Introduction

Suicide is among the top 10 causes of death in every country and, in Europe, the second leading cause of death in those who are 15–35 years old.1 In a 10-year span during the 1990s, the global proportion of suicide in Italy was 12 in 100 000 males and four in 100 000 females.2 In Italy, young people between the ages of 25 and 29 are at the highest risk for suicide, even if the highest percentage of death owing to suicide are people who are 65 or older. Although death caused by infection in spinal cord injury (SCI) has fallen substantially over the past 20 years, the suicide rate has increased over the same period.3 Among people with SCIs, death from suicide is 2–6 times more prevalent than in the general population and about five times more prevalent than in age–gender–race-matched populations. Although men are more likely to die from a suicide attempt, women attempt suicide about twice as often as men.4 Suicide is now understood as a multidimensional disorder, which results from a complex interaction of biological, genetic, psychological, sociological and environmental factors.5 Literature reports that gay men and lesbian women are two or three times more likely to attempt suicide than other young people.6, 7 Many of them feel isolated, and may have difficulties coming to terms with their own sexuality.

Problems arising from society's attitude toward homosexuals may cause mental illnesses such as depression and affective disorders, and many use alcohol and drugs as a means of coping with societal oppression.8 Fewer studies, however, have focused on the sexual history of individuals who have sustained SCI as a result of a suicide attempt, even though literature reports sexual impairments in all patients with SCI owing to attempted suicide as the most disturbing problem pre-SCI.9

Aim of the study

To evaluate the specific characteristics of sexuality in SCI patients who attempted suicide.

Methods

Participants

From March 1998 to March 2005, 54 patients with SCI were selected for our study. All these patients were hospitalized following their spinal cord lesions and completed their initial rehabilitation in our Centre.

We divided the patients into two groups. The first (suicide group (SG)), composed of 14 males and 13 females, were admitted to the Spinal Unit of Florence with a SCI caused by a suicide attempt. This group was compared with a control group (CG) of equal size, matched age, gender, time since injury, grade and injury level with reference to the American Spinal Injury Association/International Medical Society of Paraplegia (ASIA/IMPSOP).10 At the time of the spinal cord lesions, the median male age was 33.2 with a range of 21–48 years, and the median female age was 34.5 with a range of 22–51 years; two were in natural menopause for each group before SCI. During initial hospitalization the presence/absence of an actual or lifetime mental disorder was confirmed through a psychiatric interview. Possible psychiatric disorders in both groups were diagnosed according to Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) criterion.11 We excluded patients younger than 18 and patients with any psychiatric conditions in the CG. Using our database, we extracted all possible relevant data regarding the sexuality of these patients from initial recovery to final follow-up performed by March 2006.

Initial recovery

During the initial recovery, we performed a detailed sexual anamnesis for each patient pre-SCI in which we reported possible risk factors for sexuality: medical and lifestyle factors such as drug/alcohol abuse and chronic smoking,12, 13 presence of sexual dysfunctions and if they had undergone specific diagnostic investigation and/or pharmacological therapies.

Follow-up

In the follow-up, using the database, we researched all relevant data concerning sexuality, such as: presence, type of sexual dysfunctions, therapies for sexual dysfunctions and any information on fertility.

Final follow-up.

All subjects in treatments for sexual dysfunctions had agreed to suspend any therapies for sexuality at least 4 weeks before the final visit. To complete the sexual investigation of the final 4 weeks, female and male patients filled out the Female Sexual Function Index (FSFI) and the International Index of Erectile Function (IIEF5), respectively.14, 15 Moreover, all patients were evaluated on their overall sexual satisfaction: male subjects responded to questions 13 and 14 of the IIEF (15) questionnaire, whereas the females answered questions 14, 15 and 16 of the FSFI.

The investigators used consensus validation to complete data analysis, and all research findings were reviewed by the study participants for validation. Statistical analysis was considered significant with P-value less or equal to 0.05.

Results

Details of injury

The neurological functioning level of the spinal cord is shown in Table 1.

Table 1 Classification of patients with reference to the ASIA/IMPSOP
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Psychiatric assessment

SG

During the initial recovery, personal history showed long-standing mental disorders in 25 out of 27 patients (92.5%). Four subjects, three are male, with mental disorders did not come to the final visit. Two male patients quit using drugs and one resolved her conflict with her partner (see Table 2).

Table 2 Psychiatric assessment of suicide group
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In the CG post-SCI, one woman and one man followed pharmacological treatment for depressive symptoms but they did not fulfil DSM criterion for a mood disorder. These patients were never hospitalized for depression and none attempted suicide.

Pre-SCI sexuality background

SG

One female who had been sexually abused showed sexual aversion disorder as body dissatisfaction and self-consciousness resulting in sexual discomfort. One female of fertile age was in secondary amenorrhea. All females with desire impairment and the patient in amenorrhea used psychoactive medications for a minimum of 1 year.16 Sexual impairments were not exclusively tied to the subjects' most recent partner. Relevant data of all patients are reported in Table 3.

Table 3 Pre-SCI sexuality main data
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Follow-up

Males.

In the SG, one patient who attended follow-up committed suicide in 2003. In the SG, two male subjects never attended follow-up including the final visit. In the SG, one subject and his spouse decided to have a child and after withdrawing semen through electroejaculation, his partner underwent at that time an Intra Citoplasmatic Sperm Injection (ICSI); miscarriage occurred 3 weeks later. In the CG, two couples were included in an assisted fertility program and one case resulted in a full pregnancy.

Females.

Two women in the SG attempted suicide again after SCI. In March and June 2005, only two females in the SG with a lumbar incomplete lesion (both degree C according to the ASIA scale) and having a stable partner started a pharmacological treatment for arousal disorders. They used Sildenafil 50 mg for 3 months. In one case, the FSFI score concerning this domain significantly increased (more than 60% compared with baseline) passing from 1.8 pretreatment to 3.3 at the end of the treatment, even though she lost these benefits after suspending the treatment. Both in the SG and CG, one woman of fertile age did not recover her menstrual cycle post-SCI by the final visit. One woman in the SG and one in the CG achieved full-pregnancy post-SCI.

Final follow-up

In the SG, three male subjects and one menopausal female did not attend the final visit, compared with one male and one female in the CG.

Risk factors for sexuality

In Table 4, we reported all possible risk factors for sexuality in pre-SCI and in the final visit. All smokers were chronic smokers (more than 3 years) and smoked at least 10 cigarettes a day. In the final visit, two men in the SG compared with pre-SCI stopped using drugs and/or alcohol, and one male and one female quit smoking. In the CG, one female quit smoking, whereas one man and one woman had been using antidepressive therapies for a minimum of 1 year.

Table 4 Risk factors for sexuality of the two groups throughout the period of the study
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Evaluation of sexuality

For both groups, all individuals were subdivided into four classes (A, B, C and D) according to the duration of their relationships. A, 0 to 6 months without a stable partner, or an occasional relationship; B, 6 months to 5 years; C, 5 to 10 years; D, 10 to 15 years.

Males.

We reported the results of the IIEF5 score in the final visit, because in all male subjects we did not observe a significant change in their scores during follow-up (around 20%). All patients with erectile dysfunction responded to various dosages of specific treatments: intracavernosal Pge1 or phosphodiesterase inhibitors-5.

Females.

By means of anamnesis the presence of sexual dysfunctions was determined through the follow-up, and in the final visit in the same seven out of 12 patients (58.3%) in the CG compared with nine out of 12 (75%) in the SG. In those females, the domains of the FSFI scores ranged from a minimum of 0.8 to a maximum of 2.4, and the total score of the FSFI was less than 26. Females with no sexual dysfunctions in both groups reached a minimum score of 29 (range, 29–33). The principal data on sexuality are summarized in Table 5.

Table 5 Principal sexuality data of our sample in the final visit
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Overall sexual satisfaction (questions 14, 15 and 16 of the FSFI) for both groups is statistically correlated to the duration of the relationship with their partners using a linear regression test P<0.05 (Figure 1).

Figure 1
figure 1

We distributed all the females according to the duration of relationship reporting the median score for the FSFI satisfaction domain.

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Conclusions

In our sample, a peculiar aspect of SCI resulting from attempted suicide is the much higher ratio of women to men (approximately 1:1), compared with the Italian average with SCI where the male:female ratio is 4:1.

Sexual orientation represents a possible co-factor that increases the risk for attempted suicide. These findings are consistent with recent specific literature.17 Multilevel modeling analyses revealed that sexual orientation predicted suicidal ideation and suicide attempts up to three times more than heterosexual subjects.18

Additionally, one female reported a history of sexual abuse pre-SCI.19 As a consequence, this female presented sexual dissatisfaction even though she had a stable partner. In such cases, services should ensure a specific sexual program. In the final visit, this woman, following our advice, was attending group psychotherapy sessions for women molested in childhood.

In the SG, more patients suffered from sexual dysfunction pre-SCI compared with the CG. This higher presence of sexual impairments pre-SCI in the SG constitutes the main reason for the differences regarding the presence and degree of sexual impairments in the two groups post-SCI. Moreover, the SG showed higher risk factors for sexuality, mainly correlated to the chronic use of psychiatric drugs. Hence, physicians should know that it is fundamental to inform the patients that lifestyle factors such as chronic smoking and abuse of drugs and/or alcohol may damage sexuality; in doing so, physicians can help patients change their lifestyle/improve their quality of life. In the final assessment of the SG post-SCI, two out of three males stopped using drugs and/or alcohol, and overall three out of nine chronic smokers quit smoking, whereas for the CG, the most negative factors for sexuality were that two subjects presented minor depression with concomitant use of chronic pharmacological treatments.

The most negative aspect concerning sexuality in the SG group, however, is the difficulty in establishing a stable relationship pre- and post-SCI compared with the CG. The lack of a stable relationship represents an obstacle in sexual rehabilitation for the SG; most patients in the CG had the same partner before SCI, thereby facilitating the recovery of overall sexual satisfaction and avoiding any sexual fear or inhibition to sexual activity. Particularly for females in our sample, an overall satisfactory sexual life is statistically correlated to the duration of the relationship, and a positive trend is evident in the CG males as well. Relationships where the non-injured partner has a greater understanding of the partner's sexual needs are more successful in sexual adjustment according to the Basson model,20 and a long-lasting rapport with the spouse aids the couple in creating good overall sexual intimacy. In the SG, the majority of patients did not make further suicide attempts; however, a small yet significant proportion – 3 out of 27 (11.1%) – attempted suicide, one successfully, and this is cause for concern. Risk of persistent suicidal thoughts and suicide attempts is determined by a complex interplay of psychiatric history, neuroticism, traumatic life experiences and genetic vulnerability. Further research examining potential interactions between expression of genetic influence and particular environmental contexts may enhance prevention and intervention efforts.