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KEITHHAWTON,DM

CentreforSuicideResearch,UniversityDepartmentofPsychiatryandWarnefordHospital,Oxford,UK.E-mail:

keith.hawton@psychiatry.ox.ac.uk

Seepp.546-550,thisissue.

Qinetal'

s（2000,thisissue）epidemiologicalstudyofriskfactorsforsuicideinmalesandfemalesinDenmarkremindsusthatthereareimportantgenderdifferencesinsuicidalbehaviour.Thesereflectnotonlydifferencesinaetiology,whichweretheprimaryfocusoftheDanishstudy,butalsootherimportantvariationsbygenderinrelationtorisk,thenatureofsuicidalbehaviouranditspreventionandtreatment.

RELATIVERISKSOFSUICIDALBEHAVIOUR

Ratesofsuicideinmostcountries,includingDenmark,arehigherinmalesthaninfemales.Chinaisoneimportantexception,withveryhighratesinfemales,especiallyyoungwomeninruralareas（Cheng&

Lee,2000）.Inrecentyears,severalcountrieshaveexperiencedanincreaseinsuicideratesinmales,particularlyintheyoungeragegroups（Cantor,2000）.Incontrast,suicideratesoffemaleshavedeclined,especiallyinolderwomen,orremainedfairlystable,particularlyintheyoung.ThispatternisespeciallymarkedintheUK（Hawton,1992）,withanoverallriseinmaleratesandadecreaseinfemalerates（Kelly&

Bunting,1998）.Itsuggeststhatcausalfactorsand,possibly,protectivefactorshavechangedindifferentdirectionsinthetwogenders.Socialfactors,especiallylinkedtochangesingenderroles,seemthemostlikelyexplanation（Hawton,1998）.

Incontrasttosuicides,ratesofdeliberateself-harm（DSH）areusuallyhigherinfemalesthanmales.TheWorldHealthOrganization/EUROMulticentreStudyofSuicidalBehaviourhasdemonstratedthispatternthroughoutcountriesinEurope,withfindingsfromHelsinkiindicatingthatFinlandmaybeoneexception（Schmidtkeetal,1996）.Therehas,however,beenanincreaseinratesofDSHinmalesinsomecountries.IntheUKthistrendhasbeenparticularlymarkedinyoungmales（Hawtonetal,1997）.

GENDERDIFFERENCESINTHENATUREOFSUICIDALACTS

TheexcessrateofDSHinfemales,plusthestrongerassociationbetweenDSHandsuicideinmales（Hawton&

Fagg,1988;

Hawtonetal,1998）,suggestthatactsofDSHbyfemalesaremoreoftenbasedonnon-suicidalmotivation.Infemales,theappealfunctionofDSH,wherebyDSHisusedtocommunicatedistressortomodifythebehaviourandreactionsofotherpeople,seemsmorecommon.Inmales,DSHismoreoftenassociatedwithgreatersuicidalintent.Itisinterestingthatincommunitysamples,suicidalideationisreportedfarmoreoftenbyfemalesthanmales（e.g.Paykeletal,1974）.

ItiswellrecognisedthatmalestendtouseviolentmeansofbothsuicideandDSHmoreoftenthandofemales.Greatersuicidalintent,aggression,knowledgeregardingviolentmeansandlessconcernaboutbodilydisfigurement,arealllikelyexplanationsfortheexcessofviolentsuicideinmales.

AETIOLOGICALFACTORS

AsthefindingsofQinetalindicate,mentalillnessisthepredominantfactorfoundinsuicidesofbothgenders.Theirdatasuggestthatthisisanevengreaterriskinfemales.Astheauthorspointout,however,theirresultsarebasedsolelyonhistoryofinpatientadmissionandthereforewouldhavegreatlyunderestimatedthefullcontributionofpsychiatricdisorders.Theirresultsdonotinformusaboutthenatureofthepsychiatricillnessesfromwhichtheirsuicidessuffered.Psychologicalautopsystudiesclearlydemonstratethataffectivedisorderspredominateinsuicidesofbothgenders,withcomorbidityofpersonalitydisordersin40-50%andothercomorbidpsychiatricdisordersinevenmorecases（e.g.Henrikssonetal,1993;

Fosteretal,1997）.Substancemisusedisordersare,however,generallymorecommoninmalesuicides（Murphy,2000）,andindividualswithschizophreniawhokillthemselvesarealsopredominantlymale（DeHert&

Peuskens,2000）.Eatingdisorders,especiallyanorexianervosa,carryahighriskofsuicide（Harris&

Barraclough,1997）andmostsufferersarefemale.

SOCIO-ECONOMICFACTORSANDMARITALSTATUS

Unemployment,retirement,beingsingleandsicknessabsencewerethesignificantriskfactorsforsuicideintheDanishstudy.Whiledebatecontinuesovertherelativecontributionofunemploymenttosuicidalbehaviour（Platt&

Hawton,2000）,theDanishfindingsaddtotheweightofevidencethatoccupationalfactorsareparticularlyimportantinsuicidebymales.Increasedoccupationalinstabilityhasbeenproposedasonefactorbehindtherecentincreaseinyoungmalesuicides,butevidenceisequivocal（Hawton,1998）.

Fartoolittleresearchattentionhasbeenpaidtofactorswhichprotectagainstsuicide.Qinetalidentifiedtheprotectiveroleinfemalesofhavingayoungchild.Thisconfirmspreviousresearchfindingsregardingchildbearing,whichindicatethatpregnancyisalsoatimeofreducedrisk（Appleby,1996）.ItisinterestingthatbeingaparentofayoungchildappearedtoexplaintheapparentprotectiveeffectofmarriageforwomenintheDanishstudyratherthanmarriedstatusperse,whereasinmenmarriageappearedtobeaprotectivefactorinitsownright（orsinglestatusariskfactor）.Furtherpossibleexplanationsproposedfortherecentincreaseinyoungmalesuicideshavebeenthesocialandeconomicchangesthathavemadeitmorefeasibleforfemalestoleaveunsatisfactoryrelationships,whichhasprobablyexposedagreaternumberofvulnerablemalestoriskofsuicidalacts（Hawton,1998）.

TREATMENTANDPREVENTION

Morefemalesthanmalesseekhelpfromgeneralpractitionersformentalhealthproblems.ThisprobablyexplainswhytheapparentbenefitsoftheeducationalprogrammeindetectionandtreatmentofdepressionforgeneralpractitionersontheSwedishislandofGotlandwereconfinedtofemales,moreofwhomweretreatedfordepressionandfewerofwhomcommittedsuicide（Rutzetal,1999）.Whileimproveddetectionandmanagementofpsychiatricdisorderisundoubtedlyakeyfactorinthepreventionofsuicidalbehaviourinmalesaswellasfemales,thereisincreasingevidence,withtheresultsofQinetaladdingtothis,thatalterationsinsocio-economicconditionsarealsoveryrelevanttosuicidepreventioninmales.

Suicidepreventionstrategiesunderstandablyincludeensuringthatcliniciansandotherslikelytoencounterpeopleatriskhaveadequaterisk-assessmentskills.Althoughthepredictivepowerofschedulestoassistriskassessmentisunlikelyevertobesubstantial（Goldney,2000）,thefindingsoftheDanishstudyraisethequestionofwhetherdifferent,ifoverlapping,risk-assessmentschedulesarerequiredforthetwogenders.

Littleresearchattentionhasbeenpaidtopossiblegenderdifferencesinresponsetotreatmentinpeopleatriskofsuicidalacts.Clinicalimpressionsuggeststhatcomplianceofmalepatientsispoorerthanthatoffemales.ThereisalsosomeindicationfromtreatmentstudiesthatfewermalethanfemaleDSHpatientsbenefitfromtreatmentsthattheyareoffered（Hawton,1997）.Whilethismayreflectdifferencesinoverallattitudestohelp,itcouldalsoresultfromthestyleoftherapythatisavailable.Genderdifferencesinverbalabilitiesandthereluctanceofmanymalestoshareemotionalproblemsmaymakesomeoftheusualtalkingtherapieslessattractivetosomemales,atleastinitially.Treatmentprogrammesthathavemoreofapracticalemphasis,perhapsfocusedonproblem-solving,couldprovemoresuccessfulinengagingmalesatrisk.

CONCLUSIONS

Thereareconsiderablegenderdifferencesinsuicidalbehaviour,someofwhichhavebeenhighlightedbytheDanishstudyofQinetal.Theseapplytotheriskofsuicidalbehaviour,anditsnature,causes,preventionandtreatment.Werequirefurtherepidemiologicalstudiesofthiskindtodisentanglemoreofthesocialandeconomicassociationswithsuicidalbehaviourineachgender.Investigationsofgeneticandbiologicalfactorsrelatedtoriskofsuicidalbehaviourareintheirinfancybutshouldbeconductedfromagenderperspective.Researchontreatmentsforsuicidalbehaviourshouldinvestigategenderdifferencesinresponse.Initiativestodevelopgender-specificapproachesmaybeindicated.Genderdifferencesinsuicidalbehaviourclearlymeritmoreresearchattentiontogenerateinformationthatcanguideclinicalpracticeandpreventionstrategiesinwaysthatwillprovemosteffectiveforpreventingsuicidalbehaviourinbothgenders.

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