Suicide

Keith Hawton, Kees van Heeringen Lancet 2009; 373: 1372–81
Suicide receives increasing attention worldwide, with many countries developing national strategies for prevention.
Centre for Suicide Research,
Rates of suicide vary greatly between countries, with the greatest burdens in developing countries. Many more
University Department of
men than women die by suicide. Although suicide rates in elderly people have fallen in many countries, those in
Psychiatry, Warneford Hospital,
young people have risen. Rates also vary with ethnic origin, employment status, and occupation. Most people who
Oxford, UK (Prof K Hawton DSc);
die by suicide have psychiatric disorders, notably mood, substance-related, anxiety, psychotic, and personality
and Unit for Suicide Research,
University Department of
disorders, with comorbidity being common. Previous self-harm is a major risk factor. Suicide is also associated
Psychiatry, University
with physical characteristics and disorders and smoking. Family history of suicidal behaviour is important, as are
Hospital, Gent, Belgium
upbringing, exposure to suicidal behaviour by others and in the media, and availability of means. Approaches to
(Prof K van Heeringen PhD) suicide prevention include those targeting high-risk groups and population strategies. There are, however, many
Correspondence to: challenges to large-scale prevention, especially in developing countries.
Centre for Suicide Research, University Department of Psychiatry, Warneford Hospital, Background and epidemiology
of suicide can be reached on a basis of judgment of Oxford OX3 7JX, UK The estimated global burden of suicide is a million intent, as long as there is certainty that the death was deaths per year,1 and an international policy statement self-infl icted (eg, England and Wales). The decision by WHO in response to the large burden2 has prompted about the cause of death will be made in private in most many countries to initiate suicide prevention policies. countries where police or physicians are responsible for Estimated annual mortality is 14·5 deaths per the verdict and in the case of the Procurator Fiscal in 100 000 people, which equates to one death every 40 s.1 Scotland, although in England and Wales coroners' Self-infl icted death accounts for 1·5% of all deaths and hearings happen in public. is the tenth leading cause of death worldwide.3 Suicide Diff erent procedures and cultural and social practices rates vary according to region, sex, age, time, ethnic and values probably have profound eff ects on death origin, and, probably, practices of death registration.
records and lead to misclassifi cation of suicide In some countries many deaths (eg, 15% in China4) (eg, as undetermined death or death due to accident or are probably unreported, and procedures for recording illness). Some countries (eg, Finland, France, Portugal, deaths as suicide are far from uniform. Countries diff er and Sweden) have very high combined rates of suicide in their death certifi cation procedures for unexpected and undetermined death compared with rates of suicide, deaths and in their requirements for a death to be whereas other countries (eg, Belgium, Denmark, recorded as suicide. Certifi cation of the cause of Germany, and the UK) have moderately high combined unexpected death is made by diff erent bodies, including rates.5 Detailed independent investigation (verbal the police (eg, Finland), physicians (eg, China), coroners autopsy) of unnatural deaths in rural areas of India, (eg, England and Wales), coroners and medical where suicide is illegal, suggested a nine-fold to ten-fold examiners (eg, USA), or equivalent offi cials (eg, underestimation of suicide in reported rates.6 Such Procurator Fiscal in Scotland). The requirements for a fi ndings suggest that offi cial counts for the global death to be recorded as suicide also diff er, with external burden of suicide1 are substantial underestimates. In evidence of intent, such as a suicide note being required many Islamic countries, the view of suicide as a criminal in some countries (eg, Luxembourg); in others a verdict off ence might aff ect registration practices. Epidemio-logical data on suicide in Africa are scarce.
Rates of suicide vary substantially between regions and Search strategy and selection criteria
countries (fi gure 1). Within Europe, rates are generally higher in northern countries than in southern countries. We searched the Cochrane Library, Psycinfo, Medline An eff ect of latitude on suicide rates was found in Japan, (January, 2003, to July, 2008), and Embase (January, 2003, suggesting an infl uence of the daily amounts of sunshine to July, 2008). We used the search term "suicide" in on suicide.7 However, countries at about the same combination with the terms "aetiology", "epidemiology", latitude, such as the UK and Hungary, can have "prevention", and "psychological autopsy". Index terms were substantially diff erent rates of suicide. Suicide is a major used in preference to free text search terms whenever concern in former Soviet states.1 More than 30% of possible; no language restrictions were applied to the suicides worldwide happen in China, where 3·6% of all search. We commonly referenced older publications. We also deaths are by suicide.4 Few countries provide national searched the reference lists of articles identifi ed in this suicide rates segregated by residence, and these data search strategy and selected relevant articles. Reviews and show no clear pattern; although, in China, suicide rates book chapters are cited to provide readers with further are three-times higher in rural than in urban settings.4 reading. Our reference list was modifi ed on the basis of In developed countries, the male-to-female ratio for comments from peer reviewers.
suicide is between two and four to one, and this seems www.thelancet.com Vol 373 April 18, 2009
EuropeSouth and east Asia Middle East and central AsiaAfrica Figure 1: Suicide rates in selected regions and countries
to be increasing.1 Asian countries typically show much that presence of cultural supports and networks might lower male-to-female ratios, but these might also be be protective.16 However, suicide rates in populations of increasing;8 although in China more women than men immigrants also tend to co-vary with rates in country of die by suicide.4 Suicide rates are highest in elderly people in most Indigenous populations in several countries have countries. However, over the past 50 years, rates have high suicide rates compared with the rest of the risen in young people, in particular in men,9 and population, for example Native American people in the decreased in elderly people.10 More recently, suicide USA, Métis and Inuit in Canada, Australian Aborigines, rates in young males have decreased in some developed and Maori in New Zealand all have high rates of countries in which they had previously risen.11 suicide.15 Factors that might contribute include Suicide rates also vary with season, peaking in spring, marginalisation, disintegration of traditional social particularly among men, although this association support networks and cultural values, socioeconomic seems to change over time.12 Suicide rates are also high deprivation, and alcohol misuse.
among people, in particular women, born in spring and Suicide rates are high in unemployed people;19 although the reasons for this association are complex. Clear ethnic patterns in suicide rates exist. These In part, high rates are associated with mental illness, include lower rates of suicide in Hispanic and African which contributes to risks of both unemployment and Americans than in European Americans;14 although the suicide.20 Among people in employment, some historically large gap in suicide rates in black people occupational groups are at increased risk of suicide. compared with those in white people in the USA has Medical practitioners have a high risk in most countries, narrowed because of a substantial increase in suicides but female doctors are generally most at risk.21,22 Nurses in young black people.11 also have a high risk.23 In both these professional Within countries, variations in rates are seen between groups, access to poisons seems to be an important diff erent ethnic groups.15 In the UK, for example, young factor in determining the high rates.23 Among doctors, Indian women in London have a higher suicide rate anaesthetists are particularly at risk, with anaesthetic than other women, whereas young Afro-Caribbean drugs being used in many suicide deaths.21 Several women have very low rates, and men of Indian and other high-risk occupational groups (eg, dentists, African origin have lower rates than do white men.16 pharmacists, veterinary surgeons, and farmers) also There are also diff erences in methods of suicide, with have easy access to means for suicide.24women in south Asia commonly using setting fi re to Suicide rates are high in prisoners in countries that themselves as a method of suicide.17 Suicide rates within release data.25 Major risk factors are being confi ned to a ethnic groups seem to vary inversely according to single prison cell, previous attempted suicide, recent relative population density of each group, suggesting suicidal ideation, and psychiatric disorder or history of www.thelancet.com Vol 373 April 18, 2009
Panel: Risk factors for suicide
The classic method of investigating characteristics of individuals who have died by suicide is through psycho- logical autopsy, involving interviews with key informants and examination of offi cial records.33 This approach has • Personality characteristics (eg, impulsivity, aggression) shown that psychiatric disorders are present in about • Restricted fetal growth and perinatal circumstances 90% of people who kill themselves and contribute • Early traumatic life events 47–74% of population risk of suicide.34 Such studies have • Neurobiological disturbances (eg, serotonin dysfunction mostly been done in developed countries. Similar fi ndings and hypothalamic-pituitary axis hyperactivity) have come from India.35 In China, however, a much lower proportion of people who die by suicide seem to have psychiatric disorders, especially women and girls in rural areas.36 Aff ective disorder is the most common psychiatric • Psychosocial disorder, followed by substance (esp ecially alcohol) • Availability misuse and schizophrenia. Comorbidity of disorders greatly increases risk of suicide.34 The mortality risk for suicide associated with alcohol problems.26 Rates of attempted suicide in depression is many times the general population risk.37 homosexual and bisexual men and women are high, More than half of all people who die by suicide meet but evidence is lacking for suicide.27 criteria for current depressive disorder;34 although the association seems weaker in Asia. About 4% of depressed Methods of suicide
individuals die by suicide, but the risk is greatest in When a person is contemplating suicide, access to males and in those who have needed psychiatric specifi c methods might be the factor that leads to hospitalisation, especially for suicidality.38 Clinical translation of suicidal thoughts into action. The danger predictors of suicide in people with major depressive of available methods might determine whether the disorder also include a history of attempted suicide, outcome is fatal or not. In general, men tend to choose high levels of hopelessness, and high ratings of suicidal more violent means (eg, hanging or shooting) and tendencies.38 Suicide in major depressive disorder is women less violent methods (eg, self-poisoning).28 most likely to occur during the fi rst episode, and this Availability of specifi c means for suicide aff ects seems to be related to alcohol misuse and impul- national patterns in the methods used. In the USA, sive-aggressive personality traits. The eff ect of im-fi rearms are used in most suicides, with risk of their use aggressive traits is present in child and being highest where guns are kept in households.29 In adolescent suicide and decreases with age.39rural areas of many developing countries, ingestion of 10–15% of patients with bipolar disorder die by pesticides is the main method of suicide,30 refl ecting suicide, commonly early in the illness course.40 Risk toxicity, easy availability, and poor storage. As many as factors for suicidal behaviour include previous 30% of global suicide deaths might involve ingestion of self-harm, family history of suicide, early onset and pesticides.30 increasing severity of the disorder, depressive symptoms (including hope lessness), mixed aff ective states, rapid cycling, comorbid psychiatric disorder, and misuse of Numerous factors contribute to suicide, which is never alcohol or drugs.41the consequence of one single cause or stressor. These Recent estimates suggest that lifetime suicide risk in factors can be categorised as state-dependent or schizophrenia is 4–5%, the risk being highest relatively trait-dependent, or as distal or proximal factors (panel). early after onset of the disorder.42 Risk is associated less The relation between risk factors can be described in with the core symptoms of schizophrenia, such as explanatory models of suicide, such as the stress– delusions and hallucinations, but more with depression diathesis model (fi gure 2).
and specifi c aff ective symptoms (eg, agitation, sense of Acute psychosocial crises and psychiatric disorders worthlessness, and hopelessness). Other factors include are commonly the proximal stressors leading to suicidal previous suicide attempts, drug misuse, fear of mental behaviour, while pessimism or hopelessness and aggres- disintegration, recent loss, and poor adherence to sion or impulsivity are components of the diathesis for treatment.43suicidal behaviour. Familial or genetic factors, childhood Alcohol misuse, particularly dependence, is strongly experiences, and other factors, including cholesterol associated with suicide risk.44 The severity of the concentrations, infl uence the diathesis.31 The stress– disorder, aggression, impulsivity, and hopelessness diathesis model is compatible with recent gene–environ- seem to predispose to suicide. Key precipitating factors ment interaction models,32 but prospective studies of its are depression and stressful life events, particularly predictive value are needed. disruption of personal relationships.44 www.thelancet.com Vol 373 April 18, 2009
Suicide is a common cause of death in people with eating disorders, in particular anorexia nervosa.11 The risk of suicide is increased in adjustment disorder,45 and anxiety disorders and panic disorder are also associated with increased risk.45,46 However, comorbid mood and substance-misuse disorders are common in anxiety disorders and it is unclear how much these disorders mask anxiety in psychological autopsy studies or to what extent they are responsible for the increased suicide rate in patients with anxiety disorders.47 The eff ect of anxiety disorders on suicide could therefore be either underestimated or overestimated. Findings on post-traumatic stress disorder are inconclusive.48 Attention defi cit hyperactivity disorder seems to Figure 2: A stress–diathesis model of suicide
increase the risk of suicide in males via increasing Adapted from Mann 2003.31severity of comorbidities, in particular conduct disorder and depression.49 Psychopathology, including body injury, systemic lupus erythematosus,61,62 and pain.63 dysmorphic disorder probably explains, at least in part, However, many studies of associations between physical the surprisingly increased risk of suicide after cosmetic illness and suicide have methodological problems.62 breast augmentation, reported in six epidemiological
studies.50 30–40% of people who die by suicide have Other factors
personality disorders.51,52 The risk of suicide seems to be
In most studies of risk factors for suicide, a history of particularly increased in borderline and antisocial self-harm or suicide attempts is the strongest factor, personality dis orders.52,53 However, nearly all individuals present in at least 40% of cases.34 In prospective studies with personality disorders who die by suicide have of individuals who present to hospital after non-fatal concurrent depressive symptoms, substance-use self-poisoning or self-injury, 1–6% die by suicide in the disorders, or both.51,52 The concept of personality fi rst year, although the proportion varies among disorder might be less relevant in developing countries, countries.64 The risk is higher in older people, men,65 where suicidal acts often seem to be impulsive.54 people who repeatedly self-harm,66 those whose acts of About 10% of individuals who die by suicide in most self-harm involved high suicidal intent (ie, apparent countries have no apparent psychiatric disorder. wish to die),67 people who misuse alcohol, and those not However, psychological autopsy study of such people living with relatives.68 Although there is debate over indicates that most have psychiatric symptoms and whether attempted suicide should be distinguished personality characteristics similar to those in individuals from non-suicidal self-harm,69 the risk of suicide is with psych iatric disorder who have died by suicide.55,56 mainly related to whether or not an intentional act of Thus, in most countries (except China) suicide seems self-poisoning or self-injury has occurred, and less to rarely to occur in the absence of psychiatric disorders or the degree of suicidal intention.68 Suicide is commonly preceded by notable life events, in particular interpersonal or health-related events.70 Major events aff ecting whole populations, such as Suicide is associated with poor physical health and earthquakes71 or deaths of famous people,72 can be disabilities. An association between raised body-mass followed by increased suicide rates. By contrast, wars index and increased risk of depression but reduced risk can be associated with a decline in suicide rates, of suicide (15% decrease in suicide risk for each 5 kg/m² possibly because of greater cohesion and shared sense increase in body-mass index) is intriguing.57 The of purpose in a society, although the eff ect of war might association between low body-mass index and increased not apply to civil wars.73 risk of suicide cannot be explained by weight loss Physical and, in particular, sexual abuse during caused by mental illness, but low cholesterol childhood is strongly associated with suicide. The eff ects concentrations might play a part.57 Increased risk of of childhood maltreatment and its relation to suicide are suicide is associated with smoking. The relation seems compounded by intergenerational transmission of to be dose related,58 and an underlying biological abuse. Familial transmission of suicidal behaviour is mechanism is possible,59 but depression and alcohol or most likely if the person attempting suicide had been drug disorders might confound the association.60 sexually abused as a child.74 Abuse is, thus, not only a Suicide is also associated with several physical risk factor for suicidal behaviour for individuals abused disorders, including cancer (head and neck cancers in as children, but also for their off spring.11particular), HIV/AIDS, Huntington's disease, multiple Risk of suicidal behaviour can be infl uenced by sclerosis, epilepsy, peptic ulcer, renal disease, spinal-cord exposure to similar behaviour by other people. People www.thelancet.com Vol 373 April 18, 2009
bereaved by suicide have an increased risk of themselves environmental stressors.32 Discussion of nature versus dying by suicide.75 Clusters of suicidal acts can occur in nurture is fuelled by fi ndings of associations between a community, particularly in young people,76 with suicide, young maternal age, and restricted fetal and evidence of specifi c connections (eg, newspaper cuttings, childhood growth.95–97 Although social factors might text messages) in some cases. Some multiple deaths by help to explain such associations, environmental suicide involve suicide pacts,77 with a recent development stressors can include intrauterine determinants of a being meeting of suicidal individuals through internet diathesis for suicide.98websites before death.78 Some websites might encourage By contrast with non-fatal self-harm, few studies have suicide and provide detailed information about methods in vesti gated personality-related correlates of completed that may be used in a suicidal act.79 suicide.99 High levels of lifetime aggression39 are A substantial body of evidence indicates that certain associated with high risk of suicide, while most, though types of media reporting and portrayal of suicidal not all, studies suggest impulsivity also aff ects the risk behaviour can infl uence suicide and self-harm in the of suicide.55,100 Hopelessness is a strong predictor of general population.80,81 Newspaper reporting of suicides can be particularly infl uential if it is sensational,
if it includes dramatic headlines and pictures, if it Suicide in young and elderly people
reports methods of suicide in detail, and if the subject Suicide rates rise throughout the teenage years,
is a celebrity.80,82 Suicide in television dramas can especially in males. Many factors associated with suicide
infl uence risk and nature of subsequent suicidal in adults are also present in younger people. Family
behaviour.83
transmission of suicide risk is important, especially when suicide occurs on the maternal side.102 Most young people who die by suicide have psychiatric disorders, Early studies suggested involvement of neurobiological with aff ective dis orders, substance-related disorders, dysfunction in attempted and completed suicide.84,85 and disruptive behaviour disorders being most frequent, Several biological systems might be involved in suicidal and, as in adults, comorbidity of disorders being behaviour. Post-mortem studies have shown changes in common.11 Other important con tributory factors include central neurotransmission functions in association previous suicide attempts, family disruption and with suicide, particularly with regard to the serotonin discord, loss events, physical and sexual abuse, home-and noradrenalin systems, and in postsynaptic signal lessness, and homosexual and bisexual orientation.11,103 transduction.31 Furthermore, dysfunction of the hypo- Media infl uences seem important in young people,104 thalamic-pituitary-adrenal axis might predict suicide in and some suicides also seem to happen in clusters.76patients with depression, whether or not they have In elderly people in developed countries, suicide is attempted suicide.86,87 Low cholesterol concentrations strongly linked to psychiatric disorder, with depression are associated with an increased risk of suicide,88 but being the main contributor.105 A similar pattern was the greater eff ect on the risk of suicide of cholesterol found in Hong Kong.106 Alcohol misuse might be an lowering by diet than by treatment with statins is important factor in elderly people.105 Cognitive rigidity unexplained.31 and obsessional traits seem to aff ect suicide risk,107,108 Family history of suicide increases the risk at least probably because they undermine elderly people's two-fold, particularly in girls and women, independently ability to cope with challenges of ageing, which often of family psychiatric history.89 Concordance rates of call for substantial adaptations. Physical illness,109
suicide are higher among monozygotic twins than bereavement, and loss of independence110 are also
among dizygotic twins.90 Genetic factors account for important factors.
45% of the variance in suicidal thoughts and behaviours,
and candidate genes include those encoding for Prevention
tryptophan hydroxylase and the serotonin transporter.90
Several countries have established national suicide The pheno typic association with suicide is, however, prevention strategies. Some strategies include specifi c unclear; disturbances in the serotoninergic system are targets for reduction in suicides. Although the value of associated with suicide-related characteristics including these steps has not been proven, they do seem to help aggression, impulsivity, dysfunctional attitudes about focus attention on the problem of suicide. Prevention of the future, hopelessness,91,92 and impaired decision suicide can best involve strategies that focus on making.93 Poor neuropsychological function after individuals in known high-risk groups and strategies exposure to particular stressors94 might explain the aimed at general reduction in population risk of association between disturbed serotoninergic prefrontal brain function and an increased risk of suicidal
behaviour, and thus constitute an endophenotype for Strategies targeting high-risk groups
suicidal behaviour. Evidence is accumulating that such Although overall groups at risk can be identifi ed,
behaviour results from interaction between genes and prediction of suicide in individuals is diffi
www.thelancet.com Vol 373 April 18, 2009
individual risk factors account for a small proportion of patients with schizophrenia or schizoaff ective disorder the variance in risk and lack suffi cient specifi city, at risk of suicide, patients treated with clozapine had resulting in high rates of false positives.111 fewer suicide attempts and rescue interventions to The management of people at risk of suicide is chal- prevent suicide than did those receiving olanzapine.123 lenging because of the many causes and poor evidence Because most suicides associated with psychiatric base. Each person with depression should be screened hospitalisation happen shortly after admission (mostly for suicide risk by specifi cally asking about suicidal through hanging) or after discharge, safer services, thoughts and plans. If suicidal ideation is present or if intensive clinical care, and ongoing care beyond the suicidal intentions are suspected, risk factors for suicide point of clinical recovery are important to reduce the (panel) should be assessed. If suicide risk is present, risk of suicide in patients with psychiatric disorders.124further assessment should address the imminence of The high risk of suicide after self-harm or attempted suicidal behaviour. Intention to die (explicitly expressed suicide means that individuals with such behaviours, or inferred from behaviour), cogent plans, and high especially those with characteristics indicating higher levels of hope lessness might indicate imminent risk. risk, such as repeated self-harm,66,125 should be targeted This risk is likely to be heightened by alcohol misuse in prevention programmes. Specifi c psychological treat-and easy access to methods by which to carry out a ments, especially cognitive behaviour therapy, can suicidal act. In cases of high or imminent suicide risk, reduce repetition of self-harm.126 Voluntary agencies, immediate action is needed, including vigilance and including crisis self-help lines, provide a very substantial supervision of patients, perhaps through hospitalisation, resource for helping suicidal people, although their removal of potential methods of suicide, and initiation eff ect on suicide prevention is diffi cult to assess.127 of vigorous treatment of associated psychiatric disorder.
In cases of a mood disorder, treatment options Removal of means used for suicide is important in include antidepressants, mood stabilisers, and management of individuals, and modifi cation of general psychotherapy. Diagnosis and treatment of depression access to dangerous means can also be eff ective in plays a pivotal part in prevention of suicide. However, suicide prevention at the population level.128 Substitution the relation between antidepressants and risk of of one method with another does happen, but is rare.129 suicidal behaviour is debated,112,113 particularly in young One striking example of the eff ect of availability of a people.114,115 Regulatory agencies have issued warnings common means of suicide was the large reduction in that use of selective serotonin-reuptake inhibitors suicides following the change of the UK gas supply poses a small but sig nifi cantly increased risk of suicidal from toxic coal gas, the most common method used for ideation or non-fatal suicide attempts for children and suicide during the early 1960s, to non-toxic North Sea adolescents.116 Guidelines therefore recommend that gas.130 More recent examples include reduction in use of antidepressants should be given only to moderate or vehicle exhaust for suicide since catalytic converters severely depressed adolescents and only with have been introduced in cars,131 fewer suicides by psychological therapy.117 The benefi ts of adding cognitive jumping from bridges and other sites popular for this behavioural therapy are debated, but might include method of suicide have resulted from the addition of attenuation of the risk of suicidality during medication safety barriers,132 and, although to a variable extent, the treatment.118,119 Careful monitoring of symptoms, results of gun-control laws in countries where fi rearms side-eff ects, and suicide risk should be routinely done are often used for suicide.29 The major problem of in all patients, especially when initiating antidepressant intentional pesticide poisoning in rural areas of many medication.117 Although electro convulsive therapy is developing countries could be reduced by restriction of commonly the last resort in the treatment of depression, access to pesticides through safer storage and stopping it might have immediate benefi t on expressed suicidal sales of more toxic preparations.54 Hanging, which has intent in patients with depression.120 A recent become more common as a method of suicide in several meta-analysis of randomised trials suggested that the countries, presents particular challenges for prevention risk of death and suicide in people with mood disorders because of the ready availabilty of the means by which was reduced by 60% in those taking lithium.121 Possible mechanisms of anti suicidal action include its eff ects Up to 40% of individuals who die by suicide have on mood stabilisation, impulsivity, and aggression, and visited a family doctor within weeks of death.134 An a non-specifi c eff ect arising from long-term close initial study of an educational primary care programme monitoring.
to improve detection and management of depression Excess mortality in schizophrenia is mostly seen in on the Swedish island of Gotland that showed promising patients who are not taking antipsychotic drugs.122 eff ects on suicide rates135 had methodological problems, Although studies of the eff ect of treatments on suicidal but similar results from German and Hungarian studies behaviour are rare and fi ndings inconsistent, clozapine have also had positive eff ects on rates of non-fatal may have an antisuicidal eff ect. In a randomised trial in suicide attempts136 and suicide.137 www.thelancet.com Vol 373 April 18, 2009
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Confl icts of interest
26 Fazel S, Cartwright J, Nott-Norman A, Hawton K. Suicide in We declare that we have no confl icts of interest.
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27 King M, Semlyen J, See Tai S, et al. A systematic review of mental We thank Lesley Sutton for her help with the references. KH is disorder, suicide, and deliberate self harm in lesbian, gay and supported by Oxfordshire and Buckinghamshire Mental Health NHS bisexual people. BMC Psychiatry 2008; 8: 70.
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