Abstract:

Suicidal behavior and non-suicidal self-harm in vulnerable groups and population minorities pose a challenge for suicidology, complicating the universality of suicide. The goal of this paper is to analyze the lives of young women from marginalized communities, considering their experiences with suicidality and their relational and violent horizons. Nine women who took part in the fifth wave of a cohort on mental health and violence (2005-2022) in São Gonçalo, Rio de Janeiro State, Brazil, were interviewed (2022) about the contexts that kept them from committing suicide despite significant emotional distress from childhood through youth. From theme-based content analysis, three categories stood out and may contribute to an intersectional, decolonial and socially relevant approach to preventing self-destructive behavior. In the first, views on self-inflicted violence, better explained by the cores concepts of “sin” and “illness” than by the general violence they experienced. In the second, indirect references to self-harm behavior, where it was recognized that the use of euphemisms reflects not only the taboo but also the silencing of and discrimination against minorities. In the third, layers of protection and turning points, where “spirituality”, “occupation” and “motherhood” were interpreted as the main associations between factors of protection and resilience in the trajectories and daily lives of these young women. A closer look that acknowledges the humanity, rights and psychological distress of groups subjected to violence and discrimination not only enhances care and prevention of suicidal behavior but also deepens understanding of this human and universal phenomenon.

Keywords:
Self-injurious Behavior; Suicide; Minority Populations; Youth

Resumen:

El comportamiento suicida y las autolesiones no suicida en grupos vulnerables y poblaciones minoritarias representan un desafío para la suicidología, lo que hace complexa la universalidad del suicidio. En este artículo, el objetivo fue analizar la vida de jóvenes de la periferia, considerando sus experiencias con el suicidio y sus horizontes relacionales y violentos. Nueve mujeres que participaron en la quinta ola de una cohorte sobre salud mental y violencia (2005-2022) en São Gonçalo, Estado de Río de Janeiro, Brasil, fueron entrevistadas (2022) sobre los contextos que las alejaron del suicidio, a pesar del importante sufrimiento emocional, desde la infancia hasta la juventud. Utilizando la técnica de análisis de contenido, modalidad temática, se destacaron tres categorías que pueden contribuir a un enfoque interseccional, decolonial y socialmente relevante para prevenir conductas autodestructivas. En el primero, opiniones sobre la violencia autoinfligida, mejor explicada por los núcleos “pecado” y “enfermedad”, y menos por la violencia vivida en general. En el segundo, lo casi dicho sobre las conductas autolesivas, en que se reconoció cómo el uso de palabras marginales sobre el tema refleja no solo el tabú, sino el silenciamiento y la discriminación contra las minorías. En el tercero, los niveles de protección y puntos de inflexión, donde la “espiritualidad”, el “trabajo” y la “maternidad” se interpretaron como las principales asociaciones entre los factores de protección y resiliencia en las trayectorias de vida y la vida cotidiana de estas jóvenes. Estrechar perspectivas, reconocer la humanidad, los derechos y el sufrimiento psicológico de grupos que han sido violados y discriminados, no solo califica el cuidado y la prevención de la conducta suicida, sino que amplía la comprensión de este fenómeno humano y universal.

Palabras-clave:
Conducta Autodestructiva; Suicidio; Poblaciones Minoritarias; Juventud

Introduction

Suicide has become a public health concern for global youth, a group in which this fatal outcome seems to provoke greater discomfort in micro and macro social domains, and where important elements of vulnerability are recognized ¹1. United Nations Children's Fund. The State of the World's Children 2021: on my mind - promoting, protecting and caring for children's mental health. New York: United Nations Children's Fund; 2021.^,22. World Health Organization. Suicide worldwide in 2019: global health estimates. Geneva: World Health Organization; 2021.^,33. World Health Organization. Global Accelerated Action for the Health of Adolescents (AA-HA!). Geneva: World Health Organization; 2017.. Recent global data suggest a non-uniform reduction in mortality rates, a reality that is not observed in the Americas or among young people from different minorities ²2. World Health Organization. Suicide worldwide in 2019: global health estimates. Geneva: World Health Organization; 2021.^,44. Alvarez K, Polanco-Roman L, Samuel Breslow A, Molock S. Structural racism and suicide prevention for ethnoracially minoritized youth: a conceptual framework and illustration across systems. Am J Psychiatry 2022; 179:422-33.^,55. Benton TD. Suicide and suicidal behaviors among minoritized youth. Child Adolesc Psychiatric Clin N Am 2022; 3:211-21.. In Brazil, there has been a significant increase in suicide and self-harm incidence rates among adolescents and young people in the past decade ⁶6. Secretaria de Vigilância em Saúde e Ambiente, Ministério da Saúde. Panorama dos suicídio e lesões autoprovocadas no Brasil de 2010 a 2021. Boletim Epidemiológico 2024; 55(4).^,77. Alves FJO, Fialho E, Araújo JAP, Naslund JS, Barreto ML, Patel V, et al. The rising trends of self-harm in Brazil: an ecological analysis of notifications, hospitalisations, and mortality between 2011 and 2022. Lancet Reg Health Am 2024; 31:100691..

These differences guide a more detailed analysis of self-inflicted violence occurrence rates, in an effort to better understand these phenomena epidemiologically, clinically and socially, enabling interventions that can reduce early morbidity and mortality in this population ²2. World Health Organization. Suicide worldwide in 2019: global health estimates. Geneva: World Health Organization; 2021.^,88. O'Connor RC. When it is darkest: why people die by suicide and what we can do to prevent it. London: Vermilion; 2021.. Such an analysis should involve elements that attempt to explain the particularities of youth suicidality among discriminated against minorities ⁴4. Alvarez K, Polanco-Roman L, Samuel Breslow A, Molock S. Structural racism and suicide prevention for ethnoracially minoritized youth: a conceptual framework and illustration across systems. Am J Psychiatry 2022; 179:422-33.^,55. Benton TD. Suicide and suicidal behaviors among minoritized youth. Child Adolesc Psychiatric Clin N Am 2022; 3:211-21.^,99. Sheftall AH, Vakil F, Ruch DA, Boyd RC, Lindsey MA, Bridge JA. Black youth suicide: investigation of current trends and precipitating circumstances. J Am Acad Child Adolesc Psychiatry 2022; 61:662-75..

Giving importance to such characteristics means critically addressing suicidology, the field of study and debate on suicide, going beyond the biomedical perspective ⁸8. O'Connor RC. When it is darkest: why people die by suicide and what we can do to prevent it. London: Vermilion; 2021.^,1010. Baére F, Zanello V. Sexualidade e os dispositivos de gênero no comportamento suicida. In: Lima L, Navasconi PVP, editors. (Re)pensando o suicídio: subjetividades, interseccionalidades e saberes pluriepistêmicos. Salvador: EDUFBA; 2022. p. 173-201.^,1111. Navasconi PVP. Vida, adoecimento e suicídio: racismo na produção do conhecimento sobre jovens negros/as LGBTTIS. Belo Horizonte: Letramento; 2019.^,1212. Lopes FH. Suicídio & saber médico: estratégias históricas de domínio, controle e intervenção no Brasil do século XIX. Rio de Janeiro: Apicuri; 2008.. Thus, the investigative focus on self-inflicted violence can transcend the individual sphere to reach the relational and systemic domains ¹³13. Lima L, Navasconi PVP, editors. (Re)pensando o suicídio: subjetividades, interseccionalidades e saberes pluriepistêmicos. Salvador: EDUFBA; 2022.^,1414. O'Connor RC, Kirtley OJ. The integrated motivational-volitional model of suicidal behaviour. Philos Trans R Soc Lond B Biol Sci 2018; 373:20170268.^,1515. Bronfenbrenner U. Bioecologia do desenvolvimento humano. Tornando os seres humanos mais humanos. Porto Alegre: Artmed; 2011.. Not just an individual in distress but a biological subject embedded in multiple relational and violent systems, whose development and subjectivity have been shaped by proximal (face-to-face) processes within specific socio-historical structures ⁴4. Alvarez K, Polanco-Roman L, Samuel Breslow A, Molock S. Structural racism and suicide prevention for ethnoracially minoritized youth: a conceptual framework and illustration across systems. Am J Psychiatry 2022; 179:422-33.^,1616. Bronfenbrenner U, Ceci SJ. Nature-nurture reconceptualized in developmental perspective: a bioecological model. Psychol Rev 1994; 101:568-86.. This is recognized by the literature on self-inflicted violence and minorities ¹³13. Lima L, Navasconi PVP, editors. (Re)pensando o suicídio: subjetividades, interseccionalidades e saberes pluriepistêmicos. Salvador: EDUFBA; 2022.^,1717. Gaylord-Harden NK, Gilreath T, Burnside A, Mintah P, Lindsey MA. Profiles of suicidal ideation among black male adolescents: examination of individual and socioecological predictors. J Clin Child Adolesc Psychol 2023; 7:1-15.^,1818. Scharpf F, Masath FB, Mkinga G, Kyaruzi E, Nkuba M, Machumu M, et al. Prevalence of suicidality and associated factors of suicide risk in a representative community sample of families in three East African refugee camps. Soc Psychiatry Psychiatr Epidemiol 2024; 59:245-59.^,1919. Argabright ST, Visoki E, Moore TM, Ryan DT, DiDomenico GE, Njoroge WFM, et al. Association between discrimination stress and suicidality in preadolescent children. J Am Acad Child Adolesc Psychiatry 2022; 61:686-97.^,2020. Bath E, Njoroge WFM. Coloring outside the lines: making black and brown lives matter in the prevention of youth suicide. J Am Acad Child Adolesc Psychiatry 2021; 60:17-21., encouraging the consideration of counter-hegemonic and intersectional perspectives on psychological distress ¹¹11. Navasconi PVP. Vida, adoecimento e suicídio: racismo na produção do conhecimento sobre jovens negros/as LGBTTIS. Belo Horizonte: Letramento; 2019.^,2121. Fanon F. Pele negra, máscaras brancas. Salvador: EDUFBA; 2008. and drawing attention to the importance of the relational and structural domains in the course of development, as proposed by Bronfenbrenner ¹⁵15. Bronfenbrenner U. Bioecologia do desenvolvimento humano. Tornando os seres humanos mais humanos. Porto Alegre: Artmed; 2011. and Bronfenbrenner & Ceci ¹⁶16. Bronfenbrenner U, Ceci SJ. Nature-nurture reconceptualized in developmental perspective: a bioecological model. Psychol Rev 1994; 101:568-86..

According to Silva Filho ²²22. Silva Filho OC. Percepção e conhecimento de médicos residentes em pediatria no Rio de Janeiro sobre comportamento suicida na infância e na adolescência [Master's Thesis]. Rio de Janeiro: Fundação Oswaldo Cruz; 2019. suicidal behavior involves an overlap between psychological distress and violence (in its self-inflicted typology and in its physical and psychological forms). Emotional distress tends to be more evident and is viewed as a causal element that guides clinical practice ⁸8. O'Connor RC. When it is darkest: why people die by suicide and what we can do to prevent it. London: Vermilion; 2021.^,2323. Dulcan MK, editor. Dulcan's textbook of child and adolescence psychiatry. 3rd Ed. Washington DC: American Psychiatry Association Publishing; 2022.. However, recognizing violence as an inherent element in this behavior expands the possibilities for understanding its occurrence, enabling reflections on and approaches to social structure and its impact on the course of life ¹⁸18. Scharpf F, Masath FB, Mkinga G, Kyaruzi E, Nkuba M, Machumu M, et al. Prevalence of suicidality and associated factors of suicide risk in a representative community sample of families in three East African refugee camps. Soc Psychiatry Psychiatr Epidemiol 2024; 59:245-59.^,2020. Bath E, Njoroge WFM. Coloring outside the lines: making black and brown lives matter in the prevention of youth suicide. J Am Acad Child Adolesc Psychiatry 2021; 60:17-21.^,2424. Ashworth E, Jarman I, McCabe P, McCarthy M, Provazza S, Crosbie V, et al. Suicidal crisis among children and young people: associations with adverse childhood experiences and socio-demographic factors. Int J Environ Res Public Health 2023; 20:1251.^,2525. Turecki G. Early-life adversity and suicide risk: the role of epigenetics. In: Pompili M, editor. Phenomenol suicide unlocking suicidal mind. Gewerbestrasse: Springer Nature; 2018. p. 157-67.. The clash between these perspectives does not establish an etiological impasse but an overlap, where arguments are combined and the multiple causes of these phenomena are acknowledged ⁸8. O'Connor RC. When it is darkest: why people die by suicide and what we can do to prevent it. London: Vermilion; 2021.^,2222. Silva Filho OC. Percepção e conhecimento de médicos residentes em pediatria no Rio de Janeiro sobre comportamento suicida na infância e na adolescência [Master's Thesis]. Rio de Janeiro: Fundação Oswaldo Cruz; 2019..

Thus, different publications argue for the importance of recognizing violence as one of the factors determining self-harm behavior, especially when children, adolescents and youth are studied ⁴4. Alvarez K, Polanco-Roman L, Samuel Breslow A, Molock S. Structural racism and suicide prevention for ethnoracially minoritized youth: a conceptual framework and illustration across systems. Am J Psychiatry 2022; 179:422-33.^,99. Sheftall AH, Vakil F, Ruch DA, Boyd RC, Lindsey MA, Bridge JA. Black youth suicide: investigation of current trends and precipitating circumstances. J Am Acad Child Adolesc Psychiatry 2022; 61:662-75.^,2020. Bath E, Njoroge WFM. Coloring outside the lines: making black and brown lives matter in the prevention of youth suicide. J Am Acad Child Adolesc Psychiatry 2021; 60:17-21.. In these cases, adverse childhood experiences gain prominence in qualitative-quantitative studies, corroborating concerns about the care of children and youth ¹⁹19. Argabright ST, Visoki E, Moore TM, Ryan DT, DiDomenico GE, Njoroge WFM, et al. Association between discrimination stress and suicidality in preadolescent children. J Am Acad Child Adolesc Psychiatry 2022; 61:686-97.^,2424. Ashworth E, Jarman I, McCabe P, McCarthy M, Provazza S, Crosbie V, et al. Suicidal crisis among children and young people: associations with adverse childhood experiences and socio-demographic factors. Int J Environ Res Public Health 2023; 20:1251.^,2525. Turecki G. Early-life adversity and suicide risk: the role of epigenetics. In: Pompili M, editor. Phenomenol suicide unlocking suicidal mind. Gewerbestrasse: Springer Nature; 2018. p. 157-67.. This is not only for physical safety and monitoring growth but also for tracking developmental and mental health trajectories ⁴4. Alvarez K, Polanco-Roman L, Samuel Breslow A, Molock S. Structural racism and suicide prevention for ethnoracially minoritized youth: a conceptual framework and illustration across systems. Am J Psychiatry 2022; 179:422-33.^,2626. Silva Filho OC, Avanci JQ, Pires TO, Oliveira RVC, Assis SG. Attachment, suicidal behavior, and self-harm in childhood and adolescence: a study of a cohort of Brazilian schoolchildren. BMC Pediatr 2023; 23:403.^,2727. Cénat JM, Dalexis RD, Darius WP, Kogan CS, Guerrier M. Prevalence of current PTSD symptoms among a sample of black individuals aged 15 to 40 in Canada: the major role of everyday racial discrimination, racial microaggresions, and internalized racism. Can J Psychiatry 2023; 68:178-86..

Suicidal behavior is viewed as a continuum that includes ideation, planning, attempts and completed suicide, a definition aligned with public health ²2. World Health Organization. Suicide worldwide in 2019: global health estimates. Geneva: World Health Organization; 2021.^,2222. Silva Filho OC. Percepção e conhecimento de médicos residentes em pediatria no Rio de Janeiro sobre comportamento suicida na infância e na adolescência [Master's Thesis]. Rio de Janeiro: Fundação Oswaldo Cruz; 2019.. Although there is no consensus in the literature, non-suicidal self-harm is not considered part of this spectrum, since its expression may resemble a suicide attempt but there is no accompanying ideation. Despite this delicate distinction, it can also be understood as a phenomenon involving self-inflicted violence and emotional distress ⁸8. O'Connor RC. When it is darkest: why people die by suicide and what we can do to prevent it. London: Vermilion; 2021.^,2828. Avanci JQ, Assis SG, Silva Filho OC, Gonçalves AF, Tavares PHSL, Marriel NSM. Comportamento suicida e autolesão na infância e adolescência: conversando com profissionais sobre formas de prevenção. Rio de Janeiro: Fundação de Amparo à Pesquisa do Estado do Rio de Janeiro; 2023.. Both phenomena affect contemporary youth, requiring urgent reflection on development, mental health and violence ¹1. United Nations Children's Fund. The State of the World's Children 2021: on my mind - promoting, protecting and caring for children's mental health. New York: United Nations Children's Fund; 2021.^,33. World Health Organization. Global Accelerated Action for the Health of Adolescents (AA-HA!). Geneva: World Health Organization; 2017.^,2626. Silva Filho OC, Avanci JQ, Pires TO, Oliveira RVC, Assis SG. Attachment, suicidal behavior, and self-harm in childhood and adolescence: a study of a cohort of Brazilian schoolchildren. BMC Pediatr 2023; 23:403.^,2828. Avanci JQ, Assis SG, Silva Filho OC, Gonçalves AF, Tavares PHSL, Marriel NSM. Comportamento suicida e autolesão na infância e adolescência: conversando com profissionais sobre formas de prevenção. Rio de Janeiro: Fundação de Amparo à Pesquisa do Estado do Rio de Janeiro; 2023..

In the face of so many feelings, behaviors and vulnerabilities, understanding why an individual does not give in to suicide becomes a potential path for prevention, especially among minorities with marginalized trajectories. The study of death guides reflection on life ²⁹29. Elias N. A solidão dos moribundos. Rio de Janeiro: Zahar; 2001.; thus, reflecting on young women on the borders of suicide may contribute to understanding their horizons, protective pathways and turning points. The goal of this paper is to discuss how young women from the outskirts of a violent Brazilian metropolis understand the suicidal behavior they exhibited throughout the course of their life, from childhood to youth, focusing on the events and contexts that protected them from self-inflicted death.

Methodological approach

This paper is the result of a longitudinal study carried out with children in São Gonçalo, Rio de Janeiro State, Brazil, which began in 2005 ³⁰30. Avanci JQ. Comportamento suicida: uma abordagem longitudinal da infância à vida adulta. Relatório de pesquisa. Rio de Janeiro: Fundação Oswaldo Cruz; 2023.. The reflections herein presented were developed from the qualitative analysis of nine interviews conducted in a complementary phase of the fifth investigative wave (2021-2022) of the São Gonçalo/RJ Children’s Violence and Mental Health Cohort (2005-2022).

São Gonçalo is located in the Metropolitan Area of Rio de Janeiro. It is a large and densely populated municipality with adverse living conditions, limited educational resources and poor infrastructure ³¹31. Instituto Brasileiro de Geografia e Estatística. Cidades@. São Gonçalo. https://cidades.ibge.gov.br/brasil/rj/sao-goncalo/panorama (accessed on 10/Mar/2024).
https://cidades.ibge.gov.br/brasil/rj/sa... . It has numerous records of police operations, interventions with violent repercussions that reduce urban mobility, access and functionality ³²32. Hirata DV, Grillo CC. Operações policiais no Rio de Janeiro. Sumário executivo. Rio de Janeiro: Fundação Heinrich Böll; 2019.. The presence of multiple vulnerabilities, in both micro and macro social contexts, is a characteristic of the cohort and a significant descriptor in monitoring these participants.

In 2021, 129 youngsters (25.8% of the initial sample) were located through in-person visits by community health workers (CHW), phone contact or on social media, and agreed to participate by answering questionnaires after signing an informed consent form. Of these 129 participants, 35 had at least one reference, over nearly two decades of the study, to suicidal behavior and/or non-suicidal self-harm. Given the theoretical and clinical divergence between suicidal behavior and non-suicidal self-harm ⁸8. O'Connor RC. When it is darkest: why people die by suicide and what we can do to prevent it. London: Vermilion; 2021.^,2323. Dulcan MK, editor. Dulcan's textbook of child and adolescence psychiatry. 3rd Ed. Washington DC: American Psychiatry Association Publishing; 2022., a conceptual alignment was adopted in this study, using the term suicidal behavior/non-suicidal self-harm. The rationale for this grouping was that both represent psychological distress and actions against bodily integrity.

Aiming at a deeper understanding, the qualitative method ³³33. Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 14ª Ed. São Paulo: Hucitec Editora; 2014. was applied to a subset of these 35 participants. The onset of the outcome (before or after the age of 14) and the presence or absence of recurrence (more than one reference throughout the study) were additional criteria for recruitment in this phase. The age of 14 was chosen for marking the transition between the first and second halves of adolescence, with the latter being a typical phase of increased occurrence of suicidal behavior/non-suicidal self-harm ²2. World Health Organization. Suicide worldwide in 2019: global health estimates. Geneva: World Health Organization; 2021.^,44. Alvarez K, Polanco-Roman L, Samuel Breslow A, Molock S. Structural racism and suicide prevention for ethnoracially minoritized youth: a conceptual framework and illustration across systems. Am J Psychiatry 2022; 179:422-33.^,66. Secretaria de Vigilância em Saúde e Ambiente, Ministério da Saúde. Panorama dos suicídio e lesões autoprovocadas no Brasil de 2010 a 2021. Boletim Epidemiológico 2024; 55(4).^,2828. Avanci JQ, Assis SG, Silva Filho OC, Gonçalves AF, Tavares PHSL, Marriel NSM. Comportamento suicida e autolesão na infância e adolescência: conversando com profissionais sobre formas de prevenção. Rio de Janeiro: Fundação de Amparo à Pesquisa do Estado do Rio de Janeiro; 2023.. Recurrence is one of the most severe clinical elements concerning self-inflicted violence ²³23. Dulcan MK, editor. Dulcan's textbook of child and adolescence psychiatry. 3rd Ed. Washington DC: American Psychiatry Association Publishing; 2022..

There were challenges in recruiting, scheduling and conducting the meetings with the selected young women, resulting in a final group of nine participants. The nine interviews were done either in person (at an easily accessible clinic) or remotely via the Zoom Meeting platform (https://zoom.us/) from September to October 2022. They were led by the paper’s author (O. C. Silva Filho; a psychiatrist) with the administration of a previously tested semi-structured questionnaire. The interview technique made it possible for relevant themes to come up and be discussed, respecting the individuality of each participant, with analysis of the accounts leading to thematic saturation ³⁴34. Minayo MCS. Análise qualitativa: teoria, passos e fidedignidade. Ciênc Saúde Colet 2012; 17:621-6.. A second researcher (a psychologist) attended all the interviews, contributing to a supportive environment, which helped prevent any post-interview discomfort.

The young women received pseudonyms that refer to women who stand out in the defense of popular culture and human rights; thus, by honoring these women, we sought to make it difficult to identify the participants. The interviews were transcribed, creating a corpus that was examined according to theme-based content analysis ³³33. Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 14ª Ed. São Paulo: Hucitec Editora; 2014.^,3434. Minayo MCS. Análise qualitativa: teoria, passos e fidedignidade. Ciênc Saúde Colet 2012; 17:621-6.^,3535. Bardin L. Análise de conteúdo. Lisboa: Edições 70; 1977.. The transcribed material underwent repeated and progressively deeper readings in order to achieve comprehensive understanding, as well as to identify discourse similarities and differences ³⁴34. Minayo MCS. Análise qualitativa: teoria, passos e fidedignidade. Ciênc Saúde Colet 2012; 17:621-6.. The most relevant excerpts from each interview were selected, tabulated and analyzed based on the theoretical framework of the investigation. The interview process revealed contradictions, repetitions and responses to the researchers’ questions, prompting reflection. This was followed by a synthesis of each interview, which made it possible to group them by theme and content. After being cross-checked and reorganized, they resulted in three stable analytical categories with interpretative significance, no longer tied strictly to the participants’ reports ³⁴34. Minayo MCS. Análise qualitativa: teoria, passos e fidedignidade. Ciênc Saúde Colet 2012; 17:621-6.^,3535. Bardin L. Análise de conteúdo. Lisboa: Edições 70; 1977.: (1) about views on self-inflicted violence; (2) about indirect references to self-harm behavior; (3) over protective layers and turning points. These categories were compared with the national and international literature, making up the results and discussion of this work ³³33. Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 14ª Ed. São Paulo: Hucitec Editora; 2014..

All phases of the longitudinal study were approved by the Research Ethics Committee of the Sergio Arouca National School of Public Health, Oswaldo Cruz Foundation (ENSP/FIOCRUZ; CAAE 5734422.6.0000.5240).

Results and discussion

The sociodemographic profile of the interviewed young women is shown in Box 1, characterized by nine marginalized women in a minority context who exhibited different characteristics of suicidal behavior/non-suicidal self-harm (Box 2).

Nine peripheral women: overview of a minority

The interviewed young women showed different characteristics of suicidal behavior/non-suicidal self-harm (Box 2), being grouped as a female and peripheral group. No single minority is represented here; however, the group is exclusively composed of women born and living in peripheral areas of São Gonçalo. Such exclusivity ensured the inclusive nature of the study, with the nine women forming a minority marked by intersectionality or, as defined by Akotirene ³⁶36. Akotirene C. Interseccionalidade. São Paulo: Pólen Livros; 2019., by an interconnected system of oppressions.

Baére & Zanello ¹⁰10. Baére F, Zanello V. Sexualidade e os dispositivos de gênero no comportamento suicida. In: Lima L, Navasconi PVP, editors. (Re)pensando o suicídio: subjetividades, interseccionalidades e saberes pluriepistêmicos. Salvador: EDUFBA; 2022. p. 173-201. argue that gender roles in a patriarchal and violent society impact the mental health of women, to the point of questioning their emotional distress. In Brazil, women are predominant in cases of suicide attempts and non-suicidal self-harm, with the risk of suicide being higher among those aged 15 to 19 ⁶6. Secretaria de Vigilância em Saúde e Ambiente, Ministério da Saúde. Panorama dos suicídio e lesões autoprovocadas no Brasil de 2010 a 2021. Boletim Epidemiológico 2024; 55(4).^,77. Alves FJO, Fialho E, Araújo JAP, Naslund JS, Barreto ML, Patel V, et al. The rising trends of self-harm in Brazil: an ecological analysis of notifications, hospitalisations, and mortality between 2011 and 2022. Lancet Reg Health Am 2024; 31:100691.. These data highlight the relevance of sociocultural aspects in understanding suicidality ¹⁰10. Baére F, Zanello V. Sexualidade e os dispositivos de gênero no comportamento suicida. In: Lima L, Navasconi PVP, editors. (Re)pensando o suicídio: subjetividades, interseccionalidades e saberes pluriepistêmicos. Salvador: EDUFBA; 2022. p. 173-201. and concur with Jaworski’s ³⁷37. Jaworski K. The gender-ing of suicide. Aust Fem Stud 2010; 25:47-61. argument that for women, the focus of investigation should be the early stages of suicidal behavior rather than its fatal outcome.

The description of the young women as peripheral and marginalized goes beyond income or social class. The areas where the children were sampled were characterized by intense social vulnerability: marginalized, peripheral territories with high crime rates ³⁰30. Avanci JQ. Comportamento suicida: uma abordagem longitudinal da infância à vida adulta. Relatório de pesquisa. Rio de Janeiro: Fundação Oswaldo Cruz; 2023.. It is important to note that despite possible convergences or associations between the concepts of marginality and criminality, this study follows the distinction made by Coelho ³⁸38. Coelho EC. A criminalização da marginalidade e marginalização da criminalidade. Revista de Administração Pública 1978; 12:139-61. in describing the context of urban violence in Rio de Janeiro. For him, unemployment, underemployment or poverty serve as proxies for a marginalized population, elements that, while possibly facilitating the emergence of criminality, do not define it per se. At the same time, the recurrent and violent police operations in peripheral areas ³²32. Hirata DV, Grillo CC. Operações policiais no Rio de Janeiro. Sumário executivo. Rio de Janeiro: Fundação Heinrich Böll; 2019. corroborate the process of criminalizing marginality and marginalizing criminality ³⁸38. Coelho EC. A criminalização da marginalidade e marginalização da criminalidade. Revista de Administração Pública 1978; 12:139-61..

Therefore, continuing to live and interact in these areas was understood as remaining immersed in the daily reality of violence and, consequently, vulnerability while growing up ⁴4. Alvarez K, Polanco-Roman L, Samuel Breslow A, Molock S. Structural racism and suicide prevention for ethnoracially minoritized youth: a conceptual framework and illustration across systems. Am J Psychiatry 2022; 179:422-33.^,1919. Argabright ST, Visoki E, Moore TM, Ryan DT, DiDomenico GE, Njoroge WFM, et al. Association between discrimination stress and suicidality in preadolescent children. J Am Acad Child Adolesc Psychiatry 2022; 61:686-97.. Even while working and/or attending school, these young women were marginalized, victims of social inequality, with their lives and microsocial relationships shaped by structural violence ¹⁵15. Bronfenbrenner U. Bioecologia do desenvolvimento humano. Tornando os seres humanos mais humanos. Porto Alegre: Artmed; 2011..

Three categories were analyzed: (1) marginalized trajectories: views on self-inflicted violence; (2) euphemisms: indirect references to self-harm behavior; and (3) on the margin of suicide: layers of protection and turning points.

Marginalized trajectories: views on self-inflicted violence.

Theoretical and clinical arguments suggest that the overlap of different kinds of violence becomes a risk factor for its self-inflicted typology ²³23. Dulcan MK, editor. Dulcan's textbook of child and adolescence psychiatry. 3rd Ed. Washington DC: American Psychiatry Association Publishing; 2022.. This is certainly not exclusive to self-harm but it is a frequent condition in the study of violence ²⁸28. Avanci JQ, Assis SG, Silva Filho OC, Gonçalves AF, Tavares PHSL, Marriel NSM. Comportamento suicida e autolesão na infância e adolescência: conversando com profissionais sobre formas de prevenção. Rio de Janeiro: Fundação de Amparo à Pesquisa do Estado do Rio de Janeiro; 2023.. Among the interviewees, reports of violence can be grouped as follows: eight experienced family violence during childhood and adolescence; four faced violence at school; two reported sexual violence; and five experienced violence from an intimate partner.

According to the young women’s reports, their personal experiences with violence did not justify the presence of suicidal behavior/non-suicidal self-harm in their lives. This was initially surprising, as the consequences of violence are well-known in the physical, psychological, developmental and relational domains, especially for children and adolescents ¹⁹19. Argabright ST, Visoki E, Moore TM, Ryan DT, DiDomenico GE, Njoroge WFM, et al. Association between discrimination stress and suicidality in preadolescent children. J Am Acad Child Adolesc Psychiatry 2022; 61:686-97.^,2525. Turecki G. Early-life adversity and suicide risk: the role of epigenetics. In: Pompili M, editor. Phenomenol suicide unlocking suicidal mind. Gewerbestrasse: Springer Nature; 2018. p. 157-67.. The analysis did not dismiss this impact but pointed to a lack of recognition of the violence itself. The explanation went beyond the personal experiences of these young women, expanding to perceptions that reflected broader societal understandings of these phenomena.

Two explanatory core concepts prevailed throughout the analytical process: “sin” and “disease”. Both reflect the deviant nature of suicide in Western society, viewed as individual failings in or of human life. There were gradations within this category: “sin” and “disease” more easily related to completed suicide. As the most tragic outcome of the suicidal continuum, suicide was described as a “great sin” or “intense disease”, while non-suicidal self-harm was considered a deliberate act against one’s own integrity and a less severe flaw compared to suicide.

“The enemy’s role is to kill, steal, destroy. So, he wants others to kill themselves. If they do so, they will have no salvation!” (Leci Brandão).

There was a predominance of the neopentecostal perspective in the faith and value system of the interviewees. Four are practicing neopentecostals, one is non-practicing, and one is currently “removed”. The discourse of all of them was strongly marked by this faith. Even among the two young women “with no defined religion”, there was noticeable influence of neopentecostalism. This corroborates the findings of Cunha ⁴⁰40. Cunha VC. Cultura Pentecostal em periferias cariocas: grafites e agenciamentos políticos nacionais. PLURAL. Revista do Programa de Pós-graduação em Sociologia da USP 2021; 28:80-108 who highlights the spread of this segment in the outskirts of Rio de Janeiro, especially after the 1990s, strongly reflected in the culture, daily life and language of this youth. Maia ⁴¹41. Maia AAX. Os impasses e os avanços do neopetencostaismo na juventude de São Gonçalo. Revista Transversos 2020; 18:234-53. also portrays this context, describing the visibility and everyday presence of young neopentecostals in São Gonçalo.

Thus, it was shown how neopentecostal beliefs and standards pervaded the trajectories of these young women, influencing their choices, shaping their perspectives and explaining their distress and self-harm practices. In this worldview, the world is in constant tension between good and evil ⁴¹41. Maia AAX. Os impasses e os avanços do neopetencostaismo na juventude de São Gonçalo. Revista Transversos 2020; 18:234-53., with suicidal ideation viewed by the interviewees as a malignant influence that makes them stray from the Lord’s path and promises.

“There are times when we falter, when we sin. ‘Lord, I feel weak!’. Then, some bad thoughts come into our minds. We are not always fully connected to God” (Cora Coralina).

From the perspective of “suicide as sin”, exercising faith is the main intervention to be sought when faced with the suicidal continuum, preventing suicidal ideation from escalating to an attempt. Ideation can be seen as a trial or temptation that, when overcome through faith, can honor one’s relationship with the sacred. Conversely, one of the failures of spirituality occurs in the face of suicide.

A religious framework that values simple sermons, with simple examples for simple people ⁴⁰40. Cunha VC. Cultura Pentecostal em periferias cariocas: grafites e agenciamentos políticos nacionais. PLURAL. Revista do Programa de Pós-graduação em Sociologia da USP 2021; 28:80-108, has proved to be popular in peripheral areas, furthering the incorporation and spread of its principles, as identified in this corpus. Supported by prosperity and dominion theology ⁴⁰40. Cunha VC. Cultura Pentecostal em periferias cariocas: grafites e agenciamentos políticos nacionais. PLURAL. Revista do Programa de Pós-graduação em Sociologia da USP 2021; 28:80-108 and the possibility of change in this life and not just in the afterlife ⁴¹41. Maia AAX. Os impasses e os avanços do neopetencostaismo na juventude de São Gonçalo. Revista Transversos 2020; 18:234-53., neopentecostalism gained muscle, playing a considerable role in shaping the horizons and trajectories of Brazilian youth.

Although this study acknowledges the plurality of neopentecostalism, such differences are not essential here, since they express a similar worldview that helps understand the micro and macro social relationships within this chronosystem ¹⁵15. Bronfenbrenner U. Bioecologia do desenvolvimento humano. Tornando os seres humanos mais humanos. Porto Alegre: Artmed; 2011.. The aim is to incorporate them as a possible element in protection networks, accessing these spaces and institutions of neopentecostal culture and harnessing their potential as hubs for mental health care and prevention. This poses numerous challenges and conflicts, given the context of violence and conservatism, but it must be planned.

The explanation of suicide as a manifestation of illness was unanimous among the young women, a view strongly supported by the widespread diffusion of the biomedical model. According to this paradigm, about 80% to 90% of completed suicides have an associated mental disorder, a statistic often repeated in the literature ⁶6. Secretaria de Vigilância em Saúde e Ambiente, Ministério da Saúde. Panorama dos suicídio e lesões autoprovocadas no Brasil de 2010 a 2021. Boletim Epidemiológico 2024; 55(4).^,2323. Dulcan MK, editor. Dulcan's textbook of child and adolescence psychiatry. 3rd Ed. Washington DC: American Psychiatry Association Publishing; 2022.. Thus, a convergence between common sense and hegemonic scientific knowledge was evident.

“It’s a pain you carry, although you might not know it, but it’s a burden. You sleep with it, you wake up with it, you don’t want to think about it, but you end up thinking about it. It tortures you in such a way. I often say that I don’t judge those who want to take their own life” (Elza Soares).

This outlook does not seem to represent a weakening of taboos surrounding child and adolescent suicide ⁴¹41. Maia AAX. Os impasses e os avanços do neopetencostaismo na juventude de São Gonçalo. Revista Transversos 2020; 18:234-53. but rather the result of campaigns addressing suicide prevention through health. A Brazilian suicide prevention campaign was mentioned by several of the young women, suggesting that it had become part of their everyday lives, especially through social media. However, such embedment does not necessarily lead to significant individual or collective changes in prevention, often being a presence they described as indifferent or tedious.

The reports of the participants emphasized, as supported by biomedical literature, a possible connection between depression and suicidal behavior ¹1. United Nations Children's Fund. The State of the World's Children 2021: on my mind - promoting, protecting and caring for children's mental health. New York: United Nations Children's Fund; 2021.^,22. World Health Organization. Suicide worldwide in 2019: global health estimates. Geneva: World Health Organization; 2021.^,2323. Dulcan MK, editor. Dulcan's textbook of child and adolescence psychiatry. 3rd Ed. Washington DC: American Psychiatry Association Publishing; 2022., with examples of how psychological distress can lead to the occurrence of this violence. Two elements were identified as supporting this view: four of the nine young women had undergone psychotherapy; and at certain times the reports overlapped with descriptions of intense sadness and hopelessness. Although the investigation was not a diagnostic interview, the theoretical framework of suicidology made it possible to reach these conclusions in the analysis.

Eight young women reported symptoms consistent with mental disorders throughout their lives, but only four had access to psychotherapy and none underwent psychiatric treatment, with cases of irregular use of psychotropic drugs. Thus, personal experiences of emotional distress, even if not reduced to a mental disorder, could serve as an argument for the correlation between suicidal behavior and mental illness.

“It was more of a ‘I’m tired!’ situation. It was a feeling of: ‘Ah, I’ve had enough, I don’t want to live anymore. I’m tired. It only brings problems, it only brings stress, nothing gets better, I don’t see anything happening, it only brings sadness’. I would think that it would be easier to end it” (Clementina de Jesus).

It should be noted that these young women had little support to deal with their psychological distress. It was possibly recognized but not addressed due to poor access to psychosocial support networks, or, even worse, was not validated as distress at all. Alvarez et al. ⁴4. Alvarez K, Polanco-Roman L, Samuel Breslow A, Molock S. Structural racism and suicide prevention for ethnoracially minoritized youth: a conceptual framework and illustration across systems. Am J Psychiatry 2022; 179:422-33. point out that only one-third of African American youth who die by suicide have a diagnosed mental disorder. Baére & Zanello ¹⁰10. Baére F, Zanello V. Sexualidade e os dispositivos de gênero no comportamento suicida. In: Lima L, Navasconi PVP, editors. (Re)pensando o suicídio: subjetividades, interseccionalidades e saberes pluriepistêmicos. Salvador: EDUFBA; 2022. p. 173-201. and Jaworski ³⁷37. Jaworski K. The gender-ing of suicide. Aust Fem Stud 2010; 25:47-61. illustrate how the lower lethality of suicide attempts among women may be socially perceived as indicating less suffering compared to men. Navasconi ¹¹11. Navasconi PVP. Vida, adoecimento e suicídio: racismo na produção do conhecimento sobre jovens negros/as LGBTTIS. Belo Horizonte: Letramento; 2019., in a critical stance to the biomedical perspective, argues that racism is a factor in illness and suicide among Brazilian youth. These arguments come from different authors with varying theoretical perspectives, which, despite their affiliations, converge on the need to consider prejudice against minorities in the management and prevention of suicidal behavior and non-suicidal self-harm.

Euphemisms: indirect references to self-harm behavior

All interviews were preceded by a brief explanation of the research, identifying its subject and motivation. This helped in understanding the difficulty observed to speak in the first person and in using words and terms directly related to suicidal behavior/non-suicidal self-harm.

Speaking about third parties, whether known or not, was constant, allowing the young women to expand their arguments, examples and causal explanations for self-inflicted violence. Similarly, it seemed easier to resort to metaphors or illustrations to narrate and exemplify their own experiences. At this point, a comprehensive leap beyond what was actually expressed made it possible to listen to and interpret what was implied or silenced ³³33. Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 14ª Ed. São Paulo: Hucitec Editora; 2014..

“My mother would beat me and I wanted to disappear from her life. I didn’t want to die, but I wanted to die for her because she wouldn’t see me anymore. She wouldn’t even know I existed anymore. I wanted to disappear, almost die” (Clara Nunes).

“I don’t know, I think I’ve never wanted to kill myself. I wanted to disappear, to hide, to crawl into a hole and stay there hidden, without anyone seeing me. To disappear and if there was a solution, I would come back” (Conceição Evaristo).

“It was as if I were lying on a stretcher in the hospital. I was lying there, I could the doctor, but I couldn’t see anyone from my family. I would feel despondent. ‘Could this be really true? No-one? It’s not possible’. Then I saw that no one showed up. I’d get a little nervous, stressed, thoughtful” (Elza Soares).

More than identifying and even understanding what was implied by the young women, incorporating these euphemisms into the semantics of care is one of the possibilities of this research. It was considered that the crystallization of the taboo surrounding child and youth suicide ⁴²42. Silva Filho OC, Minayo MCS. Triple taboo: considerations about suicide among children and adolescents. Ciênc Saúde Colet 2021; 26:2693-8. might have been a reason for avoiding the subject. This taboo blocks the subject, silencing and constraining discourse. However, the personal narratives presented alongside the contemporary prominence given to the subject suggest that other elements might clarify these indirect references.

Drawing on studies that highlight discrimination against minorities as a risk factor for suicidal behavior/non-suicidal self-harm ¹⁹19. Argabright ST, Visoki E, Moore TM, Ryan DT, DiDomenico GE, Njoroge WFM, et al. Association between discrimination stress and suicidality in preadolescent children. J Am Acad Child Adolesc Psychiatry 2022; 61:686-97.^,2020. Bath E, Njoroge WFM. Coloring outside the lines: making black and brown lives matter in the prevention of youth suicide. J Am Acad Child Adolesc Psychiatry 2021; 60:17-21., it is considered that the lack of social validation of psychological distress in the course of these young women’s lives is a sensitive and pertinent understanding of this empirically observed issue. Non-validation or inadequate handling of a distress, which is only acknowledged, addressed and managed according to hegemonic practices and norms, as discussed by Fanon ²¹21. Fanon F. Pele negra, máscaras brancas. Salvador: EDUFBA; 2008..

Benton ⁵5. Benton TD. Suicide and suicidal behaviors among minoritized youth. Child Adolesc Psychiatric Clin N Am 2022; 3:211-21. points to a greater number of suicide attempts than reports of suicidal ideation among black youth, corroborating the idea that that the suffering of this minority is only validated when extreme action is taken. It is as if psychological distress were naturalized and prohibited in minority groups, not acknowledged. At the same time, Jaworski ³⁷37. Jaworski K. The gender-ing of suicide. Aust Fem Stud 2010; 25:47-61. stresses that the lower global suicide rates among women should not obscure the presence of suicidal ideation within this gender, drawing attention to other forms of discrimination.

Sheftall et al. ⁹9. Sheftall AH, Vakil F, Ruch DA, Boyd RC, Lindsey MA, Bridge JA. Black youth suicide: investigation of current trends and precipitating circumstances. J Am Acad Child Adolesc Psychiatry 2022; 61:662-75. argue that structural and relational violence should guide investigations, approaches and preventive actions for suicidality among minority youth. In Brazil, Navasconi ¹¹11. Navasconi PVP. Vida, adoecimento e suicídio: racismo na produção do conhecimento sobre jovens negros/as LGBTTIS. Belo Horizonte: Letramento; 2019. denounces how the scientific literature and health care ignore the intersectionality of suicidal behavior with markers of race, class, and gender.

Given that different forms of discrimination and violence are present in the social relations of peripheral groups, especially those involving women, it is essential that discussions about suicidality consider environmental adversities and adverse childhood experiences ¹⁹19. Argabright ST, Visoki E, Moore TM, Ryan DT, DiDomenico GE, Njoroge WFM, et al. Association between discrimination stress and suicidality in preadolescent children. J Am Acad Child Adolesc Psychiatry 2022; 61:686-97., addressed through sensitive listening and viewed through the lenses of justice, equity, diversity and inclusion. The repeated and naturalized violence against these groups amounts to daily micro aggressions that impact their mental health, especially when they are silenced or ignored ²⁷27. Cénat JM, Dalexis RD, Darius WP, Kogan CS, Guerrier M. Prevalence of current PTSD symptoms among a sample of black individuals aged 15 to 40 in Canada: the major role of everyday racial discrimination, racial microaggresions, and internalized racism. Can J Psychiatry 2023; 68:178-86..

In this context, the more detached discourse of the interviewed young women about suicidal behavior/non-suicidal self-harm did not seem to reflect mere discomfort at being interviewed. The implied words appeared to reveal a suppression of distress, or even to indicate lost opportunities for support in the face of different kinds of violence (Box 2) within relational systems throughout their life trajectories.

On the margin of suicide: layers of protection and turning points

This category made it possible to recognize the elements of the young women’s everyday life (social functions and/or interventions) identified as layers of protection against suicide (Box 2). These elements were grouped into eight first-order categories, which were then interpreted and reclassified into three second-order categories ³³33. Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 14ª Ed. São Paulo: Hucitec Editora; 2014.. The three categories - spirituality, occupation and motherhood - were perceived as the most significant turning points in the experiences of the young women. This synthesis provided insight into the contexts that enabled a trajectory that kept them on the margin of suicide, despite their life experiences of suicidal behavior/non-suicidal self-harm.

Highlighting these turning points was also a methodological resource used by Werner & Smith ⁴³43. Werner EE, Smith RS. Journeys from childhood to midlife: risk, resilience, and recovery. New York: Cornell University Press; 2001. in a cohort of Hawaiian children (United States) that began in the 1950s. The authors sought to understand, in adulthood, which everyday elements had been longitudinally protective. Higher education; skills learned during military service; stable marriage; participation in a faith community; recovery from a life-threatening event; and psychotherapy were recognized as protective elements in the Hawaiian cohort. Some of these elements were similar to those found in this study.

The prior discussion about the influence of spirituality in the lives of the young women justifies the importance of the “spirituality” category as an element of protection and resilience. More than an ontological consideration, its relevance herein lies in its ordinary concreteness: spirituality provides organization and inclusion in a support network in real everyday life. Organic groups that come together, validating values and striving for a better life ⁴⁰40. Cunha VC. Cultura Pentecostal em periferias cariocas: grafites e agenciamentos políticos nacionais. PLURAL. Revista do Programa de Pós-graduação em Sociologia da USP 2021; 28:80-108. The individual choice of religious engagement during adolescence showed greater appeal as social support than mere continuation of a religious family tradition ⁴¹41. Maia AAX. Os impasses e os avanços do neopetencostaismo na juventude de São Gonçalo. Revista Transversos 2020; 18:234-53..

In this study, “occupation” does not relate merely to work. Given that labor capacity is a parameter for evaluating mental disorders and suicidality as deviations from the social order ³⁹39. Conrad P, Schneider JW. Deviance and medicalization: from badness to sickness. Philadelphia: Temple University; 1992., this dimension was carefully considered beyond the term “work”. The occupation category included other interventions and protective layers (Box 2): arts (dance teaching course), pleasure in braiding (braiding course), level of education and actual work practice (integration into the social fabric). The young women confirmed that their ability - whether acquired or desired - to provide for themselves affords them security and dignity. As peripheral women, the pursuit of financial independence is a clear protective factor, given the violence and emotional distress they face, especially for those with children.

Education, a formative element of this category, was a focal point of criticism, even though only two young women had not completed elementary school. School did not prove to be a space of adequate development for their daily lives and failed to provide support in the face of violence, establishing itself as a violent environment. Regarding suicidal behavior/non-suicidal self-harm, the accounts predominantly indicated an inability to engage in dialogue and management. In this context, Sheftall et al. ⁹9. Sheftall AH, Vakil F, Ruch DA, Boyd RC, Lindsey MA, Bridge JA. Black youth suicide: investigation of current trends and precipitating circumstances. J Am Acad Child Adolesc Psychiatry 2022; 61:662-75. argue that black youth tend to feel less secure regarding mental health in school and do not seek as much help as their peers. School support systems do not reach everyone, requiring strategies that are more sensitive to the subjectivity of minority groups. The authors ⁹9. Sheftall AH, Vakil F, Ruch DA, Boyd RC, Lindsey MA, Bridge JA. Black youth suicide: investigation of current trends and precipitating circumstances. J Am Acad Child Adolesc Psychiatry 2022; 61:662-75. believe that training community leaders and religious organizations in violence intervention, conflict management and recognition of emotional distress could help spread, in a contextualized and decolonial manner, strategies for preventing and addressing suicidal behavior/non-suicidal self-harm, giving voice and agency to historically silenced and disempowered identities, as argued by Ribeiro ⁴⁴44. Ribeiro D. O que é: lugar de fala? Belo Horizonte: Letramento; 2017..

Motherhood was an important everyday factor: of the nine young women, six were mothers, with one in her third pregnancy; of the three without children, one expressed the wish to be a mother. At first glance, the presence of motherhood might seem to represent the perpetuation of the female role in procreation, whether desired or not, or even be a choice for these young women. However, the reports said otherwise. For some of the participants, pregnancy negatively impacted their life course, leading to school dropout, increased violence and worsening of psychological distress.

When asked how motherhood influenced suicidal behavior/non-suicidal self-harm, all agreed that pregnancy and childbirth were protective elements, even for those who reported distress and violence. According to the young women, motherhood was mainly an opportunity to recount their own stories, to rethink values and attitudes: an experience of change. The romanticized tone in this perspective was questioned, showing that their children became their greatest concern when they became mothers. Their children, especially the daughters, needed to be protected from the violence they had experienced. This required significant effort, resulting in life planning that led them away from suicidality.

“I have a daughter. I need to show her that this is not the way to go. I don’t need to ruin my life because if I do, my daughter will also ruin hers. Can you imagine that?” (Leci Brandão).

Not that motherhood is universally protective, especially given the possibility of worsening violence and mental disorders ²³23. Dulcan MK, editor. Dulcan's textbook of child and adolescence psychiatry. 3rd Ed. Washington DC: American Psychiatry Association Publishing; 2022.. However, it is important to recognize that motherhood may lead to reorganization in social relationships and provide hope; a hopeful horizon is a point of protection.8 At the same time, transgenerational concerns regarding gender violence should be considered ¹⁰10. Baére F, Zanello V. Sexualidade e os dispositivos de gênero no comportamento suicida. In: Lima L, Navasconi PVP, editors. (Re)pensando o suicídio: subjetividades, interseccionalidades e saberes pluriepistêmicos. Salvador: EDUFBA; 2022. p. 173-201., in which fear for the future of daughters is greater than for sons.

“This person here is a warrior, fighting for her daughters, but daily life is sad, it has become sad, something I can’t even talk about. I look in the mirror and say, ‘Why am I crying? Why am I sad? I have my daughters, I have my home!’” (Elza Soares).

It is stressed that turning points can be conceived not only as factors or layers of protection but as an association between them and elements of resilience ⁴³43. Werner EE, Smith RS. Journeys from childhood to midlife: risk, resilience, and recovery. New York: Cornell University Press; 2001., which are important due to their specificity and historicity, according to the bioecological model ¹⁵15. Bronfenbrenner U. Bioecologia do desenvolvimento humano. Tornando os seres humanos mais humanos. Porto Alegre: Artmed; 2011.. It is argued that understanding suicidality and planning psychosocial interventions should consider life trajectories, the community and the significant elements in the everyday life of individuals and their peers ¹¹11. Navasconi PVP. Vida, adoecimento e suicídio: racismo na produção do conhecimento sobre jovens negros/as LGBTTIS. Belo Horizonte: Letramento; 2019.. A critical approach to community space is not presented here as an innovation, as it is an essential element of public health. However, suicidology views this practice as inadequate, especially concerning minorities, whose marginalized existences tend to be less addressed and understood by the different fields of knowledge and public policies, as highlighted by Lima & Navasconi ¹³13. Lima L, Navasconi PVP, editors. (Re)pensando o suicídio: subjetividades, interseccionalidades e saberes pluriepistêmicos. Salvador: EDUFBA; 2022. and Ribeiro ⁴⁴44. Ribeiro D. O que é: lugar de fala? Belo Horizonte: Letramento; 2017..

Conclusions

In this paper, life was examined through experiences of suicidality reported by peripheral youth. Life and death are intertwined in a dialogue marked by distress and violence that shape the subjectivity and horizon of marginalized youth. Addressing such distress from experiences at the border of death (ideation and suicide attempts) and non-suicidal self-harm enables a dynamic view of risk and, more importantly, of protection for these minority groups, whose suffering and expressions are often less validated, receiving less support and psychosocial interventions. This perspective also highlights the impact of gender violence on the relational horizon of women.

The reality of peripheral women as a minority group was explored to reflect on suicidal behavior/non-suicidal self-harm; however, the discussion extended beyond gender and social class. One limitation of this study is that its arguments overlap different minorities, although this may strongly contribute to counter-hegemonic and intersectional discussions on suicidality among youth in the Global South. Further investigations into the relationship between suicidal behavior and urban violence, or the nuances of ethnic-sexual minorities, could complement the reflections presented here. Another potential limitation was that information on suicidal behavior/non-suicidal self-harm in the early waves of the cohort was obtained from parents/guardians and teachers, although they are important sources in child mental health research.

Diversifying clinical and epidemiological settings should be on the agenda for new suicidology research, urgently and critically acknowledging that the phenomenon of suicide does not solely comprise major and hegemonic groups. The human and the universal are filled with minorities, with their specificities and complexities; by acknowledging this, it may become more feasible to reduce morbidity and mortality from suicidal behavior among youth. Looking more closely and deeply at abused groups not only enhances care and prevention of suicidal behavior in this population but also expands understanding of the phenomenon. However, this requires recognizing the humanity, rights and mental health of historically vulnerable and marginalized groups.

At the same time, reflecting on the resilience of life and of these female bodies means acknowledging the existence of protective strategies that go beyond biomedical care. Layers of protection and turning points are established in the daily life of youth, where and with whom they move about, interact, practice their beliefs, and live out their desires and work. Transforming these contexts into “factors of protection” may mean intervening from the viewpoint of equity, intersectionality and inclusion, extrapolating from individual to structural strategies. Thus, preventing self-inflicted violence should validate, in an ethical and decolonial practice, the subjectivities, knowledge and distress that are erased and neglected.

Acknowledgments

The children, now young adults, who have taken and continue taking part in the cohort, sharing their life trajectories for our studies. The community health workers who helped collect data of the fifth wave of the São Gonçalo/RJ Children’s Violence and Mental Health Cohort making the research possible despite such adverse and violent conditions in their areas. Aline Gonçalves, PhD student at Sergio Arouca National School of Public Health, Oswaldo Cruz Foundation (ENSP/FIOCRUZ), for her dedication in contacting the youth and providing support during the interviews. To the Brazilian National Research Council (CNPq; Chamada Universal MCTIC/CNPq 2018); and the Rio de Janeiro State Research Foundation (FAPERJ; Notice of Assistance for Newly Hired Researchers 2019) for the financial support.

References

Publication Dates

History