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The suicide rate in adolescents rose dramatically between 1960
and 1981 and stabilized in the 1990s (1). There is a significant
difference in the prevalence of suicide attempts made by young women
(10.1%), compared with young men (3.8%) (2). This finding suggests
that female sex is a risk factor for suicide attempts (3,4). There
are several reasons why adolescents exhibit suicidal behaviour.
These include previous psychiatric disorders, such as major depression
(2,5), and psychosocial stressors, such as difficulties with family,
peers, school, or the law (6). However, these studies do not explain
the differences described above.
Why are girls at greater risk for attempted suicide? Regardless
of their ideological stance on development, most theorists agree
that while growing up girls experience social, cultural, and family
pressures differently from boys. It should not be surprising, then,
that their reasons for attempting suicide may also be different.
In this study, we chose to focus on gender-role conflict as a potential
psychosocial factor affecting girls’ risk for attempted suicide.
Gender-role conflict is defined as psychological or social difficulty
arising when individuals have internalized characteristics other
than those traditionally ascribed to their sex (11). Girls and women
are exposed to various expectations in relation to gender roles
(12–14), many of them conflicting (15). Hill and Lynch theorize
that gender roles intensify at puberty as a result of social pressures
from peers and parents (16). Physical maturity may provoke parental
fears about premature sexuality and result in restrictions to girls’
behaviour. Moreover, the earlier a girl develops a sexually mature
appearance, the earlier she is met with confusing cultural messages
regarding her sexuality (9).
In addition, during adolescence girls may be forced to choose between
parents’ traditional expectations and their own more contemporary
ones (17). Many homes, representing various ethnic and religious
backgrounds, define certain behaviours as appropriate or inappropriate
for young, unmarried women; young women often experience these norms
as quite limiting (18). The literature suggests that, regardless
of cultural heritage, traditional roles for young women tend to
be passive and relationship-oriented (12–14). Young women exposed
during adolescence to contradictory societal and familial role expectations
may find themselves with conflicting desires (12–14). This
study was based on the hypothesis that girls displaying suicidal
behaviour will express more gender-role conflict than boys exhibiting
suicidal behaviour.
We reviewed the medical charts of 112 patients between the ages
of 11 and 18 years who were assessed consecutively for suicidal
behaviour or ideation at the Hospital for Sick Children in Toronto.
There were 80 girls and 32 boys in the sample, and the criterion
for inclusion was suicidality. Because this hospital’s crisis
service is one of the few available to the community, the crisis
team sees teens who range from having suicidal ideation to teens
who have made serious attempts. Because of the hospital’s visibility
in the community, its crisis team attracts patients from all the
city’s ethnic groups, socioeconomic classes, and regions.
We obtained approval from the ethics review boards of the Hospital
for Sick Children and the University of Toronto. We undertook a
chart review of assessments done by the hospital’s multidisciplinary
psychiatric crisis team wherein we reviewed the charts of any adolescent
who had presented to emergency after attempting suicide or reporting
suicidal ideation. We also reviewed the charts of several adolescents
brought to the outpatient crisis clinic for suicidality.
We designed a checklist that included demographic information on
the patients, as well as information on previous psychiatric diagnoses,
family composition, family conflict, gender-role conflict, and risk-taking
behaviours. In designing the checklist, we reviewed 20 randomly
chosen charts of teens with suicidal behaviour to identify commonly
charted topics and issues. We also identified relevant topics previously
documented in the scientific literature on adolescent suicide. The
final checklist consisted of 45 questions requiring “yes”
or “no” answers. We then used the checklist to review
the charts in this study.
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Since gender-role conflict has not commonly been associated with
suicidality, it is not directly inquired about as a risk factor
during assessment. We therefore instructed the reviewers to look
at the details of the crises associated with the teens’ suicide
attempts and to register any crisis related to conflict based on
gender roles. Guidelines for identifying gender-role conflict included
conflict over role expectations between an adolescent and her parents,
her peers, her school, or the culture at large, as well as conflicting
gender-role expectations within the teen herself arising from these
influences. Gender-role conflicts emerged in socialization, in sexual
activity, and when girls were valued differently from boys.
Conflicts related to socialization were described when teenagers,
because of their sex, experienced the imposition of their parents’
traditional values. These girls fought restrictive parentally prescribed
roles with hostility or by withdrawing while at home and quietly
pursuing their own desires when away from their parent(s). Gender-role
conflicts regarding sexual activity arose when girls were not permitted
to date. Conflicts related to differential evaluations based on
sex occurred when girls felt that boys’ interests were taken
more seriously.
Two raters independently reviewed 100% of the chart histories while
completing the checklist. The 2 raters agreed in 87% of the cases.
Where the raters disagreed, a third reviewer made the final decision.
There were 80 (71.4%) girls in the study, with a mean age of 15
years (SD 1.37). Boys numbered 32 (28.6%), with a mean age of 14.8
years (SD 1.13). The ethnicity of the adolescents was not listed
in 50% of the cases. Ethnicities listed were North American or Western
European, South or Central American, Eastern European, Middle Eastern,
African, Southeast Asian, and other, which included teens of mixed
origins. There were no differences found based on ethnicity.
However, gender-role conflict was reported in 33 (29%) cases, and
when we performed a chi-square analysis, we found a significant
difference based on sex. Gender-role conflict was reported in 30
girls and in only 3 boys (see Table
1).
Suicidal girls report gender-role conflict at greater rates than
do boys. This suggests that gender-role conflict is an important
factor associated with significant distress in girls’ lives.
Adolescence is a time when girls take on new gender-specific roles.
Developmentally, adolescence is a time for exploration and individuation
(19,20), and yet our data suggest that for some girls it is a time
when options constrict (17,21,22).
This was a chart review. Given the lack of previous research on
gender-role conflicts as a potential risk factor for suicidal behaviour
in teens, the assessors did not focus on these issues when the charts
were written. We were therefore surprised that our raters were able
to find clear documentation of multiple incidences of gender-role
conflict. Nevertheless, it is likely that the charts underdocument
gender-role conflict in this population.
Many of us believe that our society provides girls and boys with
the same options for self-determination. These suicidal adolescent
girls are contradicting this assumption. Many of them feel limited
by, and conflicted about, their gender roles. Clinicians need to
be aware of these issues. Such awareness could lead to treatment
that acknowledges the girls’ struggle and that incorporates
ways for girls to negotiate with their families for more freedom
and flexibility.
Girls are encouraged by society to identify themselves through
relationships (8). In fighting for self-determination, girls may
risk the very relationships through which they identify themselves.
Our data suggest that girls who present with suicidal behaviour
experience gender-role conflict at greater rates than do boys. This
chart review further suggests that gender-role conflict is a variable
worth exploring in relation to adolescent suicidal behaviour.
The authors thank Noreen Stuckless for statistical advice, the
Hospital for Sick Children Crisis Program for sharing charts, and
Marcie Rothstein for transferring chart data.
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