Genocide exposure and subsequent suicide risk: A population-based study

Stephen Z. Levine, Itzhak Levav, Rinat Yoffe, Yifat Becher, Inna Pugachova

Research output: Contribution to journalArticlepeer-review


The association between periods of genocide-related exposures and suicide risk remains unknown. Our study tests that association using a national population-based study design. The source population comprised of all persons born during1922-1945 in Nazi-occupied or dominated European nations, that immigrated to Israel by 1965, were identified in the Population Register (N = 220,665), and followed up for suicide to 2014, totaling 16,953,602 personyears. The population was disaggregated to compare a trauma gradient among groups that immigrated before (indirect, n = 20,612, 9%); during (partial direct, n = 17,037, 8%); or after (full direct, n = 183,016, 83%) exposure to the Nazi era. Also, the direct exposure groups were examined regarding pre- or post-natal exposure periods. Cox regression models were used to compute Hazard Ratios (HR) of suicide risk to compare the exposure groups, adjusting for confounding by gender, residential SES and history of psychiatric hospitalization. In the total population, only the partial direct exposure subgroup was at greater risk compared to the indirect exposure group (HR = 1.73, 95%CI, 1.10, 2.73; P < .05). That effect replicated in six sensitivity analyses. In addition, sensitivity analyses showed that exposure at ages 13 plus among females, and follow-up by years since immigration were associated with a greater risk; whereas in utero exposure among persons with no psychiatric hospitalization and early postnatal exposure among males were at a reduced risk. Tentative mechanisms impute biopsychosocial vulnerability and natural selection during early critical periods among males, and feelings of guilt and entrapment or defeat among females.

Original languageEnglish
Article numbere0149524
JournalPLoS ONE
Issue number2
StatePublished - Feb 2016

Bibliographical note

Funding Information:
This study is part of a larger project on the psychiatric aftermath of the Holocaust jointly supported by non-overlapping funds from the Claims Conference and Israel Science Foundation. The URL of the Israel Science Foundation is il/. The URL of the Claims Conference is http://www. Through recovering the assets of the victims of the Holocaust, the Claims Conference enables organizations around the world to provide education about the Shoah and to preserve the memory of those who perished (grant no. 14441). Also, this research was supported by the Israel Science Foundation (grant no. 130/13). This work may or may not reflect the views of these funding bodies. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. We thank Professor Yehuda Bauer who clarified the years of increased/onset of persecution per country.

Publisher Copyright:
© 2016 Levine et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

ASJC Scopus subject areas

  • Biochemistry, Genetics and Molecular Biology (all)
  • Agricultural and Biological Sciences (all)
  • General


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