Nov 23 2015

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THE LANCET: Why is Suicide the Leading Killer of Teen Girls?

In May and June, 2015, media outlets around the world reported a devastating new finding that shocked the public and public health researchers alike. The Telegraph, Guardian, and National Public Radio all published articles highlighting the fact that suicide had surpassed maternal mortality as the leading cause of death among girls aged 15–19 years globally.1, 2, 3

These findings, which had been somewhat buried within WHO’s 2014 Health for the World’s Adolescents report, surprised many experts in global health and development. Why? The statistics expose two blind spots in global health and development: mental health and adolescent health. Although global attention toward each field is growing, data at the intersection of the two are scarce and skewed heavily towards developed country contexts. Of the 109 national health policies reviewed for the WHO report, 84% made some mention of adolescents, but only a quarter discussed mental health.4 Even WHO’s own report on suicide, issued only months after the adolescent health report, gave scant attention to adolescents as a key affected population.5

Those of us working in global health must begin to shed some light on these blind spots. Improvement of vital registration and school-based and hospital-based systems and surveys would go a long way towards improving our understanding of actual epidemiological trends across regions.5 Are deaths from homicides, accidents, or burns misreported as suicide, or vice versa? How significant is adolescent morbidity from self-harm and suicide attempts, and why do lethality rates generally appear to be higher in low-income than in high-income settings?

New research is needed to understand the drivers of self-harm and suicide in girls across different settings, to inform programme design and policy dialogue that can ameliorate this grave situation. But the evidence we already have suggests strongly that rigid and exploitative gender norms play a harmful part. From neuroscience, we know that adolescence is a dynamic phase of brain development, profoundly modulated by environmental factors, including social determinants such as gender norms.6 We know that, after the onset of puberty, the risk of depressive disorders increases substantially among girls, who will remain 1·5 to 2 times more likely than boys to be diagnosed with depression, a gap that will persist over their life course.6 For girls who experience victimisation in early adolescence, mental health outcomes are particularly adverse.7

From social science research, we understand that adolescents experience increased gender role differentiation and, in many cases, exaggerated forms of gender-based discrimination. Such discrimination can take the form of violence; sexual abuse and exploitation; limitations on reproductive control; child marriage; exclusion from education, employment, and decision making; and unequal chore burdens and caretaking responsibilities. Rigid gender norms can profoundly and negatively affect both girls and boys, but can particularly constrain girls’ aspirations and opportunities.

Some links between gender-based violence and mental health have already been established. About 30% of girls aged 15–19 years around the world experience violence by a partner.8 A recent meta-analysis9 showed that women’s experience of intimate partner violence was associated with increased depression and suicide attempts.

We need to understand better the relationships between adolescent mental health and sexual and reproductive health and rights. 11% of all births worldwide are among girls aged 15–19 years; almost all occur in low-income and middle-income countries, and many of them are unintended.10 In societies where access to education about sexuality IS restricted, girls who become pregnant outside marriage might believe that self-harm or suicide are their only alternatives.11, 12

Related to the phenomenon of early pregnancy is child marriage, which affects around 40 000 girls under the age of 18 years every day.13 Child brides are typically removed from their families, peers, and educational opportunities, and face higher rates of unintended pregnancy, domestic violence, and sexually transmitted infections than their unmarried peers. Although few studies have assessed the mental health effects of child marriage, one study in the USA found that child marriage was associated with high rates of long-term psychiatric disorders.14

Donor funding structures and the manner in which global health is currently addressed do not support the type of cross-cutting and multidisciplinary research that is needed to truly understand and stem the scourge of suicide among adolescent girls. Funding must be made available to catalyse research, programmes, and policy dialogues addressing the many sided nature of the challenge, with a particular focus on the role that harmful gender norms might have. We need improved monitoring and documentation of suicides and suicide attempts, and greater innovation in promoting mental health among adolescents. And as we move toward a new global development agenda and a new global strategy on the health of women, children, and adolescents, we must address the full range of health needs for adolescent girls, a crucial and previously neglected population.

We declare no competing interests.


  1. Diu, NL. Suicide is now the biggest killer of teenage girls worldwide—here’s why. The Telegraph.May 25, 2015;
  2. Valenti, J. Worldwide sexism increases suicide risk in young women. The Guardian. May 28, 2015;
  3. Brink, S. The truth behind the suicide statistic for older teen girls. NPR. June 2, 2015;
  4. WHO. Health for the world’s adolescents, a second chance in the second decade. World Health Organization, Geneva; 2014
  5. WHO. Preventing suicide: a global imperative. World Health Organization, Geneva; 2014
  6. Patel, V. Reducing the burden of depression in youth: what are the implications of neuroscience and genetics on policies and programs?. J Adolesc Health. 2013; 52: S36–S38
  7. Lister, CE, Merrill, RM, Vance, DL, West, JH, Hall, PC, and Crookston, BT. Victimization among Peruvian adolescents: insights into mental/emotional health from the young lives study. J Sch Health. 2015; 85: 433–440
  8. WHO. Adolescents: health risks and solutions. World Health Organization, Geneva; 2014
  9. Devries, KM, Mak, JY, Bacchus, LJ et al. Intimate partner violence and incident depressive symptoms and suicide attempts: a systematic review of longitudinal studies. PLoS Med. 2013; 10:e1001439
  10. UNFPA. State of the world population 2013: motherhood in childhood. Facing the challenge of adolescent pregnancy. United Nations Population Fund, New York, NY; 2013
  11. Citizen’s coalition for the decriminalization of abortion on grounds of health, ethics and fetal anomaly, El Salvador. From hospital to jail: the impact on women of El Salvador’s total criminalization of abortion. Reprod Health Matters. 2014; 22: 52–60
  12. Frautschi, S, Cerulli, A, and Maine, D. Suicide during pregnancy and its neglect as a component of maternal mortality. Int J Gynecol Obstet. 1994; 47: 275–284
  13. United Nations Children’s Fund. Ending child marriage: progress and prospects. UNICEF, New York, NY; 2014
  14. Le Strat, Y, Dubertret, C, and Le Foll, B. Child marriage in the United States and its association with mental health in women. Pediatrics. 2011; 128: 524–530

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