An empirical test of a mediation model of the impact of the traditional male gender role on suicidal behavior in men

Hit by the wave: The experiences of adult males living with lymphoedema

Lymphoedema arises when the lymphatic system has been damaged and may occur secondary to cancer treatment. While much of the extant literature focuses on quality of life in females with breast cancer- related lymphoedema, this study explores the impact of living with lymphoedema secondary to cancer treatment in males. Semi-structured interviews were conducted with 13 male participants, aged between 50 to 85 years. Data collected were analysed using interpretative phenomenological analysis. The super-ordinate theme 'Hit by a wave' encompasses the profound impact of lymphoedema on the participants' quality of life. The males expressed body image concerns and struggled with feelings of frustration, anger, anxiety and depression. Physical changes such as weight increase, disrupted sleep, pain, swollen genitals and urinary difficulties were experienced. Changes in lifestyle were also expressed, such as an increased dependence on carers; work-related and role changes. Nevertheless, many participants endorsed the need to focus on the present moment and expressed a heightened appreciation of authenticity in life. By understanding the unique narratives of males with lymphoedema, health care practitioners together with patients can formulate care plans that truly resonate with the needs, concerns, and experiences of males living with lymphoedema.

Impact of Gender-Role Attitudes and Mental Health on Hostile Sexism and Acceptance of Cosmetic Surgery

BACKGROUND

Each year, tens of thousands of people worldwide choose to undergo cosmetic surgery in order to alter their appearance. In recent years, young people have gradually emerged to comprise the main driving force behind the increasing demand for cosmetic surgery. Previous studies have found that sexism may motivate young people to undergo such surgeries. However, few studies have been conducted to determine if this psychological mechanism influences the acceptance of cosmetic surgery among Chinese university students.

METHODS

A total of 579 Chinese university students (280 girls and 299 boys, 17-20 years) volunteered to participate in the online survey. They completed a questionnaire containing the Ambivalent Sexism Inventory, the 12-item General Health Questionnaire, the Gender-Role Attitudes Questionnaire and the Acceptance of Cosmetic Surgery Scale. We firstly evaluated the underlying factor structure of the Acceptance of Cosmetic Surgery Scale using exploratory and confirmatory factor analyses, and exploring pattern of associations between the constructs was analyzed via path analysis.

RESULTS

According to the findings, hostile sexism was associated with greater levels of acceptance toward cosmetic surgery. Moreover, gender-role attitudes mediated the link between hostile sexism and the acceptance of cosmetic surgery, and this mediation was positively influenced by general mental health.

CONCLUSION

Our study contributes to a deeper understanding of Chinese university students' attitudes toward cosmetic surgery, hostile sexism may contribute to normalizing traditional gender stereotypes and encourage cosmetic surgery acceptability among Chinese university students.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

[Depression in the field of tension of gender roles]

BACKGROUND

The distribution of depression and suicidal ideation by gender reveals a gender paradox: women are at least twice as likely to be diagnosed with depressive disorders but have a lower suicide rate than men. In contrast, the suicide rate of men is at least three times higher than women, while the prevalence of depressive disorders is only half as high. Although these differences have long been known the reasons for this paradox are still not fully understood.

AIM OF THE ARTICLE AND METHOD

The aim of this narrative review article is to discuss possible explanatory models regarding gender differences in depressive disorders. Aspects related to stress processing and traumatization are considered as well as sociological and biological factors. This article summarizes information that was considered particularly relevant in the interdisciplinary dialogue regarding possible explanatory factors for gender differences in depressive disorders.

RESULTS

The summarized studies indicate that women and men differ in certain aspects of stress processing and trauma exposure but men do not have a lower risk of disease as a result. On the contrary, the frequency of depressive disorders in men seems to be underestimated due to an atypical symptom manifestation.

DISCUSSION

The implementation of knowledge about gender-specific vulnerability in the training of physicians and psychotherapists, the systematic assessment of gender beyond binary classifications as well as further diversity domains in research and healthcare as well as gender-sensitive and diversity-sensitive prevention strategies could contribute to the resolution of the gender paradox.

Broadening the Perspective on the Dynamics of Men's Suicide: Thought Suppression as a Mediator between Men's Self-Reliance and Suicidality

OBJECTIVE

In most countries, men are at higher risk than women for suicide death. Research focused on masculinity and men's mental health increasingly demonstrates that relationships between gender and various health outcomes, including suicidality, is complex as these relationships can be further explained by certain psychological processes or health behaviors. The objective of this study was to extend this area of research in a national sample of US men (n = 785) by investigating if their adherence to certain hegemonic masculine gender role norms (toughness and self-reliance through mechanical skills) is associated with the suppression of distressing thoughts and if thought suppression then increases their risk for suicidal thoughts and behaviors.

METHODS

Men in the US who have recently experienced a stressful life event completed an anonymous online survey. Structural Equational Modeling (SEM) was used to test for direct and indirect effects (i.e., mediation) between variables.

RESULTS

Men's engagement in thought suppression mediated the relationship between self-reliance and suicidality. The norm of toughness was both directly related to suicidality and mediated by thought suppression.

CONCLUSIONS

Thought suppression appears to be a process that provides some explanation for the relationships between hegemonic masculine norms and suicidality in men, though this study indicated it may play only a small role. Research continues to build that certain masculine norms, such as self-reliance and toughness, are particularly concerning for men's health.HIGHLIGHTSMen's thought suppression mediates the relationship between self-reliance and suicidalityMen's toughness impacts suicidality both directly and via engagement in thought suppressionThese findings have implications for interventions that help men manage distressing thoughts.

Suicides among adults in Paraguay: An 18-year national exploratory study (2004-2022)

BACKGROUND

The number of suicides has been increasing worldwide, year after year, becoming the fourth leading cause of death among young people between 15 and 29 years of age.

AIM

In this study, we explored the frequency and characteristics of suicides among the adult general population in Paraguay between 2004 and 2022, considering that suicide attempts and suicidal risk/ideation are frequent and relevant issues in the consultation activity, even if epidemiological evidence on the national rates of suicide is scarce.

METHODS

In this observational, descriptive, and exploratory study, official records of all deaths by suicide were reviewed and information analyzed. In addition, an attempt was made to predict the number of suicides in the next 5 years according to a mathematical modeling.

RESULTS

In the 18-year period, 5,527 suicides of adults were recorded. Patients' mean age was 36.8 ± 17 years old. A 76.77% of them were males, 77.44% were from an urban area and 25.98% from the Greater Asunción and Central Department of Paraguay. The most frequently used method of suicide was intentional self-inflicted injury by hanging, strangulation, or suffocation (all 67.6%). The expected number of national suicides in the following years from 2023 to 2027 will range between 462 and 530. Limitations include the lack of information regarding diagnoses and personal history in the suicide reports as well as the possibility of underreporting of national suicide cases.

CONCLUSION

Our results represent the first large national epidemiological report of suicides in Paraguay and may be of interest for mental health professionals and health authorities in order to reduce the suicide mortality rate within the country.

Association between unmet healthcare needs and suicidal behaviors among the Korean population

OBJECTIVE

Suicide is an important public health concern. In South Korea, suicide rates have steadily risen over the past two decades. Unfortunately, there is a dearth of literature on the effects of unmet healthcare needs on suicide. Therefore, this study aimed to analyze the relationship between unmet healthcare needs and suicidal behaviors (suicidal ideation, plans, and attempts).

METHOD

This study analyzed data from 27,498 participants assessed by the Korea National Health and Nutrition Examination Survey conducted between 2016 and 2020. Logistic regression was used to evaluate the relationship between unmet healthcare needs and suicidal behaviors, while controlling for age, sex, education, household income, occupation, smoking, obesity, and alcohol consumption.

RESULTS

Adjusted odds ratios (95% confidence interval) were significantly higher in participants who experienced unmet healthcare needs [suicidal ideation: 2.31 (1.84-2.90); suicidal planning: 2.23 (1.75-2.85); and suicidal attempts: 1.92 (1.27-2.87)]. After stratifying for sex and depression, this trend was maintained in male participants and those without a depression diagnosis.

CONCLUSIONS

This study analyzed the relationship between unmet healthcare needs and suicidal behavior. Further studies using data sources that include more detailed information on suicide and somatic symptoms are required.

Suicide rates in the Slovak Republic in 2011-2020

PURPOSE

Suicide is a serious public health problem leading to premature mortality. The aim of the present study is to describe and analyze the trends of suicide rates in the Slovak Republic in 2011-2020.

METHODS

Trends of age-standardized suicide rates were described and incidence rate ratios of suicide were analyzed by negative binomial regression. The age-standardized rates of death by the undetermined intent and its ratio to suicide rate were calculated.

RESULTS

The overall suicide rate for the Slovak population was 7.58 per 100,000. Age-standardized suicide rate had a declining trend in the reported period, from 10.24 in 2011 to 6.65 per 100,000 in 2020. The highest suicide rate was in the oldest age groups. The male to female ratio was 6.09. The most common method of suicide in the Slovak population was hanging. The age-standardized rate of deaths by undetermined intent increased from 15.72 in 2011 to 18.46 per 100,000 in 2020.

CONCLUSION

We observed the overall declining annual suicide mortality trends in the Slovak Republic in 2011-2020. Further investigation is necessary to understand the exceptionally high undetermined intent mortality.

Suicidal ideation in men during COVID-19: an examination of protective factors

BACKGROUND

Men account for three-quarters of all suicide deaths in many Western nations including Australia. Whilst extensive research has examined risk factors for suicidal ideation and behaviour in men, protective factors remain underexplored, particularly social support, resilience and coping behaviours. Such factors are important to examine particularly in the context of COVID-19, where enforced isolation (among other negative lifestyle effects) has created widespread risk for the development of suicidal ideation. This mixed-methods study aimed to examine associations of various protective factors with suicidal ideation in men, using data from an online survey conducted during the COVID-19 pandemic. In addition, we aimed to qualitatively investigate men's self-reported protective strategies when experiencing suicidal thoughts and behaviour.

METHODS

A convenience sample of 700 men (age M = 50.3 years; SD = 15.2 years) responded to an online survey including quantitative measures of suicidal ideation, planning and attempt, alongside employment and relationship status, coping, social support, resilience, and a qualitative free-text item gauging men's self-reported protective strategies. Multinomial logistic regression was applied to compare odds of sub-categories of suicide risk (ideation; planning) according to protective factors. Qualitative responses were analysed via thematic analysis.

RESULTS

Men in a relationship, and those lower in emotion-focused and avoidant coping reported lower odds of suicidal ideation. Maintaining employment throughout the pandemic was protective against suicidal ideation and planning; as was greater perceived social support from friends. Greater self-reported resilience was protective against suicidal ideation and planning. Qualitative analyses led to the development of two themes: coping and connecting, reflecting men's intra- and interpersonal management strategies; and sustaining selflessness, where men's imaginings of the collateral damage of their suicidal behaviour was protective against action on suicidal thoughts or plans.

CONCLUSIONS

Findings of this study speak to the nuanced roles of interpersonal connections, resilience and coping behaviours in protecting against suicidal ideation and planning in men. In addition, qualitative insights further cement men's identification with familial protector and/or provider roles as protective against suicidal action.

"I Called When I Was at My Lowest": Australian Men's Experiences of Crisis Helplines

Background: Helplines are an accessible form of support for people struggling with difficulties in their lives and are key services in suicide prevention and intervention. Men’s experiences of telephone helplines are not well understood, despite high male suicide rates. Methods: We conducted an online cross-sectional survey with N = 684 Australian men (aged 17–83 years, M = 50.13) using open- and closed-ended questions about their experiences of helplines during the COVID-19 pandemic. Descriptive statistics were analysed to investigate differences between men using and not using helplines. Qualitative responses were analysed using thematic analysis. Results: Within the sample, 100 men (14.6%) had used a helpline service. Men using helplines were more likely to be unemployed and in younger age brackets than those not using helplines. They were also more likely to report experiencing stressors related to COVID-19, including financial stress and job loss, perceived impact on mental health and relationship breakdown. Qualitative analysis indicated varied experiences of helplines, with men shedding light on how their interaction with a counsellor, the structure of services and their expectations of the service impacted their experience. Conclusions: Further in-depth qualitative enquiry in this space is required, with the objective of understanding how helpline services may seek to better engage with male callers.

Traditionalism vs egalitarianism: Is there an association between gender attitudes and mental health?

OBJECTIVE

This study sought to assess the extent to which gender attitudes are associated with mental health among Australian men and women.

METHODS

This study used a sample of 26,188 individuals drawn from five waves of the Household, Income and Labour Dynamics in Australia Survey. Gender attitudes were classified into three groups (traditional, moderate-egalitarian and egalitarian), and were constructed from six items. Mental health was measured using the Mental Health Inventory (MHI-5). We calculated the magnitude of associations between gender attitudes and mental health, stratified by gender, and adjusted for potential confounding.

RESULTS

Compared to men with egalitarian attitudes, poorer mental health was observed among men with moderate-egalitarian (-1.16, 95% confidence interval = [-1.84, -0.49]) and traditional gender attitudes (-2.57, 95% confidence interval = [-3.33, -1.81]). Among women, poorer mental health was observed among those with moderate-egalitarian (-0.78, 95% confidence interval = [-1.34, -0.22]) and traditional attitudes (-1.91, 95% confidence interval = [-2.55, -1.26]) compared to those with egalitarian attitudes.

CONCLUSIONS

For both men and women, egalitarian gender attitudes were associated with better mental health.

Gender Self-Confidence as a Protective Factor for Suicide Risk: Analysis of the Sample of Lithuanian Men

Background

Along with other suicide risk factors, masculinity has been analyzed as an important subject for suicidal behavior in men. This study examines masculinity as a gender self-confidence which is the intensity of an individual's belief that he meets his standards for masculinity. We use Hoffman and her colleague's concept, which provides two theoretical constructs as elements of gender self-confidence: gender self-definition and gender self-acceptance. Gender self-definition relates to how salient masculinity is in one's identity; gender self-acceptance relates to how positively one views his masculinity.

Methods

The quantitative research approach was applied in the study. The survey with a nonprobability quota sampling design was implemented to collect the data. The sample consisted of 562 Lithuanian men from various age groups and regions. The age of participants varied from 18 to 92 years (M = 42.99, SD = 17.18); 40.9% of men were from cities, 28.1% from towns, and 30.8% from rural locations. We used the Hoffman Gender Scale to measure gender self-definition and gender self-acceptance. Suicide risk was estimated with the Suicide Behavior Questionnaire—Revised. Patient Health Questionnaire-2 was used to measure depression symptoms as a controlled variable. Statistical analysis of regression and moderation was used to test the hypothesis.

Results

Higher gender self-definition and higher gender self-acceptance were associated with lower suicide risk. The moderation analysis showed that in men with relatively low gender self-definition, the effect of gender self-acceptance on suicidality was larger than in men with high or moderate gender self-definition.

Discussion

We conclude that a stronger gender self-confidence is an important protective factor in male suicide risk. Both, a smaller part of masculinity in one's identity and a negative view of one's masculinity have a cumulative effect on increased suicide risk. The findings have been discussed in accordance with the theories that explain suicidal behavior through the lenses of self-concept.

Sociocultural perspectives on suicidal behaviour at the Coast Region of Kenya: an exploratory qualitative study

OBJECTIVES

To explore perceived sociocultural factors that may influence suicidality from key informants residing in coastal Kenya.

DESIGN

We used an exploratory qualitative study design.

SETTING

Mombasa and Kilifi Counties of Coastal Kenya.

PARTICIPANTS

25 key informants including community leaders, professionals and community members directly and indirectly affected by suicidality.

METHODS

We conducted in-depth interviews with purposively selected key informants to collect data on sociocultural perspectives of suicide. Thematic analysis was used to identify key themes using both inductive and deductive processes.

RESULTS

Four key themes were identified from the inductive content analysis of 25 in-depth interviews as being important for understanding cultural perspectives related to suicidality: (1) the stigma of suicidal behaviour, with suicidal victims perceived as weak or crazy, and suicidal act as evil and illegal; (2) the attribution of supernatural causality to suicide, for example, due to sorcery or inherited curses; (3) the convoluted pathway to care, specifically, delayed access to biomedical care and preference for informal healers; and (4) gender and age differences influencing suicide motivation, method of suicide and care seeking behaviour for suicidality.

CONCLUSIONS

This study provides an in depth understanding of cultural factors attributed to suicide in this rural community that may engender stigma, discrimination and poor access to mental healthcare in this community. We recommend multipronged and multilevel suicide prevention interventions targeted at changing stigmatising attitudes, beliefs and behaviours, and improving access to mental healthcare in the community.

A Systematic Review of Adolescent Masculinities and Associations with Internalizing Behavior Problems and Social Support

Interest in the connection between masculinities and mental health continues to grow. However, no previous systematic review has explored this association for adolescents. We present the systematic review of 29 articles that explore the connection between adherence to stereotypical male gender role norms (e.g., emotional restriction), attributes (e.g., "ambitious"), and identity (most commonly, gender "typicality") and internalizing behavior problems and social support. A total of 24,795 adolescent boys (6th-12th grade) were included in the reviewed studies from 1997-2017. In the quantitative articles (n = 20), associations varied by aspect of masculinity assessed. Specifically, we found that greater endorsement of "masculine" traits (e.g., ambitious, assertive) was generally associated with fewer internalizing behavior problems and greater social support. However, lower gender "typicality" and higher adherence to stereotypical gender role norms were generally associated with more internalizing behavior problems and lower social support. In the qualitative articles (n = 9), the most predominant theme was emotional restriction (i.e., a gender role norm) and consequences for mental health. While research in this area is newer for community psychologists, the connection between masculinities and mental health is directly relevant to the field. Given the focus on individual-level conceptions of masculinity and mental health found in our review, we describe key future directions for masculinities research in community psychology.

Predictors and Confounders of Suicidal Ideation and Suicide Attempts among Adults with and without Depression

This research aims to explore whether sex, race, age, education, and marital status can significantly predict suicide ideation (SI) and suicidal attempts (SA) among adults with and without MDE; and to examine whether the association between MDE, SI, and SA changes after adjusting for age, education, and marital status as confounding factors while keeping race-sex as a constant variable. To reach this goal, data from the 2018 National Survey on Drug Use and Health were extracted and analyzed, producing 42,551 records. Study results show that among adults with MDE, adults <50 years old, adults without a college degree, never married, divorced/separated, and White males were at increased risk for SI. Among adults without MDE, adults<50, with some college education, never married, or divorced/separated were more likely to experience SI. Black males were at increased risk for SA, whether they had MDE or not. There is a diverse at-risk population for SI and SA among adults with and without MDE. Special attention should be paid to Black males.

Resilience among students at risk of dropout: Expanding perspectives on youth suicidality in a non-clinical setting

While research supports a strong association between risk of school dropout and suicidality, this youth population remains understudied. This qualitative study addresses this gap by examining self-reported risk and protective factors among 44 alternative high school students who endorsed varying levels of suicidal ideation. Criterion sampling of Suicidal Ideation Questionnaire-JR scores informed student selection for semi-structured interviews. Students were grouped by low, moderate, or high suicidal ideation scores. Transcribed interviews were analyzed using thematic analysis. The findings demonstrate subgroup differences of suicide risk and resiliency among students at risk of dropout and offer points for prevention and intervention. School practitioners can advocate for school-based suicide preventive interventions that are tailored for students who are both at risk of suicide and academic failure.

Experiences With Machismo and Pain: Latino Veterans

Physical and emotional pain from combat-related injuries and experiences are serious problems among Latino veterans. This study fleshes out existing cultural constructs and concepts (e.g., machismo and familism) from the participants' point of view and may serve as an important step in unraveling the influence of Latino culture on pain, providing a deeper and more critical theorization between masculinity, race/ethnicity, and the military. Using 26 interviews from U.S.-born Latino veterans, this study analyzes the meanings and experiences of pain from combat, masculinity, and how culture affects expressions of pain. The following themes emerged: (a) Latino culture and ethnicity, (b) machismo and pain, (c) the transforming self, and (d) feeling disconnected and dealing with pain. Overall, respondents were governed by strict gender standards influenced by their ethnic identity and exacerbated by military masculinity. Findings suggest that the study of race/ethnicity acts as a fundamental framework from which to understand the experiences and behaviors of pain.

Mental Health and Social Care Professionals After a Patient Suicide: Interrelation Between Support Needed, Sought, and Received

This article investigates the support needed, sought, and received by professionals following a patient suicide. A self-administered questionnaire about the consequences of patient suicide and support issues was completed by 704 professionals. Profiles of support were defined using a 3-dimensional, 8-fold typology based on need for, search for, and sufficiency of support. Stress reactions, professionals' characteristics, relationship with the patient, training, and providers of support were used to characterize the profiles. Most professionals acknowledged receiving sufficient support to manage the aftermath of patient suicide. Almost two thirds of the respondents who received sufficient support reported either not needing or seeking support or both needing and seeking support. Almost 1 in 10 respondents who reported needing and seeking support received insufficient support. Stress reactions were highest among professionals who needed but did not receive sufficient support. Professionals who did not need or seek support were less often in a relationship with the patient at the time of the suicide and less frequently felt close to or responsible for the patient than those who needed and sought support. Trained professionals were overrepresented among those who reported receiving sufficient support while they were less likely to report needing and seeking support or receiving insufficient support. Findings concerning support and its relationship to risk and protective factors suggest the need to adopt a multidimensional approach that distinguishes among support needed, sought, and received. Although an association may exist between perceived stress and need for support, involvement of professionals in the patient relationship may also be linked with the search for support, while training may be associated with receipt of sufficient support.

Adolescent Suicide Ideation, Depression and Self-Esteem: Relationships to a New Measure of Gender Role Conflict

Among 15-24 year olds in Ireland, completed suicide was responsible for 4.1 times more male deaths than female deaths in 2014 (World Health Organization [WHO], 2017). Few international research studies have investigated the relationship between masculinity [as assessed by a measure of gender role conflict (GRC)] and suicide ideation, and none have done so with Irish adolescents. Therefore, the purpose of the current study was to investigate the relationships between a new measure of GRC developed specifically for use with Irish adolescents (I-GRCS-A; O'Beaglaoich et al., 2016), and depression, self-esteem, and negative/protective suicide ideation. A sample of 176 adolescent boys (M = 16.9, SD = 0.94) from a non-clinical population participated in the study. Regression analyses and tests of mediation revealed that depression significantly mediated the relationship between GRC and negative suicide ideation, whilst self-esteem and depression significantly mediated the relationship between GRC and positive suicide ideation. Implications and limitations of the current study are outlined and directions for future research are discussed.

"You Never Know Who's Looking at Your Page!": African American Male Adolescents' Perceptions of Emotional Display Rules Online

Social network sites (SNSs) are a powerful new context for adolescent development. We qualitatively investigate African American adolescent boys' (N = 50, mean age = 15.8) perceptions of emotional display rules on SNSs. We present and discuss a taxonomy of display rules for anger, sadness, embarrassment, and excitement. Perceived display rules around anger and sadness were most notable. Participants' understandings of display rules around anger were complex and varied, with many describing threats of violence as marking the line between acceptable and unacceptable expressions. Although youth stated that expressing sadness via SNS could garner emotional support, this was understood somewhat consistently as unacceptable. Overall, our findings suggest that perceptions of emotional display rules on SNSs are varied, complicated, and can be difficult to navigate.

Evidence-Based Interventions for Youth Suicide Risk

PURPOSE OF REVIEW

To review and discuss recent advances in evidence-based interventions (EBIs) for youth suicide risk.

RECENT FINDINGS

There is a growing body of research on the effectiveness of interventions targeting suicidal ideation and behavior among adolescents. Dialectical Behavioral Therapy-Adolescent has shown effectiveness across two independent randomized controlled trials (RCTs). Several other interventions have shown effectiveness in only one trial and are in need of replication. New interventions are also being developed that incorporate developments in technology and adaptive intervention designs. It is recommended that future research focus on strategies for engaging underserved youth with interventions, consider the broader needs of youth living in poverty, and further tailor interventions to subgroups with distinct risk profiles. Limited EBIs exist for preadolescents, despite evidence for an increasing rate of suicidal behavior for these youth. Several interventions for youth suicide risk are highly promising, but further investigation is necessary. EBIs that are effective for preadolescents are needed, and greater efforts to tailor interventions for distinct subgroups of youth at risk are recommended.

The socialization of boys and men in the modern era: An evolutionary mismatch

This paper examines the misalignment between modern human society and certain male phenotypes, a misalignment that has been highlighted and explored in great detail in the work of Tom Dishion. We begin by briefly enumerating the ongoing developmental difficulties of many boys and young men and how these difficulties affect them and those around them. We then suggest that the qualities that have been advantageous for men and their families in our earlier evolution but that are often no longer functional in modern society are a source of these problems. Finally, we provide a brief review of prevention programs that can contribute to preventing this type of problematic development and eliciting more prosocial behavior from at-risk boys and men. We conclude with an overview of research and policy priorities that could contribute to reducing the proportion of boys and young men who experience developmental difficulties in making their way in the world.

Gender inequality and adolescent suicide ideation across Africa, Asia, the South Pacific and Latin America - a cross-sectional study based on the Global School Health Survey (GSHS)

Background: Suicide ideation is a health issue affecting adolescents worldwide. There are significant variations in suicide ideation between countries and genders, which have not been fully explained. Research is especially lacking in countries outside Europe and North America. Gender equality has been shown to matter in other aspects of adolescent mental health, such as life satisfaction, but has not been researched in relation to suicide ideation at national level.

Objective: To investigate how national gender inequality is related to self-reported suicide ideation among adolescents, and whether this association differs between boys and girls.

Methods: This is a cross-national, cross-sectional study using individual survey data from the Global School-based Student Health Survey, a survey in Africa, Asia, Latin America and the South Pacific, developed and supported by among others the WHO and the CDC; connecting this to national data: the gender inequality index from the UNDP; controlling for GDP per capita and secondary school enrolment. The data was analysed using a multilevel logistic regression method and included 149,306 students from 37 countries.

Results: Higher national gender inequality, as measured by the gender inequality index, was significantly associated with a higher likelihood of suicide ideation in both girls and boys (odds ratio: 1.38 p-value: 0.015), but for girls and both sexes this was only after adjusting for selection bias due to secondary school enrolment (as well as GDP/capita). Interaction models showed that this association was stronger in boys than in girls.

Conclusions: National gender inequality seems to be associated with higher levels of suicide ideation among adolescents in mainly low- and middle-income countries, especially among boys.

Associations Between Gender-Role Attitudes and Mental Health Outcomes in a Nationally Representative Sample of Australian Adolescents

PURPOSE

There is evidence that traditional gender-role attitudes are associated with poor mental health outcomes in adults; however, few studies have examined associations among adolescents. We sought to test associations between gender-role attitudes and mental health among Australian adolescents.

METHODS

Data were drawn from the Longitudinal Study of Australian Children, a nationally representative Australian study. Participants were 3,059 adolescents with complete data for Waves 5-6 (years 2012-2014, aged 12/13 and 14/15 years). Analyses were stratified by sex and controlled for parental education, household income, area socioeconomic position, ethnicity, religiousness, and household type. Multivariable linear regression analyses were conducted to test associations.

RESULTS

Egalitarian gender-role attitudes were associated with fewer conduct problems for adolescent males (ß -.04, 95% confidence interval [CI] -.08 to .00; p = .048) and females (ß -.06, 95% CI -.11 to -.01; p = .014), and for females, less hyperactivity (ß -.15, 95% CI -.20 to -.09; p < .001), better prosocial behavior (ß .08, 95% CI .03 to .13; p = .003), and better overall mental health (ß -.27, 95% CI -.43 to -.11, p = .001). There were no associations for peer problems or emotional problems. Associations were more apparent for females than for males, and analyses using adolescent- and teacher-reported mental health supported the main findings.

CONCLUSIONS

Egalitarian gender-role attitudes among adolescents are associated with better outcomes on some dimensions of adolescent mental health, suggesting that establishing egalitarian gender attitudes in adolescence could help impart mental health benefits among this population group.

Social support, mental health needs, and HIV risk behaviors: a gender-specific, correlation study

BACKGROUND

The HIV/AIDS epidemic continues to threaten the health and wellbeing of millions in the United States and worldwide. Syndemic theory suggests that HIV/AIDS can cooccur with other afflictions. As close to 20% of US adults live with a mental health condition, it is critical to understand the correlation between HIV risk behaviors and mental health needs, as well as protective factors such as social support in intervening the association between mental distress and HIV risk behaviors. Furthermore, as past research has shown mixed results concerning the function of social support on HIV risks by gender, it is important to conduct a gender-specific analysis.

METHODS

To assess the relationship between mental health needs, social support, and HIV risk behaviors, and to assess if social support can be a buffer, weakening the effect of mental health needs on HIV risk, in 2018, we analyzed representative, cross-sectional data from 2016 BRFSS collected from 33,705 individuals from four states in the United States, stratified by gender. Weighted logistic regression analyses, adjusted for age, race, marital status, education, and annual income, assessed the correlation between mental health needs, social support, and HIV risk behaviors. Furthermore, interaction analyses were performed to see if social support modifies the slope of mental health needs as a function of HIV risk behaviors.

RESULTS

For both genders, the odds of participating in HIV risk behaviors increase with mental health needs and decrease with the level of social support. Furthermore, social support mitigates the association between mental health needs and HIV risk behavior involvement for males, as males receiving high level of social support have least odds of HIV risk behaviors relative to males receiving low level of social support. Notably, for females, social support does not serve as a buffer against HIV risk behaviors when their mental health needs increase.

CONCLUSION

The study contributes to the knowledge base of HIV prevention and highlights the important role of mental health and social support against HIV risk behaviors when developing gender-specific prevention strategies.

Impacts of a Documentary about Masculinity and Men's Health

As part of a larger study, we developed a three-part documentary called Man Up that explored the relationship between masculinity, mental health, and suicide. In this study, we examine in detail the qualitative feedback provided by those who viewed Man Up, in order to gain a more in-depth understanding of its impact on them. A total of 169 participants provided qualitative feedback via an online survey 4 weeks after viewing Man Up. We examined their opinions about the show and whether they reported any changes in their attitudes and/or behaviors as a result of watching it. All the men who provided feedback on Man Up were overwhelmingly positive about it. The majority reported significant and profound impacts of viewing the documentary. They reported being more aware of others, more willing to help others, and more open about their emotions and problems, as well as demonstrating associated behavioral changes related to helping others and being more emotionally expressive. The data presented here demonstrate the potential for men's health outcomes to be positively impacted by novel, media-based public health interventions.

The gender suicide paradox under gender role reversal during industrialisation

Objectives

To test for social structural effects on the gender paradox in suicidal behaviour.

Methods

We analyzed newspaper reports of completed and attempted suicides in the Scottish city of Dundee during the mass movement of women into the paid labour force in the 19^th and early 20^th Centuries. We calculated rates of suicides per 100,000 of the male and female populations.

Results

We found that the female suicide rate dropped during this time period, whereas there was only a significant reduction in attempted suicide amongst men.

Conclusions

Our understanding, and action to prevent, suicide in men and women must take place in the context of our gendered social world.

Masculinity, Social Connectedness, and Mental Health: Men's Diverse Patterns of Practice

Men’s mental health has remained undertheorized, particularly in terms of the gendered nature of men’s social relations. While the importance of social connections and strong supportive networks for improving mental health and well-being is well documented, we know little about men’s social support networks or how men go about seeking or mobilizing social support. An in-depth understanding of the gendered nature of men’s social connections and the ways in which the interplay between masculinity and men’s social connections can impact men’s mental health is needed. Fifteen life history interviews were undertaken with men in the community. A theoretical framework of gender relations was used to analyze the men’s interviews. The findings provide rich insights into men’s diverse patterns of practice in regards to seeking or mobilizing social support. While some men differentiated between their social connections with men and women, others experienced difficulties in mobilizing support from existing connections. Some men maintained a desire to be independent, rejecting the need for social support, whereas others established support networks from which they could actively seek support. Overall, the findings suggest that patterns of social connectedness among men are diverse, challenging the social science literature that frames all men’s social relationships as being largely instrumental, and men as less able and less interested than women in building emotional and supportive relationships with others. The implications of these findings for promoting men’s social connectedness and mental health are discussed.

Suicide Risk Screening in Healthcare Settings: Identifying Males and Females at Risk

Suicide is the tenth leading cause of death in the United States, accounting for more than 42,000 deaths in 2014. Although this tragedy cuts across groups defined by age, gender, race/ethnicity, and geographic location, it is striking that nearly four times as many males as females die by suicide in the U.S. We describe the current regulations and recommendations for suicide risk screening in healthcare systems and also describe the aspirational goal of "Zero Suicide," put forth by the National Action Alliance for Suicide Prevention. We then provide information about suicide risk screening tools and steps to take when a patient screens positive for suicide risk. Given the substantially higher suicide rate among males than females, we argue that it is important to consider how we could optimize suicide risk screening strategies to identify males at risk and females at risk. Further research is needed to accomplish this goal. It is recommended that we consider multi-factorial suicide risk screens that incorporate risk factors known to be particularly important for males as well as computerized, adaptive screens that are tailored for the specific risk considerations of the individual patient, male or female. These strategies are not mutually exclusive. Finally, universal suicide risk screening in healthcare settings, especially primary care, specialty medical care, and emergency department settings, is recommended.

Suicide among emergency and protective service workers: A retrospective mortality study in Australia, 2001 to 2012

BACKGROUND

Emergency and protective services personnel (e.g., police, ambulance, fire-fighters, defence, prison and security officers) report elevated levels of job stress and health problems. While population-level research is lacking, there has been some research suggesting suicide rates may be elevated in emergency and protective services.

OBJECTIVES

This paper compares suicide rates between emergency and protective services occupational groups over a 12-year period (2001-2012) in Australia.

METHOD

Labour force data was obtained from the 2006 Australian Census. Suicide data was obtained from the National Coroners Information System (NCIS). Negative binomial regression was used to estimate the association between suicide and employment as an emergency or protective service worker (including prison and security officers) over the period 2001-2012, as compared to all other occupations. Information on suicide method was extracted from the NCIS.

RESULTS

The age-adjusted suicide rate across all emergency and protective service workers was 22.4 (95% CI 19.5 to 25.2) per 100,000 in males and 7.8 in females (95% CI 4.6 to 11.00), compared to 15.5 per 100,000 (95% CI 15.2 to 15.9) for males and 3.4 (95% CI 3.2 to 3.6) for females in other occupations. The highest risk by subgroup was observed among those employed in the defence force, prison officers, and ambulance personnel. The major method of death for all occupational groups was hanging.

CONCLUSIONS

Our results clearly highlight the need for suicide prevention among emergency and protective service occupations.

Influencing the Conversation About Masculinity and Suicide: Evaluation of the Man Up Multimedia Campaign Using Twitter Data

BACKGROUND

It has been suggested that some dominant aspects of traditional masculinity are contributing to the high suicide rates among Australian men. We developed a three-episode documentary called Man Up, which explores the complex relationship between masculinity and suicide and encourages men to question socially imposed rules about what it means to be a man and asks them to open up, express difficult emotions, and seek help if and when needed. We ran a three-phase social media campaign alongside the documentary using 5 channels (Twitter, Facebook, Instagram, YouTube, and Tumblr).

OBJECTIVE

This study aimed to examine the extent to which the Man Up Twitter campaign influenced the social media conversation about masculinity and suicide.

METHODS

We used Twitter insights data to assess the reach of and engagement with the campaign (using metrics on followers, likes, retweets, and impressions) and to determine the highest and lowest performing tweets in the campaign (using an aggregated performance measure of reactions). We used original content tweets to determine whether the campaign increased the volume of relevant Twitter conversations (aggregating the number of tweets for selected campaign hashtags over time), and we used a subset of these data to gain insight into the main content themes with respect to audience engagement.

RESULTS

The campaign generated a strong following that was engaged with the content of the campaign; over its whole duration, the campaign earned approximately 5000 likes and 2500 retweets and gained around 1,022,000 impressions. The highest performing tweets posted by the host included video footage and occurred during the most active period of the campaign (around the screening of the documentary). The volume of conversations in relation to commonly used hashtags (#MANUP, #ABCMANUP, #LISTENUP, and #SPEAKUP) grew in direct relation to the campaign activities, achieving strongest growth during the 3 weeks when the documentary was aired. Strongest engagement was found with content related to help-seeking, masculinity, and expressing emotions. A number of followers tweeted personal stories that revealed overwhelmingly positive perceptions of the content of the documentary and strongly endorsed its messages.

CONCLUSIONS

The Man Up Twitter campaign triggered conversations about masculinity and suicide that otherwise may not have happened. For some, this may have been game-changing in terms of shifting attitudes toward expressing emotions and reaching out to others for help. The campaign was particularly effective in disseminating information and promoting conversations in real time, an advantage that it had over more traditional health promotion campaigns. This sort of approach could well be adapted to other areas of mental (and physical) health promotion campaigns to increase their reach and effectiveness.

Can a documentary increase help-seeking intentions in men? A randomised controlled trial

BACKGROUND

We investigated whether a public health intervention-a three-part documentary called Man Up which explored the relationship between masculinity and mental health, well-being and suicidality-could increase men's intentions to seek help for personal and emotional problems.

METHODS

We recruited men aged 18 years or over who were not at risk of suicide to participate in a double-blind randomised controlled trial. Participants were randomly assigned (1:1) via computer randomisation to view Man Up (the intervention) or a control documentary. We hypothesised that 4 weeks after viewing Man Up participants would report higher levels of intention to seek help than those who viewed the control documentary. Our primary outcome was assessed using the General Help Seeking Questionnaire, and was analysed for all participants. The trial was registered with the Australian New Zealand Clinical Trials Registry (ACTRN12616001169437, Universal Trial Number: U1111-1186-1459) and was funded by the Movember Foundation.

RESULTS

Three hundred and fifty-four men were assessed for eligibility for the trial and randomised to view Man Up or the control documentary. Of these, 337 completed all stages (nine participants were lost to follow-up in the intervention group and eight in the control group). Linear regression analysis showed a significant increase in intentions to seek help in the intervention group, but not in the control group (coef.=2.06, 95% CI 0.48 to 3.63, P=0.01).

CONCLUSIONS

Our trial demonstrates the potential for men's health outcomes to be positively impacted by novel, media-based public health interventions that focus on traditional masculinity.

TRIAL REGISTRATION NUMBER

ACTRN12616001169437, Results.

Negotiating Gender Norms to Support Men in Psychological Distress

Underpinning a general pattern of higher suicide rates in men is the assumption that men do not ask for help or utilize the health-care system during times of psychological distress. There has been a failure to grapple with the dynamic of when, how and from whom men might ask for help during times of psychological distress, and what key barriers or enabling factors are likely to influence potential help-givers’ capacity or willingness to offer help to men in psychological distress. The aim of this study was to investigate how masculine norms impact men’s help-seeking as well as care givers’ behaviors and willingness to support men in need of psychological help or perceived to be at risk of suicide. Focus groups (n = 13) were used with “high-risk suicide” groups of men and community gatekeepers. The principles of grounded theory were used for data analysis. Three themes emerged: “negotiating ways to ask for, offer and accept help without compromising masculinity”; “making and sustaining contact with men in psychological distress”; and “navigating roles responsibilities and boundaries to support men in psychological distress.” Approaches to suicide prevention need to take account of how masculine norms shape men’s willingness to ask for and accept help during times of psychological distress as well as care givers willingness to offer help. The findings address a gap in the literature by looking beyond men’s help-seeking as a passive, one dimensional construct, to a more dynamic triad of help-seeking/giving/taking behaviors that are embedded in the sociocultural context of men’s lives.

Signs of current suicidality in men: A systematic review

Suicide signs have been identified by expert consensus and are relied on by service providers, community helpers' and family members to identify suicidal men. Whether signs that are reported in suicide literature accurately describe male presentations of suicidality is unclear. A systematic review of the literature was conducted to identify male-specific signs of current suicidality and identify gaps in the literature for future research. Searches through Medline, CINAHL, PsychInfo and the Behavioral Sciences Collection, guided by the PRISMA-P statement, identified 12 studies that met the study eligibility criteria. Although the results generally reflected suicide signs identified by expert consensus, there is little research that has examined male-specific signs of the current suicidal state. This review highlights the need for scientific research to clarify male presentation of suicidality. Implications for future research to improve the prompt identification of suicidal men are discussed.

Masculinity and suicidal thinking

PURPOSE

Males feature prominently in suicide statistics, but relatively little work has been done to date to explore whether endorsement of dominant masculinity norms heightens the risk of or is protective against suicidal thinking. This paper aimed to further knowledge in this area.

METHODS

We used baseline data from 13,884 men (aged 18-55) in the Australian Longitudinal Study on Male Health (Ten to Men) cohort. These men filled in self-complete questionnaires in 2013/14 which covered a range of topics, including conformity to dominant masculinity norms and suicidal thinking. We conducted logistic regression analyses to estimate the strength of association between these two variables.

RESULTS

After controlling for other key predictors of suicidal thinking, one characteristic of dominant masculinity-self-reliance-stood out as a risk factor for suicidal thinking (AOR 1.33; 95% CI 1.25-1.42).

CONCLUSIONS

It suggests that one particular element of dominant masculinity-being self-reliant-may place men at increased risk of suicidal thinking. This finding resonates with current theories of how suicidal thinking develops and leads to action. It also has implications for the full gamut of suicide prevention approaches that target males in clinical settings and in the general population, and for our broader society. Further work is needed, however, to confirm the direction of the relationship between self-reliance and suicidality, and to unpack the means through which self-reliance may exert an influence.

Perspectives of Suicide Bereaved Individuals on Military Suicide Decedents' Life Stressors and Male Gender Role Stress

The objective of this study was to pilot the newly developed Male Gender Role Stressor Inventory (MGRSI) in military suicide bereaved (i.e., decedents' family members and significant others) and to determine the association between Male Gender Role Stress (MGRS) and other life stressors observed by survivors. Sixty-five survivors attending a national survivor seminar completed original surveys, reporting demographic information about themselves and the decedent and observations of the decedent's life stressors during the 1-month and 1-year periods prior to death. The MGRSI obtained acceptable internal reliability (α = .76) and indicated that factors including honor, strength, and achievement were the most commonly reported sources of MGRS. Correlational and regression analyses revealed that legal- and trauma-related stressors 1 month prior to suicide were significantly associated with MGRSI score. MGRS may contribute to a better understanding of military male suicide. The Department of Defense and the Veterans Administration may benefit from suicide prevention programs targeting rigid male gender role beliefs and male-specific stressors.

The role of masculinity in men's help-seeking for depression: A systematic review

AIM

Conformity to traditional masculine gender norms may deter men's help-seeking and/or impact the services men engage. Despite proliferating research, current evidence has not been evaluated systematically. This review summarises findings related to the role of masculinity on men's help-seeking for depression.

METHOD

Six electronic databases were searched using terms related to masculinity, depression and help-seeking. Titles and abstracts were reviewed and data systematically extracted and examined for methodological quality.

RESULTS

Of 1927 citations identified, 37 met inclusion criteria. Seventeen (46%) studies reported qualitative research; eighteen (49%) employed quantitative methods, and two (5%) mixed methods. Findings suggest conformity to traditional masculine norms has a threefold effect on men experiencing depression, impacting: i) their symptoms and expression of symptoms; ii) their attitudes to, intention, and, actual help-seeking behaviour; and, iii) their symptom management.

CONCLUSION

Results demonstrate the problematic impact of conformity to traditional masculine norms on the way men experience and seek help for depression. Tailoring and targeting clinical interventions may increase men's service uptake and the efficacy of treatments. Future research examining factors associated with men's access to, and engagement with depression care will be critical to increasing help-seeking, treatment uptake, and effectual self-management among men experiencing depression.

Diverse and Dynamic Interactions: A Model of Suicidal Men's Help Seeking as It Relates to Health Services

There is a striking gender difference in suicide rates worldwide, with men accounting for approximately 80% of all suicide deaths. In contradictory public discussions, suicidal men are presented sometimes as victims of "poor" health services and sometimes as irremediable, "poor" help seekers. A more substantive theory of suicidal men's help seeking, which moves beyond homogenizing accounts to examine the complex interplay between help seeking and health services, is now required. Eighteen life history interviews were undertaken with men who had engaged in nonfatal suicide. Interviews were analyzed within a theoretical framework of gender relations. The findings challenge static and uniform notions of suicidal men's help seeking. While a few men actively avoided health services, others actively sought help, and in many cases help-seeking practices were triggered by unsolicited encounters with health services. Responsibility for help-seeking behavior did not rest solely with suicidal men. Men's help-seeking practices could either be facilitated or blocked by the character of the professional support that was available. Men in this study overwhelmingly rejected services that framed emotional distress and suicidal behavior as mental illness.

The Association of Partner Abuse Types and Suicidal Ideation Among Men and Women College Students

Despite the well-documented relations between intimate partner violence and suicidal ideation, gender differences regarding the relationships between intimate partner violence types and suicidal ideation are less understood. In addition, few studies have examined the risk that harassment may confer for suicidal ideation in the context of intimate partner violence. This study examined gender differences in the associations of harassment, emotional, and physical intimate partner violence with suicidal ideation in 502 college students, while controlling for the influence of depressive symptoms. Results indicated that physical abuse, but not harassment or emotional abuse, was associated with increased suicidal ideation in men. In contrast, emotional abuse, but not physical abuse or harassment, was associated with increased suicidal ideation in women. Clinicians should consider potential gender differences in the impact of intimate partner violence on suicidal ideation when assessing suicide risk.

The Association Between Masculinity and Nonsuicidal Self-Injury

Several known risk factors for nonsuicidal self-injury (NSSI), such as negative emotionality and deficits in emotion skills, are also associated with masculinity. Researchers and clinicians suggest that masculine norms around emotional control and self-reliance may make men more likely to engage in self-harm. Masculinity has also been implicated as a potential risk factor for suicide and other self-damaging behaviors. However, the association between masculinity and NSSI has yet to be explored. In the current study, a sample of 912 emerging adults from two universities in the Northeastern United States completed a web-based questionnaire assessing adherence to masculine norms, engagement in NSSI, and known risk factors for NSSI (demographics and number of self-injurers known). Stronger adherence to masculine norms predicted chronic NSSI (five or more episodes throughout the life span) above and beyond other known risk factors. Adherence to masculine norms was related to methods of NSSI. Clinical implications are discussed, including discussions of masculine norms in treatment settings. Future research should examine what specific masculine norms are most closely linked to NSSI and other self-damaging behaviors.

What Are Reasons for the Large Gender Differences in the Lethality of Suicidal Acts? An Epidemiological Analysis in Four European Countries

Background

In Europe, men have lower rates of attempted suicide compared to women and at the same time a higher rate of completed suicides, indicating major gender differences in lethality of suicidal behaviour. The aim of this study was to analyse the extent to which these gender differences in lethality can be explained by factors such as choice of more lethal methods or lethality differences within the same suicide method or age. In addition, we explored gender differences in the intentionality of suicide attempts.

Methods and Findings

Methods. Design: Epidemiological study using a combination of self-report and official data. Setting: Mental health care services in four European countries: Germany, Hungary, Ireland, and Portugal. Data basis: Completed suicides derived from official statistics for each country (767 acts, 74.4% male) and assessed suicide attempts excluding habitual intentional self-harm (8,175 acts, 43.2% male).

Main Outcome Measures and Data Analysis. We collected data on suicidal acts in eight regions of four European countries participating in the EU-funded “OSPI-Europe”-project (www.ospi-europe.com). We calculated method-specific lethality using the number of completed suicides per method * 100 / (number of completed suicides per method + number of attempted suicides per method). We tested gender differences in the distribution of suicidal acts for significance by using the χ²-test for two-by-two tables. We assessed the effect sizes with phi coefficients (φ). We identified predictors of lethality with a binary logistic regression analysis. Poisson regression analysis examined the contribution of choice of methods and method-specific lethality to gender differences in the lethality of suicidal acts.

Findings Main Results

Suicidal acts (fatal and non-fatal) were 3.4 times more lethal in men than in women (lethality 13.91% (regarding 4106 suicidal acts) versus 4.05% (regarding 4836 suicidal acts)), the difference being significant for the methods hanging, jumping, moving objects, sharp objects and poisoning by substances other than drugs. Median age at time of suicidal behaviour (35–44 years) did not differ between males and females. The overall gender difference in lethality of suicidal behaviour was explained by males choosing more lethal suicide methods (odds ratio (OR) = 2.03; 95% CI = 1.65 to 2.50; p < 0.000001) and additionally, but to a lesser degree, by a higher lethality of suicidal acts for males even within the same method (OR = 1.64; 95% CI = 1.32 to 2.02; p = 0.000005). Results of a regression analysis revealed neither age nor country differences were significant predictors for gender differences in the lethality of suicidal acts. The proportion of serious suicide attempts among all non-fatal suicidal acts with known intentionality (NFSAi) was significantly higher in men (57.1%; 1,207 of 2,115 NFSAi) than in women (48.6%; 1,508 of 3,100 NFSAi) (χ² = 35.74; p < 0.000001).

Main limitations of the study

Due to restrictive data security regulations to ensure anonymity in Ireland, specific ages could not be provided because of the relatively low absolute numbers of suicide in the Irish intervention and control region. Therefore, analyses of the interaction between gender and age could only be conducted for three of the four countries. Attempted suicides were assessed for patients presenting to emergency departments or treated in hospitals. An unknown rate of attempted suicides remained undetected. This may have caused an overestimation of the lethality of certain methods. Moreover, the detection of attempted suicides and the registration of completed suicides might have differed across the four countries. Some suicides might be hidden and misclassified as undetermined deaths.

Conclusions

Men more often used highly lethal methods in suicidal behaviour, but there was also a higher method-specific lethality which together explained the large gender differences in the lethality of suicidal acts. Gender differences in the lethality of suicidal acts were fairly consistent across all four European countries examined. Males and females did not differ in age at time of suicidal behaviour. Suicide attempts by males were rated as being more serious independent of the method used, with the exceptions of attempted hanging, suggesting gender differences in intentionality associated with suicidal behaviour. These findings contribute to understanding of the spectrum of reasons for gender differences in the lethality of suicidal behaviour and should inform the development of gender specific strategies for suicide prevention.

Boy Crisis? Sex Differences in Self-Injurious Behaviors and the Effects of Gender Role Conflicts Among College Students in China

In Western research, self-injurious behaviors are commonly viewed as "feminine" behavior. In this present study, using the data from a survey administered to 960 first- and second-year students in Xi'an Jiaotong University in China, the self-injurious behaviors among college students are analyzed by sex. The results reported that the average prevalence of self-injurious behaviors among male students is 35.2%, higher than the 20.4% observed among female students (p < .1), and the average frequency of severe self-injurious behaviors among male students is 0.4, higher than the 0.18 reported among female students (p < .05). Gender role conflicts and verbal violence are strongly associated with male students' self-injurious behaviors, whereas gender role conflicts and verbal, visual, and sexual violence are strongly associated with female students' self-injurious behaviors. This suggests that self-injurious behaviors among college students in China constitute, to some extent, a boy crisis that can be well explained by gender role conflicts. In addition, verbal violence leads to self-injurious behaviors among both male and female students, whereas visual and sexual violence lead to self-injurious behaviors only among female students.

I Would Rather Just Go Through With It Than Be Called a Wussy: An Exploration of How a Group of Young South African Men Think and Talk About Suicide

Worldwide suicide is a deeply gendered phenomenon. In South Africa, approximately 80% of suicide completers are male. This study aimed to investigate how a group of young South African men understand and think about suicidal behavior. In-depth semistructured interviews and thematic analysis using a grounded theory approach revealed that this group of young South African men had permissive attitudes to suicide and viewed suicide as a morally defensible alternative in specific situations. They spoke of suicide as a goal-directed behavior that provides a means of regaining control, asserting power, communicating, and rendering oneself visible. From this perspective, suicide was understood as a brave act requiring strength and determination. These data have congruence with the Theory of Gender and Health, which proposes that constructions of masculinity may be implicated in the attitudes and beliefs young men in South Africa hold toward suicide.

Mediating effects of stress, weight-related issues, and depression on suicidality in college students

OBJECTIVE

Through a holistic health lens, the current study examines the effects of weight-related issues and stress on suicidality while controlling for depressive symptoms in college students.

PARTICIPANTS

In total, 872 undergraduate and graduate students at DePaul University completed the American College Health Association-National College Health Assessment II Web-based survey in Spring 2010.

METHODS

Measures of suicidality, depression, weight-related issues, and life stressors were assessed, along with gender differences.

RESULTS

Females reported experiencing more weight loss attempts and total stressors than males. Weight-related issues and stress both significantly predicted depressive symptoms in a path analysis; depressive symptoms, in turn, significantly predicted suicidality. Gender differences were found; depressive symptoms mediate the relation between stress and suicidal behavior for females but not for males.

IMPLICATIONS

This investigation furthers previous research on suicidality in college students and suggests that all-inclusive interventions that address weight-related issues and stress may help reduce depressive symptoms, which then may reduce suicidal behavior.

Economic crisis and suicidal behaviour: the role of unemployment, sex and age in Andalusia, southern Spain

INTRODUCTION

Although suicide rates have increased in some European countries in relation to the current economic crisis and austerity policies, that trend has not been observed in Spain. This study examines the impact of the economic crisis on suicide attempts, the previously neglected endpoint of the suicidal process, and its relation to unemployment, age and sex.

METHODS

The study was carried out in Andalusia, the most populated region of Spain, and which has a high level of unemployment. Information on suicide attempts attended by emergency services was extracted from the Health Emergencies Public Enterprise Information System (SIEPES). Suicide attempts occurring between 2003 and 2012 were included, in order to cover five years prior to the crisis (2003-2007) and five years after its onset (2008-2012). Information was retrieved from 24,380 cases (11,494 men and 12,886 women) on sex, age, address, and type of attention provided. Age-adjusted suicide attempt rates were calculated. Excess numbers of attempts from 2008 to 2012 were estimated for each sex using historical trends of the five previous years, through time regression models using negative binomial regression analysis. To assess the association between unemployment and suicide attempts rates, linear regression models with fixed effects were performed.

RESULTS

A sharp increase in suicide attempt rates in Andalusia was detected after the onset of the crisis, both in men and in women. Adults aged 35 to 54 years were the most affected in both sexes. Suicide attempt rates were associated with unemployment rates in men, accounting for almost half of the cases during the five initial years of the crisis. Women were also affected during the recession period but this association could not be specifically attributed to unemployment.

CONCLUSIONS

This study enhances our understanding of the potential effects of the economic crisis on the rapidly increasing suicide attempt rates in women and men, and the association of unemployment with growing suicidal behaviour in men. Research on the suicide effects of the economic crisis may need to take into account earlier stages of the suicidal process, and that this effect may differ by age and sex.

Male farmers with mental health disorders: a scoping review

The issue of male farmers' mental health raises many concerns including high rates of psychological distress and suicide amid the poor uptake of health services among this subgroup. Gender is an important social determinant of health, and this paper provides an overview of connections between farming and masculinities in the context of men's mental health disorders. This scoping review summarises findings drawn from 46 studies to discuss male farmers' mental health disorders, psychosocial interventions and barriers to help-seeking. In providing the review, recommendations are made including the need for an array of study and intervention approaches to advance the mental health and well-being of male farmers and their families.

Sexuality and suicidality: matched-pairs analyses reveal unique characteristics in non-heterosexual suicidal behaviors

The present findings offer new perspectives on differences between suicide-risk heterosexuals and non-heterosexuals (lesbian, gay, bisexual, and questioning: LGBQ). Results from an anonymous online survey, employing standardized scales, showed that LGBQ participants reported significantly greater suicide-risk than heterosexuals. Seventy-nine matched pairs of suicide-risk LGBQ and heterosexuals were examined by individual suicide risk factors. Results showed no significant differences on separate measures of suicidal ideation; however, LGBQ participants were more likely to report suicide attempts, disclosure of suicidal intentions, and prediction of future suicide attempts. The LGBQ group also indicated greater likelihood of going online to develop new personal relationships. Multiple regression modeling was conducted to guide outreach and support efforts, revealing unique factors predicting help-seeking denial of suicide-risk LGBQ. Implications include the importance of online support and considering sexual minorities not just as a potential high-risk group, but also as a population with unique suicide risks and behaviors.

Self-harm and conventional gender roles in women

A total of thirty-two women admitted to a general hospital for medical treatment after self-harming completed measures of conventional positive and negative masculinity and femininity. Comparisons were made with two control groups with no self-harm history; 33 women receiving psychiatric outpatient treatment and a nonclinical sample of 206 women. Multinomial logistic regression analyses showed that those with lower scores on Instrumentality and Unmitigated Agency (positive and negative masculinity) and higher scores on Insecurity (negative femininity) had greater odds of self-harming. Relationships were weaker after accounting for generalized self-efficacy. Results are discussed in relation to previous findings and suggestions for prevention are made.