%	33	22.3%	16	10.8%	22	14.9%	13	8.8%	53	35.8%	6	4.1%	148
Aged 60 yrs	Subsistence		Illness		Revenge		Impulsion		Despair		Avoidance		Altruism		Total
and over	Number	Percent	Number	Percent	Number	Percent	Number	Percent	Number	Percent	Number	Percent	Number	Percent	Number
1980–84	2	14.3%	4	28.6%	3	21.4%	2	14.3%	0	0.0%	0	0.0%	3	21.4%	14
1985–89	7	17.5%	13	32.5%	5	12.5%	5	12.5%	2	5.0%	4	10.0%	4	10.0%	40
1990–94	2	7.7%	10	38.5%	4	15.4%	4	15.4%	4	15.4%	0	0.0%	2	7.7%	26
1995–99	35	38.5%	15	16.5%	7	7.7%	11	12.1%	9	9.9%	4	4.4%	10	11.0%	91
2000–04	76	55.1%	42	30.4%	4	2.9%	3	2.2%	2	1.5%	4	2.9%	7	5.1%	138
2005–09	66	42.9%	35	22.7%	9	5.8%	13	8.4%	13	8.4%	5	3.3%	13	8.4%	154
Total	188	40.6%	119	25.7%	32	6.9%	38	8.2%	30	6.5%	17	3.7%	39	8.4%	463

Major motives of female suicide victims follow the same temporal pattern as that of the overall sample. The top four motives in the 1980s (revenge, impulsion, despair and avoidance) were no longer dominant in more recent years. Instead, the once rare motives pertaining to subsistence and illness accounted for over one half of all motives in the 2000s. A similar temporal pattern is also observed in male victims. As compared to their female counterparts, however, male victims had more suicide incidents motivated by subsistence needs, illness-induced suffering and avoidance of burdens/obligations, and fewer incidents motivated by revenge, impulsion and despair. Incidents of altruistic suicide tend to be roughly the same among male and female victims. Victims across three age groups show distinct patterns of motives for suicide. Three major motives are most prevalent among young victims: revenge (33.2%), impulsion (23.5%) and despair (25.6%). Suicide motives related to livelihood (i.e. subsistence and illness) are seldom observed in young victims. Avoidance suicide is most prevalent in the middle-age group (35.8%) and, together with illness (22.3%), the two motives accounted for more than one half of all suicide incidents in the middle-aged group. When the number of middle-aged victims reached its peak in the years 1995–9, the most prevalent motives for suicide were avoidance of burdens/obligations (31.8%) and illness (25.0%). Except for avoidance, all major motives for suicide show an upward trend among the elderly victims. Livelihood-related motives (subsistence and illness) were much more frequent in recent years. From 1990 to 2004, the rapid increase in the number (from 2 to 76) and proportion (from 7.7% to 55.1%) of subsistence-induced elderly suicides is particularly striking.

Conclusions and discussion: Suicide in rural China remains an alarming social problem

By retrieving ethnographic reports of 849 suicide victims, findings from this study show that suicide incidents at 55 rural villages across China have substantially increased from 1980 to 2009. The well-known sex difference reported by previous studies was reversed in the years 2005–9. The substantial rise of elderly suicide victims is salient and their suicide motives were often related to subsistence needs and illness in more recent years. More middle-aged victims are observed in the years 1995–9 and their suicide behaviours were largely motivated by avoidance of burdens/obligations and illness.

Suicide in rural China is an urgent and enormous public health problem. Consistent with findings from previous studies (Phillips et al., 1999, 2002a; Conner et al., 2007; Yip et al., 2005), results from this unique large-scale ethnographic project provide evidence that suicide rates in rural China were seriously underestimated in the absence of a complete surveillance and monitoring system. If we recall that all the 55 villages investigated had 71,733 residents by the end of the year 2009, scholars can roughly estimate the gross suicide rate as 39.5 (per 100,000) per year over the period of study. In five-year groups, the annual suicide rates are 20.1 for the years 1980–4, 36.0 for the years 1985–9, 30.4 for the years 1990–4, 44.3 for the years 1995–9, 50.7 for the years 2000–4 and 55.2 for the years 2005–9. It should be noted that such a rough estimation of suicide rates is still conservative. Because we use the de jure population size from the latest year of study (the year 2009) to approximate total person-years from 1980–2009, the person-years in the earlier time periods are overestimated due to the growth of de jure population in rural China, and these suicide rates are correspondingly underestimated. As we now inspect each of the 849 suicide incidents and understand their detailed life history in the 55 villages, the suicide rates estimated based on this large-scale ethnographic project are nevertheless much higher than most, if not all, estimates reported elsewhere (Phillips et al., 2002a; Wang et al., 2014). No matter whether these high estimates of suicide rates are due to a spatial clustering of suicide incidents in the selected 55 villages or the inadequate coverage of China’s vital registration system in its vast rural areas, the levels and trend of suicide rates presented in this qualitative study deserve serious attention from policy-makers.

The sex crossover in suicide incidents casts doubt on the well-known conclusion that China is one of the few countries where the suicide rate of women is higher than that of men. Given that the proportion of male victims shows a monotonic increase after the years 1990–4, this sex crossover probably suggests a long-lasting rather than temporary shift in the sex composition of suicide victims in rural China. Ethnographic evidence collected in this project offers possible explanations of this notable sex crossover, which is driven by the decline of young female victims and the increase in elderly suicide victims. First, among all age-sex subgroup of victims, young female victims constituted the largest subgroup until the mid-1990s and thus affected the previous high female-to-male ratios. To understand these suicide incidents of young women, we concur with previous studies which show that the suicide of young women in rural China was associated with the collision between two contradictory ideologies of women (Fei, 2005; Jing et al., 2010; Johnson, 2009; Zhang, 2010). The Confucian ideology regulating the older generation views women as submissive and passive, whereas the Communist ideology shaping the younger generation sees women and men as equal both at home and at work, and advocates women’s participation in the workforce. When the younger generation tried to negotiate with or confront their parents about marriage, work and education, this ideological collision sometimes led to severe family conflicts and subsequent suicidal behaviours. For female and young suicide victims in the 1980s and 1990s, Table 2 shows that their proportions of suicide incidents attributable to despair, revenge and impulsion were unusually high. As older generations were being replaced by younger and more liberal generations, the ideological collision was no longer a major driving force for suicide in rural China and there was subsequently a sharp decline in suicide incidents by young women. In this regard, rural-urban migration of young women may also contribute to the decline of their suicide rates because they have no or less exposure to risk factors associated with this ideological collision outside their hometown (Jing et al., 2010). Second, as the two largest age-sex subgroups have shifted from young women and young men, respectively, in the years 1980–4 to elderly men and elderly women, respectively, in the years 2005–9, the number of young suicide victims is dwarfed by that of elderly victims. Since the distribution of suicide victims is dominated by elderly cases in more recent years, we cannot explain the sex crossover in suicide incidents unless the rapid increase of elderly suicide, especially among elderly men, is carefully investigated.

The increase in elderly suicide is striking yet puzzling because the number of elderly victims continued to rise during and after the rural tax-for-fee reform in the early 2000s (Yep, 2004). Suicide incidents among the middle-aged and the elderly started to surge in the late 1990s, when burdens assumed by peasants were excessive due to a series of institutional barriers (Li, 2007). In response to China’s rural crisis in the 1990s, the rural tax-for-fee reform was introduced in the early 2000s to abolish agricultural taxes, reduce peasant burdens and stimulate rural development (Kennedy, 2007). Despite the subsequent decline in middle-aged victims, it is indeed puzzling to see that the growth of elderly victims continues in the 2000s, and it coincides with improved economic conditions in rural China. To address this puzzle, our interviews conducted in different regions in China suggest that the recent elderly suicide spike is more relevant to a paradigm shift instead of economic conditions. Families in rural China were once described as ‘patriarchy in its full strengthen’ and elderly men held a respected role in allocating family resources (Fei, 1946). During economic hardship in the 1990s (Fu and Lin, 2013; Lu, 1997; Bernstein and Lü, 2000), peasants found that the loss of young and middle-aged adults within a family would seriously jeopardize the reproduction and maintenance of the family. For the elderly, their experience and knowledge acquired in the pre-reform era are no longer valued by the family. Thus, while the livelihood of young and middle-aged adults and their contributions to the family are stressed since the hard times, the perceived importance of the elderly has declined among rural families. As a result of this paradigm shift, coping strategies characterized by sacrificing the elderly (e.g. ignorance of their health problems and reduction in family support) paradoxically allow rural families to get by during difficult times. But, as the medical and subsistence needs of the elderly peasants are ignored or inadequately addressed by their own family members, the paradigm shift in rural China leads to increasing suicide incidents among the elderly, especially these motivated by subsistence needs or illness motives. Despite improved living standards and public infrastructure in more recent years, suicide in rural China may still bear an imprint of this paradigm shift.

Sample selection and recalling bias associated with any qualitative study may not allow scholars to draw a definite conclusion. Despite such limitations, this unique large-scale ethnographic study reveals distinct temporal patterns of suicide in rural China. By situating the analyses of suicide incidents in the context of China’s cultural tradition and massive socio-economic transformation, findings from this study demonstrate a tight link between socio-cultural conditions and suicide in rural China. Elderly suicide in rural China and its determinants should be a focus of future research and intervention programs.

Footnotes

Acknowledgement

We are grateful to Xiaohui Wang, Hua Yang, Baifeng Chen, Derui Li, Shiyong Zhang, Junxia Guo, Yongtao Wang, Lina Song, Liang Guo, Xiaofeng Zhao, Song Yuan, Dewen Lv, Rui Liu, Xinhua Sun, Changquan Jiao, Lian Yu, Jiao Du and our interviewees for their assistance with field research.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by the National Social Sciences Fund of China [Grant No. 13CSH004].

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Changing demographic characteristics and motives for suicide in rural China,1980–2009

Abstract

Keywords

Introduction

Methods

Study design

Data collection

Measures

Results: Changing demographic characteristics and motives for suicide in rural China

Conclusions and discussion: Suicide in rural China remains an alarming social problem

Footnotes

Acknowledgement

Declaration of conflicting interests

Funding

References