Risk factors for suicide in women
Suicidal behavior is complex and often involves the interaction of multiple contributing factors. The experience of suicidal behavior is unique and individual in nature, but there are a number of biopsychosocial and cultural factors that influence suicide risk in women, although the level of research on gender differences in risk factors is still limited.
Risk factors can be differentiated into distal or underlying factors , such as genetic factors, and proximal, more immediate factors , such as recent stressful life events. These factors interact with a confluence of social determinants, for example, intimate partner violence, limitations on autonomy, economic and health equity, issues of equality in employment, workplace harassment, social stereotypes, and cultural norms, among other aspects that can also impact women's well-being.
A wide range of risk factors are known to influence suicidal behavior in women. Some of these are illustrated below, following the Ecological Model , which groups them into three areas: individual risk factors; life experiences and relationships; and social and community factors (Dahlberg & Krug, 2002; WHO, 2014).
Individual factors
Between individual factors , we found:
- Genetic and biological factors.
- Feelings of hopelessness.
- Mental health diagnoses and related symptoms (depression, eating disorders, schizophrenia, borderline personality structure, post-traumatic stress).
- Unwanted pregnancy.
- Postpartum depression.
- Harmful use of alcohol and substances.
- Chronic illness or pain.
- Access to lethal means.
- Previous non-fatal suicidal behavior.
Mental health disorders: depression, borderline personality disorder, self-harm, and eating disorders
Women with a history of mental health diagnoses, particularly depression and anxiety, have a higher risk of suicidal behavior. However, not all women who experience mental distress end up engaging in suicidal behavior.
Mental health symptoms that women experience more often and that carry a higher risk of suicide include depression and eating disorders (both bulimia and anorexia nervosa).
Depression is a significant problem for a large number of middle-aged and older women; perimenopause and menopause are complex life stages for women, with a significant increase in depression diagnoses during this period (Cohen et al., 2006). There is debate among healthcare professionals as to whether this is a new depression due to menopause or a pre-existing depression exacerbated at this time. In this age group, women also have a higher rate and number of suicides than women of all other ages, including younger women (Lawrence et al., 2000).
Why do women suffer more from mental health disorders?
In terms of mental health, non-suicidal self-injury is also a significant issue. This behavior can be extremely complex, poorly understood, and very distressing for individuals, family, friends, and the community (Lindgren et al., 2004). It is a risk factor for suicidal behavior and eventual suicide (Ranzcp, 2004) and, like suicidal behavior, is more prevalent among women, especially younger women. A large population-based study (Martin et al., 2010a) revealed that the prevalence of non-suicidal self-injury was higher for girls aged 15–19 and 20–24 , both in the past month and over their lifetime, compared to boys in the same age groups. This study also indicated that self-harm coexists with suicidal thoughts in 48.1% of respondents and revealed a history of suicide attempts in 26.3% (Martin et al., 2010). Self-harm is often used as a maladaptive coping mechanism (Favarro et al., 2007; Martin et al., 2010b).
On the other hand, borderline personality disorder (BPD) is a serious and persistent mental disorder that is prevalent among women. Between 69% and 80% of women with BPD have suicidal behaviors, with a suicide mortality rate of up to 9% (Linehan et al., 2006).
Given the frequent coexistence of self-harm and suicidal behavior in women, it is imperative that this issue be addressed, especially in the case of younger women.
Relationship between pregnancy and suicidal behavior
The relationship between pregnancy and suicidal tendencies is complex, as motherhood generally provides a protective effect . However, there have been significant difficulties in collecting accurate data on the prevalence of suicidal behavior and suicide among pregnant people in our context.
Suicide mortality rates appear to be lower among pregnant women than among non-pregnant women (Oates, 2003; Austin, Kildea, and Sullivan, 2007). Despite the potential protective effect of pregnancy and motherhood on women, suicide is a leading cause of death among women during pregnancy and in the year following childbirth and a significant contributor to indirect maternal mortality (Austin et al., 2007; Palladino et al., 2011; Humphry, 2011).
The literature indicates that one in ten women develops depression during pregnancy (prenatal) and one in seven after childbirth (postnatal); 30% of pregnant women with depression experience suicidal ideation (Gold et al., 2012; Melville et al., 2010). Factors associated with suicidal ideation during the prenatal period include depression, perceived stress, smoking, and common mental health problems (Gavin et al., 2011; Huang et al., 2012). Austin et al. (2007) identified a risk profile unique to women of childbearing age: women with prior psychiatric hospitalization without their baby and severe mental disorders of early onset after childbirth (postpartum psychosis). In women with postpartum psychosis, the risk of suicide increased sevenfold in the year following childbirth and seventeenfold in the long term (Appleby et al., 1998).
Despite the potential protective effect of pregnancy and motherhood on women, suicide is one of the leading causes of death among women during pregnancy and in the year following childbirth.
Another factor that may contribute to the emergence of suicidal behavior during this period is gender-based violence within the couple , which also reaches its peak during pregnancy for a wide range of psychosocial reasons (Martin et al., 2004), strengthening the combined risk of pregnancy (particularly if unplanned), violence, and suicidal tendencies.
The protective effect of pregnancy may also be diminished in women under twenty years of age or in cases where the pregnancy ends in fetal death, miscarriage, loss of a child, or when it is unwanted (Qin et al., 2000; Qin and Mortenson, 2003). There is a long-standing association between depression, suicidal behavior, and unwanted pregnancy (Bunevicius et al., 2009; Newport et al., 2007).
Perinatal period and mental health: this is something that is being discussed
Despite the common myth, there is no concrete evidence linking abortion to an impact on mental health problems (Charles et al., 2008). The likelihood of a woman experiencing worse mental health after a voluntary termination of pregnancy appears to depend more on factors such as pre-existing mental health status (Robinson et al., 2009), ambivalence toward pregnancy (Kero, Hogberg & Lalos, 2004), or exposure to intimate partner violence (Taft & Watson, 2008).
Therefore, pregnancy (and other cardinal life events) may increase, decrease, or not be related to suicide risk depending on the psychological valence of pregnancy for that woman, the types of support networks provided during pregnancy and child-rearing, and the concurrent presence of underlying suicide risk factors (Phillips, 2014).
Use of toxic substances
Finally, the harmful use of alcohol and substances It is also considered a risk factor for suicidal behavior, and problematic alcohol consumption is detected in almost 28% of women and 36% of men who commit suicide (Carreta et al., 2023).
Life experiences and relationships
The second group of factors includes those related to life experience and relationships , among which:
- Exposure to adverse parenting experiences or violent parental conflict.
- History of violence or suicide in the family of origin.
- Fractured family structures
- Current romantic relationship is conflictive.
- Gender violence in the context of a couple.
- Sexual abuse.
- Underemployment or unemployment.
- Workplace stress or harassment.
- Economic difficulties and poverty.
Violence in the context of a couple
Specifically, gender-based violence in the context of a couple is a factor to consider. A review of 664 relevant studies demonstrated a strong and unequivocal relationship between gender violence in the context of romantic relationships and suicidal tendencies (McLaughlin et al., 2012).
According to the WHO, global estimates indicate that approximately one in three (30%) women worldwide have experienced physical or sexual violence from an intimate partner or sexual violence from a non-partner at some point in their lives (WHO, 2021). These experiences are linked to suicidal behavior (Oquendo et al., 2007; Curtis, 2006). Women who are seriously injured in incidents of gender-based violence are more likely to report depression, anxiety, alcohol abuse, eating disorders, post-traumatic stress, and suicidal ideation (Curtis, 2006).
Around one in three (30%) women worldwide have experienced physical or sexual violence from a partner or sexual violence by third parties at some point in their lives, experiences linked to suicidal behavior.
It is worth noting that women who have survived violence from their intimate partners are almost four times more likely to have suicidal thoughts compared to women without this history (Taft, 2006), and have a higher risk of suicide attempts (Coker et al., 2002).
Child sexual abuse
On the other hand, exposure to childhood sexual abuse can result in greater vulnerability to later psychopathology and adverse life events. The risk of suicidal ideation and attempts increases with the severity of the abuse. Suicidal ideation is more common among women who have been sexually assaulted than in the general population (Stepakoff 1998), and younger survivors may be at particular risk of attempting suicide after sexual assault (Petrak, 2002).
History in the family of origin
Within this group of risk factors, it is also important to note a family history of violence or suicide, and grief following suicide . Women are significantly affected by the suicide of someone in their family or social circle; however, this is often overlooked in suicide prevention and postvention strategies (Pitman et al., 2014). Some studies indicate that, of all relationships with the deceased, female partners and mothers of individuals who die by suicide are the groups at highest risk of exhibiting suicidal behavior (Agerbo, 2003, 2005). It is vital to apply a cultural lens when considering and addressing loss and grief in the close emotional environments of individuals who die by suicide.
Social and community factors
In the third group of factors, we find those relevant at the community and social level , such as harassment and hate crimes, social or geographical isolation, and cultural prejudices about suicidal behavior in women.
Bullying and cyberbullying
In greater depth , regarding harassment and hate crimes, there is a complex relationship between bullying and the risk of suicidal behavior (Gould et al., 2003). Harassment is defined as the continuous physical or emotional victimization of a person. Peer bullying and victimization put adolescent girls at greater risk of suicidal ideation and behavior , especially when another psychopathology is present (e.g., depression or a condition within the autism spectrum, among others) or when the bullied person belongs to a minority group (migrants, LGBTQ+ individuals, etc.) (Van Geel, 2014). It is not necessarily bullying per se; there are many relevant mediating variables; suicidal ideation and behavior are generally not attributed to a single event or factor (Arseneault et al., 2010; Wang et al., 2011).
Bullying others, and not just being victimized, is associated with depression, suicidal ideation, and suicide attempts (Kaltiala Heino et al., 2000; Roland, 2002). The strongest association between involvement in bullying and depression, suicidal ideation, and suicide attempts is found among those who are both bullies and victims ( bullyvictims ) (Kim & Leventhal, 2008; Klomek et al., 2007).
As a group, adolescents are at greater risk for suicidal thoughts and behaviors if they have been both bullies and victims . For girls, any involvement in bullying is associated with adverse outcomes . They are generally less likely to be bullies, but when they are, they experience more severe impairment than their male peers (Kim et al., 2006; Wasserman et al., 2005).
Bullying others, and not just being bullied, is associated with depression, suicidal thoughts, and suicide attempts. Adolescents are at greater risk for suicidal thoughts and behaviors if they have been both bullies and victims.
Girls are at particular risk of suicidal behavior in the context of bullying if they suffer from depression and if they use alcohol, drugs, or other substances (Lieberman et al., 2008). Frequent and sustained victimization from an early age is associated with subsequent suicide attempts (Sourander et al., 2005; Klomek et al., 2007, 2008, 2009, 2011).
Cristina Rubio
Despite its recent prevalence in the media and society at large, cyberbullying is a relatively new concept in research. Some empirical studies have demonstrated an association between cyberbullying and psychopathology and suicide (Klomek et al., 2008; Surander et al., 2010). A recent meta-analysis by Van Geels (2014) argues that the effects of cyberbullying are more severe because it can reach a wider audience via the internet and material can be stored online, causing victims to relive degrading experiences more frequently. Further longitudinal studies are needed to examine the association between cyberbullying and suicide.
Research on this topic is increasing and strongly supports the view that all forms of peer bullying and victimization are clear risk factors for depression and suicidal tendencies and should be addressed in all settings.
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