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  These singular methods of suicide are far from being just a sideshow of freakish death; they give testament instead to the desperation and determination of the suicidal mind. Their very bizarreness somehow makes the act more real. They evoke horror, certainly, but they also give us a glimpse into otherwise unimaginable misery and madness.

  The logistics of suicide in antiquity were not dissimilar to those used in the centuries since. Weapons—knives, swords (the “Roman death”), razors, scalpels, and daggers—were the most common means, then hanging, jumping, and poisoning by hemlock, opium, or other drugs. Less often, but not rarely, the Romans starved to death by refusing to eat, set themselves on fire, or provoked murder in others who were in a position to kill them (not unlike the modern “suicide by cop”). Anton van Hooff, who more than anyone has described the suicide practices of classical antiquity, notes that in Rome, as now in most countries, far more men than women killed themselves. Only in the ancient myths did more women commit suicide.

  Hanging, though a frequent method of suicide for young people and women, was regarded by the Romans as “unclean” and shameful; weapons were thought to be the honorable way to die. Euripides, as quoted by van Hooff, makes this clear:

  To die were best. How then with honour die?

  Unseemly is the noose ’twixt earth and heaven:

  Even of thralls ’tis held a death of shame,

  Noble the dagger is and honourable,

  And one short instant rids the flesh of life.

  Over the succeeding centuries, weapons continued to be a prominent method of suicide. Firearms, as they became more available, gradually overtook knives and swords as the weapons of preference. Hanging, however, remained popular, and poisons and drowning were used by an increasingly large number of people. By the late nineteenth century in Europe, hanging and poisons were by far the most common ways to kill oneself in France, England, and Prussia; drowning was next in preference. Cultural differences, however, were significant. Firearms, for example, were quite commonly used in suicides in Italy, France, and Prussia but far less often in England, where a wide assortment of drugs and poisons—prussic acid, caustic acid, mercury, opium, laudanum, potassium cyanide, arsenic, vermin killers, chloroform, strychnine, and belladonna—was put to use. After firearms, poisoning was the most common means of suicide in the United States during the same time period.

  The rivers and sea, and even the waters in city parks (such as the Serpentine in London’s Hyde Park, where many, including Percy Bysshe Shelley’s first wife, drowned themselves) were frequent sites of suicide; they also became a darkly romanticized part of literature and folklore.

  Langston Hughes, in this century, described the river’s lure in his succinct poem “Suicide’s Note”:

  The calm,

  Cool face of the river

  Asked me for a kiss.

  National preferences for modes of suicide tend to vary. “Thus,” wrote sociologist Emile Durkheim in 1897, “each people has its favorite sort of death and the order of its preferences changes very rarely.” Nineteenth-century Russians took to hanging, the English and Irish to poison, the Italians to firearms, the Americans to firearms, poisons, and illuminating gas. Proclivities for certain methods tended to go with immigrants wherever they went, or at least until they assimilated into their new countries. “Even away from their own country,” wrote Morselli, “the English and Irish preserve their predilection for poison and the pistol, whilst the German always retains his pre-eminence in hanging.” Over time, however, German immigrants to the United States tended more toward poisoning and guns, taking on the preferred means of suicide in North America; likewise, the English, Scottish, and Irish immigrants to Australia gradually assumed the suicide preferences of their adopted country.

  Within the same country, suicide methods often vary by geographical region. In Belgium, for example, poisons are used more in the southern districts, while guns are used in the wooded regions, which have a stronger cultural history of hunting. Brussels, with its taller buildings, is more frequently the site of deaths by jumping. Poisoning and hanging are the most popular means of suicide in much of India, except for Punjab, where 55 percent of suicides are by lying down on railway tracks or jumping in front of trains.

  Not surprisingly, methods of suicide change over time. During the years 1960 to 1980, for example, a study of suicide methods in sixteen countries found that deaths from domestic gas had decreased, while deaths from motor vehicle exhaust, hanging, and firearms had increased. There were no changes in the use of poisons, cutting, or drowning. The decrease in suicides from domestic gas was due to a change in government policy that lowered carbon monoxide levels in gas, thereby undercutting its deadliness. This raises critical questions about the impact of decreasing the availability of a particular suicide method—such as gas, prescription drugs, or firearms—on the overall suicide rate. Is there a genuine reduction in suicides, or do suicidal individuals simply substitute another method? This issue will be discussed later in the context of suicide prevention policies.

  In the United States, firearms are now responsible for more than 60 percent of all suicides; no other method comes close. Strangulation (hanging, strangulation, and suffocation) and overdoses (drugs, medications, and poisons) together account for another 25 percent or so. Inhalation of gases and vapors, falls, cutting, and drowning make up the remainder of self-inflicted deaths.

  What, for the suicidal, determines the method of death? Is it pragmatic? Symbolic? Or imitative? Is the method chosen for its availability, its painlessness, or is it meant, as well, as a final reflection of style or desperation? In his suicide note, Japanese writer Ryuunosuke Akutagawa laid out some of his reasoning for why he chose to die as he did:

  The first thing I considered is how to die without suffering. For this purpose, probably hanging is the best, but when I picture a person hanged to death, I feel an aesthetic abhorrence.… Drowning is not good either, because … drowning will involve more suffering than hanging does. Suicide by running into a rushing train also is aesthetically abhorrent to me. Suicide by gun or knife does not seem to work well for me because my hands shake. Jumping from a high building produces an ugly sight. Considering thus, I have decided to die with pills. To do so implies longer suffering than hanging but it has advantages. My body would appear better and there would be less risk of failure than with other methods. Its only disadvantage is the difficulty of obtaining pills. Since I have determined to use pills, I have tried to acquire them at every opportunity. At the same time, I have attempted to increase my knowledge of drugs.

  Then I considered the place of my suicide. My family members must depend on what I leave for them. My possessions are a piece of land of 100 tsubo [about 100 feet square], my home, the royalties from my books, and savings of 2,000 yen. If I commit suicide in my house its value will drop. I want to commit suicide in such a way that my body will be seen as little as possible by others—other than my family members.

  Although symbolic meanings and vivid interpretations have been given to different methods of suicide—Karl Menninger took drowning to represent a desire to return to the womb, and Freud conjectured that the various means of suicide represented sexual wish fulfillments (to poison oneself was to desire to become pregnant, to drown was to wish to bear a child, and to throw oneself from a height was to be delivered of a child; Freud did not specify whether these interpretations were equally applicable to both sexes)—the inventiveness of the interpretations would appear to outweigh the available evidence. Personality traits, as measured by standard psychological tests and administered to individuals in the months or years preceding their suicides, do not correlate with the type of suicide method chosen. Nor have any differences in intelligence level been found between those who choose to die by gunshot, poison, jumping, hanging, or drowning.

  Many factors undoubtedly play an important role in the choice of methods. The availability of the method is obviously critical. In countries in which fir
earms are readily available, such as the United States, or in professions that have easy access to guns, such as the police and the military, firearms are used disproportionately. Where toxic plants and fruits grow abundantly—for example, poisonous alary seeds from the yellow oleander in Sri Lanka, or the fatal sachasandia fruit in Argentina—or where deadly germicides, pesticides, and other agrochemicals are used freely, as they are in China, Singapore, Western Samoa, Sri Lanka, Guyana, India, and many other countries, suicide deaths reflect their ease of access.

  Where rail and metro systems flourish and other methods are less at hand; where seas and rivers, cliffs, or tall buildings are easy to find and take advantage of, these ways will be used by those wishing to die. If you are a doctor or a chemist and can lay hands upon a lethal drug, you will choose it more often than those who do not have access to or information about it. And if you are a patient on a psychiatric ward, the right of access to the more obviously lethal means removed, necessity will provoke the use of shoelaces, coat hangers, bedsheets, or a rushed jump from an unprotected stairwell. If you are a psychiatric patient outside the hospital and you have been prescribed potentially lethal medications (such as antidepressants, lithium, or barbiturates), you may opt to poison yourself with the drugs you have been given to treat your illness.

  The availability of a method is far from the only significant consideration in its choice. The perception of an act’s deadliness is clearly crucial to decision making. Some methods of suicide, such as jumping, hanging, or gunshot, leave little or no chance for detection or rescue by others. Nor do they allow the opportunity to change one’s mind. Other methods, however, such as drug overdoses or cutting, offer a more extended period of time between the suicidal act and death. Discovery of the attempt, or seeking help oneself, are more than viable possibilities; this is especially true now that highly sophisticated emergency medical services are available at large urban trauma centers and at many local hospitals.

  One person’s estimation of a method’s effectiveness is not another’s, however. Forensic pathologists, for example, when asked to rate twenty-eight methods of suicide in terms of their deadliness, ranked gunshot wounds, cyanide, explosives, being hit by a train, or jumping from a height as the most effective. The ratings made by the pathologists were highly consistent with one another. Laypeople, on the other hand, were wildly variable in their understanding of different methods. They overestimated (when compared with the pathologists) the effects of prescription drug overdoses and wrist cutting and underestimated the deadliness of gunshot. Women tended to overestimate the lethal consequences of most methods, especially medication overdoses, which suggests that many more women who survive overdoses may have intended death than is commonly thought. There is further evidence that people err in their estimates of the deadliness of suicide methods. American adolescents, who have easy access to over-the-counter medications and who use them in up to one-half of their drug overdoses, tend to greatly underestimate their potential for toxicity.

  In general, women use less violent and final means, although increasingly in recent years they have turned to firearms. One study conducted in the 1970s found that both women and men regard drugs and poisons as the “most acceptable” form of suicide, but men perceive firearms as more “masculine,” efficient, and easy to use. Women’s preference for drugs and poisons centers on their perceived painlessness, accessibility, and ease of use. Fear of disfigurement has been suggested as another possible reason to explain women’s preference for nonviolent forms of suicide, although the evidence for this is slight.

  Age also plays a role in the choice of suicide method. Now, as in antiquity, hanging tends to be used more often by younger people. So, too, does jumping from heights or leaping in front of oncoming trains. Firearms are used by both the young and the old, but increasingly by the young. The type and degree of psychopathology are also factors in the method chosen. Severely mentally ill patients are more likely than others to immolate themselves, leap in front of trains, or choose particularly bizarre and self-mutilative ways to die.

  Some individuals avoid a particular suicide method because of concern about risking the lives or psychological well-being of others: they will not use carbon monoxide poisoning, for example, because gas may seep into places where other people live; cyanide, because traces of it on the lips may endanger would-be rescuers who use mouth-to-mouth resuscitation techniques; jumping, for fear of landing on other people; and gunshot or jumping, because of the traumatic visual effects on survivors. However, most who kill themselves, for reasons of pain or impulse or crippled thought, are not able to act on any such altruistic concerns they may have. As a result, that which may appear as anger or malevolence to those left behind—a disfigured body left in a familiar or intimate place—may reflect only a desperate or precipitate act. Revenge and anger play a role in the circumstances of some suicides, but probably not most. It is next to impossible, as Morselli wrote more than a hundred years ago, to discover the reasons, “sometimes noble and weighty, sometimes shameful and thoughtless, why the suicide goes to cut his throat on his own bed, or to suffocate himself in the darkest recess of the house.”

  Symbolism and suggestion also play their part in the circumstances of self-inflicted death. Louis Dublin, former chief statistician for the Metropolitan Life Insurance Company and, as such, keenly interested in the prediction and prevention of suicide, wrote of the individual’s “psychological constellation and personal symbolism.” These conditions of thought, memory, and desire, persuaded by impulse and irrationality, are influenced as well by personal aesthetics and private meanings. They are directed, too, by the accounts of the suicides of others, accounts that are often enhanced or romanticized by newspaper and television reporting or portrayals in books or films. Some methods and places become “suicide magnets,” drawing to them not only the impulsive and the acutely disturbed but the more chronically suicidal as well.

  Leaping into a river or the sea seems always to have had both an aesthetic and practical draw. Eons ago, the Greeks—including, it is said, Sappho and Phobos—leapt to their deaths from the high cliffs of Leucas; others jumped from bridges and riverbanks into the Tiber or Euphrates. More recently, the Thames held a pragmatic allure, and by 1840 nearly 15 percent of suicides in London were individuals who had thrown themselves off Waterloo Bridge. Wading into the sea was an “easeful death” made strangely alluring by the Romantics. Drowning became such a popular way to commit suicide in nineteenth-century Paris that in order to avoid public health problems, the city paid fishermen a bounty for every body they retrieved.

  At Beachy Head, the cliffs on the eastern end of the South Downs of the English coast, suicides have been reported since the sixth century. Recent years have witnessed sharp peaks in the number of self-inflicted deaths here, suggestively related to intensive media coverage. More than 120 people threw themselves off the Sussex cliffs between 1965 and 1979. British researchers believe that the publicity given to the suicides at Beachy Head increased the likelihood that others would occur there. They cite, as an example of the effects of publicity, a fifty-six-year-old man who, while in a hospital recovering from a suicide attempt by overdose, read a newspaper report about the spate of suicides at Beachy Head. He remarked, “Fancy putting something like that in the paper for people like me to see.” Two weeks later he made his way to Beachy Head and jumped to his death. (Jumping from public monuments has also had a contagious allure—the Eiffel Tower in Paris, St. Peter’s Basilica in Rome, the Duomo of Milan, the Campanile of Giotto in Florence, the Empire State Building in New York City—an allure that resulted in the construction of protective barriers on many such buildings.)

  Publicity given to particular ways and places of suicide can certainly have a bearing on the methods chosen by vulnerable individuals. Alary seeds, from the yellow oleander plant, were unknown as a means of suicide in Sri Lanka before 1983. Newspaper coverage and a south Indian film broadcasting their use, coupled with easy public ac
cess to the plants, increased by orders of magnitude the number of poisonings in subsequent years. Similarly, press coverage of the terrible deadliness of the herbicide paraquat, noting that it took only a single mouthful to kill, greatly increased its use as a means of suicide in Fiji. An Indian film gave parallel prominence to a waterfall at Hogenakal in south India, as did television and newspaper publicity to suicides from high-rise apartment buildings at Takashimadaira, near Tokyo, and fatal jumps from multistory car parks in Australia.

  In the year following the 1991 publication of Final Exit, Derek Humphry’s best-selling book, which presented in detail a variety of ways to commit suicide (including, prominently, suffocation by plastic bag), suicidal asphyxiations involving plastic bags increased by 31 percent. Peter Marzuk and his colleagues at Cornell University Medical College in New York noted that although the total number of suicides did not increase, the publicity surrounding this particularly lethal method may have had a deadly impact on impulsive and ambivalent individuals. They suggest, with good cause, that clinicians include in their assessments of suicide risk questions not only about actions of potential concern, such as writing suicide notes or drawing up wills, but whether patients have obtained and read literature about euthanasia or assisted suicide.