Archives of Suicide Research, 24:S323–S339, 2020

# 2019 International Academy for Suicide Research

ISSN: 1381-1118 print/1543-6136 online
DOI: 10.1080/13811118.2019.1599480

Suicide Risk and Restricted

Emotions in Women: The
Diverging Effects of Masculine
Gender Norms and
Suicide Capability
Nicholas A. Fadoir , Shane T. W. Kuhlman, and
Phillip N. Smith

This study investigated whether gender moderated the association between

masculine socialization pressures of restrictive emotionality and suicide risk
through suicide capability (i.e., fearlessness about death). A sample of
inpatients admitted for recent suicidality (n ¼ 194) completed validated
measures of restrictive emotionality, fearlessness about death, and current
suicide risk. A moderated mediation effect was found opposite the hypothe-
sized direction: fearlessness about death mediated the relationship between
endorsement of the masculine gender norm of restrictive emotionality and
suicide risk in women, but not men. Gender did not moderate the associ-
ation between restrictive emotionality and fearlessness about death. The
diverging gender effects suggest that the masculine gender norm of restrict-
ive emotionality is associated with suicide capability in men and women,
while acquired fearlessness about death is more informative of risk for sui-
cide in women than men.
Keywords acquired capability for suicide, fearlessness about death, interpersonal theory of
suicide, gender paradox, male suicide

According to the Centers for Disease and 2016). What this figure conceals, though,
Control and Prevention, approximately is that many more Americans attempt sui-
45,000 individuals died by suicide in 2016 cide and live (approximately 1.4 million)
in the United States (CDC, 2017). Of and an even greater number experience the
these deaths by suicide, 77% were men. desire for death by suicide (Piscopo,
Despite expanded research and clinical Lipari, Cooney, & Glasheen, 2016). The
prevention efforts, suicide rates have risen low base rate of suicide relative to many of
24% in the United States between 1999 the known risk factors has made it difficult
and 2014 (Curtin, Warner, & Hedegaard, to study (Ribeiro et al., 2016) and, by

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 Gender, Gender Norms, and The Capability for Suicide

extension, apply research in practice to suicidal intent among attempters (Ribeiro

predict and prevent suicide (Tucker, et al., 2014) and has shown potential in
Crowley, Davidson, & Gutierrez, 2015). differentiating ideators and attempters
A recent meta-analysis found that even the (Smith, Cukrowicz, Poindexter, Hobson,
best risk factors (e.g., depressive disorder, & Cohen, 2010; Smith, Stanley, Joiner,
prior suicide attempts) are only slightly Sachs-Ericsson, & Van Orden, 2016).
better than chance in predicting suicidal Such findings support that suicide capabil-
thoughts and behaviors (Franklin et al., ity enhances suicide risk by increasing the
2017). Such problems have led some to likelihood that an individual will transition
propose a focus on explaining the transi- from suicidal ideation to suicidal action.
tion from suicidal desire and ideation to Ideation-to-action theories frame sui-
suicidal action and attempts (Klonsky & cide as an evolving process in which differ-
May, 2014). ent factors influence the temporal
Ideation-to-action models of suicide development of suicidal thoughts and
(Klonsky, Saffer, & Bryan, 2017; Klonsky behaviors (Klonsky et al., 2017). In this
& May, 2014) portray suicidal desire and way, suicide risk is dynamic and fluctuates
capability as independent processes. One over time (Rudd, 2006). Changes in warn-
can desire suicide without possessing the ing signs for suicide (e.g., mood alterations,
ability to make an attempt, just as an indi- increases in hopelessness and helplessness)
vidual might be capable of suicidal action and red flags such as an individual making
without having the desire to die. The pres- plans and preparations for suicide (i.e., writ-
ence of both desire and capability moves ing notes, giving away possessions, acquiring
an individual from ideation to action. The means) indicate that suicide risk is increas-
first of these modern ideation-to-action ing. Consequently, suicide risk can be con-
models was the interpersonal theory of sui- sidered to exist along a continuum that
cide (IPTS; Joiner, 2005). The IPTS pro- many often separate to describe low-,
poses that an individual acquires a medium-, and high-risk states. The capabil-
capability to act on suicidal thoughts ity for suicide, specifically lacking the fear of
through habituating to painful (i.e., non- death, contributes to escalation along this
suicidal self-injury, accidental injury) and risk continuum by enabling an individual
provocative (i.e., physical or sexual abuse, to move from suicidal ideation, to suicidal
other-directed violence) experiences that plans and preparations (or suicidal intent),
diminish the survival mechanisms of fear to an actual suicide attempt (Van Orden
of death and physical pain (Smith & et al., 2010). The present study examined
Cukrowicz, 2010; Van Orden et al., how the capability for suicide is associated
2010). Research has generally found evi- with suicide risk as operationalized as the
dence that experiences of pain and provo- intensity of current suicidal ideation includ-
cation are associated with suicide ing both suicidal desire and resolved plans
capability (Bender, Gordon, Bresin, & and preparations for suicide (Joiner, Rudd,
Joiner, 2011; Bryan, Cukrowicz, West, & Rajab, 1997; Miller, Norman, Bishop,
& Morrow, 2010; Franklin, Hessel, & & Dow, 1986).
Prinstein, 2011; Heffer & Willoughby, As noted above, men die by suicide
2018; Van Orden, Witte, Gordon, significantly more often than women in all
Bender, & Joiner, 2008). The capability but a few countries (Hawton, 2000; Nock
for suicide is associated with severity of et al., 2008). Yet, women more frequently

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 N. A. Fadoir et al.

experience almost every traditional risk fac- Vrints, & Conraads, 2006; Gross, 2002;
tor for a suicide than men, including Gross & Levenson, 1997; Roberts,
depression (Piccinelli & Wilkinson, 2000), Levenson, & Gross, 2008), potentially
childhood sexual abuse (Roy & Janal, serving as a painful and provocative experi-
2006), and suicidal ideation and attempts ence and thus elevating the capability for
(Nock et al., 2008). This discrepancy is suicide. Research supports that stoicism, a
referred to as the “gender paradox” in sui- prototypically masculine “denial, suppres-
cide (Canetto & Sakinofsky, 1998). sion, and control of emotion” (Wagstaff &
Although this paradox is often attributed Rowledge, 1995, p. 181) mediates the rela-
to men’s selection of more lethal methods tionship between gender and pain insensi-
of suicide (Kaplan, McFarland, & Huguet, tivity in men (Witte et al., 2012).
2009; V€arnik et al., 2008), suicide Restrictive emotionality also appears to
attempts in men are often more serious promote greater capability for suicide by
irrespective of the method’s lethality (Cibis influencing men and women to be exposed
et al., 2012; Mergl et al., 2015; Williams, to more frequent painful and provocative
Kores, & Currier, 2011). The capability life experiences (Granato et al., 2015).
for suicide has been proposed as a poten- Given its conceptual overlap with the
tial mechanism by which men are at notion of fearlessness about death, its asso-
greater risk for death by suicide compared ciation with involvement in painful and
to women (Smith & Cukrowicz, 2010). In provocative experiences and suicide cap-
fact, men do experience greater self- ability, the masculine gender norm of
reported suicide capability (Anestis, restrictive emotionality may be an import-
Bender, Selby, Ribeiro, & Joiner, 2011; ant construct in understanding the gender
Kerbrat et al., 2015; Van Orden et al., paradox in suicide
2008; Witte, Gordon, Smith, & Van The over-regulation of emotion is an
Orden, 2012) and pain tolerance (Alabas, understudied topic in suicidology. When
Tashani, Tabasam, & Johnson, 2012; “emotion dysregulation” is acknowledged
Riley, Robinson, Wise, Myers, & in the literature as a construct related to
Fillingim, 1998). Masculine gender social- suicide, what is often being discussed is the
ization and norm adherence has been sug- under-regulation of emotion. Thus, even as
gested as a potential explanation about the field moves away from the belief that
how men come to experience greater cap- suicide attempts are an unequivocal act of
ability for suicide compared to women impulsivity (Anestis, Soberay, Gutierrez,
(Granato, Smith, & Selwyn, 2015). Hernandez, & Joiner, 2014; Klonsky &
Traditional masculine socialization May, 2010), the perception remains that
values personality characteristics that suicide-related behaviors are a product of
enhance suicide capability. The masculine under-regulated affect, of too much emo-
norm of stoicism or restrictive emotional- tion. Nevertheless, as a marker of psycho-
ity may be particularly salient in this logical health, effective emotion regulation
regard. Restricting one’s emotions acts to entails recovering from too little emotion
effectively train one to respond to fearful (i.e., over-regulated), as well as too much
stimuli with fearlessness. Active suppres- (Greenberg & Bolger, 2001).
sion or restriction of emotions also dam- Given the hypothesis that masculine
ages the body physically and socialization accounts for gender disparities
psychologically (Denollet, Pedersen, in suicide through enhanced fearlessness

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 Gender, Gender Norms, and The Capability for Suicide

Gender ability to consent and complete study

measures. Most participants were on unit
Fearlessness less than a week prior to study participa-
About tion (M ¼ 4.20 days; SD ¼ 3.95). Slightly
Death
more participants were male (54%) and
Restrictive
Suicide Risk
their ages ranged from 18 to 74 years
Emotionality (M ¼ 38.89, SD ¼ 13.25). The majority of
the sample self-identified as White
(67.7%), with 13.2% as African-
FIGURE 1. Hypothesized moderated-medi- American, 3.4% as Native American, and
ation model. 3.4% as other. All study participants had
attempted suicide prior to admission and/
about death, the following study investi- or were admitted due to suicidal ideation.
gated the associations between restricted
emotional control most often practiced by
individuals adherent to masculine ideology, Procedure
suicide capability, and suicide risk, as mod-
erated by gender. We hypothesized that The university Institutional Review
the relationship between restrictive emo- and Hospital Review Boards approved the
tionality and suicide risk would be medi- study methods. Potential participants were
ated by fearlessness about death, a key facet identified as eligible for the study by hos-
of a capability for suicide, and that this pital staff based on suicide risk as a reason
relationship would be stronger in men. for admission. Potential participants were
Figure 1 depicts the moderated-mediation given a brief description of the study and,
conceptual model, in which the paths from if interested, provided with full informa-
restrictive emotionality to fearlessness about tion and encouraged to ask questions.
death, and fearlessness about death to sui- Written informed consent was obtained
cide risk, are both moderated by gender. from all participants. Data collection ses-
Very few studies examine the capability for sions consisted of self-report questionnaires
suicide in a high-risk sample. Therefore, and interviews conducted by doctoral stu-
dents in clinical and counseling psychology
the current study aimed to examine the
in a private assessment room. No compen-
hypothesized moderated-mediation model
sation was provided to participate in
in a sample of inpatients admitted for sui-
the study.
cidal thoughts or behaviors.

Measures
METHOD
Demographics. Information including the
Participants participant’s reason for admission, gender,
race, ethnicity, and time on unit were col-
The current sample (N ¼ 266) was lected by either patient self-report or
recruited from patients admitted to two chart review.
psychiatric inpatient units in the Upper
Gulf Coast region. Exclusion criteria Fearlessness about death. Fearlessness about
included cognitive impairments or psych- death was assessed using the Acquired
otic symptoms that compromised the Capability for Suicide Scale-Fearlessness

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 N. A. Fadoir et al.

About Death (ACSS-FAD; Ribeiro et al., current study), and the need to reduce par-
2014). The ACSS-FAD is a 7-item meas- ticipant burden.
ure that requests respondents to indicate
the degree to which they believe the items Suicide risk. Suicide risk immediately prior
are representative of them using a 5-point to hospital admission was assessed by the
Likert-type scale (1 ¼ not at all like me, Modified Scale for Suicide Ideation
5 ¼ very much like me). The ACSS-FAD (MSSI; Miller et al., 1986). The MSSI is
indicates good internal consistency across an 18-item semi-structured interview
multiple samples (a ¼ 0.81–0.85; Ribeiro measure of suicide risk. The instructions
et al., 2014) and measurement invariance for the interview were modified to request
across men and women. The current sam- participants to report on their experience
ple’s responses suggested adequate internal during the 48 hours immediately preceding
consistency of the ACSS-FAD (a ¼ .76). their hospital admission. The MSSI is a
validated measure of current suicidal idea-
Restrictive emotionality. Restricted emo- tion, resolved plans, and preparations, and
tionality was assessed with the 6-item does not inquire about suicide attempt his-
Conformity to Masculine Norms tory (Joiner et al., 1997). However, higher
scores on the MSSI have been associated
Inventory Short Form-Emotional Control
with the presence of a current suicide
Subscale ( CMNI-EC; Mahalik et al.,
attempt (Pettit et al., 2009), suggesting
2003; Parent & Moradi, 2009).
that the MSSI can competently assess for
Participants rate items (e.g., “I never share
movement along the risk continuum and,
my feelings”) on a 4-point Likert-type
hypothetically, a future suicide attempt.
scale (0 ¼ strongly disagree to 3 ¼ strongly
The first four items were used as a screener
agree) to obtain a total score for the
for suicide ideation status utilizing Miller
CMNI-EC. The CMNI-EC shows good
et al.’s (1986) criteria for exclusion. The
to excellent convergent, divergent, and
measure has been found to show good reli-
face validity (Levant, Hall, Weigold, & ability in high risk samples and good con-
McCurdy, 2016; Parent & Moradi, 2009; current validity with other measures of
Wong, Ho, Wang, & Miller, 2017), good suicide risk, including hopelessness (Clum
fitting factor loadings (all above 0.66), and & Yang, 1995) and suicide attempt status
excellent internal consistency (Parent & (Joiner et al., 1997). The internal consist-
Moradi, 2009). Internal consistency was ency was good in the current sample
good in the present study sample (a ¼ (a ¼ .83).
.86). Though the CMNI contains nine
additional subscales assessing adherence to Depression. Depression was assessed by
various masculine norms, only the either the Depression, Anxiety, Stress
Emotional Control and Self-Reliance sub- Scale- Depression Subscale (DASS-DS;
scales were administered to the current Lovibond & Lovibond, 1995) or the Beck
sample. Data collection was restricted to Depression Inventory-II (BDI-II; Beck,
these two subscales due to the project’s Steer, & Brown, 1996). Changes in assess-
unique focus on restrictive emotionality as ment protocol during data gathering
a promoter of suicide capability, self-reli- meant that some participants received one
ance’s role in the accessing of emergency (DASS-DS; n ¼ 181), but not the other
mental health care (not addressed in measure (BDI-II; n ¼ 26). The DASS-DS

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 Gender, Gender Norms, and The Capability for Suicide

is a 7-item self-report scale that showed the data were most likely MNAR, which
good internal consistency (a ¼ .85) in the was consistent with changes in the study
current sample and has demonstrated procedure regarding the alternative depres-
excellent convergent validity with the Beck sion measure. Following the suggestions of
Depression Inventory (Lovibond & Schlomer, Bauman, and Card (2010),
Lovibond, 1995), good test-retest reliabil- comparisons between participants with
ity, and good discriminant validity missing data and participants with com-
(Brown, Chorpita, Korotitsch, & Barlow, pleted data on the CMNI-EC, ACSS-
1997). The BDI-II showed excellent FAD, DEP, and gender indicated that
internal consistency (a ¼ .97) in the cur- these two groups did not significantly dif-
rent sample and has demonstrated good fer on the criterion variable of MSSI.
test-retest reliability and criterion validity No univariate outliers were found for
across samples (Wang & Gorenstein, any variables. None of the participants
2013). We standardized the raw scale were identified as multivariate outliers
scores for both measures using local means (p < .001) using the Mahalanobis distance
and standard deviations to obtain a com- procedure. In assessing for violations of
parable depression (DEP) score for all normality, there was no evidence of skew
participants. or kurtosis for all indicator variables (i.e.,
scores between 0 and þ/ 1). Since our
hypothesized model included a categorical
RESULTS variable, we used listwise deletion for gen-
der and suicide attempt history, and avail-
Preliminary analyses able item analysis for the continuous study
variables (Parent, 2013). The final sample
Prior to our primary analyses, we consisted of 185 participants (42.7%
screened for missing values, univariate and women, 57.3% men). Of the remaining
multivariate outliers, normality violations, participants, 36.5% were admitted for a
and potential confounds of suicide attempt recent suicide attempt, 36.2% participants
status at admission and suicide attempt had a history of one suicide attempt, and
history. To determine the pattern of miss- 38.4% had made multiple attempts.
ing data in our sample, we conducted a Reason for admission did not significantly
missing values analysis using IBM SPSS differ by gender, v(1) ¼ 0.01, p ¼ .890,
statistics version 24 (2016). First, the 266 nor did attempt history, v(2) ¼ 1.95, p ¼
participants were screened for missing val- .377. Suicide attempt history by gender
ues on the four continuous variables can be seen in Table 1.
(CMNI-EC, ACSS-FAD, MSSI, DEP) The IPTS hypothesizes prior suicide
and gender. We found 27.07% of cases to attempts as an indicator of acquired cap-
have missing values on at least one of the ability for suicide. Therefore, we compared
variables. Missing data included 6.0% for mean differences on the MSSI and FAD
MSSI, 14.3% for ACSS-FAD, 15.0% for by suicide attempt history (no attempts,
the CMNI-EC, 22.2% for the standar- one attempt, multiple attempts). A one-
dized depression covariate, and 13.9% for way ANOVA revealed significant differen-
the gender variable. Little’s missing com- ces in MSSI by attempt history, F(2, 184)
pletely at random test was significant, ¼ 6.29, p ¼ .002. Post-hoc comparisons
v2(14) ¼ 46.81, p < .001, indicating that found that individuals with a history of

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 N. A. Fadoir et al.

TABLE 1. Descriptive Statistics, Gender Differences, and Internal Consistency of Study Measures
and Suicide Attempt History by Gender

M (SD) M (SD) M (SD) d a

Total Men Women
Restrictive Emotionality 9.83 (4.42) 10.13 (4.37) 9.42 (4.49) 0.16 .86
Fearlessness about Death 23.33 (6.96) 24.59 (6.53) 21.63 (7.20) 0.43 .75
Suicide Risk 26.74 (12.08) 27.38 (12.54) 25.90 (11.48) 0.12 .84
Depression 0.00 (1.00) 0.06 (0.99) 0.09 (1.01) 0.09 –
Suicide Attempt History Total (Total%) Men (Total%) Women (Total%)
No Attempts 47 (25.4%) 31 (16.8%) 16 (8.6%)
One Attempt 67 (36.2%) 36 (19.5%) 31 (16.8%)
Multiple Attempts 71 (38.4%) 39 (21.1%) 32 (17.3%)

Note. p < .05;  p < .01; p < .001; N ¼ 185. Men n ¼ 106. Women n ¼ 79; Depression is a combination
of standardized scores on BDI-II and DASS-DS.

multiple suicide attempts (M ¼ 30.22, potentially confounded by suicide attempt

SD ¼ 11.68) possessed significantly higher status at time of admission. No differences
suicide risk as measured by the MSSI than were observed on the MSSI between indi-
those no attempt history (M ¼ 22.51, viduals who presented to hospital admis-
SD ¼ 11.83), p ¼ .002. No significant dif- sion with a recent suicide attempt
ferences were observed on the MSSI (M ¼ 27.92, SD ¼ 12.24) and those who
between individuals with a history of a sin- presented to hospital admission for suicide
gle suicide attempt (M ¼ 26.01, ideation alone (M ¼ 26.30, SD ¼ 11.61),
SD ¼ 11.68) and individuals with a history t(179) ¼ 0.89, p ¼ .374. We therefore
of multiple attempts, p ¼ .092, nor indi- did not control for suicide attempt as rea-
viduals with no attempt history, p ¼ .262. son for admission in the primary analyses.
Significant differences were also observed
on the FAD by suicide attempt history, Primary analyses
F(2, 184) ¼ 4.72, p ¼ .010. Individuals
with multiple suicide attempts possessed Primary analyses were carried out in
significantly higher FAD (M ¼ 25.28, IBM SPSS statistics version 24 (2016).
SD ¼ 6.72) than individuals with a single Descriptive statistics and gender differen-
attempt (M ¼ 22.15, SD ¼ 6.82), p ¼ ces of study measures are presented in
.021, as well as individuals with no Table 1. Independent samples t-tests
attempt history (M ¼ 22.06, SD ¼ 6.98), found that men reported significantly
p ¼ .035. No significant differences were higher fearlessness about death
observed in FAD between individuals with (M ¼ 24.59, SD ¼ 6.53) than women
a single suicide attempt and no attempt (M ¼ 21.63, SD ¼ 7.20), t(183) ¼ 2.92,
history, p ¼ .998. Given these findings, p ¼ .004, d ¼ .43. No other significant
we included suicide attempt history as a differences were observed between men
covariate in all subsequent analyses. and women among study variables (p >
Finally, an independent samples t-test .05). Table 2 presents intercorrelations by
was performed to assess if the MSSI was gender. With regards to the correlation

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 Gender, Gender Norms, and The Capability for Suicide

TABLE 2. Bivariate Correlations Among Study Variables by Gender

Variable 1 2 3 4
1. Restrictive Emotionality – .31 .24 .43
2. Fearlessness about Death .10 – .40 .23
3. Suicide Risk .08 -.01 – .30
4. Depression .19a .03 .26 –

Note. p ¼ .053; p < .05;  p < .01; p < .001; Men below diagonal (n ¼ 106); Women
a

above diagonal (n ¼ 79); Depression is a combination of standardized scores on BDI-II and

DASS-DS.

between study variables, different patterns dummy coded with women as the indica-
emerged between men and women. In tor level (Women ¼ 0, Men ¼ 1). See
women, all the study variables were signifi- Figure 1 for a representation of this model.
cantly and moderately correlated. Among PROCESS models utilize stepwise lev-
men, there was only a significant associ- els of analyses of which all three are
ation between depression and suicide risk reported. The first step is the relationship
(r ¼ .26, p ¼ .007) and a marginally sig- between restrictive emotionality and fear-
nificant association between restrictive lessness about death as moderated by gen-
emotionality and depression (r ¼ .19, p ¼ der. The second is the relationship between
.053). Contrary to study hypotheses, there fearlessness about death and suicide risk as
was no association between restrictive moderated by gender. Lastly, the third is
emotionality and fearlessness about death the entire conditional process model includ-
(p ¼ .324), nor fearlessness about death ing the mediation of the relationship
and suicide risk in men (p ¼ .885). between restrictive emotionality and suicide
To test the main study hypothesis, a risk by fearlessness about death and the
moderated mediation analysis was con-
moderation of gender on this mediation.
ducted using version 3.1 of the SPSS-
For Step 1, seen in Table 3, restrictive
macro PROCESS (Hayes, 2017), model
emotionality significantly predicted fear-
58. Specifically, we tested to see if gender
lessness about death controlling for gender,
moderated the indirect effect of restrictive
depression, suicide attempt history, and
emotionality on suicide risk through fear-
lessness about death. PROCESS uses the interaction between restrictive emo-
ordinary least squares regression-based tionality and gender, b ¼ 0.44, p ¼ .012.
path analysis to produce 95% bias-cor- Independently, gender was a significant
rected bootstrapped confidence intervals predictor of fearlessness about death,
(95% BCa CI) of the indirect effect. The b ¼ 3.01, p ¼ .003, suggesting that men
current analysis produced 5,000 bootstrap reported greater fearlessness about death.
samples. Significance of the indirect effect The interaction between gender and
is indicated when confidence intervals do restrictive emotionality was nonsignificant,
not include zero. The standardized depres- p ¼ .156. Therefore, although men
sion variable was used as a covariate. endorsed higher levels of fearlessness about
Continuous predictor variables were mean death, men and women’s experience of
centered to control for multicollinearity. restrictive emotionality was equally associ-
Missing data on the gender variable was ated with higher levels of fearlessness
handled with listwise deletion. Gender was about death.

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 N. A. Fadoir et al.

TABLE 3. Direct and Indirect Effects of Restrictive Emotionality on Suicide Risk Through
Fearlessness about Death as Moderated by Gender

Moderated Mediation Results B SE 95% Confidence Interval

Outcome: Fearlessness about Death R ¼ .13, F(5, 179) ¼ 5.51,
2
p < .001
Restrictive Emotionality 0.44 0.17 (0.098, 0.781)
Gender 3.01 0.99 (1.060, 4.962)
Depression 0.27 0.51 (0.743, 1.287)
Suicide Attempt History 1.76 0.62 (0.539, 2.975)
Restrictive Emotionality X Gender 0.32 0.22 (0.758, 0.123)
DR2 ¼ .01, F(1, 179) ¼ 2.03, p ¼ .156
Outcome: Suicide Risk R2¼ .16, F(6, 178) ¼ 5.80, p < .001
Restrictive Emotionality 0.10 0.20 (0.295, 0.495)
Fearlessness about Death 0.41 0.19 (0.041, 0.775)
Gender 1.64 1.74 (1.784, 5.073)
Depression 2.73 0.88 (1.001, 4.459)
Suicide Attempt History 3.14 1.09 (1.000, 5.288)
Fearlessness about Death X Gender 0.49 0.25 (0.980, 0.004)
Men 0.08 0.17 (0.418, 0.249)
Women 0.41 0.19 (0.041, 0.775s)
DR ¼ .02, F(1, 178) ¼ 3.97, p ¼ .048
2

Conditional Indirect Effect

Men 0.01 0.10 (0.103, 0.056)
Women 0.23 0.12 (0.010, 0.398)
Index of Moderated Mediation 0.19 0.11 (0.415, 0.005)
Note. N ¼ 185; B: unstandardized direct or indirect effect; SE: Standard error of the unstandardized direct or
indirect effect; 95% Confidence Interval ¼ low and high confidence interval of the unstandardized effects;
Bolded text indicates significant effects; Gender was dummy coded as Women ¼ 0, Men ¼ 1.

In Step 2, fearlessness about death sig- .030, but not men, b ¼ 0.08, p ¼ .619.
nificantly predicted suicide risk controlling As can be seen in Figure 2, lower levels of
for restrictive emotionality, gender, depres- fearlessness about death (i.e., one standard
sion, suicide attempt history, and the deviation below the mean) were associated
interaction between gender and fearlessness with higher levels of suicide risk in men
about death, b ¼ 0.41, p ¼ .030. Gender (M ¼ 28.42) than women (M ¼ 23.16),
was not significantly related to suicide risk but elevated levels of fearlessness about
(p ¼ .345), however the interaction death (i.e., one standard deviation above
between gender and fearlessness about the mean) were associated with higher lev-
death was significant, b ¼ -0.49, p ¼ .048. els of suicide risk in women (M ¼ 29.29)
When we decomposed the interaction than men (M ¼ 27.15).
between gender and fearlessness about Lastly, for Step 3, the index of moder-
death, we found the relationship between ated mediation was significant [b ¼
fearlessness about death and suicide risk 0.19, 95% BCa CI (0.415, 0.005)]
was significant for women, b ¼ 0.41, p ¼ demonstrating that the conditional

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 Gender, Gender Norms, and The Capability for Suicide

FIGURE 2. Association between fearlessness about death and suicide risk moderated by gender. Low ¼ 1 stand-
ard deviation below mean. High ¼ 1 standard deviation above mean.

indirect effect of restrictive emotionality Cukrowicz, 2010; Van Orden et al.,

on suicide risk through fearlessness about 2010). The current study examined how
death differed by gender. That is, fearless- restrictive emotionality might be associated
ness about death explained the association with increased suicide risk via its influence
between restrictive emotionality and sui- on fearlessness about death and how this
cide risk in women b ¼ 0.18, 95% BCa CI relationship may be more important for
[0.010, 0.398], but not men, b ¼ 0.01, men compared to women. Consistent with
[0.103, 0.056]. the existing literature, men reported
greater fearlessness about death compared
to women (Anestis et al., 2011; Kerbrat
DISCUSSION et al., 2015; Van Orden et al., 2008;
Witte et al., 2012). However, contrary to
Men die by suicide more often than our hypothesis, fearlessness about death
women, despite presenting with fewer sui- mediated the relationship between restrict-
cide risk factors and correlates (Nock ive emotionality and suicide risk in
et al., 2008). The IPTS concept of a cap- women, but not men. Thus, while men
ability for suicide, namely fearlessness of possess higher levels of suicide capability
death and increased pain tolerance, has (Ribeiro et al., 2014), and take their lives
been offered as a theoretical explanation at approximately four times the rate of
for this gender paradox; arguing that men women (CDC, 2017), in an acute
are more capable of suicide and therefore inpatient sample, fearlessness about death
more likely to move from ideation to was more important in explaining suicide
action (May & Victor, 2018; Smith & risk for women.

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 N. A. Fadoir et al.

The current study hypotheses were acquired gradually via painful experiences
predicated on the idea that men develop (Joiner, 2005). Klonsky and May’s Three-
greater capability for suicide, in part, from Step Theory (2015) hypothesized two add-
socialization pressures that promote itional suicide capabilities: dispositional
restrictive emotionality. Interestingly, (i.e., trait-level pain tolerance and fearless-
restrictive emotionality was not correlated ness that is largely genetic; Smith et al.,
with fearlessness about death in men; 2012) and practical (i.e., knowledge and
though it was for women. Despite being access to lethal means). Men’s greater like-
conceptually similar, masculine norms of lihood of transitioning to lethal suicidal
restrictive emotionality do not promote the behavior may be more related to disposi-
development of fearlessness about death for tional, biological, and/or genetically influ-
men, but may be a mechanism by which enced factors such as impulsivity,
women come to develop fearlessness about recklessness, aggression, and violence. That
death (Granato et al., 2015). This finding is is, regardless of a man’s experience of fear-
consistent with at least one prior study that lessness about death, it may be more
found stoicism, a related construct to important to his risk for suicide that he is
restrictive emotionality, was associated with capable of acting aggressively and violently.
objectively measured physical pain tolerance, On the other hand, women who lack ten-
but not fearlessness about death (Witte dencies towards aggression and violence
et al., 2012). Rather, sensation seeking was may require greater acquired fearlessness to
more critical for men’s experience of fear- be capable of suicide. Regardless of what
lessness about death. Fearlessness about factor is most relevant for men’s suicide
death also appears to be more strongly asso- risk, the current study suggests that the
ciated with painful and provocative experi- fearlessness about death aspect of suicide
ences in which a person has an active (vs. capability may not be evenly predictive of
passive) role (Bryan, Hernandez, Allison, & suicide risk across men and women; espe-
Clemans, 2013; Granato, Boone, Kuhlman, cially in high-risk samples.
& Smith, 2017) Indeed, it has been sug- The idea that fearlessness about death
gested that “capability may not function as may be more relevant for women is note-
an outcome … but rather may function as a worthy given the concept’s early associ-
vulnerability for experiencing painful and ation with prior suicide attempts (Smith
provocative experiences that increase the et al., 2010; Van Orden et al., 2008),
likelihood of developing or manifesting which are largely a female experience
other risk factors for suicide” (Bryan, (Hawton, 2000; Nock et al., 2008).
Sinclair, & Heron, 2016, p. 383, emphasis Further, much of our current thinking
in original). about suicide deaths are founded and
The current findings also suggest that developed within a research literature that
men’s suicide risk is less related to their largely examines proxy events (i.e., suicidal
fearlessness about death, compared to ideation and attempts), which are, again,
women. By extension, other factors must largely female experiences. As such, much
promote men’s greater capability for sui- greater consideration for how men and
cide and their greater likelihood of transi- women may differ in their development
tioning from ideation to action (Klonsky and experience of suicide risk is warranted.
& May, 2014). The IPTS originally con- The results have specific clinical impli-
ceptualized the capability for suicide as cations. Although suicide capability should

ARCHIVES OF SUICIDE RESEARCH S333

 Gender, Gender Norms, and The Capability for Suicide

be considered routine among suicide risk emotionality) or are confounded by setting

assessment, what aspect and how such capa- (i.e., asking about suicide in an inpatient
bilities are considered important requires hospital) may also challenge the validity of
clarification. The current results suggest that the results. Lastly, the current study exam-
fearlessness about death is more important ined the risk of transitioning from ideation-
in assessing acute suicide risk in women to-action, as operationalized by the MSSI
than men. Clinicians should recognize that (Miller et al., 1986), a clinician adminis-
restrictive emotionality and emotional sto- tered interview of suicidal desire and plans
icism may be another potential indicator of and preparations for suicide (Joiner et al.,
fearlessness about death in women. Such 1997). The MSSI is multidimensional and
traits may also indicate potential challenges item content encompasses a broad spectrum
to the validity of data collected in a suicide of suicidal thinking, assessing for suicide
risk assessment (Brownhill, Wilhelm, risk along a continuum from suicide idea-
Barclay, & Schmied, 2005). The cultural tion to suicide intention. However, it does
value of presenting a “cool” exterior may not assess for suicide attempt history.
stigmatize help-seeking behaviors and dis- Future research on how individuals transi-
closures of psychological distress, thereby tion from ideation to attempts should assess
impeding potential social support (Addis & for past attempts, as past attempts are still
Mahalik, 2003; Vogel, Heimerdinger- considered the best predictor of future sui-
Edwards, Hammer, & Hubbard, 2011). cide deaths (Bostwick, Pabbati, Geske, &
Clinicians should also address alternative McKean, 2016). Features of prior attempts
forms of capability, especially practical cap- (i.e., method, medical lethality, number,
ability (i.e., knowledge and access to lethal intent, etc.) are also vital data points for
means) to inform both risk assessment and clinicians and researchers in understanding
considering in safety planning and means future suicide risk (Joiner, Walker, Rudd,
constraint interventions. & Jobes, 1999).
The current study results need to be Despite these limitations, the current
interpreted in light of several limitations. study contributes to our understanding of
Statistical mediation models with cross- suicide capability by demonstrating that in
sectional data are often criticized because a high-risk clinical sample, fearlessness
they inherently imply temporal causation about death was more indicative of suicide
(Maxwell & Cole, 2007; Maxwell, Cole, risk in women than men. Additionally, the
& Mitchell, 2011) that can only be shown conditional indirect effect of restrictive
through experimental or longitudinal emotionality on suicide risk through fear-
designs. Therefore, any conclusions lessness about death was only significant
derived from these results should be seen for women. Results suggest the existence
as provisional and dependent on future of gender differences in variables that serve
longitudinal data. Additionally, the signifi- to increase the likelihood of transitioning
cant mediation, moderation, and moder- from suicide ideations to suicide attempts.
ated mediation effect sizes were small, and
the current discussion needs to be consid- AUTHOR NOTE
ered in light of these modest effects.
Furthermore, the use of self-report instru- Nicholas A. Fadoir, MA, Psychology
ments to assess for variables that by defin- Department, University of South
ition entail underreporting (i.e., restrictive Alabama, Mobile, Alabama, USA.

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 N. A. Fadoir et al.

Shane T. W. Kuhlman, MS, The mediating role of painful and provocative

Psychology Department, University of experiences. Journal of Affective Disorders, 129(1-
South Alabama, Mobile, Alabama, USA. 3), 301–307. doi:10.1016/j.jad.2010.07.023
Bostwick, J. M., Pabbati, C., Geske, J. R., &
Phillip N. Smith, PhD, Psychology
McKean, A. J. (2016). Suicide attempt as a risk
Department, University of South factor for completed suicide: Even more lethal
Alabama, Mobile, Alabama, USA. than we knew. American Journal of Psychiatry,
Correspondence concerning this article 173(11), 1094–1100. doi:10.1176/
should be addressed to Phillip N. Smith, appi.ajp.2016.15070854
Psychology Department, University of Brown, T. A., Chorpita, B. F., Korotitsch, W., &
South Alabama, UCOM 1000, 75 S. Barlow, D. H. (1997). Psychometric properties
University Blvd., Mobile, AL 36688, USA. of the depression anxiety stress scales (DASS) in
Email: PNSmith@southalabama.edu clinical samples. Behaviour Research and Therapy,
35(1), 79–89. doi:10.1016/S0005-
7967(96)00068-X
Brownhill, S., Wilhelm, K., Barclay, L., &
ORCID
Schmied, V. (2005). ‘Big build’: Hfidden
depression in men. Australian & New Zealand
Nicholas A. Fadoir http://orcid.org/
Journal of Psychiatry, 39, 921–931. doi:10.1080/
0000-0002-0943-6527 j.1440-1614.2005.01665.x
Bryan, C. J., Cukrowicz, K. C., West, C. L., &
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