Preventing suicide with a gender perspective
According to the World Health Organization (WHO, 2018), a gender perspective is a paradigm, an approach, that seeks to give relevance to sociocultural and historical dimensions, and examines the effects, asymmetries, and inequalities produced by the historically constructed place of women in society. It takes into account inequalities in power, access to resources, the sexual division of labor, and gender socialization.
A gender-based approach to health reveals the relationship between gender roles and stereotypes, gender inequalities, and symptoms.
Gender-related determinants of health are the social norms, expectations, and roles that increase rates of exposure to and vulnerability to health risks, as well as protection against them, and that determine health-promoting behaviors , patterns and opportunities for seeking healthcare, and responses from the health system based on gender. They are one of the main social determinants of health inequities.
The intersectional perspective expands this reading and allows us to have a view that relates how other social vectors such as age, sexual orientation, gender identity, ethnicity, educational level, economic level and psychic or physical diversity, among others, are dynamically related and how the intersection of these axes can give rise to specific vulnerabilities (Vohra-Gupta, 2023).
Therefore, incorporating gender and intersectional perspectives into health is not only a matter of ethics and justice, but also of the effectiveness of interventions.
Why do women have more depressive disorders than men?
What do we mean when we talk about suicidal behavior?
Suicide is a broad term that includes the Suicidal ideation (thoughts of taking one's own life), suicide planning (taking preparatory steps for the act), suicide attempts (non-fatal self-harm performed with the intention of dying), and completed suicide. People who experience suicidal thoughts and make suicide plans have a higher risk of attempting suicide, and people who experience all forms of suicidal tendencies have a higher risk of death by suicide, although a previous suicide attempt is the strongest predictor of future suicide (WHO, 2014).
Non-suicidal self-injury , that is, self-harm without the intention of dying, is common among women and can be a recurring, extremely distressing, and complex situation. For most people, this behavior is not intended to end their lives; however, those who self-harm deliberately are more likely than the general population to also experience suicidal tendencies (Witt, 2023).
While the gender and intersectional perspective could help us understand some suicidal behavior in men, linked to cultural roles and stereotypes, and also in other groups, such as ethnic, sexual, etc. minorities, we will focus on trying to understand this behavior in women in greater depth.
What is suicidal behavior?
What do we know about the differences in suicidal behavior between men and women?
Research on suicide consistently shows that women have higher rates of suicidal behavior —that is, suicidal ideation, planning, and attempts—compared to men; however, men are more likely to die by suicide (WHO, 2014). This is known as the "gender paradox in suicide" (Canetto & Sakinofsky, 1998).
Gender plays a significant role in suicide and suicidal behavior. Thus, sex differences have been reported in relation to :
- Causal factors.
- Risk and protective factors.
- The very nature of suicidal behavior and how it manifests itself.
- The methods used in suicide.
- Attention-seeking patterns in suicidal behavior.
There are many theories and explanations regarding the differences in suicide and suicidal behavior between women and men (Hawton, 2000; Canetto, 2008; Jaworski, 2007; Schrijvers et al., 2012). Some of these postulates include (Stack, 2000; Smalley et al., 2005; McKay et al., 2014):
- Issues of gender equality and inclusion.
- Differential impact of socio-economic crises by gender.
- Differences in socially acceptable methods for dealing with stress and conflict for women and men.
- Differences in vulnerability to psychopathology.
- Biological and neurobiological differences.
- Availability and access to different methods of suicide.
- Differences in cultural roles.
- Availability and consumption patterns of alcohol and drugs,
- Differences in help-seeking and acceptance rates for emotional distress and mental disorders between women and men.
It is worth noting that some of these differences may vary according to cultural contexts rather than functioning as universal constants.
Differences in methodology
As for the Methodologically , it has been historically noted that even with the same intention to die, women would choose methods of varying lethality, for example, while men would choose more violent and therefore more lethal methods (Denning et al., 2000). However, trends have been changing, and women are increasingly adopting more lethal methods (Byard et al., 2004; Austin et al., 2011). It has been postulated that changing ideas about femininity and masculinity and gender roles in Western societies have affected the choice of methods; however, more research is needed to fully understand and address the shift to more lethal methods and how this varies within minority groups (Women's Health Victoria, 2011).
Women are more represented in non-fatal suicidal behaviors, but much less visible in dialogue, research, and public policies on suicide prevention.
Women may have the same intention to die; however, the resulting "attempted suicide" status is often not well documented in data collection, medical reports, or even most national statistical systems. As a result, while women are more represented in non-fatal suicidal behaviors, they are far less visible in the dialogue, research, and public policies on suicide prevention.
Differences when seeking help
Regarding help-seeking patterns , women are 2.3 times more likely than men to attend a hospital after a suicide attempt, creating an opportunity for compassionate care, psychoeducation, treatment, and linkage. for ongoing support in community health resources. Therefore, greater accuracy in recording reported non-fatal suicidal behaviors is vital for suicide prevention efforts and can be used to determine the prevalence and correlations of non-fatal suicidal behaviors, as well as the effectiveness of interventions and the design of support programs to meet the needs of women and at-risk populations (Schrijvers, 2012).
Mónica Civill Quintana
Gender prejudices and biases
It is postulated that one of the reasons that would explain the lack of investment in the knowledge and research of suicidal behavior in women could be related to the presence of some prejudices on the part of health professionals, that is, gender biases, such as, for example, the tendency to consider suicidal behavior in women as manipulative and not serious behaviors (despite the evidence of intention, lethality and hospitalization), and to describe their attempts as "unsuccessful", "failed" or "attention-seeking" (Beautrais, 2006).
Current knowledge of sex/gender differences remains incomplete, particularly regarding non-fatal suicide attempts, and also across different age groups, ethnicities, or religious backgrounds. Similarly, research on suicidal behavior among transgender women, intersex people, people on the female spectrum who do not identify as women or men, and those with culturally specific genders beyond the female/male binary remains limited.
There is a tendency to view suicidal behavior in women as manipulative rather than serious, and to describe their attempts as "unsuccessful," "failed," or "attention-seeking."
Despite the growth and progress in the field of suicide prevention in recent years, attention has focused more on understanding and preventing suicide mortality than on the consequences of non-fatal suicidal behaviors.
Undoubtedly, it is imperative to dedicate attention and resources to preventing suicide mortality; however, it is also relevant to focus on understanding and preventing non-fatal suicidal behavior in women . Overall, the number of women who think about suicide, plan suicide, attempt suicide, and die by suicide is considerable and has a significant impact on public health in general and on women's health in particular (Chaudron & Caine, 2004).
What do the statistics reflect about the differences between men and women in suicidal behavior?
The suicide rate The suicide rate among men is higher than that among women globally, in most countries of the world, with a ratio of 3.2:1 (men/women) in 1950; 3.6:1 in 1995; and 3.9:1 in 2020. With one exception, China, suicide rates among women are consistently higher than suicide rates among men, especially in rural areas (Phillips, Li, & Zhang, 2002). This cross-cultural variability is important to consider, as comparative findings suggest that suicide rates are influenced by local cultural factors related to gender .
As mentioned, women have higher rates of suicidal behavior . However, both in our region and globally, there is a lack of longitudinal follow-up statistics on suicidal behavior; that is, we do not know the true prevalence of suicidal ideation, planning, and attempts, which prevents us from having a more accurate understanding of the scope of this problem.
Risk factors for suicide in women
According to data from the National Institute of Statistics (INE) in 2022, 3,126 men and 1,101 women committed suicide that year. For women, the most vulnerable age group initially was 15-29 years old (117 cases). Subsequently, the number of suicides showed a slight downward trend in the 30-44 age group, with a new peak increase between 50-54 years old (134 cases), followed by a gradual reduction from age 60 onward. It is worth noting, however, that the number of suicides among older women is not insignificant. If we include all cases of women aged 65 to 95 and over, without breaking them down into smaller age groups, we find that 354 older women committed suicide last year. Given that, although there are some variations between years, previous statistics maintain the trend, we could try to analyze these peaks in incidence from a gender perspective.
There is a lack of statistics on monitoring suicidal behavior; that is, we do not know the real prevalence of suicidal ideation, planning, and attempts, which prevents us from having a more accurate idea of the scope of this problem.
For example, could suicidal behavior in women aged 15-29 be related to the impact of relational or attachment stressors at that age? What role do family conflicts, peer problems, bullying, and first romantic relationships play?
Could the reduced incidence in the 30-50 age group be related to the role of caregivers as both a factor contributing to the burden (due to the unequal distribution of responsibilities) and a protective one? This is a stage in life where caring for young children and elderly or dependent family members can become a central focus of women's time and efforts.
In the 50+ age group , what impact do the death of dependent elderly adults, children leaving home, a reduced prospect of changes in life trajectory (marriage, work, etc.), perimenopause, and menopause have?
What role do loneliness, loss of contact or death of friends, isolation, chronic illnesses, among other factors, play in the case of women over 65 years of age ?
Preventing suicide from a gender perspective
At the sociocultural and public policy level , it is important to continue working on deconstructing marked gender roles and stereotypes and on social, economic and labor inequalities, which have a differential impact on men and women.
As a society, we must generate profound and structural changes that allow us to reduce the risks of exposure to different forms of violence from early stages of the lives of girls and women, in the family context, in school and work environments, and in sexual and affective relationships.
Similarly, it is essential to improve national and regional statistics to obtain more specific information on the scope, impact, and consequences of non-lethal suicidal behavior, which is highly prevalent among women. It is necessary to generate a larger body of scientific literature that will allow us to expand our knowledge of sex/gender differences in suicidal behavior, both non-lethal and lethal.
We must work on deconstructing gender stereotypes and the social, economic, and labor inequalities that affect men and women differently.
In the health field , it is essential to be able to increase the prevention, detection and therapeutic support of anxiety-depressive disorders in girls and women, paying special attention to life moments of greater vulnerability: adolescence, pregnancy (especially if it is unwanted), death or suicide of family members or intimate relationships, menopause, chronic illnesses or unwanted loneliness.
It is also necessary to promote the existence of specific perinatal care programs for women with pre-existing mental health problems or those that begin during pregnancy or childbirth.
It is also relevant to detect and address other co-occurring situations related to the increased risk of suicidal behavior in girls and women, such as alcohol and substance use and self-harming behaviors.
Among healthcare professionals and researchers, it is important to develop training in gender perspective in general, and in identifying specific biases and prejudices in particular, regarding non-lethal suicidal behavior in girls and women, thus avoiding the tendency to underestimate it. Consultations on this topic offer a unique opportunity for compassionate care and access to specific and sensitive therapeutic options.
Likewise, active efforts must be made to reduce the over-prescription of medication as the primary or sole treatment for the emotional distress of girls and women seeking help. It is essential to increase the availability of psychological and psychotherapeutic resources.
Promoting resilience, social connectivity, fostering violence-free relationships, guaranteeing access to sexual and reproductive rights, and ensuring equity in educational, employment, and health opportunities can create the conditions for a positive social environment that supports well-being through protective factors that mitigate the risk of suicidal behavior in girls and women.
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