Abstract

Suicide among women is a matter of public health, and there is a lack of scientific literature on this issue. In this theoretical essay, we sought to discuss suicide among women in Brazil from a gender perspective. For that purpose, we adopted the idea that gender extrapolates the concept of sex, considering that differences between people are produced by culture and arrangements through which society transforms biological sexuality into the realizations of human life. Therefore, this article is organized in a way to indicate some explanatory models of suicide among women, discussing gender inequalities and approaching the matter of intersectionality from a protective view. Moreover, we believe that the theme is extremely complex, considering that stigma still resists, as does prejudice related to this issue. Hence, it is of utmost importance to view the structural questions that refer to suicide in women, such as violence and gender inequalities.

Key words:
Suicide; Women; Gender and Health; Mental Health

Introduction

Suicide is considered to be the human act of inflicting death upon oneself, in a deliberate manner and aware of the fatal outcome¹1 Durkheim E. O suicídio: um estudo sociológico. 1ª ed. São Paulo: Edipro; 2017.. It is one of the oldest themes related to the way in which individuals are affected by societies and collectives in which they live, and the conceptions regarding this issue change according to the historical context. In antiquity, in societies such as the Greek and the Maya, this was a permitted act. In the religious perspective of the Judeo-Christian tradition, especially since the 18th century, this was objectionable. With the advent of Modernity, in the 19^th century, the act began to be seen as a social phenomenon, as of the studies by Émile Durkhein, while in post-modernity, there was the consolidation of a view concerning suicide as a health grievance caused by multiple factors, such as issues of a psychological, economic, biological, political, philosophical, historical, and cultural natures²2 Ribeiro JM, Moreira MR. Uma abordagem sobre o suicídio de adolescentes e jovens no Brasil. Cien Saude Colet 2018; 23(9):2821-2834.^,33 World Health Organization (WHO). Preventing suicide: a global imperative [Internet]. Geneva: WHO; 2014 [acesso 2022 set 15]. Disponível em: https://www.who.int/publications/i/item/9789241564779..

Currently, suicidal behavior is classified into fatal (the consummated suicide) and non-fatal, which is manifested in terms of ideation and attempted suicide. As far as ideation goes, there are thoughts of self-inflicted death which may be more serious when followed by a plan to carry it out. Suicide attempts involve intentional acts that may lead to self-inflicted death or may not, thereby constituting an important risk factor for consummated suicide³3 World Health Organization (WHO). Preventing suicide: a global imperative [Internet]. Geneva: WHO; 2014 [acesso 2022 set 15]. Disponível em: https://www.who.int/publications/i/item/9789241564779..

For the World Health Organization (WHO), suicide is an important and serious public health problem; it is estimated that it causes the death of approximately 703,000 people around the world annually⁴4 World Health Organization (WHO). Suicide worldwide in 2019: global health estimates [Internet]. Geneva: WHO; 2021 [acesso 2022 set 15]. Disponível em: https://www.who.int/publications/i/item/9789240026643., representing a global average rate of nine deaths for every 100,000 people. The biggest burden of such a health grievance (77% of the total deaths) is observed in both low- and middle-income countries, with higher rates among men, with the exception of Sri Lanka, El Salvador, Cuba, Ecuador, and China, which are countries that show higher rates among women or equivalent rates among men and women⁵5 Barrigon ML, Cegla-Schvartzman F. Sex, Gender, and Suicidal Behavior. Curr Top Behav Neurosci 2020; 46:89-115..

In Brazil, the suicide coefficients for men were 3.8-fold higher than those for women (10.7 deaths per 100,000 men and 2.9 deaths per 100,000 women), in the period from 2010 to 2019. These results proved to be similar to what is observed in most countries around the world⁶6 Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Mortalidade por suicídio e notificações de lesões autoprovocadas no Brasil. Boletim Epidemiológico [Internet] 2021 [acesso 2022 set 12]. Disponível em: https://www.gov.br/saude/pt-br/media/pdf/2021/setembro/20/boletim_epidemiologico_svs_33_final.pdf.
https://www.gov.br/saude/pt-br/media/pdf... . However, it is important to highlight that, in Brazil, the temporal tendency of suicide among women was on the rise in several age groups (15 to 60 years of age), between 1997 and 2015⁷7 Rodrigues CD, Rorigues HM, Konstatyner TCRO. Trends in suicide rates in Brazil from 1997 to 2015. Braz J Psychiatry 2019; 41(5):380-388.. In the majority of the states from the Northeast Region of Brazil, this was also evident in the records from 1996 to 2018⁸8 Dantas ESO, Farias YMF, Rezende EB, Silva GWS, Silva PG, Meira KC. Estimates of suicide mortality in women residents in northeast brazilian states 1996 to 2018. Cien Saude Colet 2021; 26(10):4795-4804..

Besides the increasing tendency of deaths by suicide among women, it is important to mention the “suicide paradox”, a concept used to refer to the fact that more men actually die from suicide, while women present more ideation and attempts, and are therefore more affected by suicidal behavior in general⁹9 Beautrais AL. Women and suicidal behavior.Crisis 2006; 27(4):153-156.^,1010 Meneghel SN, Gutierrez DMD, Silva RM, Grubits S, Hesler LZ, Ceccon RF. Suicídio de idosos sob a perspectiva de gênero. Cien Saude Colet 2012; 17(8):983-992.. In that sense, 68% of the 338,569 notifications of suicide in Brazil, from 2010 to 2018, happened among women¹¹11 Meira KC, Dantas ESO, Jesus JC. Suicídio: uma questão de gênero [Internet]. 2021 [acesso 2022 set 25]. Disponível em: https://demografiaufrn.net/2021/03/22/suicidio-uma-questao-de-genero/.
https://demografiaufrn.net/2021/03/22/su... .

The consistency of the data allows us to infer that those differences in the expression of the suicide phenomenon among both men and women are not a matter of chance, nor are they related simply to biological differences. On the contrary, the differences are related to the social construction of gender roles in a patriarchal society, which promotes asymmetry in the power relationships and results in the subordination and oppression of women by men¹²12 Zanello V. Saúde Mental, Gênero e Dispositivos: Cultura e Processos de Subjetivação. 1ª ed. Curitiba: Appris; 2018.^,1313 Segato RL. Gênero e colonialidade: em busca de chaves de leitura e de um vocabulário estratégico descolonial. E-Cadernos Ces 2012; 18:1-5.. According to this view, it is important to explore this phenomenon according to the gender perspective, considering that differences and inequalities determine people’s way of life and may well influence the appearance of suicidal behavior.

The importance of discussing suicide from this point of view, is primarily determined by the urgency in observing a theme that has been historically stigmatized. This discussion is based on an understanding of gender issues, which extrapolates the concept of sex (male, female) adopted by epidemiology. The current gender definition considers that differences among individuals are produced by culture, thus defining a set of arrangements by which a society transforms biological sexuality into accomplishments of life and creates power asymmetry among males and females¹⁴14 Saffioti HIB. Gênero, patriarcado, violência. 2ª ed. São Paulo: Editora Perseu Abramo; 2004..

This article, following an essay format, seeks to contribute in a theoretical and reflective manner, to the theme of suicide among women, since there is a scarcity of studies in international literature taht approach the theme in a robust manner⁹9 Beautrais AL. Women and suicidal behavior.Crisis 2006; 27(4):153-156.^,1515 Dantas ESO, Silva GWS, Guimarães J. Aspectos psicossociais do suicídio em mulheres do sertão do Rio Grande do Norte, Brasil. Cad Saude Colet 2022; 30(2):215-223.^,1616 Meneghel ST, Moura R, Hesler LZ, Gutierrez DMD. Tentativa de suicídio em mulheres idosas - uma perspectiva de gênero. Cien Saude Colet 2015; 20(6):1721-1730.. Hence, our study aims to discuss suicide among women in Brazil from a gender perspective.

This article is organized in the following manner: (1) presentation of explanatory models for suicide among women; (2) discussion on gender inequalities that define psychological suffering and suicidal behavior among women; and (3) considerations about suicide among women and intersectionality.

Suicide among women according to explanatory models

Throughout history, most of the people who studied suicide related this theme to the male universe, granting to the suicidal act adjectives which define the life of men and reinforce hegemonic masculinity: strength, courage, virility, explosive personality and impulsivity, among other adjectives. Thus, in a chauvinistic way, for a long period of time, it was understood that the lower number of cases of suicide among women could be justified by physical fragility, greater sensitivity, and less courage to attempt suicide by aggressive means⁹9 Beautrais AL. Women and suicidal behavior.Crisis 2006; 27(4):153-156.^,1515 Dantas ESO, Silva GWS, Guimarães J. Aspectos psicossociais do suicídio em mulheres do sertão do Rio Grande do Norte, Brasil. Cad Saude Colet 2022; 30(2):215-223..

In this sense, when the sociologist, Émile Durkheim, developed his classic work about suicide in the 19^th century, he stated that the phenomenon appears differently among genders because women had a less developed mental life, as well as less aspirations, ambitions, and personal needs. The author defines that women who followed the hegemonic script of femininity, linked to the family and socially subordinated to men, would have less risk of suicide¹1 Durkheim E. O suicídio: um estudo sociológico. 1ª ed. São Paulo: Edipro; 2017..

Going against Durkheim, there is evidence that the reduction of gender inequalities is a determining protection factor for women against all kinds of violence, including self-inflicted. In this sense, a study developed in 33 developing countries found that suicide rates among women were lower in countries with social structures that give priority to gender equality¹⁷17 Rudmin FW, Ferrada-Noli M, Skolbekken JA. Questions of culture, age and gender in the epidemiology of suicide. Scand J Psychol 2003; 44(4):373-381..

Since the beginning of the 20^th century, psychiatry began to define the narratives of suicide, highlighting the role of the individual and individuality in detriment of the sociocultural, economic, and political environment. Suicide began to be seen according to a biomedical point of view, as well as according to mental disorders and their symptoms, especially depression, bipolar affective disorder, schizophrenia, alcohol and drug abuse, and personality disorders³3 World Health Organization (WHO). Preventing suicide: a global imperative [Internet]. Geneva: WHO; 2014 [acesso 2022 set 15]. Disponível em: https://www.who.int/publications/i/item/9789241564779.^,1818 Minayo MCS, Figueiredo AEB, Mangas RMN. O comportamento suicida de idosos institucionalizados: histórias de vida. Physis 2017; 27(4):981-1002.^,1919 Botega NJ. Comportamento suicida: epidemiologia. Psicol USP 2014; 25(3):231-236..

According to this psychological view of suicide, predominant even today, the social markers present in the lives of women are underplayed, including gender violence, which is quite frequent in the lives of women, including marital, sexual, patrimonial, among other types of violence. In opposition to this hegemonic model, even if considering the presence of mental disorders, it is necessary to look beyond the symptomatology limited by psychopathology, since human suffering - which is also present in people with mental disorders - is something that is also covered by stigma, prejudice, abandonment, and several forms of social exclusion¹²12 Zanello V. Saúde Mental, Gênero e Dispositivos: Cultura e Processos de Subjetivação. 1ª ed. Curitiba: Appris; 2018.^,1616 Meneghel ST, Moura R, Hesler LZ, Gutierrez DMD. Tentativa de suicídio em mulheres idosas - uma perspectiva de gênero. Cien Saude Colet 2015; 20(6):1721-1730.^,2020 Baére F, Zanello V. O gênero no comportamento suicida: uma leitura epidemiológica dos dados do Distrito Federal. Estud Psicol 2018; 23(2):168-178..

In the field of neurobiology, studies conducted especially in the last few decades have tried to define the relationship between biomarkers and suicidal behavior²¹21 Berardelli I, Serafini G, Cortese N, Fiaschè F, O'Connor RC, Pompili M. The Involvement of Hypothalamus-Pituitary-Adrenal (HPA) Axis in Suicide Risk. Brain Sci 2020; 10(9):653.

22 Gross JA, Turecki G. Suicide and the polyamine system. CNS Neurol Disord Drug Targets 2013; 12(7):980-988.^-2323 Allen L, Dwivedi Y. MicroRNA mediators of early life stress vulnerability to depression and suicidal behavior. Mol Psychiatry 2020; 25(2):308-320.. Those studies proved to be consensual regarding the power of environmental stress in terms of creating important physiological mechanisms, such as polyamin and that from the hypotalamus-hipofisary-adrenal axis, given that those biological mechanisms may contribute to the occurrence of mental disorders and to the increased risk of suicide.

The physiological response to stress, which is studied by neurobiology, is a frequent process in the lives of women, and generally begins early on. It is common that women are exposed to multiple types of violence (sexual, physical, psychological, patrimonial, and moral), and this may influence cerebral responses in a negative manner, making women poorly adapted to adult life and/or old age¹⁰10 Meneghel SN, Gutierrez DMD, Silva RM, Grubits S, Hesler LZ, Ceccon RF. Suicídio de idosos sob a perspectiva de gênero. Cien Saude Colet 2012; 17(8):983-992.^,1414 Saffioti HIB. Gênero, patriarcado, violência. 2ª ed. São Paulo: Editora Perseu Abramo; 2004..

In addition, psychology defines that people seek self-extermination as they are unable to find any possible solution to escape their own unbearable psychological suffering. Shneidman²⁴24 Schneidman E. Definition of suicide. Northvale: J. Aronson; 1994. considered that suicide is the result of the confluence of three elements: pain, disturbance, and pressure (psychological), and once they have become unbearable, there is no other way out for the individuals.

From a critical and complementary standpoint, the humanities indicate a form of logic that sees suicide as a means of expression and communication. However, to understand suicidal behavior as a means of communication, it is necessary to resort to the construction of hegemonic femininity in patriarchal society as something defined by power relationships, in which men impose and create limits for behaviors deemed to be masculine and feminine²⁵25 Tedeschi LA. Os desafios da Escrita feminina na história das mulheres. Raído 2016; 10(21):153-164.. In that perspective, silence is considered to be a female attribute. In that space of silence and silencing, this type of identity has been defined over time²⁶26 Marquetti FC. O suicídio e sua essência transgressora. Psicol USP 2014; 25(3):237-245.^,2727 Marquetti FR, Marquetti FC. Suicídio e feminilidades. Cad Pagu 2017; 49:e174921..

In other words, to comprehend suicide among women, we must understand that the question is complex and that it cannot be reduced to simplistic explanations based on one single explanatory model. We believe that it is important to consider its many factors as being interconnected. According to this logic, it is necessary to consider the moral and sociopolitical changes in the gender roles defined by society.

Gender inequalities that cause psychological suffering and suicidal behavior

Gender is a relational concept, which involves unequal power relationships. This inequality places more prestige or less prestige on individuals according to the biological sex. Thus, historically, heterosexual men have been given more consideration and power in relation to women and to feminized bodies¹²12 Zanello V. Saúde Mental, Gênero e Dispositivos: Cultura e Processos de Subjetivação. 1ª ed. Curitiba: Appris; 2018.

13 Segato RL. Gênero e colonialidade: em busca de chaves de leitura e de um vocabulário estratégico descolonial. E-Cadernos Ces 2012; 18:1-5.^-1414 Saffioti HIB. Gênero, patriarcado, violência. 2ª ed. São Paulo: Editora Perseu Abramo; 2004..

According to this perspective, gender inequality would be a product of the submission of women in patriarchal society, since it is defined as a system of male domination that has in its roots the sexual division of labor - the maintenance of the main female activities within the home environment, the denial of sexual and reproductive rights, and in the chauvinist customs that impose obedience and silence even in the face of violent situations²⁸28 Sousa LPD, Guedes DR. A desigual divisão sexual do trabalho: um olhar sobre a última década. Estud Ava 2016; 30(87):123-139.. In other words, gender inequalities make women more vulnerable.

Vulnerability is an ontological condition that can affect any individual, defined by the possibility of one being hurt. However, it is not defined in the ontological sphere, but rather in the ethical sphere, as an appeal for a non-violent relationship between the self and the other²⁹29 Neves MCP. Sentidos da Vulnerabilidade: característica, condição, princípio. In: Barchifontaine CP, Zoboli ELCP, editores. Bioética, vulnerabilidade e saúde. 1ª ed. Aparecida: Ideias & Letras; 2007.. In this construct, there will be people with more likelihood of being hurt, and who, consequently, are more easily injured. Vulnerabilization, in this context, is the act or the effect of causing vulnerability. In other words, hurting and keeping people from developing their potential (capabilities), and the one who is hurt is considered to bevulnerable³⁰30 Schramm FR. Bioética da Proteção: ferramenta válida para enfrentar problemas morais na era da globalização. Rev Bioetica 2008; 16(1):11-23.. Our study established that suicide among women is intimately related to the gender vulnerability that individuals suffer and that is imposed by society.

In the field of public health, gender matters are usually related to suicide after the death has occurred, especially according to the epidemiological view which presents the rates of suicide attempts and of deaths by suicide as differentiated according to gender. However, some authors indicate that the ideation, the suicidal attempt, and the actual death by suicide are affected by gender issues; therefore, gender is present in every phase of the suicidal bahavior²⁰20 Baére F, Zanello V. O gênero no comportamento suicida: uma leitura epidemiológica dos dados do Distrito Federal. Estud Psicol 2018; 23(2):168-178.^,3131 Jaworski K. The gender-ing of suicide. Austr Fem Stud 2010; 25(63):47-61..

Following this logic, gender violence is a strong predictor for the advent of suicidal behavior⁹9 Beautrais AL. Women and suicidal behavior.Crisis 2006; 27(4):153-156.^,3232 Drevies K, Watts C, Yoshihama M, Kiss L, Schraiber LB. Violence against women is strongly associated with suicide attempts: evidence from the WHO multicountry study on women's health and domestic violence against women. Soc Sci Med 2011; 73:79-86.^,3333 Minayo MCS, Cavalcante FG. Estudo compreensivo sobre suicídio de mulheres idosas de sete cidades brasileiras. Cad Saude Publica 2013; 29(12):2405-2415.. We emphasize that, beyond the explicit marks of gender violence, which may appear as physical wounds, there is also psychosocial suffering inherent to any violent action. This is present, inclusively, in the fact that many women internalize the suffering and are not able to show it. That in turn weakens interpersonal and family relationships, retro-feeds traumas, and may leave women with the feeling that there is no possible escape other than self-inflicted death³³33 Minayo MCS, Cavalcante FG. Estudo compreensivo sobre suicídio de mulheres idosas de sete cidades brasileiras. Cad Saude Publica 2013; 29(12):2405-2415..

An important indication of this close relationship between suicidal behavior and violence is related to the presence of sexual abuse in childhood. This kind of violence subordinates women to a process of suffering which may last for an extremely long time, and significantly increases the chances for the development of serious mental disorders. According to this logic, the risk of suicidal ideation increases with the extent of the sexual abuse suffered³⁴34 Cruz MA, Gomes NP, Campos LM, Estrela FM, Whitaker COM, Lírio JGS. Repercussões do abuso sexual vivenciado na infância e adolescência: revisão integrativa. Cien Saude Colet 2021; 26(4):1369-1380..

In Brazil, reports of violence against women have been rising over the years. In 2011, there were 75,033 reports; in 2015, the number rose to 162,575, which represents a 116.67% increase. The cases reported to the Call 180 service (“Ligue 180”, in Portuguese), a phone service to report violence against women, increased 37.6% in April 2010 as compared to April 2019³⁵35 Beeston D. Older people and suicide. Stoke-on-Trent: Centre for Ageing and Mental Health, Stanfordshire University; 2006.^,3636 Meira KC, Jomar RT, Santos J, Silva GWS, Dantas ESO, Resende EB, Rodrigues WTS, Silva CMFP, Simões TC. Efeitos temporais das estimativas de mortalidade corrigidas de homicídios femininos na Região Nordeste do Brasil. Cad Saude Publica 2021; 37(2):e00238319.. In 2020, particularly, the COVID-19 pandemic was in full force and many changes were imposed upon people’s way of life, such as social isolation, work and study in the home office model, labor and income shortages, and the ailment and death of very close friends and relatives³⁷37 Fórum Brasileiro de Saúde Pública (FBSP). Violência doméstica durante a pandemia de Covid-19 - Ed. 2 [Internet]. São Paulo: FBPS; 2020 [acesso 2022 set 12]. Disponível em: http://forumseguranca.org.br/wp-content/uploads/2020/06/violencia-domestica-covid-19-ed02-v5.pdf..

During the pandemic, unprecedented in current history, women were more affected negatively, not only by the increase in cases of domestic abuse, due to the increased coexistence with the main aggressors, but also due to the accumulation of gender roles which overlapped previously defined roles. Usually, the burden of household tasks falls upon women, as does child care and care for sick relatives; moreover, during the pandemic period, women were/still are a relevant part in professions related to taking care of the sick, such as nursing and physical therapy³⁸38 Dantas ESO. Saúde mental dos profissionais de saúde no Brasil no contexto da pandemia por Covid-19. Interface (Botucatu) 2021; 25(Supl. 1):e200203.^,3939 Fornari LF, Lourenço RG, Oliveira RNG, Santos DLA, Menegatti MS, Fonseca RMGS. Domestic violence against women amidst the pandemic: coping strategies disseminated by digital media. Rev Bras Enferm 2021;74(Supl. 1):1-8..

Although there is still little or no evidence of an increase in deaths by suicide during the first phase of the pandemic, the rates of mortality and of suicide attempts have increased in several scenarios, in countries such as Canada, Chile, Japan, Germany, among others⁴⁰40 Bellizzi S, Lorettu L, Nivoli A, Molek K. Suicide of women and girls during the COVID-19 pandemic. Int J Gynecol Obstetrics 2022; 157(3):742-743.. In Asian countries, which have expressive rates of suicide among women, some important facts have been observed. In Japan, the monthly rates of suicide increased 16% during the second wave of COVID-19, between July and October 2020, with a higher increase among women (37%). In South Korea, there was an increase of 43% in suicides among young women in the first semester of 2020, as compared to the previous year⁴⁰40 Bellizzi S, Lorettu L, Nivoli A, Molek K. Suicide of women and girls during the COVID-19 pandemic. Int J Gynecol Obstetrics 2022; 157(3):742-743.. In Brazil, there was an increase in the rates of suicide during the first, third, and fourth trimesters of 2020 when compared to the same periods in the quadriennium of 2016-2019, representing, respectively, 14.07%, 10.88%, and 13.45% increases⁴¹41 Brasil. Ministério da Saúde (MS). Banco de dados do Sistema Único de Saúde - DATASUS. Informações de Saúde, Sistema de Informações sobre Mortalidade [Internet]. [acesso 2022 set 12]. Disponível em: http://www.datasus.gov.br/catalogo/sim.htm.
http://www.datasus.gov.br/catalogo/sim.h... .

International experience makes us reflect on the way in which challenging moments for society, such as the COVID-19 pandemic, can negatively influence the lives and deaths of women, considering the gender roles imposed and the biopsychosocial consequences such as loneliness, isolation, boredom, fear, and uncertainty which bring marginalization, changes in mental health, worsening of physical problems, economic crisis, and domestic abuse.

In this context, the public health responses must guarantee that every woman who faces situations of violence are supported, helped, and cared for, based on the principle of integrality, which takes into consideration the multiple dimensions and complexities of people’s problems, based on a pluridimensional view of individual and collective health, which requires humane and democratic actions of health promotion and prevention.

Suicidal behavior among women and intersectionality

Brazil is a country with a large territory and is heterogeneous in its cultural and socioeconomic aspects. In this light, gender inequalities do not affect every woman in the same way. Some are more vulnerable than others, especially black women, women who live in extreme poverty, those who are out of the formal labor market, those working in informal jobs, as well as those who are outside of the mandatory normality and conformity.

Since we are not defining women as a monolithic category, intersectionality arises as an important matter to be discussed. Akotirene⁴²42 Akotirene K. Interseccionalidade. 1ª ed. São Paulo: Jandaíra; 2019. states that the field of intersectionality has the aim of providing visibility and theoretical-methodological instrumentality to the inseparable structure of racism, capitalism, cisnormativity, and patriarchal structure. In this sense, the patriarchal structures, which are chauvinistic and sexist, oppress and make women from different social classes, races, ethnic groups, and sexualities, as well as with dissident expressions of gender, vulnerable, although in different ways.

Intersectionality has come from the critical premise, initially constructed by American black women who denounced the existence of a white, middle-class, heterosexual feminism, which did not address every woman. Therefore, it proposes an analysis of domination’s structural interactions, which takes into consideration the political and legal aspects and seeks to unveil the specificities of oppression in the bodies and lives of a wide range of women, but without relativization, which shifts the power relationships, transforming them into an object of discursive dispute⁴²42 Akotirene K. Interseccionalidade. 1ª ed. São Paulo: Jandaíra; 2019..

Considering this, it is important to highlight that the experiences of women who are black, poor, lesbian, gay, bisexual, transgender, queer, intersexual, asexual, pansexual, non-binary, and LGBTQIA+, regardless of the many overlapping elements, are all distinct in terms of exclusion and social erasing. When we consider suicide among black women, the booklet entitled Deaths by suicide among adolescents and young blacks⁴³43 Brasil. Ministério da Saúde (MS). Óbitos por Suicídio entre Adolescentes e Jovens Negros 2012 a 2016 [Internet]. 2019 [acesso 2022 set 18]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/obitos_suicidio_adolescentes_negros_2012_2016.pdf.
http://bvsms.saude.gov.br/bvs/publicacoe... , from the Brazilian Ministry of Health, shows that the risk of suicide in the age bracket of 10 to 29 years was 45% higher among young people who declare themselves to be black or brown in 2016.

Grada Kilomba, a black theorist, philosopher, and activist, argues that structural racism is a strong marker for the interpretation of suicide among black people. The author understands racism as a means through which to agency deterioration, of worsening, and of murdering the “ego”. “Suicide may [...] be seen as a performative act of an imperceptible existence”⁴⁴44 Kilomba G. Memórias da Plantação: Episódios de Racismo Cotidiano. 1ª ed. Rio de Janeiro: Cobogó; 2019.(p.188).

From this perspective, we must understand racism as a historical and political process that creates social conditions in such a way that racially identified groups are systematically discriminated⁴⁵45 Navasconi PVP. A exceção que é a regra - Corpos condenados da terra. Rev Esp Acad 2021; 20:81-91.. When we are dealing with black women, the violent isolation disqualifies the “self” and makes it even more isolated and invisible. Under the auspices of the “not being”, Kilomba makes associations among racism, isolation, erasing, and suicide.

In this context of the isolation and erasing of human identities, we can also deal with suicide among indigenous peoples. It is estimated that between 2011 and 2015, the suicide rate among the Brazilian indigenous population was 15.2/100,000 inhabitants, which is about three times higher than that of the non-indigenous population during the same period⁴⁶46 Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Perfil epidemiológico das tentativas e óbitos por suicídio no Brasil e a rede de atenção à saúde [Internet]. 2017 [acessado 2022 set 10]. Disponível em: http://portalarquivos2.saude.gov.br/images/pdf/2017/setembro/21/2017-025-Perfil-epidemiologico-das-tentativas-e-obitos-por-suicidio-no-Brasil-e-a-rede-de-atencao-a-saude.pdf.
http://portalarquivos2.saude.gov.br/imag... .

Although there are few Brazilian studies on suicide among indigenous people, it is understood that the multiple types of violence they have suffered throughout history and the ineffectiveness of public policies to protect these indigenous peoples, may have influenced those deaths. One major issue is the invasion of their territories, which began with colonization and continues even today. Some call attention to the permanent invasion, which is perpetrated by the current government itself and which has a close connection with agribusiness and illegal mining on indigenous lands⁴⁷47 Berenchtein Netto N. Educação, saberes psicológicos e morte voluntária: fundamentos para a compreensão da morte de si no Brasil colonial [tese]. São Paulo: Pontifícia Universidade Católica de São Paulo; 2012..

For indigenous peoples, the land means a lot more than a place to plant. For them, there is a sacred connection with the land, ancestry, and spirituality. According to this logic, when the land is lost, identity is also lost, causing the deterioration of the cultural and ethnic values of those peoples. Moreover, indigenous women face issues which make them even more vulnerable, such as marital abuse, which is further aggravated by the difficulty they have in accessing services for women’s protection. Indigenous women may also face conflicts when they contradict the models, as occurs when they migrate to urban areas and choose a partner with no family interference⁴⁸48 Gil PA. Suicídio de indígenas em Roraima: cultura e intervenção. Rev Zona Impacto 2018; 2:145-173..

As mentioned above, most of the deaths by suicide occur in low- and middle-income countries, such as Brazil. In the decade of 2011-2020, there was an increase in evidence regarding the relationship between economic insecurity, poverty, and increase in suicides. American scholars have described this growth in mortality rates in recent years among populations with low and middle incomes. Social determination for suicide, in those cases, is highlighted by the presence of a social gradient in the so-called deaths by despair: the less the number of years of education and the lower socioeconomic level, the higher the risk of death⁴⁹49 Case A, Deaton A. Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century. PNAS 2015; 112(49):15.078-15.083.^,5050 Knapp EA, Bilal U, Dean LT, Lazo M, Celentano DD. Economic Insecurity and Deaths of Despair in US Counties. Am J Epidemiol 2019; 188(12):2.131-2.139..

In Brazil, one study conducted by the Oswaldo Cruz Foundation, which aimed to access suicides in Brazil during the COVID-19 pandemic in 2020, revealed some aspects of socioeconomic inequality in terms of regions in the country and in terms of gender. There was a general decrease of 13% in suicide rates among the general population, regardless of the expectations for the period. On the other hand, there was an increase in suicides in the North and Northeast regions of the country, reaching 40% increase among women, aged 60 years and older, from the Northeastern region⁵¹51 Orellana JDY, Souza MLP. Excess suicides in Brazil: inequalities according to age groups and regions during the covid-19 pandemic. Int J Soc Psychiatry 2022; 68(5):997-1009..

In connection with the issues already exposed here, it is consensual in the field of suicidology that suicidal behavior comes from human suffering, in its various expressions. It should be reiterated that such suffering has a concrete historical origin and does not appear solely as a private or spontaneous experience from the individuals’ psyche. It is motivated, foremost, by intersubjective relationships with the “other” and with social reality, and those relationships are intertwined with power and domination issues in societies that are patriarchal, racist, sexist, and cisnormative⁵²52 Araújo TB. Suicídio LGBTQIA+: do sofrimento ético-político às políticas públicas de prevenção. Sex Polit Rev Bras Polit Publicas LGBTI+ 2019; 1(1):323-345..

Heterocisnormality functions as a device and controller of power, linked to techniques, strategies, or means of subjugation used to penetrate and manage control of the body. In this binary ideal of gender, people who do not fit within the pre-established and manipulative norms live a cyclic and systematic process of structural violence, which is present “in social life - including its many variables of an educational, family, and cultural nature - and especially, in political life”⁵³53 Caravaca-Morera JA, Padilha MI. Necropolítica trans: diálogos sobre dispositivos de poder, morte e invisibilização na contemporaneidade. Texto Contexto Enferm 2018; 27(2):e3770017. (p. 4).

Meanwhile, the suicide rates for transgender persons are nearly 45% higher than those of the cis-gender individuals. Even so, there are still very few studies that examine reliable statistics regarding suicidal behavior among gender and sex minorities. In Brazil, a study with 154 transsexual participants verified that 48.3% showed suicidal ideation, while 23.8% had already attempted suicide - rates which are much higher than those of the general population⁵⁴54 Rafael RMR, Jalil EM, Luz PM, Castro CRV, Wilson EC, Monteiro L, Ramos M, Moreira RI, Veloso VG, Grinsztejn BGJ, Velasque LS. Prevalence and factors associated with suicidal behavior among trans women in Rio de Janeiro, Brazil. Plos One 2021; 16(10):e0259074.. Another study conducted with transsexuals from a state from Northeastern Brazil identified a prevalence of 41.4% of suicidal ideation within that population⁵⁵55 Silva GWS, Meira KC, Azevedo DM, Sena RCF, Lins SLF, Dantas ESO, Miranda FAN. Fatores associados à ideação suicida entre travestis e transexuais assistidas por organizações não governamentais. Cien Saude Colet 2021; 26(Supl. 3):4955-4966..

It is important to note that the group of people identified as LGBTQIA+ is subjected to a high prevalence of discrimination and multiple types of violence throughout their lives. Moreover, government violence trivializes and justifies such suffering, since hate and moral panic discourses are traits of the Jair Bolsonaro government, which is openly against the essence and the way of life of the LGBTQIA+ population⁵⁴54 Rafael RMR, Jalil EM, Luz PM, Castro CRV, Wilson EC, Monteiro L, Ramos M, Moreira RI, Veloso VG, Grinsztejn BGJ, Velasque LS. Prevalence and factors associated with suicidal behavior among trans women in Rio de Janeiro, Brazil. Plos One 2021; 16(10):e0259074.^,5656 Benevides BG, Nogueira SNB. Dossiê dos assassinatos e da violência contra travestis e transexuais brasileiras em 2019/ANTRA/IBTE [Internet]. 2020 [acessado 2022 set 20]. Disponível em: https://antrabrasil.org/assassinatos.
https://antrabrasil.org/assassinatos... .

Consequently, our study proposes that women who are most vulnerable require more protection³⁰30 Schramm FR. Bioética da Proteção: ferramenta válida para enfrentar problemas morais na era da globalização. Rev Bioetica 2008; 16(1):11-23.. Protection, as defined here, is within the coverage of Protection Bioethics (a subset of Bioethics of a Brazilian and Latin-American origin), which must be understood beyond the paternalistic perspective. Therefore, protection must be considered through a group of actions that aim to strengthen the potential and the capabilities of each woman.

Final considerations

The current study presents a necessary discussion about suicide among women in Brazil, in an expanded perspective regarding gender issues. It sought to improve the common knowledge on a theme that has been historically stigmatized in and relatively absent from scientific literature. Although our study shows the difficulties in the lives of women in Brazil, whose subsequent vulnerability can lead to suicidal behavior, there is still much be explored on this theme.

The explanations about suicide, based on theoretical models, are still incapable of filling in the gaps that permeate women’s lives. Life in contemporary times is variable, and the instituted social relationships are still marked by elements that oppress, silence, and abuse women, generating inequalities and a wide range of suffering.

It is clear that suicide prevention in this segment of the population is something that must necessarily pass through assertive strategies of the protection of women’s integrality, which depends on the institutional capacity of the Brazilian State, on affirmative social policies, and on repeated tensions for change in social paradigms.

Complementarily, public policies in Brazil must have intersectoral interaction, involving the areas of health, law, social assistance, and specific sectors of society, in order to achieve an understanding of the ethical and political suffering that specifically affects women who are black, poor, and LGBTQIA+. Taking this into consideration, reducing the stigma and reducing structural vulnerability are of utmost importance. These actions would clearly help to reduce suicidal behavior and help the country become a place with better conditions for every woman, without distinction.

We hope that the reflections in this study may incite critical thinking and urgent actions from the many social segments and institutions in the country, with the objective of preventing the submission of women to unequal conditions and avoidable suffering, which are repeated on a daily basis. Moreover, this study does not exhaust the discussions regarding this theme; in fact, the discussions must be furthered by all those interested in improving the lives of women in Brazil.

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