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Ciênc. saúde coletiva vol.17 n.10 Rio de Janeiro Oct. 2012
Suicide of elderly men in Brazil
Suicídio de homens idosos no Brasil
Maria Cecília de Souza MinayoI; Stela Nazareth MeneghelII; Fátima Gonçalves CavalcanteIII
Latino Americano de Estudos de Violência e Saúde Jorge Carelli,
Escola Nacional de Saúde Pública, Fundação Oswaldo
Cruz. Avenida Brasil 4036/700, Manguinhos. 21040-361 Rio de Janeiro RJ. firstname.lastname@example.org
IIEscola de Enfermagem, Universidade Federal do Rio Grande do Sul.
IIILaboratório Social, Mestrado em Psicanálise, Saúde e Sociedade, Universidade Veiga de Almeida.
Discute-se o suicídio de homens idosos no Brasil. O texto se fundamenta em estudos de gênero e masculinidades e dá ênfase ao sentido de "masculinidade hegemônica" dentro da lógica do patriarcalismo que, no caso dos suicídios, se expressa na perda do trabalho como referência existencial e no sentido de honra como escudo. O estudo contempla casos de 40 homens que faleceram por suicídio no período entre 2006 a 2009 em dez municípios do país e tinham idade acima de 60 anos. Pela técnica de autópsia psicossocial foram coletados e analisados dados da história e modo de vida; avaliação dos antecedentes; impacto na família; letalidade do método; proximidade de fontes de apoio; tentativas anteriores; estado mental que antecedeu o ato; reações da família e da comunidade. Embora sejam vários os fatores que se associam à morte autoinfligida nesse grupo social, é inegável a importância da cultura masculina hegemônica na preeminência do número de suicídios de homens idosos em relação com as mulheres idosas. É fundamental dar atenção especial aos homens nos momentos de passagem da vida laboral para a aposentadoria, nas situações de perdas de familiares referenciais e quando são diagnosticados com enfermidades crônicas degenerativas que provoquem deficiências, perda de autonomia ou impotência sexual.
Palavras-chave: Suicídio, Suicídio de idosos, Suicídio de homens idosos, Masculinidades
This paper assesses the suicide of elderly men in Brazil. The text is based on studies of gender and masculinity and emphasizes the sense of "hegemonic masculinity" within the logic of patriarchalism that, in the case of suicide, is expressed in the loss of employment as an existential reference and as a loss of honor. The study includes 40 cases of men over 60 who committed suicide between 2007 and 2010 in ten districts of the country. Using the psychosocial autopsy technique, data were collected and analyzed from their history and lifestyle; evaluation of the background to the act; the impact on their families; lethality of the method; proximity to sources of support; previous attempts; mental status which preceded the act; reaction of families and communities. Although many factors are associated with self-inflicted death in this social group, the influence of a hegemonic masculinity culture in the predominance of suicides among elderly men compared with elderly women is undeniable. It is essential to give special attention to men at the moment of transition from working life to retirement, loss or important family members, and when they are diagnosed with chronic and degenerative diseases that cause disabilities, loss of autonomy or sexual impotence.
Key words: Suicide, Suicide of the elderly, Suicide of elderly men, Masculinities
This paper deals with suicide deaths in elderly men in Brazil according to a qualitative study conducted in a multicenter research in ten Brazilian municipalities. Although it is a subject rarely addressed by studies in the health area, self-inflicted death in men and in elderly men today is a public health problem recognized by the World Health Organization1. Death and injuries statistics from violence in Brazil show that in all age groups men are the main victims and major perpetrators, taking into account all subcauses and even in groups above 60 years old. In most Western countries, mortality rates from external causes (injuries, accidents, and suicide) among men reach a coefficient two to five times higher than among women2,3, and suicide ones, which is among three to five times higher4.
Although suicide is a phenomenon known to have multiple causes, the fragilities related to gender are an important explanatory factor. Studies on gender increased with the feminist movement, which initially focused on the female condition, leaving men and masculinities behind. Research on this social group emerged in the past years, once "gender" became understood as the grammar that supports the perceived differences between the sexes and gives meaning to the hierarchical power relationships5. Studies on masculinity broke the silence about male sexuality, health, and reproduction, and the theoretical perspective that underlies this new approach analyzes men concerning their unique aspect related to women6.
The concept of patriarchy is used to understand power hierarchies and effects on physical and mental health of men and women, produced by the sex/gender system. This concept is perceived as a sociopolitical system that pervades and governs all human activities, collective and individual ones, and includes the differentiation of roles and hierarchies between sexes6.
"Masculinities" is a notion that concerns men's position towards gender relations, drawn from the concept of "culturally hegemonic masculinity", which refers to culturally and politically dominant roles in a particular historical moment, being men's a norm and the ideal to be followed. Thus, this idea is constituted in relation to other subordinated masculinities and in relation to women, ensuring the functioning of the patriarchal order5,6.
Male masculinity and sexuality are built and updated through the body, which is defined by the ability to perform tasks of leadership and supremacy. Sexuality preserves the characteristic of masculine power as domination through penetration, the shame of being penetrated, and through the competition manifested by the conquers to show off to other men7,8. In general, despite changes in labor sexual division, under the hegemonic view, men still play the role of providers and like to perpetuate this idea. This role is underpinned by the notion of honor and responsibility to support women and children, giving men the power to have his family obedient to them. The same cultural environmentl9-11 that establishes and reproduces male supremacy, however, affects men when, for example, leads them to neglect their health and to deny risks related to any failure as provider. When affected by the disease, men tend to be quiet and do not seek support12.
This paper takes into account that the pattern of prevailing masculinity in which men are socialized contributes for them to become, at the same time, main victims and perpetrators of different expressions of social violence, and especially of lethal self-harm. Once solving social and personal conflicts in an aggressive manner is a pattern of the hegemonic masculinity culture, using weapons, and deliberate exposure to risks and self-harm.
Thus, the study on suicide of elderly men is important, as self-inflicted death is an act that implies the subject and thus calls into question the cultural values and problems internalized by them12. In old age and ill, the predominant model of masculinity that values stoicism and control of emotions, male chauvinism and competitiveness tends to exacerbate, once along the life cycle other adults assume command roles in society and in the family, leaving the elderly to a less important place. This feeling of being in second place often makes them to feel useless due to absence of work, feeling useless unable or loser when it suffers economic setbacks, and humiliated or impotent due to relational problems or sexual performance13.
This article addresses the pattern of socially dominant masculinity as a vulnerability factor for suicide of elderly men. The aim is to deepen the relationship between performance of masculinity, especially when it is difficult to express it due to old age, illness, or economic loss.
A qualitative study which data collection was conducted through psychosocial autopsies of elderly men's family members who died by suicide. The data analyzed here are part of a quantitative and qualitative multicenter research14-15. For the qualitative research, the study selected 51 cases in 10 Brazilian municipalities with high rates of mortality by suicide of elderly people in five regions of the country. The analysis included 40 cases of men who died by self-harm within an interval of two to five years. The sources of information were the official databases on mortality, expert reports, death records in notary's office, hospital records, and information from professionals of the Brazilian Unified Health System. The fieldwork included interviews with relatives and neighbors of the elderly who died by suicide, located through letters, telephone calls, visits scheduled with or without support from health professionals.
The main research tool was the technique of psychosocial autopsy14,15, understood as a strategy for data collection that integrates social and anthropological aspects to the analysis of the emotional state of the individual. The psychosocial profile of suicidal elderly men was drawn from data of their history and way of life; evaluation of antecedents and atmosphere of the act of killing; impact on the family; lethality of the method; proximity of sources of support; existing intention to commit suicide; mental status that preceded the fatal act; image and reactions of family (type of communication, interpersonal relationships, rules and expression of affection) and of community.
The data used in this paper were compiled to understand the peculiarities of the situation of elderly men who died by suicide, regardless of location where the suicide occurred. The autopsies were analyzed in depth, case-by-case, under an approach that took into account the interviewees, interpretations of researchers, and data contextualization. The final analysis was a new organization of qualitative information from the central category "masculinity" and from two subcategories: "work" and "honor."
The research project that originated this paper was approved by the Ethics Committee for Research of the Oswaldo Cruz Foundation (CEP/FIOCRUZ). All study participants signed a Free and Informed Consent form (ICF). Ethical recommendations and guidelines were properly followed and family members who were in crisis were directed to reference services and are being assisted.
Results and Discussion
Although information from family members was emphasized in this study, it was important to present a temporal analysis, which elaboration used data from the Mortality Information System of the Ministry of Health. The historical data on the suicide, according to age group, offers an eloquent visualization concerning differentiation of mortality by sex in all age groups in Brazil, a situation present in most countries1. It is noteworthy the continuance over time a pattern of higher prevalence of deaths among elderly males16 (Chart 1).
There is also a table summarizes in part the characterization of elderly men who died by suicide and whose cases are analyzed here. Most of them (55%) were between 60 and 69 years old, followed by the ones between 70 and 79 years old (25%), and above 80 years old (20%). In the five regions of the country the sample distribution of the events was: five in the north (12.5%), fourteen in the northeast (35%), seven in the west-central (17.5%), four in the southeast (10%), and ten in the south (25%). The following Table 1 shows a breakdown by marital status, education, religion, and home location (urban or rural)15.
Although half of these men had completed or not elementary school, and some high school (50%), a significant proportion had completed only elementary education (47.5%), was illiterate or semi-illiterate (22.5%), or had not information on schooling (12.5%). Only one of the men who committed suicide attended college. The southern and northeastern regions concentrated almost all illiterate individuals. In the northeast, they lived in a town with rural features similar to three cities in the south. Best levels of education were found among elderly people living in large cities. There is a predominance of Catholic religion, followed by Christians, and ten of them, according to the family, had no religion. It is understood that the division by skin color is not successful in the analysis due to the ethnic and regional diversity of the group studied. Most of the elderly men committed suicide by hanging (65%), firearms (20%), and poisoning (10%)15.
Among these men, most of them used to work or were still working in three segments of activity: agriculture (34%); services providers: carpenter, bricklayer, blacksmith, upholsterer, driver, waiter, and dispatcher (31.8%); and administration of their own business (20.5%): retailer, businessman, rural producer, farmer, restaurant, store, and shop owners15.
Work, masculinity, and suicide
For men, the most significant factor associated with suicide is the loss of status provided by the job - creating in them a feeling that there is no longer a social place, not found at home at retirement. For many, retirement or compulsory idleness implies a radical change of organization of time, of financial income, and comes full of an (anti) symbolic value, once it changes the meaning of the social role played so far13. The stories of these elderly men showed: (a) loss of meaning of life, which led to be at home only, to isolation, and to a feeling of worthlessness. This loss brought forth mainly a difficulty to adapt to changes: manifested mainly by the suffering of having to involuntarily leave work due to illness or loss of functional autonomy by insistence of family members. The main inadaptation observed was on the use of time and home confinement.
The following is an example, narrated by a family member of an elderly man:
He had recently lost his job at the company he was a director, which went bankrupt and left him without any compensation. The request for retirement was rejected as the company did not pay properly social security, there were several years more to retire. The family's financial situation was badly shaken by the father's unemployment. The children had to interrupt studies for nonpayment of college. His wife started to work at three places. He became involved in a business partnership of low profitability and had many conflicts with the business partner. All this overwhelmed him so he took his own life (about FM, 60 years, unemployed businessman, Amazonas State, Brazil).
The case mentioned above concerns an young elderly. The unemployment did not only took away his primary mean of survival and personal fulfillment, but compromised his quality of life, social inclusion, the belonging to a class17 and also the role of provider.. The open wound in his traditional performance left him in such extreme vulnerability such that the only way out that seemed feasible was suicide. In more than 10 cases analyzed among younger elderly, there were reports of much suffering due to unemployment or involuntary abandonment of work, often at an age when the family would still need their financial support. This caused them feelings of humiliation and lack of perspective. In at least two cases, the families continued to ask from these men the same standard of living they had before they retired, as an interviewee describes:
HCO showed no change of perception. However, my brother's suicidal act can be associated with financial issues, the debts of over 80 thousand reals incurred by the daughter and the wife's insistence to renovate the house and to buy a new car. And he had no conditions for such. In the day of the suicide he drank a lot and after every can of beer he would say "I'm leaving today, I will end everything." After the drinking, he went to the car and grabbed the gun, and called his daughter and the mother. There, in front of them, he stuck the gun in his mouth and pulled the trigger. Mother and daughter that much tormented him, witnessed the act (about HCO, electronic technician, 61, Piauí State, Brazil).
Many of the elderly men (19) with 70 years old or more also felt the burden of retirement or work leave, which was unacceptable for them as they were not ready to be idle, this was considered as a transgression or deviation18. Most would feel worthless, I am no good for anything else and could not even enjoy the deserved resting after a long working life: the days outside the work environment became a long, tedious, and endless loss of time. Several excerpts show such situation:
Work was the core in his life and the physical disabilities led him, at eighty years old, to stop working, causing feelings of helplessness and worthlessness. He felt lifeless, without work and without companionship. Time for him was endless (about JB, 92, retired farmer, Rio Grande do Sul state, Brazil).
The doctor stated that he was unable to work and he [the father] would not accept. He lamented about it, he would feel useless, said it was better to die; said he had no right to eat once he was not working (about FAC, 68, retired, Amazonas state, Brazil).
After he stopped working because he retired, he was no longer able to live. He was always sad, isolated, suffered from insomnia, took too long to sleep, he would live with himself only (about RPS, 72, retired, Piauí state, Brazil).
Usually, for the older ones among the elderly, the moment they stop the activities and loose power over their families coincided with many other losses such as widowhood, the fact of having to leave home and live with their children, and the suffering from illnesses that now hinder their autonomy. Thus, many felt, according to their family members not talking, quiet, sad, marginalized no place inside their homes and without a narrative repertoire capable of expressing body and health limitations. The fact that they had leave their homes in which they have always lived and having to live with their children - a situation found in at least five cases - concludes this feeling of inadequacy to the world19.
Although many say that work lost its meaning in contemporary society, it is precisely the lack of it that reaffirms its importance20. This is particularly true for the elderly whose life habits were shaped by the material, psychological, and moral construction of work ethics21.
By analyzing the relationship between suicide and work, Dejours and Bègue22 recall that, historically and in several parts of the world, farmers have been a group with high suicide rates. The peasant logic has in the categories "land", "work" and "family" the foundation for building an ethic that guides their actions, which main goal is to ensure the physical and social reproduction of the domestic group. The link between work and family is found in the life stories of many of the elderly who committed suicide, especially those from rural areas23,24. The living conditions, loneliness, and isolation play an important role in the genesis of this phenomenon, in addition of increasingly common threats by bank debts and impoverishment caused by economic crises.
In Rio Grande do Sul, where suicide rates are the highest in the country25, the municipalities selected for the study were predominantly agricultural and had tobacco as main crop. The narratives of the families highlighted their increasingly dependency on tobacco. Moreover, in concrete situations, there is still an aggravating factor as in the case of debt, the death of the family head can release the due balance. Thus, suicide often represents a way out for the elderly to honorably leave from a financial crisis. The following statements refer to the explanations of family members about reasons relating to suicide, by the failure to keep the farmer's social role:
The situation was aggravated by the need to mortgage the property as a result of a loan requested by the son to plant tobacco. He had never request loans before and was against such type of commitment. There was a major drought in the following year causing total loss of the crop. This process of debt generated feelings of unworthiness and fear of bankruptcy (about RK, 74, retired farmer, Rio Grande do Sul state, Brazil).
Retired and sick (he had a prostate related disease and needed to wear diapers and probe), he kept on planting tobacco, trying to survive. He would go to the farm with the probe and worked with the hoe. After he retired he stopped everything. The money was not enough to even buy medicine for him. They would give us food. The house was down there, it fell apart, it was all rotten (about JLS, 81, retired farmer, Rio Grande do Sul state, Brazil).
Masculinity, honor, and suicide
For many elderly people who committed suicide, issues related to honor24-27 are associated with loss of property, status, and losses in business ventures, when their reputation was tainted or that illnesses turned them impotent.
Concerning material losses, for farmers, the main issues were problems with crop harvests, business loss, and debts. For urban workers, the purchasing power reduction due to retirement, panic due to financial default, worries about loans granted and not paid back, and fear of impoverishment and fail to function as provider.
In studies on the culture of honor25-27, the pair honor/shame establishes standards, rules of conduct, and hierarchies, assuming specific features in every society. Honor is still an important referential in the structuring of gender unequal relations and to the behavior in labor activities, in which the worker assumes a moral commitment to fulfill the agreement with the employer. The moral concern to repay the debt traps the worker to himself and to others23. In the excerpts below, there is concern about saving, about not having debts and to honor the commitments made:
He was very concern about paying the bills, he would pay in advance to not owe anyone. When he could no longer pay and acquired more debts, he was in despair. There was a financial loss, and with my mother's illness, he spent everything he saved in his whole life (about AS, 78, retired public employee, Rio de Janeiro state, Brazil).
He said he did not need to spend, he liked to save money, he would never borrow, he was afraid of not being able to pay things. He used to say "everyone will starve!" He was terrified! The year he committed (suicide), we got a loan, then he would always said "it is too dry and I will not be able to pay it" (about RK, 74, retired farmer, Rio Grande do Sul state, Brazil).
A man may feel dishonored when he cannot pay his debts but also when he suffers unfair or false accusations. This happened to a pastor accused of embezzling funds from his church. The accusation was disproved, but the wound remained incurable. The same happened with another elderly men who were unjustly arrested for drug dealing. He suffered a lot in prison and when he left, he could not adjust either socially or at work. Both cases are exemplified below:
He was a pastor. He was depressed and felt like a defeated man. He spoke of his sadness because he felt betrayed, because people thought he had stolen from the church. Although this episode was resolved, he could not forget nor stop suffering from it (about PI, 66, pastor, Mato Grosso do Sul state, Brazil).
He died from a stab wound to the chest. He had many possessions because he was a fighter, but he lost everything. He had a very troubled relationship with a second wife. He was arrested along with her for drug dealing and used to say that it was wrongly. He was very humiliated in prison and he said this wife betrayed him. He went out prison and lived sad, isolated, and lonely. He never recovered. He tried to kill himself several times with BB gun (about EG, 61, freelance seller, Mato Grosso do Sul state, Brazil).
The fact that many men have been raised and educated under the precepts of hegemonic masculinity, with rudeness and lack of affection to be trained for the role masculinity, leads them to reproduce this type of bond with others. As parents and providers, they feel as guardians of honor and control the moral and sexual conduct of wife and children:
He had many disappointments with his daughter; he did not want her to go out and arrive late. She left home and went to live with others. She was a lesbian. One of his sons was gay. He said that none of his daughters was worth it. (About OGB, 62, bricklayer, Amazonas state, Brazil).
The prospect of being the one responsible for the economic survival of the family is a key element that persists even when the man does not work or becomes dependent from his children or other people. To fail in fulfilling this role may translate in dishonor and shame:
He did not give a dime at home, everything was afforded by the mother. The little he received was for the daughter of another marriage. He returned to live with us, but still had a relationship with the other woman. His greatest shame was that he financially depended on my mother, because the little money he received was for the other woman, they had a son and he was terrified of being arrested for not paying child support. (about JNC, 62, upholsterer , Piauí state, Brazil).
Traditionally, within the sexual division of labor and of skills, the house is the feminine or feminizing space, and men do not like to get hold of such space to not endanger his masculinity. Many women prefer to keep men out of housework. Several elderly people, by limitations due to age or illness, end up being restricted to their home and dependent on the care of children or wife. The stories show that many of them did not accept at all such limitations and even without physical condition, they avoided what they call role of little women28. Thus, there is a view of superiority and attachment to the traditional sexual division of labor. When this relationship is disrupted by lack of autonomy, widowhood, separation, or even abandonment by the wife, the elderly man is more vulnerable to suicide.
He got very isolated, with no family around. I believe that if he had more support, if the family was closer to him, he would not have committed suicide (about ESS, 79, retired farmer, Rio de Janeiro state, Brazil).
He was a closed person, quarrelsome; he would not communicate much with his children. He came from the countryside and never got used to the city. He suffered multiple losses, lost a son in a work accident, and lost his wife. Seven days after the death of his wife, he killed himself (about SJ, 90, retired farmer, Amazonas state, Brazil).
He hanged himself. He was 90 years old. The children blocked his properties; his wife would hit him with a stick. He had a guilty feeling as he had a mistress, he used to live overwhelmed by fear and sad by the abandonment of his children, and by his wife abuse (about LD, 80, retired engineer, Mato Grosso do Sul state, Brazil).
In the socialization of men within the male chauvinism perspective, it is imperative the exercise of an urgent sexuality, and if such sexuality is repressed it jeopardizes virility. Sexual practices with multiple partners is acceptable for men, along with the expected ability to keep sexual relations due to the good function of the sexual organ29. The inability to have sexual relations threats the male identifying process and mobilizes intense feelings of aggression against himself or against each other. There are several cases of men saying they could not bear being cheated on, abandoned and replaced:
He had a troubled relationship with his wife, who humiliated him and called him old. There were several types of fights between husband and wife. There was even suspicion about the paternity of the couple's second child. This situation would depress and isolate him (about EP, 61, freelance retailer, Mato Grosso do Sul state, Brazil).
He disagreed with the separation and with the fact that his ex-wife was remarried. He was a simple man from the countryside; he had strict standards and would not accept very well the new circumstances he experience with his family. He felt an excruciating pain that interfered with his sex life to the point where he stated, "I am no longer a man to a woman" (about OGB, 62, bricklayer, Amazonas state, Brazil).
His wife mistreated him; the violence would happen with a wooden club, like a baseball bat. The wife´s lover would come to their own house and he felt very humiliated. He could not stand it! (about RB, 80, retired engineer, Mato Grosso do Sul state, Brazil).
For many men, the fact of losing control over their wives or partners, which in patriarchal culture means a failure in carrying out the role of masculinity, may be more unbearable than death or suicide.
Focusing on the idea of loss of honor, there are also the experiences of degenerative diseases. In this study, these situations came up through several ways, as injuries by car or work related accidents, limb amputations, or blindness by diabetes problems and, particularly, surgeries to treat bladder, hernia, intestine requiring colostomy, and of prostate cancer, which left several of them impotent. Several of them also suffered a lot by the threat of having limbs amputated due to diabetes.
He would not accept leaving the job. He was diabetic, he was afraid of going blind and losing limbs, and he got bladder cancer. He was afraid and ashamed of degeneration (aboutCLS, 83 years, retired dispatcher, Rio de Janeiro state, Brazil).
He said he was no longer a man. He had his pelvis broken, unable to walk and got a prostate problem. He lived in a greatest sorrow, silent and lonely (about FG, 92, retired carpenter, Mato Grosso do Sul state, Brazil)
He hanged himself with 81 years old. Over time, he became violent and said he was no longer a man because he was impotent. He had to undergo bladder and prostate surgery, he had to use a probe and felt much shame and humiliation (about JLS, 81, retired farmer, Rio Grande do Sul state, Brazil).
This type of conflict can be expressed in the statement "I can no longer function as a man," a recursive sentence in the stories of elderly men included in this study. It is believed that the cultural model of honor is more likely to be found in the habits of older men and there's a good chance that this pattern will modify as gender equality progresses, especially in urban areas.
The suicide of elderly men is now considered a public health problem in most countries1,27-29. As shown in this study, there are several factors associated with self-inflicted death of this social group, being undeniable the importance of the hegemonic male culture as a preeminence factor of male suicides rates compared to female ones. This is demonstrated through psychosocial autopsies15 as well as historical and ecological studies16.
In general, most authors mentioned in this study points out that elderly women die less by violence or self-violence than men die, and take more care of their health and sociability. Once, even in old age, they tend to continue their roles as caretakers, they keep housework chores, and have a closer and more communicative relationship with family members and with the surrounding community. In addition, when they get sick, they seek medical help more often, and culturally resist more to suffering and pain12,28,33,34.
Facing such reasons, today in Brazil, taking care of the elderly man's health is a topic of high relevance. Unfortunately and despite the fast growth of life expectancy, the Brazilian National Men's Health Policy (PNAISH) National contemplates guidelines only for men between 25 and 59 years old, for the period traditional and ideologically recognized as productive35. Thus, it is paramount to rescue the debate that established this limit, once the demographic picture today shows that many elderly men are living up to 90 or more years, as range above 80 years old is the fastest growing one (in proportion) in the country36. All professionals that work in geriatrics know that Brazilian men over 60 years old are increasingly integrating in society and have active sexual and working life. However, there is a group with serious health problems, for who - especially in the countryside - lack proper care and assistance. Due to the obvious quantitative and qualitative change in the profile of the age cohort formed by the elderly, such cohort should be included in the Health Policies directed to men. If the care given, according to the perspective of gender, is limited only to the traditional productive life, it would seem that the Ministry of Health Ministry would be focusing guidelines for action for people over 60 years old in the National Health Policy for the Elderly37, which would be based on the idea of care per lifecycle. However, the "gender" category is also not found in the last policy, as it does not distinguish the unique needs of men and women. This leads to the conclusion that the health sector, from the official point of view, considers elderly above 60 years as asexual. Thinking specifically on the phenomenon of suicide, the study analyzed the National Policy for Mental Health38, which aims to consolidate an open, community-based care model. The policy proposes the free circulation of people with mental disorders to services, communities, and cities, and advocates care based on the resources that the community offers. This model relies on network of several services and equipment such as Centers for Psychosocial Care (CAPS), Therapeutic Residential services (SRT), Centers for Living and Culture, and comprehensive care units (in general hospitals and specialized CAPS ). However, in the guidelines, the document emphasizes the youth group and does not even mention the elderly.
Thus, the aforementioned health policies emphasize that there is no place for the elderly under gender perspective. Elderly men are a group at high risk for self-inflicted violence, so the topic of this study should be reinserted in the guidelines for action in the health sector, with the proper significance it deserves. It is very important to health care systems and social services to become aware of this public health condition1.
It should be emphasized that elderly men need specific attention, especially in moments of transition from working life to retirement, in situations involving loss of significant family members and when they are diagnosed with chronic degenerative diseases, such as diabetes and cancer or have to face disabilities or dependencies. Moreover, the discussion and encouragement about changes in traditional gender roles helps men and women to tolerate faults in the masculinity standard performance.
The policy guidelines for health promotion certainly provide a language towards action. Still, there is no doubt that elderly men, like elderly women, need much more recognition and support than they receive today in the programs, services, and from their families. Concerning the relatives, many of the reports noted that the elderly men complained of loneliness, sadness, and suffered by the absence or poor communication with their children and grandchildren, exactly when they were more vulnerable due to several losses and illnesses.
Thus, suicide of elderly men speaks less of death than of conditions, situations, and problems they face at end of life and shows, with eloquence, the burden of cultural and relational issues that discard, ignore, or isolate them.
MCS Minayo, SN Meneghel and FG Cavalcante participated equally in all stages of preparation of the article.
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