There's a dramatic difference between men's and women's suicide rates and the methods they use -- but there's no simple explanation for it.

By Martin Downs
WebMD Feature

Reviewed By Brunilda Nazario

When hospital emergency rooms receive people who have attempted suicide, doctors usually are able to save their lives. But there's something striking about the thousands every year whose decision to end it all is reversed in the ER. The majority of them, by far, are women.

Numbers from the National Center for Health Statistics show this clearly. In the year 2000, the latest year for which statistics are available, men died four times as often as women did when they attempted suicide, even though women were three times more likely than men to try it in the first place.

For those who work on the floor of a busy ER, this is common knowledge. "Far more females come in with suicide attempts, suicide gestures, than do males," says Stephan Lynn, MD, an ER doctor at St. Luke's-Roosevelt Hospital in New York City.

On the occasions when he does treat men who have attempted suicide, the injuries tend to be extreme compared with those he sees in women. He recalls one case in which a man had stabbed himself 20-30 times in the chest and gut, and most of the wounds were deep. In contrast, he says, women who try to slash their wrists often merely scratch the surface. "Some of them don't even go completely through the skin," he says.

Also, he says men who attempt suicide with pills tend to take heavier overdoses than women do.

But Lynn only sees patients whose lives could hope to be saved, and these are examples of the most survivable ways one might try to kill one's self. They are the exception for men, not the norm. When men attempt suicide, there's usually no use in calling an ambulance.

"Males tend to choose methods that are more immediately lethal," says Lanny Berman, PhD, executive director of the American Association of Suicidology.

Hanging is common, but more than 60% of men who killed themselves in 2000 did so with a gunshot.

Exploring the Darkness

There's no simple explanation for the dramatic difference between men's and women's suicide rates and the methods used.

It may be partly biological. "Suicide is an aggressive behavior," Berman says. And males, in general, are more aggressive than females.

The word "males" is important here, because it's not just adult men who die by suicide more often than women. The trend begins in late adolescence, around age 15, according to Madelyn Gould, PhD, who studies youth suicide at Columbia University. Before this age, suicide is rare. Also, trends in adolescents over 15 mirror trends in adult men and women.

Then there's the fact that men are less willing to seek help for their problems, physical and emotional, than women are. Women who survive a suicide attempt are much more likely than men to avail themselves of mental health services, Berman says.

Considering that, in addition to the fact that women choose less decisive means of suicide, one might wonder if an overdose of pills is just a "cry for help," and that women don't really mean to kill themselves most of the time.

Gould disagrees. "I don't think that the intent is greater among men," she says.

She points to the suicide rates in some Asian and Latin American countries, where the ratio of deaths by suicide in males and females is equal. "In those countries, women -- as in our country -- will attempt by an ingestion," she says.

In developed nations with good healthcare systems, we can call an ambulance if we find someone unconscious from an overdose, and reasonably expect that they'll get medical attention in a matter of minutes. But in the developing world, healthcare isn't so efficient. Also, women who attempt suicide in Asia tend to do it by swallowing paraquat, a common but very lethal herbicide. "The likelihood of being saved from that is nil, or comparable to shooting yourself," Gould says.

A Deadly Mix

More lethal methods seem to account for the higher rates of death by suicide in American men. But for someone to act with extreme violence toward oneself may also require what researchers call a "disinhibitor," meaning that it's much easier to pull the trigger when you're drunk or stoned.

People do all sorts of things when they're intoxicated that they would restrain themselves from doing while sober, and suicide is no exception.

According to the National Institutes of Mental Health, men are more likely to abuse drugs and alcohol than women are. But people rarely take their own lives on a whim, no matter how severe their substance abuse may be. "It requires a vulnerable individual," Berman says.

The fact that men tend not to seek help for depression may be key to understanding why their suicide attempts are so often fatal.

In recent years, overall deaths from suicide in the U.S. have declined. Ted Greenberg, another suicide researcher at Columbia University, says that his studies of trends in adolescent suicide worldwide strongly suggest that of all possible factors, the availability of better antidepressant drugs, namely SSRIs, is most likely the cause.

But better drugs wouldn't have mattered without a fundamental change in mental health professionals' thinking about suicide. "The difference between now and 20 years ago is that most people in the field say that suicide is a complication of a psychiatric disorder, and that we should be addressing the psychiatric disorder, not the symptom," Greenberg says.

Take all these things together, and a clearer picture of suicide in men begins to emerge.

A man with untreated depression tries to drown his sorrows in alcohol or with illicit drugs, which only amplifies them. Then comes a moment when scattered thoughts of suicide coalesce to form a plan: There's a shotgun in the closet upstairs, an extension cord in the garage. The next time his inhibitions are dissolved, the plan is all too easy to carry out.

Published April 28, 2003.

SOURCES: Stephan Lynn, MD, senior faculty, department of emergency medicine, St. Luke's-Roosevelt Hospital Center. Lanny Berman, PhD, executive director, American Association of Suicidology. Madelyn Gould, PhD, professor, Columbia University. Ted Greenberg, MPH, researcher, Columbia University. American Association of Suicidology web site. National Institutes of Mental Health web site. Journal of the American Academy of Child and Adolescent Psychiatry, April 2003.

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