Background: An important gender difference has been reported regarding suicidal behavior with an overrepresentation of females in nonfatal suicidal behavior and a preponderance of males in completed suicide, also known as the 'gender paradox of suicidal behavior'. The concept of a 'suicidal process' classifies suicidal behavior chronologically; this process starts with suicidal ideation and then implies a progression of suicidality ranging from suicidal ideation over plans to suicide attempts and finally fatal suicide.

Aims/methods: The current paper aims to deepen the knowledge on the gender paradox by collecting and discussing the recent literature on this topic: the most relevant, impacting gender-related factors will be discussed within the suicidal process concept.

Results: Several factors had a gender-dependent impact on suicidal behavior: psychosocial life stressors such as stressful life events but also sociodemographical or socio-economical factors, and sexual abuse. The gender differences in psychiatric (co)morbidity and in response to or attitude towards antidepressant treatment also appear to have an impact. Furthermore, not only suicide methods but also the gender-dependent variation in reporting suicide has an influence. Finally, the gender differences in help seeking behavior as well as region-dependent cultural beliefs and societal attitudes are discussed.

Conclusions: Especially life-events seem to exert an important influence at the beginning of a suicidal process, whereas the other factors occur at a further stage in the process, however without a fixed chronology. Also, the duration of the suicidal process is much shorter in male than in females. Finally, some implications with regard to clinical practice and suicide prevention are suggested.