This article contains discussion of a topic which some readers may find disturbing. The discussion is not graphic, but may still be upsetting. Please err on the side of protecting yourself if this is a sensitive topic for you.

Trigger warning: self-harm, suicide.

I have only ever been to San Francisco once. At the time, I was a first-year medical student exploring different medical specialties, and I traveled there to attend a conference for obstetrics and gynecology.

It was an incredibly motivating experience. Those of you who have gone to conferences probably know what I’m talking about. The excitement! The hubbub! What could be better than a bunch of people who all love to talk about something that you’re interested in, too? There were workshops for medical students on suturing, delivering babies, robotic laproscopy, a Q&A by current residents and practicing ob/gyns, and more. I was busy morning till night. There was no lack of things to see, people to meet, and places to explore.

Strangely, my most vivid memory is of the protestors who stood outside the convention center with picket signs. I might have expected some anti-abortion groups to show up, but no, not at all! Instead, these were anti-circumcision groups for male newborns. I viewed the protestors with curious amusement, because ob/gyns did not perform circumcisions at the hospital that I rotated through and, well, I have never known an ob/gyn to treat very many patients with male genitalia. Perhaps other places have different practices, but anyways, this topic is not my expertise and I digress.

I was in the city for two days. However, to my regret (and I don’t remember the reason anymore), I didn’t visit the Golden Gate Bridge, one of the “Wonders of the Modern World.”

The bridge is renowned for its visual beauty and suspension design. It is famous for one more thing: it is the second-most common suicide site in the world.

In 1975, David H. Rosen, MD published a study of persons who survived jumping from either the Golden Gate or the San Francisco-Oakland Bay bridge. He interviewed seven of ten known survivors. In his publication, he states that, “Each person was made aware that he or she could refuse to answer any of the questions during the interview, and assured that anonymity would be preserved. . . . [T]heir participation was entirely voluntary.” (Rosen, 1975)

In his interviews, Dr. Rosen asked several questions. Why the choice of the bridge? What did they experience during the fall and upon impact? Did they lose consciousness? What has been the long-term impact of this event on their lives?

Dr. Rosen also discusses several psychological aspects of near-death experiences, including the three phases of resistance, life review, and transcendence as described by Russell Noyes, MD, and the phenomenon of ego-death/rebirth. As a survivor said, after his jump, he was “refilled with a new hope and purpose in being alive. . . . I appreciate the miracle of life – like watching a bird fly – everything is more meaningful when you come close to losing it.”

It has been over forty years since this publication. Since then, suicide rates have continued to increase. In this context, there are three points from Dr. Rosen’s article that I would like to discuss. First, the survivors report that they got the idea of jumping from press coverage. Second, the survivors chose the bridge because it symbolized something to them, and if it had not been available, they would not have used any other method of suicide. Third, all survivors interviewed recommended a barrier to prevent others from attempting suicide.

1. Press Coverage

The effect of press coverage on suicide rates has been well documented. Named the “Werther effect” after a character of the novel The Sorrows of Young Werther, who dies by suicide, it is thought that exposure to the idea of solving problems through suicide can send troubled people over the edge. This observation is echoed in Dr. Rosen’s interviews. One survivor said, “Newspaper editors should voluntarily stop all press coverage of the Golden Gate Bridge suicides – extensive press coverage put the idea into my mind.”

In response to this effect, the World Health Organization released a booklet in 1999, titled “Preventing suicide: a resource for media professionals.” The booklet has since been updated twice (most recently in 2017) to accommodate for changes in technology such as social media. It provides evidence of media impacts on suicidal behavior and guidelines for the responsible reporting of suicide. I think that it is a valuable read for anyone working in the media and giving information about suicide.

2. A Symbolic Choice

Second, the bridge was an important, symbolic choice for all of the interviewed survivors. Dr. Rosen reports that “four of the six [survivors] said they would not have used any other method if the Golden Gate Bridge had not been available… Often this was related in a symbolic way to the association of the Golden Gate Bridge with death, grace, and beauty.”

Symbolism plays a large role in our understanding of the world, and this holds true for the concept of suicide. People use symbols to communicate with others, guide our behavior, and inspire our actions. Symbolism is also apparent in suicide prevention, for example Project Semicolon, a non-profit organization dedicated to suicide prevention. A quote from their website: “Instead of ending a sentence, a writer can use a semicolon to continue on, and so too can an individual choose not to end his or her life, but continue on living.”

When discussing methods of suicide completion with people who present to the psychiatric emergency room, my level of concern increases when the plan clearly has symbolic meaning to the person. I become further alarmed when the person appears to view death as romantic or desirable. These statements are important to my evaluation, as they give valuable insight into the person’s psychological state.

Although an individual suicidal action is unpredictable, there can be certainty that an event may or may not occur in some places. If a place holds meaning to a community, then further events will likely occur. Places of symbolic significance, like the Golden Gate Bridge, should be monitored.

3. The Aftermath

Third, all the survivors recommend a suicide barrier. This is related to an area of suicide prevention called means reduction, in which lethal means are made less available or deadly. Although there may be some displacement to other methods, the overall suicide rate decreases.

In 2013, a barrier was installed at a bridge in Canada. The study showed that suicide rates at this site decreased, which persisted even when attempts at other bridges or jumping sites were studied. Little to no displacement to other jumping sites occurred. (Perron, 2013)

This holds true for other methods of suicide, including the famous coal gas story. Prior to the 1950s, most households in the United Kingdom used coal-derived gas, which contained about 10-20% carbon monoxide. As time progressed, more people began to use natural gas, which releases much less carbon monoxide. This resulted in a sustained decrease in overall suicide. (Kreitman, 1976)

Currently, the installation of netting at the Golden Gate bridge is scheduled to be completed in 2021 at an estimated project cost of $221 million. (San Francisco Chronicle)

Suicide prevention is a complicated topic that encompasses much more than the aspects presented in this brief discussion. As a young physician, this article is especially memorable, as the idea of approaching survivors of suicide and broaching a sensitive topic takes a certain type of courage. I am thankful that Dr. Rosen wrote this article, as there are important lessons to be learned from his discussions with these survivors. I hope these lessons can save future lives.

You can find the publication on PubMed Central here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1129714/

More Information

Rosen, D.H. Suicide survivors: A follow-up study of persons who survived jumping from the Golden Gate and San Francisco-Oakland Bay bridges. Western Journal of Medicine 122: 289-294, Apr 1975.

World Health Organization. Preventing suicide: A resource for media professionals. Geneva, Switzerland: Author. 2017. http://www.who.int/mental_health/suicide-prevention/resource_booklet_2017/en/

Perron S, Burrows S, Fournier M, Perron PA, Ouellet F. Installation of a bridge barrier as a suicide prevention strategy in Montréal, Québec, Canada. American Journal of Public Health. 2013 Jul;103(7):1235-9.

Kreitman N. The coal gas story. United Kingdom suicide rates, 1960-71. Br J Prev Soc Med. 1976;30(2):86-93.

If you or someone you know is suicidal, please seek help.

International Resources

• The International Association for Suicide Prevention maintains a Global Crisis Centre Directory.
• The Befrienders maintain a hotline database; use the “Find a Helpline by Country” control at the top of their page.

United States

• National Suicide Prevention Lifeline: 1-800-273-8255 (TALK)
• • Veterans press 1 to reach specialised support.
• Online Chat: http://chat.suicidepreventionlifeline.org/GetHelp/LifelineChat.aspx
• Crisis Text Line: Text “START” to 741-741
• Youth-Specific services (voice/text/chat/email) from the Boys’ Town National Hotline: http://www.yourlifeyourvoice.org/Pages/ways-to-get-help.aspx
• Spanish: 1-800-SUICIDA

Please let me know if any of these links are out of date.