Background: In the Xhosa culture, suicide by hanging is viewed very negatively. However, recently hanging has been on the increase in the Transkei sub-region of South Africa. Poverty, unemployment, alcoholism and HIV may play a role in these deaths. Objective: To study 20 years’ (1996-2015) trend in suicide byhanging in the Transkei subregion of South Africa (1996-2015). Method: This is a retrospective descriptive study from the records of Mthatha Forensic Pathology Laboratory. Results: Over a period of 20 years (1996-2015), 24 693 medico-legal autopsies were performed in the Transkei sub-region of South Africa. Of these, 1 555 (6.3%) deaths were recorded as being the result of hanging. The average rate of hanging is 17.3 per 100 000of the population per year. The majority (88.5%) were males. The rate of hanging has increased from 8.3 per 100 000 in 1996 to 16.7 per 100 000 of the population in 2015. The male-to-female ratio is 1:7.7 (1376/179). The highest number of hangings, 484 (5.5/100 000),was recorded among males between 21 and 30 years, while among females of 11 to 20 years, 66 (0.75/100 00) such deaths occurred over a period of 20 years. Conclusion: The incidence of suicide by hanging has doubled in the Transkei sub-region of South Africa over a period of 20 years. It is more common among young adult males. This health crisis needs urgent attention. Keywords: Suicide; Hanging; Self-harm; Death.