Abstract

Introduction

The high rates of suicide, attempted suicide and suicidal ideation characterize this topic as being a significant public health problem. Deaths from suicide have risen 60% in the last forty-five years¹1. World Health Organization (WHO). Multisite Intervention Study on Suicidal Behaviours SUPRE – MISS: protocol of SUPRE – MISS. Geneva: WHO; 2002., representing the thirteenth cause of death worldwide²2. Brzozowski FS, Soares BG, Benedet J, Boing AF, Peres MA. Suicide time trends in Brazil from 1980 to 2005. Cad Saude Publica 2010; 26(7):1293-1302.. Studies into attempted suicide are much rarer and more difficult to undertake. It is estimated that many of these cases remain unknown to the health services, are not diagnosed correctly or are sub-notified.

According to Durkheim³3. Durkheim E. O Suicídio. 3ª ed. Lisboa: Editorial Presença; 1982., suicide is a social fact, representing a complex situation, involving a series of determining factors that change according to a person's culture, moment in history and social group⁴4. Meneghel SN, Victora CG, Faria NMX, Carvalho LA, Falk JW. Características epidemiológicas do suicídio no Rio Grande do Sul. Rev Saude Publica 2004; 38(6):804-810.. Cases of attempted suicide may be considered as acts of self-aggression that did not result in a lethal outcome, in spite of repeated attempts, and represent one of the principle predictive factors of suicide, and over 10% end in death after one or several attempts⁵5. De Leo D, Padoani W, Lonnqvist J, Kerkhof AJ, Bille-Brahe U, Michel K, Salander-Renberg E, Schmidtke A, Wasserman D, Caon F, Scocco P. Repetition of suicidal behaviour in elderly Europeans: a prospective longitudinal study. J Affect Disord 2002; 72(3):291-295..

Most people, during their lives, often think about their own death, which is part of the maturation and ageing process. However, when they begin to make plans and take measures to bring this about, this factor becomes more concrete, and can move beyond an ideation – a vaguer characteristic – to an attempted and consummated suicide. In a population study undertaken in Brazil, it was found that 17.1 % of those interviewed had thought about committing suicide; 4.8 % had planned to commit suicide and 2.8 % had attempted suicide during the course of their lives⁶6. Botega JN, Marín-Leon L, Oliveira HB, Barros MBA, Silva VF, Dalgalarrondo P. Prevalências de ideação, plano e tentativa de suicídio: um inquérito de base populacional em Campinas, São Paulo, Brasil. Cad Saude Publica 2009; 25(12):2632-2638..

The determining factors for self-aggression are varied, and are caused by psychological, economic, social, gender inequality and life crises, although there is still no definite consensus about such relationships. Losses, serious or debilitating illness, economic setbacks, events that cause intense emotional suffering can increase the risk of all forms of auto-aggressive behavior, when people begin to perceive death as an alternative to avoid pain.

It is estimated that for every consummated suicide that occurs among the population, at least twenty attempts have been made⁷7. Organización Mundial de la Salud (OMS). Prevención del suicidio: un imperativo global. Washington: OMS; 2014.. Among the elderly, this relationship is even narrower; the ratio between attempted and consummated suicide is approximately 2:1, which makes this an even more serious phenomenon⁸8. De Leo D, Padoani W, Scocco P, Lie D, Bille-Brahe U, Arensman E, Hjelmeland H, Crepet P, Haring C, Hawton K, Lonnqvist J, Michel K, Pommereau X, Querejeta I, Phillipe J, Salander-Renberg E, Schmidtke A, Fricke S, Weinacker B, Tamesvary B, Wasserman D, Faria S. Attempted and completed suicide in older subjects: results from the WHO/EURO Multicentre Study of Suicidal Behaviour. Int J Geriatr Psychiatry 2001; 16(3):300-310..

In Brazil, a population-based study found that suicide ideation, together with planned and attempted suicide are more prevalent among younger women. Suicide ideation and planning occur more frequently among those who live alone (single, widowed and separated), among spiritualists and those with higher incomes. For every three suicide attempts, only one is treated at a health post⁶6. Botega JN, Marín-Leon L, Oliveira HB, Barros MBA, Silva VF, Dalgalarrondo P. Prevalências de ideação, plano e tentativa de suicídio: um inquérito de base populacional em Campinas, São Paulo, Brasil. Cad Saude Publica 2009; 25(12):2632-2638.. Another Brazilian study estimates that excess mortality among individuals who attempt suicide showed that the mortality rate was higher than expected for the population and that 90% of those who did eventually commit suicide, did so during a period of twenty-four months following their original attempted suicide⁹9. Vidal CEL, Gontijo ECDM, Lima LA. Tentativas de suicídio: fatores prognósticos e estimativa do excesso de mortalidade. Cad Saude Publica 2013; 29(1):175-187..

In most countries, the suicide rate is three or four times higher for men, while women show higher rates of ideation and attempted suicide⁶6. Botega JN, Marín-Leon L, Oliveira HB, Barros MBA, Silva VF, Dalgalarrondo P. Prevalências de ideação, plano e tentativa de suicídio: um inquérito de base populacional em Campinas, São Paulo, Brasil. Cad Saude Publica 2009; 25(12):2632-2638.,¹⁰10. Haqqi S. Suicide and Domestic Violence: Could There Be a Correlation? Medscape J Med 2008; 10(12):287.

11. Marín-León L, Barros MBA. Mortes por suicídio: diferenças de gênero e nível socioeconômico. Rev Saude Publica 2003; 37(3):357-363.-¹²12. Shimitt R, Lang MG, Quevedo J, Colombo T. Perfil epidemiológico do suicídio no extremo oeste do estado de Santa Catarina, Brasil. Rev Psiquiatr RS 2008; 30(2):115-123., which is known as the “suicide paradox,” represented by the greater frequency of attempted suicide among women and consummated suicides among men¹³13. Canetto S. Women and Suicidal Behavior: a cultural analysis. Am J Orthopsychiatry 2008; 78(2):259-266..

Women who begin their sexual experiences at an early age and live in conservative communities, who have had an abortion, or an unwanted pregnancy and have problems with their body image, are all factors that can represent the risk of self-aggression¹⁴14. Beautrais AL. Women and suicidal behavior. Crisis 2006; 27(4):153-156.. Domestic violence and sexual abuse, conservative gender roles and mental suffering¹⁵15. Devries K, Watts C, Yoshihama M, Kiss L, Schraiber LB. Violence against women is strongly associated with suicide attempts: evidence from the WHO multi-country study on women's health and domestic violence against women. Soc Sci Med 2011; 73(1):79-86.

16. Werneck GL, Hasselmann MH, Phebo LB, Vieira DE, Gomes VLO. Tentativas de suicídio em um hospital geral no Rio de Janeiro, Brasil. Cad Saude Publica 2006; 22(10):2201-2206.

17. Lima DD, Azevedo RCS, Gaspar KC, Silva VF, Mauro MLF, Botega NJ. Tentativa de suicídio entre pacientes com uso nocivo de bebidas alcoólicas internados em hospital geral. J Bras Psiquiatr 2010; 59(3):167-172.

18. Werlang BSG, Botega NJ. Comportamento suicida. Porto Alegre: Artmed; 2004.-¹⁹19. Diehl A, Laranjeira R. Suicide attempts and substance use in an emergency room sample. J Bras Psiquiatr 2009; 58(2):86-91. are predictors of self-aggression, as well as exercising prostitution and sexual exploitation²⁰20. Shahmanesh M, Wayal S, Cowan F, Mabey D, Copas A, Patel V. Suicidal behavior among female sex workers in Goa, India: the silent epidemic. Am J Public Health 2009; 99(7):1239-1246.,²¹21. Hong Y, Li X, Fang X, Zhao R. Correlates of Suicidal Ideation and Attempt Among Female Sex Workers in China. Health Care Women Int 2007; 28(5):490-505..

In suicide studies carried out in Brazil, it was observed that many of the elderly women had been victims of violence and had committed suicide after having strictly fulfilled the gender role imposed on them by a patriarchal society²²22. Minayo MCS, Cavalcante FG. É possível prevenir a antecipação do fim? Suicídio de Idosos no Brasil e possibilidades de Atuação do Setor Saúde [projeto de pesquisa]. Rio de Janeiro: Fiocruz; 2010.

23. 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):1983-1992.-²⁴24. Hesler LZ. Suicídio em municípios do sul do Brasil – um enfoque de gênero [dissertação]. Porto Alegre: Universidade Federal do Rio Grande do Sul; 2013..

The self-aggressive behavior of women, as seen in attempted and consummated suicides, is considered to be less common than for men and is therefore studied and valued less²⁵25. Devries KM, Seguin M. Violence against Women and Suicidality: Does Violence Cause Suicidal Behaviour? In: Garcia-Moreno C, Riecher-Rossler A, editors. Violence against Women and Mental Health. Basel: Karger; 2013. p. 148-158.. Furthermore, the factor of gender has been little employed as a means to analyze life events, including suicide, which makes studies of this type even more relevant. This article seeks to understand the inequalities and acts of violence based on gender that have occurred in the lives of elderly Brazilian women who have attempted to commit suicide.

Methodological trajectory

This is a qualitative study and information was gathered by means of in-depth interviews with elderly men and women who had made one or more suicide attempts. This investigation is part of a national multicenter research study called “A study on attempted suicide among the elderly from a public health perspective”²⁶26. Minayo MCS, Cavalcante FG, Figueiredo AE, Mangas RM. Estudo sobre tentativas de suicídio em idoso sob a perspectiva da saúde pública [projeto de pesquisa]. Rio de Janeiro: Fiocruz; 2013..

Within the five macro-regions of Brazil, municipalities with a high coefficient of suicide mortalities among the elderly or the population in general were selected, based on the theory that areas with the highest suicide rates, are those that also have the highest number of cases of attempted suicides⁷7. Organización Mundial de la Salud (OMS). Prevención del suicidio: un imperativo global. Washington: OMS; 2014.,⁸8. De Leo D, Padoani W, Scocco P, Lie D, Bille-Brahe U, Arensman E, Hjelmeland H, Crepet P, Haring C, Hawton K, Lonnqvist J, Michel K, Pommereau X, Querejeta I, Phillipe J, Salander-Renberg E, Schmidtke A, Fricke S, Weinacker B, Tamesvary B, Wasserman D, Faria S. Attempted and completed suicide in older subjects: results from the WHO/EURO Multicentre Study of Suicidal Behaviour. Int J Geriatr Psychiatry 2001; 16(3):300-310.. Twelve cities were included in this sampling, Venâncio Aires, Santa Cruz do Sul, Candelária and Porto Alegre (Rio Grande do Sul- RS); in the northern region: Manaus (Amazonas-AM); northeast: Fortaleza (Ceará – CE), Recife (Pernambuco – PE), Teresina and Piripiri (Piaui – PI); central-west: Campo Grande and Dourados (Mato Grosso do Sul -MS) and in the southeast: Rio de Janeiro (RJ).

The procedure to identify those who had attempted suicide varied according to region and, in order to find these people, contact was made with municipal health secretariats, emergency health and public security services, hospitals, Centers for Psychosocial Care (CAPS), and Long-Stay Institutions (ILP). In some of the municipalities, professionals in the area spoke of a low level of attempted suicide cases among the elderly, which made the process to find and select participants more difficult. Contact with elderly people in the Long-stay Institutions was arranged through intermediation with the managers.

The intention was to carry out six interviews with people with a history of attempted suicide in each of the municipal districts, forming an intentional sampling of seventy-two people. There were some locations where fewer people were interviewed so that, in the end, fifty-nine interviews were undertaken with elderly people around the country, thirty-two of whom were women.

This article describes the findings of a study to investigate whether gender vulnerability and violence had occurred in the lives of twenty-seven women who had attempted suicide and who represented the majority of those interviewed. Five women who did not mention incidents of gender inequality or violence, were not included in this study.

A specific itinerary was used to interview elderly people²⁶26. Minayo MCS, Cavalcante FG, Figueiredo AE, Mangas RM. Estudo sobre tentativas de suicídio em idoso sob a perspectiva da saúde pública [projeto de pesquisa]. Rio de Janeiro: Fiocruz; 2013., which included identification data, demographic details, family background, morbidities, mental state prior to the suicide attempt, possible causes, impact on the family, presence of gender vulnerability or violence and possibilities of surmounting the fact.

After the interviews, the data were compiled and organized into a corpus before being subjected to a pre-analysis in order to understand the reports and make an analytical summary of each case and of all the cases combined.

The analysis began by reading through the personal life stories of each respondent. This provided information showing that violence was a factor of emotional suffering at all stages of the person's life through to old age. The perspective used here is based on the lifespan approach²⁷27. Baltes PB. Theoretical propositions of the lifespan developmental psychology: on the dynamics between growth and decline. Dev Psychol 1987; 23(5):611-696.,²⁸28. Baltes PB. The aging mind: Potentials and limits. Gerontologist 1993; 33(5):580-94., which makes it possible to understand human development as an ongoing multidimensional and multidirectional process.

This analysis made it possible to see the effects that gender inequality and violence produce over the course of a lifetime, culminating in a person's desire to die when they are elderly. Thus, work was not conducted using categories, but with phases in the life cycle and it was possible to identify how at every stage of development – infancy, youth, adult life and old age – women have to follow a script according to their gender and the extent to which this can cause personal suffering. A story was constructed from separate pieces of the narratives of nearly all of the interviewees. In almost all cases, violence permeated at least one stage of each person's development, to a greater or lesser degree of intensity and gravity. Thus, it was decided not to identify the individual statements of the deponents involved in this study. The reason for this was that situations of inequality and violence were common in the lives of all of these elderly women, irrespective of where they lived or how old they were, so that the quotes taken from their statements could have been made by any one of them. The idea behind this was that by synthesizing this material it is possible to minimize the individual characteristics of these cases and thereby provide a wider perspective of other determining factors involved.

The intention was not to generalize or universalize, but to show common – albeit singular – aspects that are repeated in the lives of these women. A summarized subtitle was used for every phase of their lives, which emerged from reading the biographic details of those who had attempted suicide.

This project was approved by the Ethics & Research Committee at the National Public Health School (CEP/ENSP). All participants signed an Informed Consent Form (TCLE). Ethical conduct and recommendations, as established by Resolution CNS/Nº 466/12²⁹29. Brasil. Ministério da Saúde (MS). Conselho Nacional de Saúde. Resolução nº 466, de 12 de dezembro de 2012. Diário Oficial da União 2013; 13 jun., were respected and those who were found to be experiencing emotional suffering were assisted by the respective services and are being monitored.

Findings and Discussion

The sampling of selected women is formed by twenty-seven elderly women interviewees who described situations of inequality and violence related to their gender at one or several moments during their lifespan; 56% are aged between sixty and seventy, 33% are illiterate and a high proportion (44%) did not complete elementary school. Nearly half of them (44%) worked and continue to work in jobs related to domestic and care-providing services. Although most now live in urban areas (85%), many of these women were born and lived for many years in rural areas, working in agriculture-related activities. Most were married at some point in their lives, although (22%) were separated or (33%) widowed in their old age. Many had children and 44% live in a home belonging to someone else or in a Long-stay Institution (ILP) and, although many (77%) receive some sort of benefit payment or pension, these are not sufficient to enable them to live outside these institutions or in their own homes.

Issues linked to gender in the lives of these women, which are understood to be factors that led them to consider or attempt to commit suicide, may involve the rigid gender roles they played, an unequal position or lack of power in relation to their husband, children or family members. It may also be due to violence (verbal, psychological, physical, sexual, asset-related or institutional) which they have suffered and have mentioned as occurring during one or several moments of their lives. These acts of violence were perpetuated during their infancy, youth, and adult life and in their old age, by their parents, intimate partners, children, family members, people known to them, their bosses, service professionals, among others. Verbal or psychological violence was mentioned by twenty-one of the twenty-seven elderly women interviewees, thirteen mentioned physical violence, violence related to assets was mentioned by seven and sexual violence by five women.

Gender inequality and violence in the lives of elderly women who tried to commit suicide

Differences in the distribution and frequency of suicidal behavior between the sexes has influenced the debate about the importance of a person's gender in their life events, including suicide⁴4. Meneghel SN, Victora CG, Faria NMX, Carvalho LA, Falk JW. Características epidemiológicas do suicídio no Rio Grande do Sul. Rev Saude Publica 2004; 38(6):804-810.,¹³13. Canetto S. Women and Suicidal Behavior: a cultural analysis. Am J Orthopsychiatry 2008; 78(2):259-266.,¹⁴14. Beautrais AL. Women and suicidal behavior. Crisis 2006; 27(4):153-156.. Inequalities in the distribution of power between genders as well as the attribution or assumption of roles specifically designed for men and women are part of a patriarchal society³⁰30. Saffioti H. Rearticulando gênero e classe social. In: Costa A, Bruschini C, organizadores. Uma questão de gênero. Rio de Janeiro, São Paulo: Rosa dos Tempos, Fundação Carlos Chagas; 1992. p. 183-215.

31. Saffioti H. Já se mete a colher em briga de marido e mulher. São Paulo em Perspectiva 1999; 13(4):82-91.-³²32. Pateman C. O contrato sexual. Rio de Janeiro: Paz e Terra; 1993.. The hierarchies of power generate inequalities and expose women to violent situations during the course of their lives. This process begins with the social inclusion of girls and educational differences according to gender, followed in adult life with the sexual division of labor and lack of remuneration for domestic activities. Added to which the infringement of sexual and reproductive rights, including rape as a form of sexual initiation, forced or arranged marriages or marriages used to escape family violence, compulsory maternity, the criminalization of abortion, difficulties in having access to contraception or to negotiate safe sex and, in old age, the plundering of assets and rights. Such factors create situations of such intense suffering that the can lead to ideation, attempted or consummated suicide³³33. Blumenthal SJ. Suicide and gender. [acessado 2011 abr 18]. Disponível em: http://susan-blumenthal.org/wp-content/uploads/2010/04/Susan-Blumenthal-Suicide_and_Gender.pdf
http://susan-blumenthal.org/wp-content/u... .

The use of violence is a fundamental element for subjugating women to live under a patriarchal system. Violence is used at every stage of life in societies ruled by a sexual division of roles. One of the most serious effects of gender violence is the suicide rate of the women involved, since these two events are directly related²⁵25. Devries KM, Seguin M. Violence against Women and Suicidality: Does Violence Cause Suicidal Behaviour? In: Garcia-Moreno C, Riecher-Rossler A, editors. Violence against Women and Mental Health. Basel: Karger; 2013. p. 148-158.,³⁴34. Ellsberg M, Jansen HA, Heise L, Watts CH, Garcia-Moreno C. Intimate partner violence and women's physical and mental health in the WHO multi-country study on women's health and domestic violence: an observational study. Lancet 2008; 371(9619):1165-1172.,³⁵35. D’Oliveira AFPL, Diniz CSG, Schraiber LB. Violence against women in health-care institutions: an emerging problem. Lancet 2002; 359(11):1681-1685..

The women mentioned, who are now all over the age of sixty, were born during the 1940s and 1950s and were educated and socialized under a more conservative system than would be the case nowadays. In addition to the more restrictive social system of those times, many of these women were born and lived for part of their lives in rural areas, where gender standards were and continue to be more rigid than in the cities. This factor should be borne in mind during the course of this narrative³⁶36. Minayo MCS, Cavalcante FG. Estudo compreensivo sobre suicídio de mulheres idosas de sete cidades brasileiras. Cad Saude Publica 2013; 29(12):2405-2415..

The families of many of these women were brought up to believe that excessive hard work, poverty and social exclusion were a normal part of a woman's life, which highlights the trans-generational aspect involved as well as the social reproduction of certain gender models.

Infancy: abandoned girls, nobody wanted me

Gender differences occur even before birth, when in some societies, the birth of a boy is more welcome and where females are traditionally undervalued, leading to a high level of abortions and abandoned children of the female sex, as can be seen in some countries and regions of the world.

Differentiated gender education conveys the expectations for each of the sexes, gender roles value males in detriment to females and legitimize male dominance³⁷37. Bourdieu P. A dominação masculina. 2ª ed. Rio de Janeiro: Bertrand do Brasil; 2002., the exercise of unequal power between the sexes and female inferiority. In this context, women are deprived of autonomy and the right to decide, even about their own bodies. The areas of learning and the socialization processes reinforce gender bias and stereotype as being an alleged (female and male) truth of nature based mainly on biological determinants, which appears to be the natural course of things.

In addition to these structural situations, adverse experiences in childhood, such as exposure to violence and trauma at an early age, increase feelings of depression and affect a person's capacity to face stressful situations, which can lead to self-aggressive behavior³⁸38. Dube SR, Anda RF, Felitti VJ, Chapman DP, Williamson DF, Giles WH. Childhood abuse, household dysfunction, and the risk of attempted suicide throughout the life span: Findings from Adverse Childhood Experiences Study. JAMA 2001; 286(24):3089-3096.. The vulnerable women, whose statements were heard in this study, and who had lost the will to live, spoke of their gender socialization that educated them to work, obey and serve others. Several of these elderly women emphasized the strict way they were taught in childhood to perform their daily tasks and the physical punishment they were subjected to. In this stage of their lives, the girls began to undergo a process of subjectification to fulfill their gender destiny, incorporating their sexual roles and accepting submission as the normal conduct for women.

Several of the elderly women who took part in this study, from different areas of the country, suffered from the effects of a rigorous form of gender education. Many were born and spent their childhood in rural areas. Others were orphaned at a very early age or were the survivors of families that had separated and who were under the responsibility of family members and others who raised them. My mother died before she could teach me anything. My father left us to our own devices, doing nothing, until a woman offered to take us to her house. However, she treated me badly and only wanted me to work from when I was just a small child.

In these cases, it was impossible to predict the level of commitment, affection or ties that would be established in their new family dynamics. And for the children concerned, no explanations were given, they simply had to obey. That is to say, they had no power to decide, choose or agree about their future. As well as having to cope with the feelings of loss of their mother, they had to deal with other forms of hardship, such as the loss of their families, being separated from their siblings and relations, and having to provide unpaid domestic labor as well as to be subjected to physical punishment. The desire for death and attempts at self-destruction that this interviewee and other women experienced confirm that violence perpetrated against children causes mental health problems for the rest of their lives¹⁵15. Devries K, Watts C, Yoshihama M, Kiss L, Schraiber LB. Violence against women is strongly associated with suicide attempts: evidence from the WHO multi-country study on women's health and domestic violence against women. Soc Sci Med 2011; 73(1):79-86..

Giving away girls to perform unpaid domestic work in wealthier homes was a frequent occurrence in the past and still occurs today in various regions of the country. And, from a very early age, if they do not obey the rules, punishment and discipline were instilled through physical violence. I was alone in the world. I was often beaten with a piece of wood, a club and even a bullwhip.

Several women describe running away to avoid abuse, ill-treatment and punishment, I was treated very badly in the home. I spent most of my time in other people's houses to avoid being beaten all the time. Others spoke of the hard work they had to do in the fields from morning to night. Trained to clean, to work and to carry out domestic chores, they spent their childhood being exploited, unable to go to school, to play, rest, or to satisfy their basic needs, being treated in a way that borders on slavery.

Youth: I lost my girlhood because of this stupid male sex fixation

A low level of education and inferior social status, few job opportunities and economic dependence on their partners or extended family are some of the risk factors that can lead women to attempt suicide in their youth and adult life¹⁴14. Beautrais AL. Women and suicidal behavior. Crisis 2006; 27(4):153-156.,³⁹39. Bebbington PE, Cooper C, Minot S, Brugha TS, Jenkins R, Meltzer H, Dennis M. Suicide Attempts, Gender, and Sexual Abuse: Data From the 2000 British Psychiatric Morbidity Survey. Am J Psychiatry 2009; 166(10):1135-1140.. Many women abandoned school in their adolescence to carry out domestic work while others never received any sort of formal education, I really wanted to study but wasn't allowed to; my life was just about work and he (the person she had been given to) didn't send me to school to study, or do anything, I can't even spell my name, I know absolutely nothing. A third of all the Brazilians interviewed in the course of this study, and who had tried to commit suicide, were illiterate.

Other suicide risk factors include disadvantages linked to gender, such as early and arranged marriages, unwanted pregnancies, lack of sexual and reproductive autonomy, as well as violence and sexual abuse¹⁴14. Beautrais AL. Women and suicidal behavior. Crisis 2006; 27(4):153-156.,¹⁵15. Devries K, Watts C, Yoshihama M, Kiss L, Schraiber LB. Violence against women is strongly associated with suicide attempts: evidence from the WHO multi-country study on women's health and domestic violence against women. Soc Sci Med 2011; 73(1):79-86.,²⁰20. Shahmanesh M, Wayal S, Cowan F, Mabey D, Copas A, Patel V. Suicidal behavior among female sex workers in Goa, India: the silent epidemic. Am J Public Health 2009; 99(7):1239-1246.. It has been well established that sexual abuse is another form of violence associated with attempted suicide, representing a relatively high risk and shows that the young victims involved suffer long-term negative effects, especially when they have received no psychosocial support, which includes being heard, or receive proper care and attention²⁵25. Devries KM, Seguin M. Violence against Women and Suicidality: Does Violence Cause Suicidal Behaviour? In: Garcia-Moreno C, Riecher-Rossler A, editors. Violence against Women and Mental Health. Basel: Karger; 2013. p. 148-158.,⁴⁰40. McLaughlin LJ, O’Carroll RE, O’Connor RC. Intimate partner abuse and suicidality: A systematic review. Clin Psychol Rev 2012; 32(8):677-689..

Sexual abuse and forced sexual initiation of girls are quite common factors and marked the beginning of the sexual experiences of several of the elderly women who tried to commit suicide.

I had already run away from my brother-in-law's home, because he was constantly chasing me, at night he wanted to make advances on me because I was already quite grown-up. Others began their sexual lives by being raped by their brothers, fathers or step-fathers. One of these elderly interviewees described how, while still an adolescent, she had tried to kill herself because she had been abandoned by her boyfriend and was infected with HIV. During the interview, she showed how guilty she still felt about this event: I only attract diseases. An aggravating factor in all this is that these elderly women, when young, felt powerless to denounce their aggressors, since they believed this would only make them more vulnerable in the male-dominated world in which they lived and that is why they kept the scars of this cruel act to themselves throughout their lives.

In many cases, marriage within a patriarchal society means that the husband takes ownership of his wife's assets and property, work, body and sexuality³²32. Pateman C. O contrato sexual. Rio de Janeiro: Paz e Terra; 1993.. Families, especially those from rural areas, transfer to the man the economic responsibility of looking after his wife and children. Part of this responsibility involves the power to decide all aspects of family life. This means that the woman has no sexual or reproductive autonomy. Sex within marriage is seen as a duty and the children, whether wanted or otherwise, represent a woman's destiny, a mission they need to fulfill. In a society based on a ‘code of honor,’ it is up to the men to look after their wives and daughters and, when they do not behave according to the rules established by the patriarch, control is exercised by means of violence⁴¹41. Vandello JA, Cohen D. Male honor and female fidelity: implicit cultural scripts that perpetuate domestic violence. J Pers Soc Psichol 2003; 84(5):997-1010.,⁴²42. Osterman LL, Brown RP. Culture of Honor and violence against the self. Pers Soc Psychol Bull 2011; 37(12):1611-1623.. Young girls were given away in marriage, just after menarche, to husbands who were usually much older than they were: I got married when I was fourteen, to a man twenty years older, I did not know what I had to do to serve a man. Marriages were arranged for young girls who knew nothing about sex or how the body functions. In such situations, a woman's sexual life is associated with violence, an act of intrusion, death. The interviewees repeatedly lament this painful fact more than forty, fifty or sixty years after the events: when my mother forced me to get married, I was a child in every respect, I knew nothing about the world […]; my breasts were still growing, I was just a child; we got married not knowing anything. Then, after getting married, things happened that made me think I was dying. Thus, it can be seen that a very negative psychological impact is created with the association between sex and death.

For many of the women interviewed, the role of a woman was limited to serving a man, since they were not allowed to express any form of sentimental feelings, opinions, desires or plans for the future. A union of marriage that takes place without the full understanding of an adolescent girl can result in fear, grief, malaise and great dissatisfaction with their lives. These accounts confirm that the effects of sexual violence lead to feelings of low self-esteem, suffering, depression, in losing the will to live, in fact, to thinking about, attempting and consummating acts of suicide²⁵25. Devries KM, Seguin M. Violence against Women and Suicidality: Does Violence Cause Suicidal Behaviour? In: Garcia-Moreno C, Riecher-Rossler A, editors. Violence against Women and Mental Health. Basel: Karger; 2013. p. 148-158..

Gender disadvantages also emerged as a lack of opportunities for leisure activities and socialization, because of the surveillance that these young women are subjected to by the men (their fathers and brothers): We were not allowed to go out; to go to parties to have fun was forbidden. Thus, all these women could look forward to in their relationships was a domestic environment and a life of hard work, doing a man's work, at a time in their lives when their development and potential as a human being are of fundamental importance.

Adult life: Wives, mothers and caregivers, my marriage was not very good, but I tried to put up with it as best I could

Even during their adult lives, it was common for these women to perform traditional gender roles that including being responsible for maintaining the marriage, caring for the home and children. Marriage and maternity are obligatory prospects for many women, and this was certainly the case of the elderly women interviewed for this study. During their married life, these women faced economic hardships, often having to cope single-handedly with looking after the home, their children, husbands and family members. I got very fed up without my husband, without any human warmth, I had to look after all my children while they were still very small, with very little money.

Conjugal contracts in societies where sexual inequality is the norm, means that women have less power than the men and it is common to use violence and medicalization to keep them under control and to make them accept their situation of inequality⁴³43. Boltanski L. As Classes Sociais e o Corpo. Rio de Janeiro: Graal; 1979.,⁴⁴44. Stark E. Coercive Control: How Men Entrap Women in Personal Life. Interpersonal Violence. Oxford: Oxford University Press; 2007.. However, violence that is perpetuated within a conjugal environment produces physical, psychological, and social effects and can end in suicide¹⁵15. Devries K, Watts C, Yoshihama M, Kiss L, Schraiber LB. Violence against women is strongly associated with suicide attempts: evidence from the WHO multi-country study on women's health and domestic violence against women. Soc Sci Med 2011; 73(1):79-86.,²⁵25. Devries KM, Seguin M. Violence against Women and Suicidality: Does Violence Cause Suicidal Behaviour? In: Garcia-Moreno C, Riecher-Rossler A, editors. Violence against Women and Mental Health. Basel: Karger; 2013. p. 148-158..

The elderly women mentioned in this survey, talked about a wide range of violent acts committed by their partners resulting from jealously, disagreements about the upbringing of their children, daily events and economic issues. They spoke of threats, unfaithfulness and being abandoned, verbal, physical and moral acts of aggression, committed by their fathers, husbands, relatives and then by their sons. I am like a prisoner; he offends me with his words; he was very much of a male chauvinist. Although tied down to a domestic life which involved looking after their own family, the heavy and precarious work they did, often in exchange for little or no payment, was imposed on them as an additional burden.

Their role as mothers occupied the entire lives of those interviewed. Authors like Badinter⁴⁵45. Badinter E. Um Amor conquistado: o mito do amor materno. Rio de Janeiro: Nova Fronteira; 1985., consider motherhood to be a cultural factor, however there are women whose experiences as mothers are so intense that this cultural aspect seems to be firmly buried within their biological makeup. This became evident in the demonstrations of excruciating pain experienced by some of these women, who had lost one or several children: I cannot even describe the pain I felt […], this loss was very painful. These feelings become even more profound when death is premature, avoidable or unexpected, so that mourning becomes an unceasing, acute and unalleviated process of pain. I just want to lie down all day thinking about her [the daughter who died] and to think about dying.

In the symbolic context of high maternal self-worth, this issue also affects women who do not have children. It haunts them, like a traumatic sign of subjectivity that cannot be fulfilled, often due to an impediment on the part of their partner who imposes his will: I really wanted to have a child so that I would always have at least one person close to me when I grow old […] it is his fault I could not have a child.

A life overburdened with excessive work and by suffering is further burdened down by a sense of guilt that is closely linked to the elderly person's process of socialization which, because of that particular period in their lives, was dominated by a rigid patriarchal culture. One can see that they have always retained a sense of guilt, by the way they pause, the way they talk, their silences. Guilt about a husband who committed suicide, by the husband who left them, by betrayal, by a life that no longer has any meaning. This sense of culpability is part of the mechanisms of subjection that begins with a differential gender upbringing, followed by a sexual division of labor, and ends when an elderly woman no longer knows what she wants in life. It seems I have spent my whole life trying to do something that I never managed to do, and I don't even really know what my objective was. The end result is a lack of a sense of the purpose and meaning of life which creates a feeling of emptiness, which is often mentioned by elderly women.

Old Age: My solution is to kill myself

In their old age, women finally find they have time for themselves, but this time, which is not chronological but subjective, is empty and without meaning. They live or have lived with men they did not choose, with children who have abandoned them and have suffered both material and symbolic losses. I just don't know how I managed to survive until now. The children on whom they dedicated their time and affection have moved away, are like strangers, no longer speak to their parent and often showing they clearly reject them: just the way my children have distanced me from their lives […] I feel abandoned; none of them want me; if my children do not even talk to me, imagine my grandchildren.

Several, not a few, were brutally affected by asset-related violence. They lost their homes, which were taken away from them, sold and occupied by others. They were deceived by family members who cleaned out their family assets, sold property, destroyed the family home to clear their debts, used these assets, to buy drugs. He sold everything […] the house stands empty, everything has gone. Members of their families put pressure on them to sign papers to sell their homes, which means they ended up having to live thanks to the charity of others. Other elderly women do not have access to a bank account and are prevented from managing their own earnings or pensions, which are totally appropriated by family members, who do not even leave enough in the account for basic purchases. They are obliged to live beyond their means, impoverished and neglected in their old age. I had a disagreement with one of my sons. It was about some money he borrowed.

Alone, isolated, without any form of activity, bored by daily life, the hours seem to be interminable, so elderly women think about killing themselves and often long to die. I'm only left with sadness and a sense of emptiness […] my only companion is the television set, when I realize there is no-one left around me, that's when the panic sets in. Some of these elderly women are living in Long-stay Institutions, so as not to disrupt the lives of my children; several live with others who take them in out of kindness; some live with their children but do not talk to them, with daughters-in-law who treat them badly. Many feel like outsiders and out of place. I long to live in my own home, so as not to be such a burden; she [her daughter] has already told me that I disrupt her life.

Even in their old age, they continue to perform the role of caregiver, even when they no longer have the health or strength to do so. The interviewees mentioned extemporaneous responsibilities, due to poverty, the need to perform domestic chores or to look after the sick, family members, grandchildren, due to the absence of other caregivers, either due to work, illness, abandonment or death. Sometimes, this act of caring involves trying to supervise or control others, trying to prevent them from behaving in an undesirable way, that will harm them, and negatively affect their lives⁴⁶46. Costa JF. Ordem médica e norma familiar. Rio de Janeiro: Edições Graal; 2004.. I think a lot about these children [grandchildren], about helping my daughter; if I should die, she is going to suffer a lot […]. So I try to pull myself together. This excessive burden of responsibility, together with a lack of funds, illness or incapacity represents a physical, economic and personal overload. My job is to cook, look after the children [grandchildren], and sometimes I am made to do this.

These elderly women are also subject to other losses, deaths and mourning which further weaken them, even so, many still want to go on living, managing to downplay the adversities they face, telling the researchers that they will no longer try [to commit suicide]. The way they say this is taken to represent the true essence of life which, like a spark, needs to be kept alight.

Final Considerations

Many reflections emerge at the end of this text and these life stories in motion lead one to perceive gender inequalities and acts of violence as one of the determining factors for self-aggressive behavior in elderly women. These acts of violence are revealed in their biographies, both cross-sectional and longitudinal, and the effect of the hardships they have suffered is something they feel during their entire lives, sometimes culminating in suicide. Such acts of violence in childhood made a profound impact on their lives, either by curtailing opportunities for development, or by reducing their subjectivity as women, who become mere beings dominated by others. Many begin their sexual life early in their youth and enter into destructive relationships, reproducing a relationship where males have dominance over women. As adults, these women are pushed to their limits, in a continual process that wastes away their vital energy, which in their old age crystallizes into a feeling that they have lost their sense of purpose and value in life, which it often seems only death can alleviate.

The accounts of these elderly women confirm to what extent a patriarchal society denies women their rightful role in society. Diminishing the value of a human being is maintained and made to seem natural by means of an ideological discourse that reproduces and maintains gender hierarchies of power. In this context of symbolic domination, there emerge identities and subjectivities produced through negative experiences, the effects of which impact on the women themselves in the form of a sense of guilt and acts of self-aggression.

Finally, although no claim is made to have fully unveiled the complex mechanisms of self-aggressive behavior, the fact is that a study of suicide among elderly people from a gender perspective is in the process of being constructed, though it requires greater theoretical density and further studies and research.

References

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