Prevalence According to Anton J. L. van Hooff, hanging was the most common suicide method in primitive and pre-industrial societies.[5] A 2008 review of 56 countries based on World Health Organization mortality data found that hanging was the most common method in most of the countries,[6] accounting for 53 percent of the male suicides and 39 percent of the female suicides.[7] In England and Wales, hanging is the most commonly used method, and is particularly prevalent in the group of males aged 15–44, comprising almost half of the suicides in the group. It is the second most common method among women, behind poisoning. In 1981 hanging accounted for 23.5 percent of male suicides, and by 2001 the figure had risen to 44.2 percent.[2] The proportion of hangings as suicides in 2005 among women aged 15–34 was 47.2 percent, having risen from 5.7 percent in 1968.[8] In the United States it is the second most common method, behind firearms,[9] and is by far the most common method for those in psychiatric wards and hospitals.[10] Hanging accounts for a greater percentage of suicides among younger Americans than among older ones.[11] Differences exist among ethnic groups; research suggests that hanging is the most common method among Chinese and Japanese Americans.[12] Hanging is also a frequently used method for those in custody, in several countries.[1] [edit] The act The running bowline, a type of slip knot In general, there are two ways of performing suicide by hanging: suspension hanging (the suspension of the body at the neck) and drop hanging (a calculated drop designed to break the neck). Manual strangulation and suffocation may also be considered together with hanging.[13] To perform a suspension hanging, a rope or other ligature is tied into a noose which goes around the neck, a knot (often a slip knot, which tightens easily) is formed, and the other end of the rope is tied to a ligature point; the body is then suspended, which tightens the ligature around the neck. With suspension hanging, the person slowly dies of strangulation, which typically takes between ten and twenty minutes, resulting in a considerably protracted, grisly and painful death. [14] In addition to rope, other materials can easily be fashioned into an improvised noose e.g. a bed-sheet, ripped T-shirt, shoelaces or telephone extension cable. Regardless of the material used to form the noose, suspension hanging will kill its victims in three ways: compression of the carotid arteries, the jugular veins, and the airway.[15][16] About 5 kg of pressure is required to compress the carotid artery; 2 kg for the jugular veins;[15] and at least 15 kg for the airway.[17] The amount of time it takes to lose consciousness and die is difficult to predict accurately and depends on several factors. Some believe unconsciousness occurs in five seconds, though Alan Gunn writes that it generally takes longer. It took a man who filmed his hanging 13 seconds to become unconscious, 1 minute and 38 seconds to lose muscle tone, and 4 minutes and 10 seconds for muscle movement to cease.[18][19] Full suspension is not required; most hanging suicides are done by partial suspension, according to Wyatt et al.[20] Geo Stone, author of Suicide and Attempted Suicide: Methods and Consequences, suggests that death by obstruction of the airway is more painful than by the other ways.[13] The aim of drop hanging, which is also frequently used in executions, is to break the neck. Participants fall vertically with a rope attached to their neck, which when taut applies a force sufficient to break the spinal cord, causing death.[13][21] The length of the drop, usually between five and nine feet long, is calculated such that it is long enough to allow a less painful death, but short enough to avoid a decapitation.[22] Regarding the practicalities of performing a drop hanging, Stone recommends using a low-stretch rope such as manila or hemp, that the rope be more than an inch thick, and that the knot be close to the chin and situated such that it will move towards the chin when the rope is pulled.[13] This form of suicide is much rarer than suspension hanging[17] and is likely to be less painful.[23]