ReviewThe gender paradox in suicidal behavior and its impact on the suicidal process
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.
References (65)
- et al.
Lifetime suicide risk in major depression: sex and age determinants
J. Affect. Disord.
(1999) - et al.
Risk factors for suicide in young people suffering from schizophrenia: a long-term follow-up study
Schizophr. Res.
(2001) - et al.
Suicide in adolescents: using life charts to understand the suicidal process
J. Affect. Disord.
(2007) - et al.
Suicide. Lancet.
(2009) - et al.
Suicidal hanging in Manipal, South India—victim profile and gender differences
J. Forensic Leg. Med.
(2008) - et al.
Suicidal poisoning in Southern India: gender differences
J. Forensic Leg. Med.
(2008) - et al.
Sex and depression in the National Comorbidity Survey, 1: lifetime prevalence, chronicity and recurrence
J. Affect. Disord.
(1993) - et al.
Suicidal ideation and behaviour in the aftermath of marital separation: gender differences
J. Affect. Disord.
(2010) - et al.
Sexual abuse and suicidality: gender differences in a large community sample of adolescents
Child Abuse Negl.
(2004) - et al.
Male depression in females?
J. Affect. Disord.
(2010)
Why women are less likely than men to commit suicide
Compr. Psychiatry
The suicidal process; prospective comparison between early and later stages
J. Affect. Disord.
Borderline personality disorder, self-mutilation and suicide: literature review
Encephale
Prevention of male suicides: lessons from Gotland study
Lancet
Sex differences in rates of depression: cross-national perspectives
J. Affect. Disord.
Diagnostic and Statistical Manual of Mental Disorders
Classification of attempted suicide: a review of empirical studies, 1963–1993
Suicide Life Threat. Behav.
Psychiatric diagnoses in 3275 suicides: a meta-analysis
BMC Psychiatry
Illness course, comorbidity, gender, and suicidality in patients with bipolar disorder
J. Clin. Psychiatry
Gender issues in youth suicidal behaviour
Emerg. Med. (Fremantle)
Suicide attempts, gender, and sexual abuse: data from the 2000 British Psychiatric Morbidity Survey
Am. J. Psychiatry
Gender difference in suicidal expressions and it's determinants among young people in Cambodia, a post-conflict country
BMC Psychiatry
Gender differences in the association of mixed anxiety and depression with suicide
Br. J. Psychiatry
Affective disorders and suicide risk: a reexamination
Am. J. Psychiatry
Long-term suicide risk of depression in the Lundby cohort 1947–1997–severity and gender
Acta Psychiatr. Scand.
Personality traits as correlates of suicidal ideation, suicide attempts, and suicide completions: a systematic review
Acta Psychiatr. Scand.
Meanings of gender and suicidal behavior during adolescence
Suicide Life Threat. Behav.
The gender paradox in suicide
Suicide Life Threat. Behav.
Gender differences in healthcare service utilisation 1 year before suicide: national record linkage study
Br. J. Psychiatry
Men and depression
Clinical and Empirical Perspectives
The coroner's system and under-reporting of suicide
Med. Sci. Law
Life events, gender and suicidal behaviours in the acute community setting
Australas. Psychiatry
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