Review
The gender paradox in suicidal behavior and its impact on the suicidal process

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Abstract

Background

An important gender difference has been reported regarding suicidal behavior with an overrepresentation of females in nonfatal suicidal behavior and a preponderance of males in completed suicide, also known as the ‘gender paradox of suicidal behavior’. The concept of a ‘suicidal process’ classifies suicidal behavior chronologically; this process starts with suicidal ideation and then implies a progression of suicidality ranging from suicidal ideation over plans to suicide attempts and finally fatal suicide.

Aims/methods

The current paper aims to deepen the knowledge on the gender paradox by collecting and discussing the recent literature on this topic: the most relevant, impacting gender-related factors will be discussed within the suicidal process concept.

Results

Several factors had a gender-dependent impact on suicidal behavior: psychosocial life stressors such as stressful life events but also sociodemographical or socio-economical factors, and sexual abuse. The gender differences in psychiatric (co)morbidity and in response to or attitude towards antidepressant treatment also appear to have an impact. Furthermore, not only suicide methods but also the gender-dependent variation in reporting suicide has an influence. Finally, the gender differences in help seeking behavior as well as region-dependent cultural beliefs and societal attitudes are discussed.

Conclusions

Especially life-events seem to exert an important influence at the beginning of a suicidal process, whereas the other factors occur at a further stage in the process, however without a fixed chronology. Also, the duration of the suicidal process is much shorter in male than in females. Finally, some implications with regard to clinical practice and suicide prevention are suggested.

Introduction

Suicide is responsible for an estimated global burden of one million deaths per year and an estimated annual mortality of 14.5 deaths per 100,000 people. Moreover, being the tenth leading cause of death worldwide, suicide accounts for 1–5% of all deaths (WHO, 1989, WHO, 2002, Hawton and van Heeringen, 2009). Suicidal behavior not only encompasses completed suicide, but extends from ideas and thoughts about suicide that are never acted on, to suicide attempts of varying degrees of medical severity, to fatal suicide.

With regard to the suicidal behavior, an important difference in male to female ratio has repeatedly been reported for both (nonfatal) suicidal attempts as well as for fatal suicide acts: females have higher rates of suicidal ideation and behavior than males, while mortality from suicide is typically higher for males than for females (Canetto and Sakinofsky, 1998, Murphy, 1998, Beautrais, 2002, Henderson et al., 2005). More specifically, in developed countries the male-to-female ratio for suicide is between two (Western Europe) and four (USA) to one (Hawton and Van Heeringen, 2009), while suicidal ideation as well as nonfatal suicidal behavior is more common in females than in males (Beautrais, 2002, Canetto and Sakinofsky, 1998, Murphy, 1998, Van rijsselberghe et al., 2009). This striking gender gap in suicidal behavior, i.e. the overrepresentation of females in nonfatal suicidal behavior and the preponderance of males in completed suicide, previously has been described as the “gender paradox of suicidal behavior” (Canetto and Sakinofsky, 1998). Obviously, the ‘gender’ concept not only refers to the biological differences between both sexes, but also to the social norms and cultural expectations that differ between sexes (Möller-Leimkühler, 2003).

As already mentioned, suicidal behavior encompasses suicidal ideation as well as fatal and nonfatal suicide acts. Several authors make a chronological link between suicidal ideation and suicide acts by applying the concept of a ‘suicidal process’: this process starts with suicidal ideation and then implies a progression of suicidality going through ideation, plans about taking one's life and communication regarding suicidal ideation, and growing through often recurrent suicide attempts with increasing lethality and suicide intent, and ends with fatal suicide (Van Heeringen, 2001, Runeson et al., 1996). Such a concept also implicates that once a person has entered the suicidal process, i.e. experienced suicidality, he or she will become more vulnerable to future suicidal behavior. Depending on which stage of the suicidal process is achieved, the impact of factors such as life stress, socio-economic circumstances or mental illness on the risk of suicidal behavior might differ (Arensman and Kerkhof, 1996, Neeleman et al., 2004).

In a previous paper, Canetto and Sakinofsky (1998) described the gender paradox in suicidal behavior and demonstrated that this paradox is a real phenomenon and not a mere artifact of data collection. Moreover, they tried to explain the gender paradox by proposing several theories. Accordingly, the current paper aims to deepen the knowledge on this intriguing paradox by collecting and reviewing the recent literature on this topic. It is our goal to attract attention to this paradox and search for the most relevant gender-related factors that influence this phenomenon. Moreover, we aimed to find out whether these factors have a different gender-dependent suicide-risk. These factors will be discussed by using the suicidal process as a conceptual framework. As can be seen below, for some factors a lot of evidence is available whereas the knowledge of other factors is rather limited, thus allowing only hypothetical and preliminary formulations. Notwithstanding, we preferred to also include these hypothetical suggestions in order to obtain a broad sight on this paradox.

Extending the knowledge on the gender paradox could lead to the development of more appropriate clinical tools to assess suicide risk in both males and females separately.

Section snippets

Method

A MEDLINE survey of the relevant literature was conducted, using the following search terms, in various combinations: ‘gender paradox’, ‘suicidal behavior’, ‘suicidal process’, ‘(fatal) suicide’, ‘suicide attempt’, ‘suicide rate’, ‘gender differences’, ‘male’, and ‘female’. All abstracts were screened and potentially relevant papers and all relevant cross-references were examined in full.

Results

In this chapter, the factors that have been reported to influence the suicidal process will be listed, with a focus on a possible gender-load of each factor.

Discussion

The current paper aimed to further investigate the gender paradox of suicidal behavior, i.e. the discrepancy between the overrepresentation of females in nonfatal suicidal behavior and the preponderance of males in fatal suicide. In the present overview, those factors that contributed to and impacted this gender paradox, were systematically listed and discussed. In the discussion section, we will situate these factors within the ‘suicidal process’ concept, i.e. the process in which an

Role of funding source

There is no funding source to be reported.

Conflict of interest

There are no conflicts of interest to be reported for any of the authors.

Acknowledgments

The authors would like to thank prof. C. Van Heeringen for his useful comments on earlier versions of this manuscript.

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