Jurnal Sains Kesihatan Malaysia 16(2) 2018: 77-84

DOI : http://dx.doi.org./10.17576/JSKM-2018-1602-10

Artikel Asli/Original Article

Incidence of Suicide by Hanging in Klang Valley from 2007 to 2016

(Insiden Bunuh Diri secara Gantung Diri di Lembah Klang dari tahun 2007 hingga 2016)

SITI RAHMAH ABD KARIM, SRI PAWITA ALBAKRI AMIR HAMZAH & NOOR HAZFALINDA HAMZAH

ABSTRACT

Malaysia was ranked at 148 by World Health Organization (WHO) in suicide statistic for 2012, where males had a higher
tendency to commit suicide, recording a 4.7 per 100,000 in comparison to female (1.5 per 100,000). As hanging is one of
the most common methods to commit suicide, this retrospective study was conducted to observe the incidence of suicide
by hanging in Klang Valley from four different hospitals. The current study is conducted to provide local database of
suicide occurrence by hanging in Klang Valley. A total of 893 suicide cases by hanging from 2007 to 2016 were recorded
from post mortem records and analysed. Suicide rates in Klang Valley showed a rising trend from 2007 to 2016. Males
from age group 30 to 34 years old and females from 20 to 24 years old have the highest number of suicide fatalities
compared to other age groups. Meanwhile, fatalities from the age group of 10 to 14 years old and 80 years old and above
showed similar result which is only 7%. 78% of the fatalities were recognized as Malaysian and half of them were Indian.
Majority of the victims/cases (45%) who committed suicide by hanging are of Hindu religious denomination. Non-citizen
in Malaysia that have the highest suicide rates were from Nepal, Indonesia and Myanmar. Victims also committed suicide
more during the day and the peak hours being at 12.00 pm to 5.59 pm.
Keywords: Forensic science; forensic pathology; suicide; hanging; Klang Valley

ABSTRAK

Malaysia berada di kedudukan 148 dalam statistik bunuh diri yang telah dikeluarkan oleh Pertubuhan Kesihatan Sedunia
(WHO) pada tahun 2012 di mana lelaki mempunyai kecenderungan yang lebih tinggi untuk bunuh diri dengan kadar
4.7 per 100,000 berbanding dengan wanita (1.5 per 100,000). Oleh kerana kejadian gantung diri adalah salah satu
cara yang sering digunakan untuk membunuh diri, kajian retrospektif ini dijalankan untuk mencerap kadar kejadian
bunuh diri dengan cara menggantung diri di Lembah Klang daripada empat hospital berbeza. Kajian ini dijalankan
untuk menambah data di pangkalan data tempatan berkenaan kejadian gantung diri. Sebanyak 893 kes bunuh diri
dengan cara menggantung diri dari tahun 2007 hingga 2016 telah direkodkan dan dianalisis. Kadar bunuh diri di
Lembah Klang menunjukkan peningkatan dari tahun 2007 hingga 2016. Lelaki berumur 30 hingga 34 tahun dan wanita
berumur 20 hingga 24 tahun adalah kumpulan umur yang mempunyai kadar kematian bunuh diri tertinggi berbanding
dengan kumpulan umur yang lain. Manakala, kematian bagi kumpulan umur 10 hingga 14 tahun dan 80 tahun ke atas
menunjukkan kadar peratusan yang sama iaitu 7%. 78% daripada kematian bunuh diri adalah warganegara Malaysia
dan separuh daripada mereka adalah berbangsa India. Kebanyakan kes gantung diri (45%) adalah terdiri dari mangsa
beragama Hindu. Warga asing di Malaysia yang mempunyai kadar bunuh diri tertinggi adalah daripada Nepal, Indonesia
dan Myanmar. Mangsa juga lebih ramai menggantung diri pada waktu siang dan waktu kemuncak adalah pada 12.00
tengahari hingga 5.59 petang.
Kata kunci: Sains forensik; patologi forensik; bunuh diri; gantung; Lembah Klang

INTRODUCTION 2009). Whilst the statistic revealed that Malaysia was

placed lower than other Asian countries, Thailand and
Suicide statistic published by WHO in 2012 showed that Indonesia were ranked 56th and 135th, respectively, an
Malaysia was placed at 148 with 3 suicide cases per alarming report indicated that Malaysia has experienced
100,000 people per year, which showed males had a higher a whopping 60% increase in the suicide rate for the past
tendency to commit suicide, recording a 4.7 per 100,000 45 years (Sinniah et al. 2014). Unsurprisingly, the top
in comparison to female (1.5 per 100,000). The National three major causes of deaths reported in United States
Suicide Registry Malaysia (NSRM) reported a gender ratio was suicide. Most of the victims were youths and young
of 2.9:1 skewing towards male and findings are similar to adults between 10 to 24 years old (Centers for Disease
Singapore in 2006 (National Suicide Registry Malaysia Control and Prevention 2007; Kok et al. 2011). The same

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 trend was observed in suicide rates among youths under themselves without proper planning or knowledge. Besides
30 years old in Malaysia indicating Malaysia was catching that, they thought that hanging would leave their bodies
up with Japan, which has a terrifying suicide rate of above without any terrifying or disturbing images as this method
30 per 100,000 populations (Kok et al. 2011; Maniam did not cause bloody or messy scene.
et al. 2014).The definition of suicide becomes complicated Therefore, as hanging is one of the most common
when it comes to the terminology because terminologies method to commit suicide observed by Murty et al. (2008)
related to suicide such as suicide attempt and suicide intent and National Suicide Registry Malaysia (2009), the current
do not have any specific definition and often misclassified. study is focusing on suicide by hanging by observing the
According to De Leo et al. (2004) and American Psychiatric trends from 2007 to 2016 and demographics data among
Association (2013), three important criteria in defining the the victims in Klang Valley.
act of suicide are listed from Centers of Disease Control
back in 1980s. First, an act of suicide must consist of
behavior with fatal outcomes. Second, a suicide act must MATERIALS AND METHODS
either be active or passive self-harm and finally a suicide
victim must have the intent or an expectation to die Demographic data of suicide by hanging from January
(Andriessen 2006; Rosenberg et al. 1988). Meanwhile, 2007 to December 2016 was collected retrospectively from
Carroll et al. (1996) defined suicide attempt as deliberate Forensic Departments of four different hospitals in Klang
acts by the victims that would cause self-harm at some level Valley; Pusat Perubatan Universiti Kebangsaan Malaysia,
but not resulting to death. This act may or may not result in Hospital Tuanku Ampuan Rahimah, Hospital Sungai Buloh
injuries to the victims. These two terminologies, which is and Hospital Serdang. Klang Valley is located at the center
suicide and suicide attempt need to have a comprehensible of Kuala Lumpur and consists of combination of several
definition as these two terms seems to overlap, resulting in districts such as Kuala Lumpur, Petaling, Hulu Langat,
misclassification. According to Perdekamp et al. (2010) and Klang and Gombak. Based on Department of Statistics
Fathelrahman et al. (2006), a person who attempted suicide Malaysia (2011), the estimated population in Klang Valley
has high risk of committing suicide. However, this trigger is 7.2 million. Major ethnic and races in Klang Valley
factor may differ for long and short-term period before the are made up of Malay (45.9%), Chinese (43.2%), Indian
victims kill themselves (Suokas et al. 2001). (10.3%) and others (1.6%). Demographic data such as age,
Suicide methods vary according to geographical gender, nationality and ethnic group, religion and time of
factors, which are classified into either Western or Asian death were collected and recorded for analysis. The age
countries. For instance, the most common method used to groups were divided into 15 age band groups (10-14, 15-19,
commit suicide in western countries is firearms (Ajdacic- 20-24, 25-29, 30-34, 35-39, 40-44, 45-49, 50-54, 55-59, 60-
gross et al. 2008). On the other hand, Asian countries such 64, 65-69, 70-74, 75-79, >80) according to World Health
as Singapore and Hong Kong prefer falls from height, Organization (2014). The time of death for the fatalities
while victims from Malaysia and Japan favored hanging was divided into six hours period. Data was analysed to
to commit suicide (Wu et al. 2012). This also correlates to observe the incidence of suicide by hanging for the past
the findings of NSRM 2009 where 328 cases of suicide in ten consecutive years. A few ethical considerations have
that year, the main method used was hanging, suffocation been taken to ensure the confidentiality of the data and
and strangulation (176 cases, 53.7%) (National Suicide patients’ information such as name, identification card
Registry Malaysia 2009). number and address of the deceased were not recorded.
Death by hanging is due to asphyxia in which the All data recorded was for the purpose of this study only
victim’s body is suspended by a ligature encircling and and not shared with non-authorized personnel (who is not
compressing the neck, hence blocking the passage of air related to this study).
into the lungs (Ahmad & Hossain 2010). The weight of
the body is enough to cause death to the victim (Reddy
RESULTS AND DISCUSSION
& Lowenstein 2011). Hanging has been observed to be
the most favored method used as it has less or no cost
involvement, except for the ligature material, as well A total of 893 suicide cases were collected in this study.
as one of the fastest method to cause death (Ahmad & Figure 1 showed the fluctuation of suicide rates from 2007
Hossain 2010). According to Knight (2004), a thin rope to 2016. 2013 has the highest percentage of suicide cases
used as ligature material would cause unconsciousness with 14% (n = 138). In contrast, the lowest percentage of
in 15 seconds. The ligature material can be made from suicide cases was in 2007 with 8% (n = 77). Meanwhile,
anything such as wire, bed sheet, scarf and many other suicide cases in 2008, 2009 and 2011 show similar
possibilities. Biddle et al. (2010) conducted a study in the percentage of 9%.
United Kingdom involving 22 respondents who was saved Based on Table 1, 703 males and 190 females are in
from near suicide attempts. Eight of them had decided to this study and the number of males is almost four times
use hanging to commit suicide. Respondents chose hanging of females. This shows that males (79%) were more
because hanging was easily executed and they can hang prone to commit suicide by hanging compared to females

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 (21%). Based on Armitage et al. (2015) and Hayati et al. countries. Nepal had the highest number of cases (n = 74),
(2014), males have a higher tendency to commit suicide followed by Indonesia (n = 42), Myanmar (n = 31) and
as compared to females who have suicidal ideation and Bangladesh (n = 23). Next is Thailand with 4 cases, while
suicide attempts which rarely lead to death. Pakistan, Sri Lanka and Vietnam had the same number of
In addition, Klang Valley is made up of many races suicide cases (n = 3) for each. Cambodia and Germany had
and ethnicity; therefore this study classified these cases 2 cases reported respectively. The rest of the non-citizen
into citizen and non-citizen. Table 1 showed majority of victims from Botswana, Maghribi, Poland, Korea, New
suicide case by hanging was among citizen, with ratio 4:1 Zealand, Uzbekistan, Sudan, Romania and Iran had the
to non-citizen. Fatalities among non-citizen consist of 19 same number of suicide case (n = 1).

160

140
128
120
105
100
Number of cases

95
100
85 82
77 80 75
80
66

60

40

20

0
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Year

FIGURE 1. Total number of suicide cases in Klang Valley from 2007 to 2016

On top of that, half of the cases among Malaysian was their believers from committing suicide and Malays have
dominated by Indian with total of 50.50% (n = 352). Even negative thoughts towards people who committed suicide
though Malay is the largest population in Klang Valley, only (Hussain & Hyman 1994). This principle was comparable
6.17% of suicide cases involved Malay. The other ethnic with Buddhist beliefs where any kind of action that either
groups such as Bidayuh and Orang Asli have the lowest hurt oneself or other people was regarded as disrespectful
percentage of suicide by hanging with only 0.43%. As such, to their religion, thus could be a reason behind the lower
Hindu religious denomination has the highest percentage suicide rates among Chinese in comparison to the Indian
in suicide by hanging (45%), as compared to Buddha and population (Yip 1996). However, Kok (1992) stated that
Islam with 40% and 13% respectively. Other religion such in certain situations, Chinese would commit suicide for
as Christian made up 3% in suicide cases. honor and integrity.
A percentage of the victims (30.23%) committed An over representation of the suicides (45%) were
suicide during the day, from 1200 to 1759. There are among the Indian population and by extension of Hindu
slightly differences in number of victims that committed religious denomination for the past ten years. Few studies
suicide during the day, the hours between 0600 to 1159 (250 which had been conducted showed that Indian had higher
cases) and 1800 to 2359 (255 cases). Number of victims suicide rates in Malaysia as well as other countries, with
who committed suicide during early morning is the lowest, hanging as the most common method to commit suicide
with 115 cases. Three cases are classified as unknown as (Adityanjee 1986; Maniam 1988; Maniam 1994).
there was no data on time of death. The National Crime Record Bureau in India reported
Race, religion and cultural norms did have a significant that seven of 100,000 suicide victims per year attempted
influence for those who decided to commit suicide (Oquendo to kill themselves by hanging, ingestion of insecticides or
et al. 2005). Muslims made up the least percentage of barbiturates, for every five minutes (Baby et al. 2006). In
committing suicide by hanging even though the Malay is addition, Vijayakumari (2011) reported that 95% of suicide
the largest population in Klang Valley. Other studies also deaths were by hanging. Hindus religious denomination
showed similar results (Maniam 1988; Murty et al. 2008; may have less number of suicide cases if Indian has a less
Murugesan & Hock 1978). Islam indeed strictly prohibits ascetic way of life, in which they believe that individual

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 souls advance through various spiritual levels by a Indonesians lower as compared to Nepalis (Abdul-Aziz
laborious process of pain and suffering. However, based 2001). Coupled with the fact that Nepalis speak a different
on Venkoba (1975) and Radhakrishnan & Andrade (2012), language, most practice a different faith and migrated later
the act of suicide was allowed for those who devoted their than the Indonesians; makes it more difficult for them to
lives to their God which contribute to higher number of interact with local populace (Abdul-Aziz 2001; Carballo
fatalities among Indian. & Nerukar 2001).
Few studies showed the relationship between
TABLE 1. Socio-demographic data of suicide by hanging in suicide occurrence and the time of death as conducted by
Klang Valley from 2007 to 2016 Barraclough (1976) and Galleranl et al. (1996). However,
there was no deeper study regarding the relationship
Categories Number of fatalities % between suicide occurrence and time of death. The peak
hours to commit suicide were during the day, from 1200 to
Gender
1759 which contributed to 30.23% of the total cases. This
Male 703 79
Female 190 21 result was supported by Pokorny (1960) and Durkheim
Nationality (1897). Surprisingly, people who committed suicide had
Citizen 697 78 similar daily activities as other normal people and were
Non-citizen 196 22 not quiet and isolated (Morselli 1897; Williams & Tansella
Race 1987). On top of that, Durkheim (1897) also explained that
Malay 43 6.17 social life was most intense during the day. In contrast,
Chinese 299 42.90 other authors reported that almost 70% of suicide cases
Indian 352 50.50 by hanging occurred at midnight because there was less
Others 3 0.43 likelihood for other people to realize and prevent them from
Religion
committing suicide (Ahmad & Hossain 2010).
Islam 119 13
Figure 2 showed the age of fatalities in suicide by
Buddha 353 40
Hindu 399 45 hanging ranging from 13 to 90 years old. The highest
Others 22 3 total fatalities (138 cases) were from the age group 25-
Time of death 29 years old. The second highest (133 cases) was from
0000-0559 115 12.88 the age group 30-34 years old and the third was from the
0600-1159 250 28.00 age group 20-24 years old. This findings were similar to
1200-1759 270 30.23 Nadesan (1999). Langhinrichsen-Rohling et al. (2009) also
1800-2359 255 28.55 stated that economic crisis could be one of the trigger factor
Unknown 3 0.34 that led adults to commit suicide in Klang Valley since
Klang Valley is an urban area with a high cost of living.
In contrast, many authors reported that suicide rates were
The suicide trend among non-citizens seemed to be highest in young adults between the age 15-24 years old
increased, whereby National Suicide Registry Malaysia (Fischer et al. 1993; Hawton et al. 1993; Kok & Goh 2011).
(2009) reported that only 10.7% of migrants ended Risk factors that could lead them into committing suicide
their lives in Malaysia. In the current study, Nepal over included unemployment, alcohol or drugs misuse, personal
passed Indonesians and Bangladeshis with 70 cases, as illness and the most significant trigger factor was poor
compared to findings from Ali et al. (2014) where 11 relationship with their partner (Appleby et al. 1999).
suicide cases was Nepalis (from 290 cases) back in 2008. Not only that, suicidal behavior in Malaysia is
This suggested that they might still struggle to cope in a associated with interpersonal conflict and this is further
new environment and felt socially isolated (Vijayakumar accentuated in urban setting. Numerous societal changes
et al. 2004). In contrast, the number of Indonesians as the country push towards being a developed country by
and Bangladeshis less committing suicide than Nepalis year 2020, increased urbanization and led the population
because they had adapted well living in Malaysia. They into a state of ‘anomie’, where the accustomed relationship
arrived at Malaysia in late 80’s, earlier than Nepalis thus of an individual and their society is suddenly shattered,
reducing the risk of being suicidal (Abdul-Aziz 2001). The heightening interpersonal conflict (Armitage et al. 2015).
higher number of suicide cases among non-citizen were Mental illness was also one of the common trigger
influenced by social environments, financial problems, factors in suicide among adults and 19% of them showed
unemployment, language barrier and any psychiatric characteristics of schizophrenia (Appleby et al. 1999).
disorders thus lead to suicidal behaviors (Hovey 2000; National Suicide Registry Malaysia (2009) reported that
Ponizovsky & Ritsner 1999). This shows that non-citizen 7.1% of suicide victims in Malaysia had family history
was not strongly affected by religious matters even though of suicide or psychiatric illness. This findings was small
Islam and Buddhist prohibit suicide among their believers. as compared to other psychological autopsy (PA) studies
However, the similarities of culture and language between because not all suicide cases are captured, especially
Indonesian and Malaysian causes the suicide rates among for non-medically certified death cases (Maniam 1995).

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 0
≥ 80 7
4 Female
75-79 4
Male
70-74 9
9
5
65-69 18
7
60-64 25
10
55-59 36
12
50-54 42
15
45-49 72
15
40-44 67
18
35-39 90
14
30-34 119
28
25-29 110
35
20-24 80
17
15-19 18
1
10-14 6

0 20 40 60 80 100 120 140

Number of suicide cases

FIGURE 2. Distribution of suicide cases in Klang Valley from 2007 to 2016 according to range of age

INSERM Collective Expertise Centre (2005) reported that The data also showed that males have a higher
Canada, Great Britain and Finland practiced PA to identify tendency to commit suicide by hanging as compared to
various risk factors to predict suicidal action, a meticulous females, as noted by previous studies (Armitage et al. 2015;
collection of data, in order to understand the circumstances Hayati et al. 2004). However, females had higher rates of
of the death of the suicide victims. Even though PA is a suicidal ideation and suicide attempts which rarely lead
useful tool for suicide prevention, there is a debatable to death, thus explaining why they had lower number of
standardisation in gathering the information, especially in fatalities in suicide (Canetto 2008; Schmidtke et al. 1996).
data collection (Pouliot & Leo 2006). Difficulties to contact In addition, Denning & Cox (2000) stated that the method
family members and friends, time elapsed between suicide used in committing suicide was influenced by gender.
and first interview with contacts and bias information Females preferred a less aggressive method compared to
during the interviews are among methodological male in committing suicide, such as using drug overdose
limitations in performing PA, not to mention that PA is a or carbon monoxide poisoning. In contrast, males tended
time consuming study. Hence, a better standardisation, or to commit suicide by means of hanging or firearms
at least a guide is needed before implementing the PA study which were more aggressive and assured to cause fatality
(INSERM Collective Expertise Centre 2005). (Callanan & Davis 2012).
For gender comparison, males in the age group 30-34 Figure 2 also showed that elderly people from 65
years old have the highest number of cases (119 cases) years old and above had lower number of fatalities with
while for females, the 20-24 years old show the highest only 56 cases. National Suicide Registry Malaysia (2009)
number with 35 cases. This age group shows a higher rate stated that family members are caring for their elders, who
in males as this is the most active phase of life, physically, supported them medically, ensuring prolonged lifespan
socially and emotionally. The phase also brings about and lowering the suicide tendency. In addition, Ahmad
tremendous stress, strain and financial burden, all of which & Hossain (2010) believed that elders have lower suicide
if not handled appropriately, can lead to crisis and suicidal rates since they were more focused on religious matters and
behavior, seen in similar studies worldwide. Females on the enjoyed their life with their family. In contrast, the elderly
other hand, have a higher rate in the 2nd decade, as they are age group have the highest risk to commit suicide in many
more likely to face stress from marital conflict during and western countries (Conwell & Duberstein 2001; Leenaars
following marriage (Kanchan & Menezes 2008). 1995). Bennett & Collins (2001) noted that only 11.5% of

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 elders were accounted in suicide cases and hanging were cases were directly reported to the police, therefore police
in the top three suicide methods besides using firearms and cooperation is helpful to get the relevant information.
drug overdose. Various studies conducted on suicide rates NSRM could also provide adequate information regarding
among elders seem to have different findings in different the victims. However, the number of suicide cases that
Asian countries. One study in Singapore showed a similar had not been reported to the police might be even more
result where elders had lower suicide rates (Kua et al. due to social stigma of suicide (Pritchard & Amanullah
2003), while in Hong Kong, elders had the highest suicide 2006). As a result, the number of suicide case reported was
rates as compared to other age groups (Yip et al. 1998). lower than the actual cases. Besides that, future research
Suicide cases in Malaysia, especially by means of should focus on why Indian has the highest suicide rates
hanging, are on the rise (National Health and Morbidity compared to Chinese and Malays. Many factors should be
Survey 2015). The relevant authorities should take included such as the accessibility to the ligature material,
immediate action to reduce the rates of suicide especially Indian culture and tradition, biological factors and many
among young adults. This is because young adults are at the other possibilities. Moreover, misclassification of death
stage where they would face many unbearable difficulties would confer a substantial difference in the incidence.
and overwhelming them, leading to suicide. Spreading This current study only included four general hospitals,
suicide awareness to the public should also be done more therefore, for future research; data should be collected from
frequently, starting from teenagers at school. They should other general hospitals. Finally, an inferential technique
be informed that help is available to overcome difficulties, could be used to show correlation between demographic
to recognize signs of depression and suicidal ideation and sociological factors.
as well as being aware of friends’ or family members’
suicidal tendencies. Besides that, program on protective
mechanisms such as building self-confidence, interpersonal CONCLUSION
solving skills and social support should be promoted
to individual of all ages. Social support should include This study shows that the rate of suicide by hanging in
family social support to help coping mechanism, access Klang Valley is in a rising trend from 2007 to 2016, as the
and involvement of faith leaders from religious bodies as number increased from 2011 to 2016. The total number of
high religiosity confers a protective factor against suicidal cases reported on suicide by hanging was 893 cases with
behavior (Armitage et al. 2015). 703 males and 190 females. More than half of the victims
The results of this study should be regarded as a were citizen; only 22% of them were non-citizen. Indian
wakeup call for implementation of the psychological and Hindu religious dominations are the largest group
autopsy study in this country. Standardisation of the to commit suicide by hanging. The age group with the
methodology especially in interviewing the family highest number to commit suicide was 20-39 years old,
members and friends of the suicide victim should be revised where 30-34 years old for males and 20-24 years old for
and patented, in order to understand the reason behind all females. Most of the victims committed suicide during the
the suicidal cases and even for suicidal ideation cases, day, especially from 1200 to 1759.
which is difficult to capture.
In 2012, the government initiated the five-year
ACKNOWLEDGEMENT
National Suicide Prevention Strategic Action Plan with
aims to increase the current ratio of psychiatrists to
population by three-folds from 1: 150,000 to a more ideal The authors would like to express their gratitude to Forensic
1: 50,000. Under the action plan, the ministry also plans to Departments of Hospital Serdang, Hospital Sungai Buloh,
reduce stigmatisation and increase the availability of mental Pusat Perubatan Universiti Kebangsaan Malaysia and
health services to the public by migrating availability of Hospital Tuanku Ampuan Rahimah for providing the data
treatment from hospitals to community mental health for this research.
centres (National Health and Morbidity Survey 2015).
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