Suicide in Judaism with a Special Emphasis on Modern Israel

Judaism considers the duty of preserving life as a paramount injunction. Specific injunctions against suicide appear in the Bible, Talmud, and thereafter. Nevertheless, Jewish tradition emphasizes that one should let himself be killed rather than violate cardinal rules of Jewish law. Mitigating circumstances are found for the six deaths by suicide mentioned in the Bible, for example to account for one's sins, or avoid shameful death. Heroic suicide is praised throughout the Jewish history, from the suicide of Samson and the collective suicide in Masada, to the collective readiness of Jews in Medieval times and during the Holocaust to kill themselves rather than succumb to their enemies. Suicide rates for Jews are lower than those of Protestants and Catholics. Similarly, suicide rates in Israel are lower in comparison to Europe and North America, although being higher than those in most Moslem Asian and North African countries. This low rate of suicide is found in Jewish Israelis of all ages, including in adolescents. Elevated suicidal risk may be found in specific sub-populations, including male Israeli soldiers, immigrants from the former USSR and Ethiopia, in particular adolescent immigrants from the former USSR, elderly Holocaust survivors, and young Israel-Arab women. The meaning of these findings is discussed according to different socio-cultural perspectives.


Introduction
It was the French-Jewish sociologist Emile Durkheim who made these optimistic remarks at the turn of the century, in 1897, in his famous work Le suicide, which marked the beginning of the scientific study of suicide [1].Inspired by positivism and a faith in progress, Durkheim set out to probe the relationship between society and the individual, and the social phenomenon of suicide appeared to him the ideal subject, demonstrating the need for establishing sociology as an independent academic discipline.
The universality of suicide as a form of human behavior across all societies and cultures is well documented [2].Attitudes toward suicide have varied over time and place, reflecting the ideologies of each society to the value of life and the concept of death.Thus, the attitudes toward suicide in some societies of the ancient world, for example the Ancient Egyptians or the Greeks of the Homeric period, could be described as "justifiable in specific situations" and "non-condemning" [3].In contrast, current Western negative attitudes toward suicide are likely a consequence of Judeo-Christian traditions.St. Augustine's 4th century writings against suicide and the 6th century council of Braga both illustrate Christianity's consistent regard of suicide as the most grievous crime of all [2].

Introduction
In Judaism, the duty of preserving life, including one's own, is considered a paramount injunction [4].Nevertheless Jewish tradition has constantly emphasized that one should let himself be killed rather than violate three cardinal rules of Jewish law: Commands against idol worship, murder, and incest [4].In the Bible, although no explicit command forbidding suicide is given, the sovereignty of God and not of man over life and death is repeatedly emphasized: "It is I who put to death and give life" (Deuteronomy 32 :39)."The Lord kills and makes alive" (Samuel I 2:6).Job rhetorically asks, "In whose hand is the life of every living thing, and the breath of all mankind?" (Job 12 :10).The context supplies the unequivocal answer: God.Although God is equally sovereign over the deaths of all men, those of his people touch him deeply: "Precious in the sight of the Lord is the death of His godly ones" (Psalms 116 :15).
Theologically, suicide interferes with human purpose on earth that is to be co-partner with God in recreating another Garden of Eden on this planet.Suicide also supersedes God's role as the judge who decrees who is to be rewarded and who is to be punished.The taking of one's life places man in that supreme role.Further, the suicide is denied reincarnation, a part of traditional Jewish theology.Finally, a phrase that is said when a person dies, epitomizing Judaism's theological posture, is "God gives and God Takes".By killing oneself, one is presuming to be powerful enough to take over a right that belongs to God alone [5].

Historical Background
Six deaths by suicide are recorded in the Bible: Samson, King Saul and his arm bearer, Ahitophel, Avimelech and Zimri.In every instance mitigating circumstances for the suicidal act can be found, for example to account for one's sins or mistakes, or to avoid captivity, unbearable torture, or shameful death.In the case of Avimelech, the Old Testament account of his death, after capturing the city of Thebez and assaulting a fortified tower in the center of the city, reads: "So Avimelech came to the tower and fought against it, and approached the entrance of the tower to burn it with fire.But a certain woman threw an upper millstone on Avimelech's head, crushing his skull.Then he called quickly to the young man, his armor bearer, and said to him, 'Draw your sword and kill me, lest it be said of me, "A woman slew him.'"So the young man pierced him through, and he died" (Judges 9:52-54).
The account of king's Saul's is almost identical to that of Avimelech.It reads: "And the battle went heavily against Saul, and the archers hit him; and he was badly wounded by the archers.Then Saul said to his armor bearer, 'Draw your sword and pierce me through with it, lest these uncircumcised come and pierce me through and make sport of me.'But his armor bearer would not, for he was greatly afraid.So Saul took his sword and fell on it.And when his armor bearer saw that Saul was dead, he also fell on his sword and died with him (Samuel I 31:1-6 and Chronicles I 10:1-6).It seems that these two accounts are virtually identical.
In the case of Ahitophel who was King David's counselor and then betrayed him, David prayed that Ahitophel's advice would be regarded as wrong and foolish, which indeed was the case (Samuel II 15:31).The bible reads: "Now when Ahitophel saw that his counsel was not followed, he saddled his donkey and arose and went to his home, to his city, and set his house in order, and strangled himself; thus he died and was buried in the grave of his father" (Samuel II 17:23).Lastly, the king Zimri gained the throne of Israel by assassination.He lacked popular support and was soon attacked by a rival."And it came about, when Zimri saw that the city was taken, that he went into the citadel of the king's house, and burned the king's house over him with fire, and died, because of his sins which he sinned, doing evil in the sight of the Lord, walking in the way of Jeroboam, and in his sin which he did, making Israel sin (Kings I 16:18-19).

Suicide and Heroism
Another relevant typology in Judaism relates to heroic suicide, demonstrated, for example, in the story of Samson.Samson's death is thus recorded: "It so happened when [the Philistines] were in high spirits, that they said, 'Call for Samson, that he may amuse us.'So they called for Samson from the prison, and he entertained them.And they made him stand between the pillars.Then Samson called to the Lord and said, 'O Lord God, please remember me and please strengthen me just this time, O God, that I may at once be avenged of the Philistines for my two eyes.'And Samson grasped the two middle pillars on which the house rested, and braced himself against them…and he bent with all his might so that the house fell on the lords and all the people who were in it.So the dead whom he killed at his death were more than those whom he killed in his life" (Judges 16:25-30).
Heroic suicide is particularly materialized in the narrative of Masada, the most famous case of collective suicide in Jewish history [6].Masada-a fortress built on top of a mountain overlooking the Dead Sea in the Judean desert, was the last stronghold against the Roman Empire at the end of the Jewish revolt of 66-73 A.D. After a long and enduring siege, the Romans succeeded to demolish the walls and it was evident that the invasion of the fortress was inevitable.The leader of the rebels, Elazar Ben-Yair, convinced his people to die.It was a profound religious conviction and an equally strong sense of freedom that led the 960 surviving defenders of Masada to kill their wives and children and then each other rather than surrender to the Romans.
Still, it is of interest to note that although the suicide of Ben Yair and his warriors in Masada has become a symbol of bravery in modern Israel and all over the world, it has never been mentioned in Judaic rabbinic literature.Moreover, for years, it has been known only through the account of Josephus, a Jewish historian of the Roman times.Any mention of suicide is conspicuously absent in Yosippon [7], a later Hebrew account of the Jewish revolt; here the defenders fought against the Romans to the death Some argue that Josephus's story of Masada sheds some insight into his own views on suicide [8].Thus, while regarding suicide as completely alien to Jewish intellect, spirit, and law, Josephus, has nevertheless, seen it as justifiable, even admirable, as part of the heroic legacy of Judaism in times of persecution and captivity.
Indeed, from the chapter of Masada, voluntary death as an ultimate refuge of persecution [9] can be followed in Jewish history through the High and Late Middle Ages into the modern era.It can be shown that suicides on a mass scale have occurred during the persecutions occasioned by the Crusades, the Black Death, the expulsions from Spain and Portugal, and the pogroms of the Chmelnicki uprisings in Eastern Europe.There is no saying if, and to what extent, memories of those acts of despair and religious fervor have been still alive in Jewish communities of the twentieth century, particularly during the Holocaust [9].Still, suicide of Jews under Nazi rule is a phenomenon with a historical dimension, that is to say, there are precedents going far back into Jewish history, always connected with particular moments of crisis, persecution and despair [6].
Some authors argue that suicides of Jews during the Holocaust should be regarded as acts of heroism and resistance, for example the readiness of the Jewish warriors in Second World War Polish ghettos to die rather than to be captured by the Germans [6].This point of view has encountered considerable opposition and has not been widely accepted.Kwiet [9] suggests that during the Holocaust period, Jews, both individually and collectively, have developed a variety of strategies of defense and survival determined by tradition as well as by the prevailing social and personal circumstances.The strategies have varied in form and intensity, ranging from emigration, accommodation and collaboration to protest, escape attempts, politically organized resistance and suicide.
Suicide was the ultimate and most radical attempt to resist Nazi terror.Not surprisingly, the Nazis sought to prevent Jewish suicides.Wherever Jews tried to kill themselves-in their homes, in hospitals, on the deportation trains, and in the concentration camps-the Nazi authorities would invariably intervene in order to save the Jews' lives, wait for them to recover, and then send them to their prescribed deaths [9].

Judaic Injunctions against Suicide
The Biblical basis for the injunction against suicide has been derived from the Noahide laws: "For your lifeblood too, I will require a reckoning" (Genesis 9:5).This statement has been seen as a prohibition not only against suicide but also against any form of self-mutilation.The Hebrew Bible contains several additional prohibitions with regard to self-mutilation.For example, "Yeare the children of the Lord your God: Ye shall not cut yourselves, nor make any baldness between your eyes for the dead" (Deuteronomy 14:1) [8].
Injunctions against suicide continue to appear in the Talmud (5), and in later post-Talmudic writings [4].The prohibition against suicide is clear in Jewish Rabbinic law.It is written that a suicide victim is not given full burial honors.Rending one's garments, delivering memorial addresses, and other rites to honor the dead are not performed for a suicide victim, whose burial is done in a separate place, outside of the cemetery [4].Only rites respecting mourners are permitted [4].Still, there are exceptions to the prohibition against suicide even in the Talmud.Thus, according to the Talmud (Sanhedrin, 74a) one is obliged to accept death when the alternative is to be forced to commit adultery, murder, or idolatry.It should be nevertheless stressed that this means allowing oneself to be killed under certain prescribed circumstances, not to actively killing oneself.
Some mitigation in the overall restriction of suicide continues to appear in later Jewish codes of law.Thus, the codes of Maimonides from the 12th Century, and the Shulhan Arukh from the 16th Century, distinguish between suicide while of sound mind-to which these restrictions apply, and suicide while of unsound mind (including suicide by minors and people with mental illness), which is forgiven.Still, injunctions against suicide still apply in Modern Judaism, in that official orthodox burial ceremonies are not performed in the case of suicide [10].
Altogether, there seems to be an inherent duality of Judaism in ancient and modern times with respect to suicide.On the one hand, to regard it as a sinful and forbidden act that should be opposed as a paramount Jewish injunction; yet to allow, if not worship, the readiness of the individual to take his/her life when it comes to protect the existence of the Jewish religion, morality, or nation [6,11].

Introduction
Israel presents ample opportunities for the study of the association of Judaism with suicide.Nevertheless, other socio-cultural influences are likely of considerable relevance.More than many other countries, Israel is a society in transition, undergoing major socio-economic and socio-cultural changes both before, and since its independence in 1948.This is of particular relevance, as social instability may increase the risk of suicide [12].Other important socio-cultural factors likely influencing suicide relate to the considerable ethnic diversity in Jewish Israeli society, the influence of the massive immigration to Israel in the past 60 years from many countries around the globe, and the repeated switches between war and peace conditions within a relatively brief period of time [10,13].
A recent study by Oron [14] analyzes the relations existing between war conditions and suicide rates in Israel from its independence to the recent 2nd Lebanon War.In keeping with studies of other existential wars (World Wars 1 and 2), Oron [14] has shown a reduction in suicide rate during the three existential wars Israel has faced (the Independence War in 1948, the Six Days War in 1967, and the Yom Kippur War in 1973), with an increase in the rate of suicide in the year after, and either a stabilization or a decrease in its rate in the next years.Similar to other researchers, Oron [14] associates the reduction in suicide rates during war conditions with an increase in the national sense of cohesion, commitment and solidarity that decrease once again when the crisis is over.Wars that are not existential (e.g., the Suez War in 1956) have usually a lesser effect on the suicide rate of the population.Still, a decrease in suicide rate has been noted during the 2nd Lebanon War in 2006 in comparison to 2005, the sole conflict-free year since the 2nd Palestinian uprising in 2000.In keeping with this trend, Lester [15] has shown a significant inverse correlation between the number of suicide terrorist attacks/number of people killed in these attacks and suicide rates in Israel from 1983-1999.Lastly, an increase in suicide rate has been found during the 1st Lebanon War, the first controversial war Israel has faced in 1982, in comparison to the years preceding this war [14].

Suicide in the General Jewish Israeli Population
From the early documentation of suicide in Europe by Durkheim in the second part of the 19th century and in North America in the 1920s, the suicide rates for Jews have been consistently lower than those of Protestants and in most, although not all studies, also lower in comparison to Catholics [10,16].In keeping with these trends, the suicide rates in Israel are also relatively low [17,18].Thus, of all European countries investigated in the late 1980s, only England and Greece have had lower suicide rates than Israel [19].In a report of the World Health Organization of suicide rates in 110 countries in the 1990s [20], Israel ranks in the 73rd place for males (10.5/100,000) and the 76th place for females (2.6/100,000).Lastly, in a further report of suicide rates in 25 European countries in recent years, Israel ranks in the 23rd place for males, and the 24th place for females [21].Accordingly, suicide rates in Israel are consistently lower than those found in most countries in Europe and North America, in the range of many South and Central American countries, and higher in comparison to Muslim countries in Asia and North-Africa.In keeping with these findings, the suicide rates of Israeli Jews are mostly considerably higher than those of Israeli Arabs [10,[21][22][23].These findings likely reflect the inclination of Judaism to negate suicide to a greater extent than Christianity, but to a lesser extant than the Islam [2,10,22].
Several factors may account for the relatively low suicide rate in Israel, in addition to the influence of Judaism [10,22].Thus, the tendency towards secularization, likely increasing the risk of suicide, is more pronounced in Western industrialized countries than in Middle-Eastern or North African countries [24,25].Israel is in this respect less secular than most European and North American countries.Currently, more than a half of Israeli Jewish citizens are of Middle-Eastern or North-African descent.Israelis of this descent likely tend to keep their traditional religious adherence, an inclination potentially associated with reduced suicidal risk [25].From a different perspective, suicide rates are usually higher in industrialized compared to non-industrialized non-urban societies, reflecting greater psychosocial distress and social alienation in the former [12].Again, Israel is in this respect in a middle-ranked position between Europe and North America on the one hand and Asia (with the exception of Japan and South Korea) and North-Africa on the other.
Suicide is recorded in Israel since its independence in 1948.The highest rates have been found in the early 1950s (around 18/100,000) decreasing to 11-14/100,000 in the 1960s and 1970s, and to rates between 8.1-8.5/100,000 in the early 1980s.It rose to values of 10.8-11.2/100,000from the mid 1980s to the mid 1990s.From 1995-2009, the annual Israeli suicide rate has fluctuated between 6.3-9.4/100,000[17,18,21,23,26,27].Although the temporal changes in suicide rates in Israel may be influenced by methodological inconsistencies (e.g., the lack of systemized reliable multi-informant medical and forensic recordings before 1974 [10]), they may be nevertheless associated with several important socio-demographic processes: Firstly, the high suicide rates in the early years of Israel might be related to the highly unstable socio-political condition at that time, when the young nation was at a constant threat to its existence, likely presenting a continuous state of alert, coupled with a highly unfavorable economic condition [10,13,17].Secondly, the increase in suicide rates in the mid 1980s to the mid 1990s may reflect the influence of the massive immigration from the former USSR and Ethiopia to Israel, as will be dealt with later in this chapter.
Thirdly, the majority of the Jewish population in the early years of Israel was of Jewish Ashkenazi, (i.e., Eastern European) descent.By contrast, the immigration in the 1950-1960s brought to Israel mostly Non Ashkenazi Jews from North Africa and Middle Eastern countries, which currently comprise the majority of the Jewish Israeli population [10].It has been repeatedly shown that Jews born in Europe may have brought to Israel the potential proneness to suicide in many of their native countries, in contrast to the low rate of suicide in many Muslim North-African/Middle Eastern countries, whereas the heterogeneously constituted group of Israeli-born Jews stands in-between [10].This indeed has been the condition until the mid-1980s [18].However, since the mid-1990s, the suicide rates among Jews born in North-African/Middle Eastern countries have reached values close to those of European and American-born Jews [27].Moreover, since 2000, the highest suicide rate is found in those Israeli-born of Non-Ashkenazi descent [27].
Israeli Jews of non-Ashkenazi descent tend to attempt suicide to a greater extent, particularly with respect to repeated attempts, in comparison to Ashkenazi Jews [10,22,28].The higher rate of repeated suicide attempts among individuals of Asian/North African descent may reflect their tendency to express emotions and frustrations more openly, including the use of behavioral channels.Accordingly, this pattern may suggest an expression of emotional distress rather than a wish to die [29].By contrast, guilt feelings, which are positively associated with suicide and death-related wishes, are more common in European than in Middle Eastern cultures [10].
A low suicide rate is also found in Jewish Israeli adolescents [22,27].The average rate of suicide between 1975-1989 for 15-19 years old Israeli Jewish males (5.3/100,000) and females (1.9/100,000) has been among the lowest in the world [22].The suicide rate for 15-17 years old for the years 1990-2008, fluctuating between 2.7-5.7/100,000 for males and 1.8-3.0/100,000for females, is still considered low in comparison to most European countries [21].Among other likely protective factors in addition to the influence of Judaism, a striking finding is the low rate of suicides in Israeli youth performed under the influence of alcohol and drugs [30,31].This likely reflects the relatively low rate of substance use in Israeli adolescents in comparison to European and North American countries [32].

Suicide in Male Israeli Soldiers
One striking exception to the low rate of suicide in Israeli youth, as shown in data gathered from 1975 to 1994, is the high rate of completed suicides in 18-21 years old males vs. both 15-17 and 21-29 years old males [22,23].As most 18-21 year old males likely serve in the Israeli army, the high suicide rate in this age group likely reflects the considerable psychosocial stress and loss of previous social support networks associated with recruitment and service, combined with the availability of firearms [22,23].During peace time, suicide is the leading cause of death in the Israeli Army [18].Moreover, the suicide rate in male Israelis aged 18-21 is higher than in any other age group [27].
In addition, a significant increase in suicide rate has occurred in 18-21 years old males (but not in 15-17 and 21-29 years old males) from 1984-1985 to 1992-1994 (3.9/100,000 vs. 18.2/100,000, respectively).This change may reflect an increase in the overall stress associated with serving in the army following the first Palestinian uprising in 1987, as well as a greater availability of weapons during that period due to military requirements [10,23].Indeed, a dramatic rise in the use of firearms in suicides of 18-21 year old males has been found during this time period (11% vs. 77% of all suicides, respectively) [22].In the same token, a recent analysis in the US army has shown an increase in the suicide rate among 18-24 years old male soldiers from 2004-2008, surpassing comparable civilian rates in 2008 [33].Among the factors likely associated with higher suicide risk, the authors note the trend toward greater exposure to combat events in Iraq and Afghanistan in soldiers who have later committed suicide.
A well-designed study in Israeli combat soldiers who have killed themselves during service [34] has found a highly distinctive profile of this group.Most have appeared above average in intelligence, physical fitness, and in personality measures predictive of successful adaptation to military service, with no evidence of pre-existing mental health problems, and their motivation and performance during service have been generally more than satisfactory.Their suicide has been unexpected, conceived in psychological autopsies to represent a sense of failure to live up to their expectations, appearing for the first time in their life, and leading to the development of narcissistic insult and concomitant depression [34].These "good soldiers" have avoided the seeking of professional help, and have usually not communicated their distress and suicidal ideation to significant others [34,35].These findings stand in sharp contrast to findings in the US army, showing significantly greater prevalence of mental health problems treated on an outpatient basis in soldiers committing suicide [33].

Suicide in Immigrants from the Former USSR and Ethiopia
Whereas high suicide rates have been shown for 18-21 years old Israeli males of all ethnic backgrounds, these rates have been specifically elevated in young male immigrants from the former USSR [23].Immigration is known to be associated with an increase in suicide risk, particularly among younger immigrants [36].Accordingly, between 2000 and 2009, a third of all suicides in Israel have occurred in immigrants, a percentage far exceeding their proportion in the Israeli population [21].The highest suicide rate has been found in former USSR youths aged 15-24 [27].The elevated suicide risk in young Russian-born immigrants to Israel may be related to identity crises, loss of familial and social support, severe intergenerational conflicts, social isolation, immigration-based difficulties with the Hebrew language, and a sense of estrangement in the new country [37].Similar differences between immigrants and Israeli-born individuals have also been shown for attempted suicide [21].
Additional support for the association of immigration with increased suicide risk comes from two Israeli studies assessing temporal trends in completed [17] and attempted [28] suicides during the 1980s and 1990s.Nachman et al. [17] have found an overall increase in the rate of suicide from 1987 to 1992, stabilizing thereafter to 1997.Stein et al. [28], examining attempted suicide in two cities in Israel (Holon and Bat Yam) have shown high rates from 1990-1992, with a steady decrease from 1993 to 1998.Both studies relate these temporal changes to the massive immigration of around 400,000 Jews from the former USSR to Israel during the late 1980s and the early 1990s.Indeed, Russian-born individuals have been found to be over-represented among suicide attempters in Holon and Bat Yam in comparison to their overall representation in these two cities [28].Additionally, the suicide rate among Russian immigrants to Israel has been shown to be significantly higher in comparison to that of both Russian-born and Israeli-born individuals [37,38].This is of special note, as the suicide rate in Russia is among the highest in Europe [21].
Israel has faced a massive immigration also from Ethiopia, occurring in two waves, in the early 1980s and the early 1990s.Elevated suicide and attempted suicide rates have been shown also for Ethiopian immigrants to Israel in comparison to native-born Israelis, especially in 15-24 years old Ethiopian males [21,23,27,39,40], although the findings for Ethiopian immigrants have been usually less striking in comparison to immigrants from the former USSR.Still for the years 2000-2004, young Ethiopian males have had 7.4 times higher suicide rates compared to non-immigrant Israeli Jews, and 2.8 times higher rates compared to former USSR immigrants [27].This trend, although to a lesser extent, continues in 2007-2009 [21].Additionally, in Ethiopian males, the average annual percentage of suicides from all suicidal acts (attempted and completed suicides) has been found considerably higher (43%) in comparison to both former USSR immigrants (21%) and native-born Israelis (17%) [27].
Lastly, in a psychological autopsy of 44 of the 49 reported suicides of immigrants from Ethiopia for the years 1983-1992, Arieli et al. [41] have found that the male/female suicide ratio among Ethiopian immigrants is twice higher in comparison to the general Israeli population.In addition, only two suicide methods have been used by both Ethiopian males and females-hanging and jumping from high places.The frequent use of violent methods has been replicated also in more recent suicides of Ethiopian immigrants [42].Interestingly, violent methods are prevalent in both genders also in suicides and attempted suicides occurring in Ethiopia itself [42].
Some suggest that the high suicide risk among Ethiopian immigrants likely reflects their difficulties in adjusting to a completely new culture that does not always accept them as equals [42].Thus, the high suicide rate of Ethiopian male immigrants may reflect the distress and sense of humiliation associated with the loss of their traditional dominant role at home following immigration in comparison to their homeland [41].Similarly, suicide in Ethiopian women immigrating to Israel may be associated with the loss of protection from community leaders that have kept them previously safe from domestic violence [41].Others relate the high suicide risk of Ethiopian immigrants to the difficulties in the diagnosis and management of severe psychopathology by Israeli-born professionals who are often not familiar with the Ethiopian culture [43], as well as to the reluctance of immigrants from Ethiopia to use the Israeli mental health systems [42].Lastly, suicidal behavior in first-generation immigrants may be related to their exposure to severe traumatic experiences and loss of many family members during the immigration from Ethiopia to Israel [42].

Other Populations of Interest
Three additional points of interest deserve attention.The first relates to the relatively high proportion of suicidal behavior in Holocaust survivors in comparison to the elderly population in Israel [44].Aging in Holocaust survivors may be associated with reactivation of past traumatic syndromes.This reactivation, coupled with the presence of physical disturbances, some of them unique to the survivors of the concentration camps, and with an increase in psychosocial distress that may occur in any elderly population, may increase the risk of suicide in this population [10,44].
Secondly, the lowest annual suicide rate in Israel as assessed for 2007-2009 has been found among the inhabitants of the Jewish settlements in the Western Bank (3.7/100,000 vs. 7.4/100,000 for the general Israeli population, see [21]).A similar trend exists also for attempted suicide [21].These findings likely reflect the sizable proportion of observant religious Jews living in the settlements, as well as the cohesion and sense of mission and entitlement found in this population, despite, or perhaps even because, of the constant threat it is exposed to [15].
Thirdly, greater religious belief and commitment, and to a lesser extent, greater religious attendance, may be associated with lower suicide rates and less tolerance toward suicide in both Christianity and Judaism [25,[45][46][47].To the best of our knowledge, this issue has not been investigated in Israel.Still, a study assessing attitudes to suicide and suicidal ideation in Jewish Israeli adolescents has shown that lesser religious affiliation is significantly associated with both greater tolerance of suicide and greater suicidal ideation [11,48].

Suicide in Israeli Arabs
Lastly we address the issue of suicidal behavior among Israeli Arabs, of whom the majority are Muslims, and the rest Arab-Christians and Druze [10].In general, Islam forbids suicidal behavior [49,50] and its attitude to suicide is more condemning than both Christianity and Judaism [51].Indeed, suicide is considered illegal in Muslim countries [49].Although since 1985 no Middle Eastern country has provided data on suicide to the World Health Organization [52], current suicide rates still appear lower in Muslim countries [49,52].
The finding of low suicide rates in many Muslim countries has been replicated also in Israeli Arabs [50].Similar findings exist also with respect to attempted suicide.Whereas differences may exist between Israeli Jews and Arabs in the disclosure of information about suicide [10,50], the suicide rates of Israeli-Arabs of both genders are consistently lower for all age groups in comparison to Israeli Jews [10,[21][22][23]50].Socio-demographic factors likely reducing the suicide risk in Israeli Arabs in comparison to the Jewish majority include lower rates of urbanization, greater social and religious cohesion, a greater inclination to live in groups (extended families, tribes), and less use of alcohol [10,23,50].
It is of note that the difference in the rate of attempted suicide in Israeli Jews vs. Israeli Arabs has considerably decreased in recent years [21,29,50].The highest rates of attempted suicide among Israeli-Arabs are currently found among 15-29 years old women [21,29,50], who tend to live in a highly patriarchal society where women's rights are relatively few [53].Attempted suicide in the Arab population may represent a means to convey emotional distress, rather than a wish to die [29].Thus, the rise in deliberate self-harm behaviors in young, likely married, Arab women in recent years may constitute one of a few means they have to convey, albeit indirectly, their distress, as well as their wish not to have to accept anymore their problematic life conditions [29,53].
Another interesting finding relates to the relatively high suicide rate among 15-24 years old Israeli-Arabs, being higher in this cohort than in any other age group [21,52].More than a third of all suicides among Israeli Arabs in recent years occur in 15-24 years old individuals in comparison to less than 20% in the case of Israeli Jews [21,52].This finding may reflect the ever growing stress in which young Israeli Arabs may find themselves particularly in recent years, torn between their relations with the Jewish Israeli majority that does not always accept them as equals, and their ambivalence towards their Palestinian neighbors.
A third exception to the low suicide rate among Israeli Arabs is the high rate of suicide found in young Druze males.This finding may reflect the greater exposure of Druze youngsters to the influence of the mainstream Jewish Israeli lifestyle, particularly as male Druze do serve in the Israeli army [22].Still, the absolute numbers of completed suicides in the Druze population are too small to draw definite conclusions [10].

Concluding Remarks
Historically, Judaism presents firm negative attitudes towards suicide [4].The impact of this religious socio-cultural construction is expressed in the low rate of suicide found in Modern Israel Jews in comparison to Christian Protestants and Catholics.An interesting support for the assumption about the importance of religious attitude in suicide comes from the authors' own study assessing attitudes to suicide and suicidal ideation in Jewish Israeli adolescents [11,48].This study shows that lesser religious affiliation is associated with both greater tolerance of suicide and greater suicidal ideation.
Exceptions to the overall low suicide rate in Israeli Jews are the high rates of suicide found in male Israeli soldiers, new immigrants to Israel, and Holocaust survivors.Other at risk populations include young Israeli Arab women.These specific populations, necessitate early identification of distress associated with lack of adjustment to their specific circumstances, and tailoring of specialized adequate culture-sensitive interventions.