Gender differences in use of suicide crisis hotlines: a scoping review of current literature

Abstract

Purpose

Little is known about the gender profile of callers to crisis hotlines, despite distinct gender differences in suicide risk and behavior. The authors assessed current knowledge of the role of caller gender in the use of crisis hotlines for suicide, specifically whether there are differences in frequency, reason for call and caller outcomes by gender.

Design/methodology/approach

The authors conducted a scoping literature review of peer-reviewed studies published since 2000 in Medline, PubMed and PsychInfo, examining a total of 18 articles based on 16 studies.

Findings

Overall, women represent a higher percentage of calls to crisis hotlines worldwide, despite men having higher rates of suicide. Primary reasons for calling hotlines were the same for men and women, regardless of geography or culture. When gender differences in reason for call were reported, they were consistent with literature documenting gender differences in the prevalence of risk factors for suicide, including higher rates of substance use among men and higher instances of domestic violence/abuse among women.

Research limitations/implications

There was variability in the studies the authors examined. This review was limited to research on crisis telephone hotlines and did not include text or chat services. Due to data reporting, the findings are constrained to reporting on a male/female gender binary.

Originality/value

Findings on gender differences in crisis line use suggest a need for continued research in this area to determine how to best meet the needs of callers of all genders.

Citation

Krishnamurti, L.S., Monteith, L.L., McCoy, I. and Dichter, M.E. (2022), "Gender differences in use of suicide crisis hotlines: a scoping review of current literature", Journal of Public Mental Health, Vol. 21 No. 2, pp. 152-161. https://doi.org/10.1108/JPMH-10-2021-0136

Introduction

Crisis telephone hotlines have been at the front of global public health interventions to prevent suicide since the initiation of the first such hotlines in the USA and the UK in the 1950s (Litman et al., 1965). The accessible and anonymous format of hotlines provides callers in crisis with an important and sometimes life-saving intervention and connection to other services. Despite their widespread use globally, and inclusion in public health recommendations to prevent suicide (U.S. Department of Health and Human Services, Office of the Surgeon General, 2021), research is limited regarding the specific demographic characteristics of callers to crisis hotlines. The anonymous format of the hotline, as well as the importance of prioritizing the immediate crisis, are often barriers to collecting in-depth demographic information on individual callers (Gould et al., 2007). To date, research on crisis hotlines has focused on their efficacy in reducing suicide risk of callers during and following the call (Hoffberg et al., 2020).

Research on suicide and gender has long shown distinct gender differences in suicidal self-directed violence prevalence and risk factors (Canetto and Sakinofsky, 1998). Notably, women experience higher instances of nonfatal suicide attempts, while men are more likely to die by suicide than women of any age group (Schrijvers et al., 2011; Freeman et al., 2017). Those who identify as gender or sexual minorities also face particular risks for suicidal ideation (Haas et al., 2011). Despite the distinct differences in suicide risk and behaviors by gender, prominent interventions like those provided by crisis hotlines are rarely tailored to the caller’s gender identity. Recent work on crisis hotlines suggests that simply offering more tailored services would be beneficial for callers with a mental health crisis, particularly among those who are gender and sexual minorities (Goldbach et al., 2019).

Considering the well-established relationship between gender and suicide, and the prevalence of hotlines as a first step in suicide prevention efforts worldwide, we conducted a scoping review of current literature to determine what is known about the relationship between gender and crisis hotline use. Due to the variability of studies in this area, we selected the scoping review as our intention was to provide a map (Pham et al., 2014) of the existing knowledge on gender and crisis line use. We organized our findings by recurrences in the reviewed articles reporting on the proportion of calls by gender, reasons for calling by gender and outcomes of calls made to crisis hotlines by caller gender.

Methods

To assess current knowledge on gender and crisis hotline use, we conducted a literature search in Medline, PubMed and PsychInfo databases in January 2021. We began with a broad search of peer-reviewed literature in English language journals from the year 2000, using the keywords crisis line or hotline or helpline and suicide or suicidal ideation and gender terms, including male, female, men, women, transgender, intersex. We elected to focus on articles published between 2000 and 2020 to include the two most recent decades of literature, noting that research prior to 2000 may have limited relevance for contemporary programs. One member of the team performed an initial extraction, and this information was crossed-checked by a second member. The initial search generated 122 articles. Two independent raters coded individual abstracts for inclusion, and a third rater confirmed selections, with disagreements negotiated and resolved by full-text review of contested articles. To address our specific research question, we limited inclusion to peer-reviewed, English language articles published since 2000 reporting on the gender characteristics of callers to suicide or mental health crisis hotlines or helplines. We excluded 34 studies of hotlines for other concerns (e.g. gambling, domestic violence, substance abuse), and those that did not report on callers. We excluded four articles not written in English and four non-research articles, such as editorials. We further examined and excluded 52 articles that did not report data on caller gender, or those that focused only on one gender without providing comparison data in their findings. We conducted a full-text review of 29 articles and excluded a further 11 that did not report on caller gender. A total of 18 articles based on 16 studies were included in this review. We report on the frequency of calls by gender, reasons for calls made to hotlines and call outcome. Data from the studies were not tested for statistical significance. Per EQUATOR network guidelines for scoping review, this review was not registered.

Data type and gender assessment

The body of literature reporting on gender in crisis hotlines is wide-ranging in both scope and location (see Table 1). Multiple studies were conducted in the USA, the UK and Australia, with respectively large-scale national crisis telephone networks for suicide prevention. The literature we examined used three types of data: administrative records (Barber et al., 2004; Chan et al., 2018; Fakhoury, 2002; Hannemann, et al.,2021; Iqbal et al., 2019; Ohtaki et al., 2017; Ramsey et al., 2019; Shaw et al., 2019; Spittal et al., 2015; Tan et al., 2012; Villanueva et al., 2019), caller and call responder reported data (Coveney et al., 2012; Gould et al., 2007; Gould et al., 2016; Meehan and Broom, 2007; Witte et al., 2010) and silent monitoring (Mishara et al., 2007; Mishara et al., 2016). Analysis of administrative records was the most commonly used data type among the literature we examined. Among studies using this type of data, we found variation in the type and reliability of administrative records analyzed. For example, Hannemann et al. (2021) reported on caller outcomes using medical records, suicide mortality data and call records. More common among studies using administrative records, however, was the use of electronic records stored on crisis line databases, although some studies used call logs and/or paper checklists. Studies noted strengths and limitations of data sources; for example, that the administrative data, though comprehensive in sample inclusion, are limited to what the caller reports and the responder documents. Survey and interview data are, alternatively, limited by participation bias.

A majority of the included studies used demographic data from self-reported information collected from callers or collected verbally by the call responder (Chan et al., 2018; Hanneman et al., 2021; Iqbal et al., 2019; Meehan and Broom, 2007; Ohtaki et al., 2017; Shaw and Chiang, 2019; Spittal et al., 2015; Villanueva et al., 2019). Other studies used data on caller gender from call sheets that were completed by the call responder after the call (Barber et al., 2004; Fakhoury, 2002; Tan et al., 2012) or pre- and post-assessment data from calls (Gould et al., 2007, 2016; Witte et al., 2010). One study collected data from online surveys distributed to callers following the call (Coveney et al., 2012).

Proportion of callers by gender

In all but two included studies, caller gender was reported as dichotomously male or female and unknown gender reported as missing. One study (Spittal et al., 2015) reported on the number of callers who identified as transgender or intersex, and included these as independent categories in addition to the male/female gender binary. Only one study included a third “other” gender category in their sample (Ramsey et al., 2019).

Among the articles reporting on the frequency of calls by caller gender, most found a greater proportion of calls by women, compared with calls by men, with women representing 51%–66% of calls (Chan et al., 2018; Fakhoury, 2002; Gould et al., 2007; Meehan and Broom, 2007; Mishara et al., 2016; Ramsey et al., 2019; Shaw and Chiang, 2019; Spittal et al., 2015; Tan et al., 2012). It was also found that repeat and frequent callers to crisis hotlines were more likely to be female (Coveney et al., 2012; Spittal et al., 2015), which is in contrast to prior research that has shown the profile of repeat callers to typically be single men (Middleton et al., 2014).

The overall higher instance of female callers was sometimes attributed to social stigma regarding men’s comfort in discussing mental health, specifically in some non-Western contexts (Meehan and Broom, 2007; Shaw and Chiang, 2019; Tan et al., 2012). Notably, the gender distribution of callers may also vary over time; for example, in a 2007 study by Gould et al. analyzing a year’s worth of calls to eight sites of the National Suicide Prevention Lifeline in the USA, women represented over 61% of the caller sample. Yet in a 2016 study sampled from the same sites, females represented only 51% of the total call sample (Gould et al., 2016). The study authors noted this as an unexpected shift in proportion with no immediate explanation.

Alternatively, several studies reported an even distribution of male and female callers to crisis hotlines (Barber et al., 2004; Gould et al., 2016; Iqbal et al., 2019; Mishara et al., 2007; Ohtaki et al., 2017), and among calls to the Veterans Crisis Line in the USA, male callers accounted for 86.5% of all crisis calls, which is proportionally representative of the demographics of US military veterans by gender (Hanneman et al., 2021).

Gender differences in reasons for calling crisis lines

Of the studies that reported on reasons for call, all indicated multiple themes were expressed in a single call. Among these, the most frequently reported reasons for calling a crisis line for both men and women were mental health and interpersonal problems. Interpersonal problems were defined in varied ways across the literature, but all referred to stress within a family or another unspecified relationship, often with an intimate partner. Interpersonal problems were the most common reasons for all calls in six of the reviewed articles (Barber et al., 2004; Coveney et al., 2012; Gould et al., 2007; Mishara et al., 2007; Spittal et al., 2015; Tan et al., 2012). In at least two contexts, loneliness or isolation were identified as a theme of calls concurrently with relationship problems (Barber et al., 2004; Tan et al., 2012). Of studies that elaborated on reasons for calls regarding interpersonal problems, Mishara et al. (2007) reported that women were more likely to express concerns with other family members or children, while men were more likely to report an intimate relationship problem.

Although the reviewed studies did not reveal gender differences in the most common reasons for call, differences were observed in other areas of reason for call. These gender differences are consistent with studies on other characteristics of suicide risk and behavior by gender, including women experiencing higher rates of suicidal ideation (Ohtaki et al., 2017) and suicide attempt (Gould et al., 2007; Meehan and Broom, 2007), as well as more women calling due to abuse and domestic violence. In the US context, an evaluation of the National Suicide Prevention Lifeline showed that 65% of female callers had a prior suicide attempt compared to 49% of men. This was a consistent finding throughout the reviewed literature, regardless of cultural context or geographic location.

Several studies reported that men discussed financial problems and poverty more than women in the context of hotline calls, which is consistent with literature on financial strain as a known risk factor for suicide among men (Barber et al., 2004; Ohtaki et al., 2017; Villanueva et al., 2019). In an evaluation of calls to Lifeline Australia, the authors note this as a surprising finding as female heads of households were more likely to be impoverished than male-headed families in Australia (Barber et al., 2004). This was similar in Japan, where financial problems were a primary reason for suicide regardless of gender (Ohtaki et al., 2017). In multiple contexts, men were also more likely to report problems with substance use and addiction than women (Gould et al., 2007; Villanueva et al., 2019).

A study of calls to a crisis line in Bangladesh showed that both men and women widely underreported having thoughts of suicide during their calls, which the authors attributed to social stigma (Iqbal et al., 2019). An analysis of calls among the indigenous Inuit in Northern Canada revealed that younger males more frequently made prank calls to the crisis hotline while also being at the highest risk for suicide by both age and gender in the community of Nunavut (Tan et al., 2012). The authors noted that this was likely related to stigma among males in seeking help for mental health, citing the general underuse of services among high-risk men in this community. Additionally, and potentially related to stigma, in a study of suicidal callers to a crisis hotline in Japan, men more commonly expressed concern with physical rather than emotional health, even when also reportedly experiencing suicidal ideation (Ohtaki et al., 2017).

Outcomes of crisis calls by gender

A small number of the reviewed studies reported on the outcomes of calls to crisis hotlines, with some indicating gender differences in these outcomes. The majority of studies that assessed call outcome focused on reporting suicide mortality rates (Chan et al., 2018; Hanneman et al.,2021; Ramsey et al., 2019; Shaw and Chiang, 2019). Other studies reported on the decrease in suicidal intent or absence of a suicide event following a call (Gould et al., 2007, 2016; Mishara et al., 2007, 2016; Witte et al., 2010). Even when outcomes were assessed, not all studies presented outcome findings by gender.

Of studies that reported on gender differences in the outcomes of death by suicide, men consistently experienced higher suicide mortality than females across contexts. In a sample of 118 suicides among a 40,700 call sample from the United Kingdom’s Lifeline, 61% of deaths were among men (Ramsey et al., 2019). In a study of callers to the National Suicide Prevention Hotline in Taiwan, men were more than twice as likely to die by suicide as women who had contacted the helpline, despite women representing 59% of calls (Shaw and Chiang, 2019). Another study of elderly adults who contacted the Care and Call Service helpline in Hong Kong found that the suicide rates for both male and female callers were 2.6 times greater than the corresponding older population of Hong Kong seniors who had not contacted the helpline (Chan et al., 2018). Older male adults living alone with a history of mental illness were identified as being at the highest risk of dying by suicide. In a study of the Veterans Crisis Line, Hanneman et al. (2021) examined 158,927 unique callers over five years and found that women were 0.47 times as likely as men to die by suicide within 12 months following the call.

Mishara et al. (2016) reported gender differences in decreased suicidal intent of callers in an analysis of two studies evaluating the efficacy of crisis lines in the USA and Canada. Though the total number of follow-up calls was limited, in general, women improved more frequently than men, with 18.6% of female callers demonstrating decreased suicidal urgency compared to 11.8% of male callers. Findings from an article by Witte et al. (2010) analyzing data from Gould et al. (2007) similarly found that women were much more likely to have follow-up call data than men, representing 69.7% of the follow-up call sample.

Discussion

Though research on the interaction of gender and crisis hotlines is somewhat limited in scope and reliability, several important pieces of information emerged from our scoping review of literature published since 2000. Regardless of the caller’s cultural context or geographic location, women represent a higher percentage of calls to crisis hotlines worldwide (with the Veterans Crisis Line in the USA as the single exception). This is consistent with patterns of help-seeking and service utilization by women as compared to men (Mackenzie et al., 2006; Wendt et al., 2016). Because men are more likely than women to die by suicide, their relative underutilization of crisis hotline services emphasizes the need to better engage men to seek preventative care, including perhaps better marketing services to men in areas with heightened social stigma (Hunt et al., 2018a).

It is also important to note that the primary reasons for calls made to crisis hotlines (i.e. mental health and interpersonal concerns) appear to be the same for men and women callers globally, despite the range of cultural and social contexts that might influence local attitudes toward mental health and help-seeking. When gender differences in reasons for call were reported, these were consistent with the broader literature regarding gender differences in the prevalence of risk factors for suicide, including higher rates of substance use among men and higher instances of domestic violence and abuse among women. This suggests that individuals are using crisis hotlines for issues that likely contribute to their overall suicide risk. Understanding whether these calls are made in the context of elevated acute suicide risk is an important next step for determining the extent to which these crisis line contacts are targeting acute versus chronic suicide risk.

The reviewed studies show that repeat calls to crisis hotlines are common, particularly among women, who were disproportionately represented among repeat callers in the reviewed literature, although we did not identify any studies within our review that illuminated the reasons for this. Future research elucidating explanations for this gender difference would be useful, particularly considering that women were also more likely to report specific interpersonal reasons for calling (e.g. abuse, domestic violence); these could be explored further among repeat women callers as a potential reason for their engagement.

Another important point raised by this review is the overall lack of research on gender minority, including non-binary, individuals’ use and experiences with crisis line services. Elevated suicide rates among gender minority individuals highlight the need for further investigation into their experiences and outcomes engaging with crisis services. In particular, understanding if gender minority individuals have different patterns of use, alternative reasons for using crisis lines and disparate outcomes associated with use will be important for future research. In this sense, expanding demographic reporting to be inclusive of nonbinary gender is essential. A recent study (Lim et al., 2021) of the experiences of gender fluid callers to a crisis hotline in Australia found that these callers preferred to avoid the hotline, citing that responders were not appropriately able to recognize or support the specific mental health needs of gender minorities. This is a call for crisis services to adapt to better understand and address the concerns of gender-diverse individuals; part of this task is to broaden the scope of understanding of gender. This is particularly important as there is some evidence to suggest the presence of potential gender bias by call responders in regard to the type of intervention skills used with callers of different genders (Hunt et al., 2018b).

Limitations

One inevitable limitation of this review is that, due to the overall absence of reporting on non-binary gender in most research during this time range, our findings on gender and crisis line use are limited to male and female callers. There are inherent challenges to assessing self-identified gender within the context of crisis hotlines, including the anonymous format of most, as well the necessity of prioritizing safety in acute emergencies. Assessing gender identity, however, may also provide important information to facilitate the call. Given that gender in most cases was recorded by hotline responders, there is a potential for misgendering, limiting our understanding of crisis line use patterns by gender. Our review is also limited to studies of telephone calls to crisis hotlines and does not include contacts through online chat and text services, which are becoming increasingly popular in crisis suicide prevention. One reason for this exclusion is the lack of current research on these newer technologies; future research would benefit from expansion to include access beyond telephone calls. Our study also did not include examination of potential responder bias by caller gender or of the potential impact of responder gender. Prior literature in this area suggests that there may be bias in the ways in which providers respond to callers based on understanding of caller gender (Hunt et al., 2018). Lastly, the literature included in our analysis was limited to English language articles only and those published from 2000 to 2020.

Despite these limitations, the findings yielded by this scoping review provide an understanding of the extent to which there are gender differences in reasons for calling crisis helplines, the frequency of such calls and the extent to which there are gender differences in call outcomes. Results suggest a need for continued research in this area to determine how to best meet the needs of crisis line callers – of all genders.

Table 1

Description of reviewed literature

Author, year	Location and setting	Data source	Question assessed	Total call sample	% Women	% Men
Barber et al. (2004)	South Australia, national Lifeline crisis hotline	Admin records	Frequency, reason for call	409	49.9%	50.1%
Chan et al. (2018)	Hong Kong, Care and Call Service (CCS) Senior Citizen Home Safety Association of Hong Kong	Admin records	Frequency, outcome	106,583	65.6%	34.3%
Coveney et al. (2012)	UK, Samaritans crisis hotline	User/helper report	Frequency, reason for call	1,309	77.9%	22.1%
Fakhoury (2002)	UK, SANELINE	Admin records	Frequency	1,331 (2000) 10,359 (2002)	61% (2000) 63% (2002)	39% (2000) 37% (2002)
Gould et al. (2007)	US, National Suicide Prevention Lifeline	User/helper report	Frequency, reason for call, outcome	1,085	60.6%	39.4%
Gould et al. (2016)	US, National Suicide Prevention Lifeline	User/helper report	Frequency, reason for call, outcome	491	51.1%	48.9%
Hanneman et al. (2021)	US, Veterans Crisis Line	Admin records	Frequency, outcome	158,927	13.5%	86.5%
Iqbal et al. (2019)	Bangladesh, Kaan Pete Rio national crisis hotline	Admin records	Frequency, reason for call	14,344	47.71%	51.15%
Meehan and Broom (2007)	South Africa, Suicide Crisis Line	User/helper report	Frequency, reason for call	535	59.1%	40.9%
Mishara et al. (2007)	US, National Suicide Prevention Lifeline	Silent monitoring	Frequency, reason for call, outcome	2,611	N/A	N/A
Mishara et al. (2016)	US National Suicide Prevention Lifeline and Quebec, Canada Lifeline	Silent monitoring	Frequency, outcome	2,611 (USA) 1,652 (Canada)	N/A (USA) 64% Canada	N/A (USA) 36%
Ohtaki et al. (2017)	Japan, Inochi No Denwa national crisis hotline	Admin records	Frequency, reason for call	541,694	52.1%	47.9%
Ramsey et al. (2019)	UK/Northern Ireland, national Lifeline crisis hotline	Admin records	Frequency, outcome	40,700	56.2%	42.1%
Shaw and Chiang (2019)	Taiwan, Taiwan National Suicide Prevention Hotline (NSPH)	Admin records	Frequency, outcome	201,368	58.6%	41.4%
Spittal et al. (2015)	Australia, national Lifeline crisis hotline	Admin records	Frequency, reason for call	411,725	61.7%	31.9%
Tan et al. (2012)	Canada, Nunavut Kamatsiaqtut Help Line (NKHL)	Admin records	Frequency, reason for call	3,974	54.4%	45.6%
Villanueva et al. (2019)	Spain, national Teléfono de Esperanza crisis hotline	Admin records	Reason for call	10,765	63.7%	36.3%
Witte et al. (2010)	US, National Suicide Prevention Lifeline	User/helper report	Outcome	1,085	60%	40%