Abstract

This study analyzes how social groups with non-heteronormative sexualities are often associated with suicide and posits some consequences of this association in academic and social contexts. This reflection contributes to a necessary conversation that extends beyond the theoretical positions of researchers and has a social effect. In this paper I highlight some of the experienced effects produced by the association between suicide and sexual diversity by acknowledging how sexuality assumes a specific social meaning. The article is divided into four sections. In the first two, I analyze how the notion of epidemiological risk becomes an identity trait in populations with non-heteronormative sexualities. In the third section, I reflect on academic research regarding the association between gender and suicide. The last section presents a proposal for interpreting suicidal behavior from a gender perspective that problematizes the affective and political meaning of the association.

Keywords:
Suicide; Gender; LGBTIQ; Risk; Suicidology; Mental Health

Introduction

The suicide of Sergio Urrego, who was 16 years old, in 2014, had an important media and judicial effect in Colombia. This case was one of the 1,878 that occurred that year in the country as indicated by the National Institute of Legal Medicine and Forensic Sciences (2014). However, Sergio Urrego was a young gay boy and his death evidenced a series of exclusion and harassment practices by the directives of the educational institution where he studied and also by the psychologist of the institution, who assumed the charges of discrimination in 2017.

However, this death also revealed a broader social experience about non-heteronormative sexualities⁶6This study uses the notion of non-heteronormative sexualities to name those experiences of sexuality, gender, desire, affection and filiation that have been arbitrarily subsumed under the category of homosexuality. Thus, it is a notion that allows highlighting the multiplicity, historicity and cultural character of sexuality, while questioning heteronormativity understood as a matrix of power that pretends to base and regulate the experience of sexuality and gender on heterosexuality. (Guzman; Platero, 2012). and suicide: it showed that suicide should not be limited exclusively to an individual mental health issue. In this situation, suicide shows an interconnection of knowledge about life, death and sexuality that exceeds individualities. It evokes the voices of experts, judges, journalists and other citizens who reveal that suicide is a situation with political, social, historical and cultural implications. It also serves to highlight the social modes of relating to these sexualities.

Thus, it is necessary to consider that theoretical notions produce effects in reality and also in the social experience of people. Classifications not only fulfill a function of ordering some objects, but also indicate the positions and attitudes held on that which is classified. Concepts that are produced in scientific practice and are commonly considered to be immune from prejudices, also reproduce with sophistication the representations and practices of their context of production. For example, racialization processes had an influence on medical practice when they served to support racial eugenics or to justify the deficiency in health in some population groups in Latin America (Noguera, 2003NOGUERA, C. E. Medicina y política: discurso médico y prácticas higiénicas durante la primera mitad del siglo 20 en Colombia. Medellín: Universidad Eafit, 2003.). This shows that categorizations and classifications in the field of health are not removed from their contexts of emergence, particularly those associated with sexuality and gender.

However, the social consequences of other classifications or theoretical relationships that have been produced in psychology or psychiatry seem more inappropriate. In this case, it could be considered that the effects of the association of suicide with diverse sexual groups have not been problematized from this point of view (Jaworski, 2016JAWORSKI, K. The gender of suicide: knowledge production, theory and suicidology. New York: Routledge, 2016.). When it is pointed out that these groups have a higher prevalence of suicide ideation or attempts, the social and political implications of this linkage are rarely discussed. For this reason, it is significant to propose a debate that problematizes the epistemological and methodological effects of the association between sexual diversity and suicide, but also its derivations in the cultural interpretation - as in the media - and the policies related to suicide.⁷7For the development of this article, bibliographic sources in Spanish, Portuguese and English addressing the association between suicide and non-heteronormative sexualities were analyzed. The search for articles was carried out by means of a systematic combination of keywords in the databases (Scopus, PubMed, SciELO, Dialnet and Redalyc). For the development of the critical reflection, some systematic reviews of specialized literature were central, which are referenced in the article.

Suicide and gender diversity: the social production of risk

Asking what a suicidal person is may seem obvious: a person who has chosen to end his or her own life. But beyond this apparent obviousness, the definition of suicide and the suicidal person becomes relevant because of the methodological implications and complexity of the study of suicidal behavior. The World Health Organization (OMS, 2014) states that more than 800,000 cases of suicide occur annually in the world. A statistic that indicates the magnitude of the phenomenon, but which also homogenizes and generalizes the people who die. For this reason, questions about social and cultural characteristics, which are much more unique and difficult for epidemiology to estimate, are central to understanding how the perception of the suicidal person is socially produced (Marsh, 2015MARSH, I. Critiquing contemporary suicidology. In: WHITE, J. (Ed.). Critical suicidology: transforming suicide research and prevention for 21st century. Vancouver: UBC Press, 2015. p. 15-30.).

At first, one of the ways to produce a definition of the suicidal person was to identify populations with a greater propensity to suicide. Nowadays, the risk groups are multiple and dissimilar from each other (Overholser; Braden; Dieter, 2012OVERHOLSER, J. C.; BRADEN, A.; DIETER, L. Understanding suicide risk: identification of high-risk groups during high-risk times. Journal of Clinical Psychology, Hoboken, v. 68, n. 3, p. 349-361, 2012.). Some studies indicate that people with mental problems, alcohol users, prisoners, refugees, war veterans and migrants are more likely to commit suicide (OMS, 2014). These groups are identified and coded under statistical criteria that allow to understand characteristics of suicidal behavior in large numbers of the population. But it goes unnoticed that the numbers also produce representations and meanings about suicide and the suicidal person. Quantitative data produce explanations of the phenomenon and, at the same time, shape trends in scientific research and influence health policy agendas that codify and intervene on specific population groups that are typified as at-risk (White, 2015WHITE, J. Shaking up suicidology. Social Epistemology Review and Reply Collective, Victoria, v. 4, n. 6, p. 1-4, 2015.).

Linked to the above, a first aspect that stands out in the social production of the suicidal person is the displacement of epidemiological data to broader social contexts and groups. This exercise of transposing epidemiological data into the media has consequences that are rarely recognized and predicted by experts. The work of researchers is almost always focused on the production of data, its systematization and subsequent analysis, while reflection on the effects of academic research on suicide in society does not seem to be a priority. This situation becomes evident when the media uses expert information on suicide and, beyond establishing whether its uses are “correct” or “incorrect,” the effects are more notorious and with greater impact than those that would be produced even by the specialized bibliography (Johnson, 2016JOHNSON, H. J. Bisexuality, mental health, and media representation. Journal of Bisexuality, Abingdon, v. 16, n. 3, p. 378-396, 2016.).

Considering the above, it is unsuccessful to focus on making value judgments about the media or the meanings of suicide in popular culture without examining the role of the expert discourse. On the contrary, research on suicide could ask, incisively, about the effects that academic constructs have on social and cultural interpretations of the phenomenon. For example, content analysis of journalistic information on suicide has been useful for understanding how the media represent the suicidal person, but analyses of the social, political, and cultural prejudices associated with suicidal individuals in the media have rarely been proposed (De Pinho; Kantorski; Hernández, 2009DE PINHO, L. B.; KANTORSKI, L. P.; HERNÁNDEZ, A. M. B. Análise crítica do discurso: novas possibilidades para a investigação científica no campo da saúde mental. Revista Latino-Americana de Enfermagem, Ribeirão Preto, v. 17, n. 1, p. 126-132, 2009.). This task would imply proposing critical and interpretative conceptual matrixes of discourse analysis that are beyond statistical analysis (Orozco Villa, 2019OROZCO VILLA, E. O. Análisis crítico del discurso y suicidio: más allá de la narrativa de la enfermedad. Arbor, Madrid, v. 195, n. 794, art. a533, 2019.). Something similar would occur if an analysis of the effects of expert knowledge on cultural life were proposed.

However, considering the above mentioned implications, several studies have shown that suicidal ideation and suicide attempts are higher in groups with non-heteronormative sexualities than in heterosexual groups (Flowers, 2001FLOWERS, P. Gay men and HIV/AIDS risk management. Health: An Interdisciplinary Journal for the Social Study of Health, Illness and Medicine, Thousand Oaks, v. 5, n. 1, p. 50-75, 2001.; King et al., 2008KING, M. et al. A systematic review of mental disorder, suicide, and deliberate self harm in lesbian, gay and bisexual people. BMC Psychiatry, Fort Lauderdale, v. 8, n. 1, art. 70, 2008.; Meyer; Dietrich; Schwartz, 2008MEYER, I. H.; DIETRICH, J.; SCHWARTZ, S. Lifetime prevalence of mental disorders and suicide attempts in diverse lesbian, gay, and bisexual populations. American Journal of Public Health, Washington, DC, v. 98, n. 6, p. 1004-1006, 2008.; Stone et al., 2014STONE, D. M. et al. Sexual orientation and suicide ideation, plans, attempts, and medically serious attempts: evidence from local youth risk behavior surveys, 2001-2009. American Journal of Public Health, Washington, DC, v. 104, n. 2, p. 262-271, 2014.). These studies tend to relate variables linked to homophobia, discrimination and social support with individual responses associated with suicide. Many of these researches recognize the difficulties that exist in establishing causal relationships between the variables studied; but, beyond the theoretical and methodological warnings of the experts, in social translations the association of variables is often mixed up with causal relationships. Thus, it is common to observe how in many media it is suggested that diverse sexuality could be a cause of suicidal behavior. It is a premise that can be naturalized by society and also in academic circles, resulting in a possible pathologization of non-heteronormative sexualities (McDermott; Roen; Scourfield, 2008MCDERMOTT, E.; ROEN, K.; SCOURFIELD, J. Avoiding shame: young LGBT people, homophobia and self-destructive behaviours. Culture, Health & Sexuality, Abingdon, v. 10, n. 8, p. 815-829, 2008.).

Naturalization makes social and psychological phenomena lose their complexity, making many of the analyses and interventions result in repetitive readings or bureaucratized interventions of suicide. Consequently, the cost of the association between non-heteronormative sexualities and suicide is also political because, beyond the informed readings of experts, narratives that have social effects and are supported by scientific criteria are produced.

An example of this is Waidzunas’ (2012WAIDZUNAS, T. Young, gay, and suicidal: dynamic nominalism and the process of defining a social problem with statistics. Science, Technology, & Human Values, Thousand Oaks, v. 37, n. 2, p. 199-225, 2012.) analysis of the epidemiological association between the category “gay youth” and suicide risk. The author points out that interest in the study of the relationship between suicide and the category of “gay youth” began in the 1980s in the United States. This trend is marked by the political incidence of gay activists in public spheres and their demands for inclusion in health systems. However, Waidzunas shows that, starting with the government report by Paul Gibson in 1989, a gradual identification of gays as a population with a higher risk of suicide attempts began. Thus a group of people who were previously marked by medical, political and intellectual violence also become a new risk group associated with suicide.

Waidzunas (2012WAIDZUNAS, T. Young, gay, and suicidal: dynamic nominalism and the process of defining a social problem with statistics. Science, Technology, & Human Values, Thousand Oaks, v. 37, n. 2, p. 199-225, 2012.) analyzes the association between these categories based on the notion proposed by Bruno Latour called “black boxing.” This notion makes it possible to understand how certain statements that have scientific validity arise from assertions made by experts and are considered valid without analyzing their theoretical or empirical contexts of origin. In this case, Waidzunas (2012WAIDZUNAS, T. Young, gay, and suicidal: dynamic nominalism and the process of defining a social problem with statistics. Science, Technology, & Human Values, Thousand Oaks, v. 37, n. 2, p. 199-225, 2012.) shows that the association between homosexuality, adolescence and suicide is constructed by political, scientific and social institutions. Thus, the constant repetition of the data, the holding of events that discuss suicide in people with non-heteronormative sexualities, the interventions of experts and other acts of visibility, both academic and in the media, legitimize an association that is assumed as an evident fact, even though many times the data are not conclusive or do not express causal relationships.

While it is possible to recognize that there is empirical data that could support the association between non-heteronormative sexualities with suicidal behaviors, the notion of risk is produced under epidemiological criteria that focus on some biological, psychological and social characteristics. It is understood that the objective of knowing these risk factors is to find empirical bases that support the design of intervention strategies that are specific and appropriate; but other effects occur simultaneously that are not evident when it is accepted that a population group is at risk. This means that risk, being a category of epidemiology with precise epistemological delimitations (Almeida Filho; Castiel; Ayres, 2009ALMEIDA FILHO, N.; CASTIEL, D. L.; AYRES, J. R. Riesgo: concepto básico de la epidemiología. Salud Colectiva, Lanús, v. 5, n. 3, p. 323-344, 2009.), acquires a semantic charge that serves to produce a new mode of social stigmatization. In this case, it is an association that can serve to legitimize a meaning about non-heteronormative sexuality marked by the incidence of suicide.

For this reason, when epidemiological data become an identity feature, the groups that have been the object of analysis must face new problems. For example, when one analyzes the way in which historically there was a relationship between HIV and homosexuality, one finds that it not only had technical effects and saved lives, but also produces a series of identities marked by the disease. This argument was discussed by Sontag (2003SONTAG, S. La enfermedad y sus metáforas: el Sida y sus metáforas. Buenos Aires: Aguilar, Altea, Taurus, Alfaguara, 2003.) pointing out that being infected with HIV in the 1980s was synonymous to being recognized as part of an at-risk group or part of a “community of outcasts.” A group that immediately evoked homosexual men suffering from “the pink disease.”

At present, the situation is not very different and, in this particular case, suicide is gradually establishing itself as another identifying characteristic of a population group. It is assumed that death by one’s own hand is a situation that seems inherent to the life experience of people with non-heteronormative sexualities, which may result in new forms of stigmatization and invisibilization of political situations that have historically oppressed these social groups.

The notion of risk is more than an epidemiological or clinical category, as it also operates as a cultural representation that stimulates and orders social relations with the identified populations. In this sense, expert discourses propose a reading of suicide that, as happened with HIV, gradually becomes an identity trait of a group. This point may be controversial because the expert discourse proposes a precise and rigorous use of concepts that assumes a value neutrality, but sometimes it is not known that diseases also reproduce symbolic expressions that are part of a system of values that are broader than scientific practice itself.⁸8However, it should be recognized that also, under some political circumstances, these aspects can be considered as strategic identities (Spivak, 2003).

The grammars of the experts serve to construct, always in various ways, some interpretations that are central to the social phenomena being studied. It should be recognized that this situation is not the direct responsibility of the researchers; but the interpretations that are made socially are always complex and mediated by the historical impact of the receivers of the information (for example, groups with political decision-making capacity, but without technical knowledge of the issues). Thus, the recognition of the political and social effects of the production of knowledge is an inevitable responsibility today, especially if it links social groups that have traditionally been stigmatized.

For the above reasons, when proposing a problematization of the notion of suicidal risk in non-heteronormative sexualities, it is important to think about a politics of translation. This means recognizing that the most rigorous scientific analyses can always be translated, even in the same academic fields, as identity marks on those groups or individuals who are studied. In this sense, epistemological and methodological reflections are not enough; ethical and political reflections on the meaning of the production of concepts about suicide in non-heteronormative sexualities are also important. Similarly, it is important to recognize that the notion of risk, which is part of a hegemonic epidemiological tradition, can easily become a surreptitious form of stigmatization of these sexualities in academic contexts.

Risk content: biological determinism and depoliticization of suicide

Until this moment it has been discussed how through the notion of risk it is possible to configure identity traits, but it is also important to problematize the content of risk. In other words, in order to understand how suicide occurs, it is not enough to know who commits suicide (risk population), it is essential to identify the elements associated with the behavior (risk factors). Research on suicide in most cases indicates that it is a multi-causal phenomenon (OMS, 2014). This means that suicide may be mediated by aspects of biological and psychopathological characteristics, cognitive styles of information processing, family dynamics and adverse economic situations (Ellis, 2008ELLIS, T. El estudio de la cognición y suicidio: comienzos e hitos del desarrollo. In: ELLIS, T. Cognición y suicidio: teoría, investigación y terapia. México: Manual Moderno, 2008. p. 11-26.; Guibert Reyes; Torres Miranda, 2001GUIBERT REYES, W.; TORRES MIRANDA, N. Intento suicida y funcionamiento familiar. Revista Cubana de Medicina General Integral, Havana, v. 17, n. 5, p. 452-460, 2001.; Nordt et al., 2015NORDT, C. et al. Modelling suicide and unemployment: a longitudinal analysis covering 63 countries, 2000-11. The Lancet Psychiatry, Amsterdam, v. 2, n. 3, p. 239-245, 2015.; Sudol; Mann, 2017SUDOL, K.; MANN, J. J. Biomarkers of suicide attempt behavior: towards a biological model of risk. Current Psychiatry Reports, New York, v. 19, n. 6, art. 31, 2017.). All these heterogeneous elements configure representations about suicide and the suicidal person, which show a multiplicity of the phenomenon that can result in decontextualization.

In the case of people with non-heteronormative sexualities, some differentiated types of risk have been established. An association with a higher prevalence of mental disorders, psychoactive substance use and alcohol consumption has been reported. It has also been suggested that homophobia (perceived, experienced and internalized) and sexual or psychological abuse play a role in the manifestation of suicidal ideation and behavior. Consequently, the discourses of medicine, psychiatry and psychology are based, most of the time, on epidemiological data in order to enunciate a series of situations and contexts that seem to be key at the time of the study of suicide in this population group.

Thus, these readings on the risks of suicide in these groups have been useful for reflecting on the phenomenon and guiding intervention practices, but they cause some analytical problems that are not usually discussed. A first drawback has to do with the biological overdetermination of social experience. This process focuses attention, almost exclusively, on biologicist readings that seek the medicalization of suicidal behavior centered on individuality. The explanation provided by Pineda (2013PINEDA, C. A. Etiología social del riesgo de suicidio en adolescentes y jóvenes lesbianas, gay y bisexuales: una revisión. Psicogente, Barranquilla, v. 16, n. 29, p. 218-234, 2013., p. 229) is relevant to understand this issue:

Although it is important to explain the psychobiological processes that may influence suicidal behavior, these may be limited when placed out of context. Until now, studies have not been conclusive in demonstrating the direct incidence of biological factors on suicidal behavior beyond its occurrence associated with mental disorders. However, this interpretation tends to be standardized in theoretical frameworks explaining suicide, and it is considered that suicidal behavior can be explained by biological characteristics. For this reason, suicidal behavior is conceived more as the effect of a biological reaction than as a structured behavior with a cultural, social, political and subjective meaning.

References to homophobia or social stigma as risk factors associated with suicidal behavior appear in some research studies (Ferlatte et al., 2017FERLATTE, O. et al. Stigma and suicide among gay and bisexual men living with HIV. AIDS Care, Abingdon, v. 29, n. 11, p. 1346-1350, 2017.; Rimes et al., 2018RIMES, K. A. et al. Psychosocial factors associated with suicide attempts, ideation, and future risk in lesbian, gay, and bisexual youth: the youth chances study. Crisis: Journal of Crisis Intervention and Suicide Prevention, Boston, v. 40, n. 2, p. 83-92, 2018.). It is noted that these situations can be considered as triggers for mood disorders or mental illness. This interpretation can be limited and leads to the assumption that homophobia⁹9It is necessary to highlight that the notion of homophobia is understood as a device producing symbolic or physical violence that comes from discrimination, exclusion or destruction of the bodies of people with non-heteronormative sexualities. Each expression of homophobia must be understood from the singularity, understanding that its manifestation is relative to the characteristics of the group or persons affected. social stigma are social situations that occur homogeneously in all contexts, omitting historical and cultural singularities. These are interpretations that privilege individual aspects, but which, paradoxically, distance themselves from the subjective experience of suicide.

Some theoretical models, such as minority stress (Meyer; Dietrich; Schwartz, 2008MEYER, I. H.; DIETRICH, J.; SCHWARTZ, S. Lifetime prevalence of mental disorders and suicide attempts in diverse lesbian, gay, and bisexual populations. American Journal of Public Health, Washington, DC, v. 98, n. 6, p. 1004-1006, 2008.), offer important tools for the explanation of suicidal behavior in people with non-heteronormative sexualities; but the research use of the model continues to consider suicidal behavior as a product of forms of processing and coping that privilege the individual. In addition, research logics focus on providing measurements without providing explanations about the contexts in which the phenomena occur. Even the use of the adjective minority is problematic because it continues to support a reading that establishes hegemonic interpretations of sexuality and its association with statistical calculation. Continuing to think about sexuality in relation to the notions of minorities or majorities may become a limitation caused by ignorance about the theoretical and political interpellations that have been made about sexuality and gender in recent years.

The models that are commonly used to understand the phenomenon of suicide give primacy to biological components (stressor responses) and overdetermine individual traits, while social configurations are placed as part of a certain “scenography.” Thus, the definition of “psychosocial risk factors” that constantly appear in ecological or biopsychosocial models, due to their theoretical configuration, limit the understanding of complex practices of cultural significance and historical construction of the experience of dying. Analytical limitations of these proposals have mobilized the development of theoretical alternatives that understand suicidal behavior, including its relationship with gender and sexuality, from perspectives involving detailed interpretations of the social and cultural discourses in which suicide occurs, considering that death by one’s own hand is a practice composed of a historicity that is not exclusively limited to quantitative data (White, 2015WHITE, J. Shaking up suicidology. Social Epistemology Review and Reply Collective, Victoria, v. 4, n. 6, p. 1-4, 2015.).

Both the overdetermination of biological aspects and the saturation of a suicidal identity associated with non-heteronormative sexualities exemplify two ways of interpreting the association between categories and the production of risk. Despite this, it should not be ignored that there are other argumentative and conceptual reiterations in the studies on suicide and the association with these sexualities. Thus, for example, discrimination is a constant topic of discussion in researches, becoming a category or variable that is referred to as a causal element in suicidal behavior. In this way, we find again a homogenization and generalization of some social situations. Equating, for example, religious discrimination with racial or gender discrimination - as occurs with the use of the minority stress model - indicates a partial approach to the phenomenon. Discrimination interpreted as a generality is a limited analytical category because it denies the social variability of the phenomenon and makes invisible ideological constructions and political components that make life precarious.

In this context, it is important to consider that discriminations - in plural - are practices that are produced and differentiated under specific historical, political and cultural frameworks. Assuming this consideration allows the complexity and uniqueness of the phenomenon of suicide not to be subtracted. The above argument does not deny the particularity of the experiences of discrimination; on the contrary, it seeks to understand how some kinds of practices are socially established as discriminatory, and subjective interpretations make suicide become part of the social repertoire to position oneself in the face of this practice, which would be far from understanding suicide as a simple response. This calls into question readings that support hegemonic views on gender and sexuality in the field of mental health research (Fish, 2008FISH, J. Navigating queer street: researching the intersections of lesbian, gay, bisexual and trans (LGBT) identities in health research. Sociological Research Online, Thousand Oaks, v. 13, n. 1, p. 104-115, 2008. Disponível em: <Disponível em: https://bit.ly/2Lonqkf >. Acesso em: 11 jan. 2021.
https://bit.ly/2Lonqkf... ).

It should not be ignored that some political practices have an impact on the mental health of people with non-heteronormative sexuality and they may even have an effect on suicidal behaviors. The inability to access the rights associated with marriage or adoption can have very high psychological and social costs. Currently, in many Latin American countries, it is observed that broad political sectors are reluctant to maintain or expand the rights of sexually diverse groups. These forms of discrimination and stigmatization are the product of systematic policies and not of spontaneous social behavior. In this sense, in each context there are institutions and agents with a specific historicity that promote discrimination. For this reason, thinking of a single, general form of discrimination reduces the political power of the analysis and also the forms of intervention.

Internalized homophobia or internalization of homophobia in research?

Although there have been transformations in the ways in which non-heteronormative sexualities are conceptualized in psychopathology (Drescher, 2015DRESCHER, J. Out of DSM: depathologizing homosexuality. Behavioral Sciences, Basel, v. 5, n. 4, p. 565-575, 2015.), stigmas persist in some areas that continue to consolidate ways of discrimination. Recently, it has been observed that the academic production linked to the study of sexual diversity has been crossed by critical positions that question some possible homophobic tendencies in the academic field. However, De la Espriella (2007DE LA ESPRIELLA, R. Homofobia y psiquiatría. Revista Colombiana de Psiquiatría, Bogotá, DC, v. 36, n. 4, p. 718-735, 2007.) shows that some theoretical perspectives in psychiatry implicitly legitimize and sustain the pathologization of non-heteronormative sexualities. It should be noted that these forms of homophobia are not reduced to the conceptual sphere, but also transcend the meanings of sexual diversity for health professionals and the timeliness of care for individuals.

This issue has significant implications as it points to multiple barriers in access to health. An example is found in the research conducted by Ritterbusch, Correa Salazar and Correa (2018RITTERBUSCH, A. E.; CORREA SALAZAR, C.; CORREA, A. Stigma-related access barriers and violence against trans women in the Colombian healthcare system. Global Public Health, Abingdon, v. 13, n. 12, p. 1831-1845, 2018.) with a group of transgender women in Colombia, in which systematic forms of violence were evidenced in some health care environments. Although Colombian legislation does not establish differences in care, the narratives of the participants reveal multiple forms of discrimination and systematic mistreatment. In this case, the authors propose that these discriminations are articulated with the academic education and training of health personnel; aspects that should produce curricular reforms that are compatible to sexual and gender diversity. These cases are useful to propose a reflection that evidences the intersectionality of discriminations, which show the confluence between political and historical situations of the context, the academic practices of the medical discourse and the subjective positions of the health care personnel (Fish, 2008FISH, J. Navigating queer street: researching the intersections of lesbian, gay, bisexual and trans (LGBT) identities in health research. Sociological Research Online, Thousand Oaks, v. 13, n. 1, p. 104-115, 2008. Disponível em: <Disponível em: https://bit.ly/2Lonqkf >. Acesso em: 11 jan. 2021.
https://bit.ly/2Lonqkf... ).

The above example may be useful to think that the relationship between expert knowledge and homophobia has concrete consequences in people’s lives, but it also shows how the educational contexts in which people responsible for the health of the population are trained reproduce these practices. It is also important to analyze how the attitudes of health professionals can affect the opportunity and quality of care. Barriers to health care illustrate forms of structural discrimination that accentuate social gaps between population groups. In this case, it can be considered that barriers to care are not only the result of institutional situations, but also the attitudes of health personnel.

If we consider that the attitudes of health professionals have a negative impact on care, this issue is relevant when thinking from the perspective of care and suicide prevention. For this reason, when the existence of preconceptions about non-heteronormative sexualities is denied, the development of differential approaches to health care is limited and practices marked by homophobia are reproduced. In this sense, as proposed by Nieto and Orozco (2016NIETO, L.; OROZCO, E. Reflexiones sobre la aproximación metodológica al estudio de las actitudes de los profesionales frente al suicidio. Textos y Sentidos, Pereira, n. 13, p. 181-197, 2016.), research on health professionals’ attitudes about suicide is key to the development of strategies for the care and prevention of suicidal behavior.

Within this framework of discussion, it is evident how forms of stigmatization are reproduced in the contexts of health care. This issue becomes more complex when it is considered that something similar occurs in research environments. While the works of Jaworski (2016JAWORSKI, K. The gender of suicide: knowledge production, theory and suicidology. New York: Routledge, 2016.) and Waidzunas (2012WAIDZUNAS, T. Young, gay, and suicidal: dynamic nominalism and the process of defining a social problem with statistics. Science, Technology, & Human Values, Thousand Oaks, v. 37, n. 2, p. 199-225, 2012.) propose a critique on the conceptual association between suicide and sexual diversity, it is evident that reflection on the internalization of homophobia - and any rejection of non-heteronormative sexualities - tends to go unnoticed in the field of research. It must be considered that researchers can build their approaches based on indelible social and cultural prejudices, so that their research methods are rigorous and epistemologically sustained.

For example, Kitts (2005KITTS, R. L. Gay adolescents and suicide: understanding the association. Adolescence, Amsterdam, v. 40, n. 159, p. 621-628, 2005.) proposes that in some fields of knowledge issues related to gender have been studied extensively, but points out that there is a limitation in research in medicine and psychology. The author’s hypothesis focuses on the fact that, since there is a possible association between the topic studied and the sexual orientation of the researchers, it may happen that they avoid working on these topics for fear of being identified as part of a group with non-heteronormative sexuality. Although it is a hypothesis that could be problematized, it is useful to situate the extra-theoretical implications that gender studies produce in fields of knowledge that are characterized by heteronormative social relations and that in their historical development pathologized and medicalized sexualities that were not considered normal.¹⁰10Kitts (2005, p. 623, our translation) describes this situation as follows: “I would not be surprised if readers of this article assumed that I was gay. This was a risk I was hesitant to take. Unfortunately, it is a risk that some physicians would be unwilling to take for fear of compromising their careers. This fear impedes important gay issues from being heard in the mainstream. Goldfried stated that, despite the growing literature on homosexual issues, conventional psychology has tended to ignore much of the work that has been done in this area. Thus, important issues, such as suicide among homosexual adolescents, remain invisible not only to conventional psychology, but also to general medical care.” This is affirmed when we consider that gender studies have been the object of intellectual and political suspicion in many academic contexts, especially in Latin America. In this regard, the notion of hermeneutic injustice developed by Perez (2019PÉREZ, M. Violencia epistémica: reflexiones entre lo invisible y lo ignorable. Revista de Estudios y Políticas de Género, Buenos Aires, v. 1, n. 1, p. 81-98, 2019.) may be instructive in highlighting some difficulties of mental health studies in understanding the particularity of suicidal behavior in this population:

Likewise, the study of the theoretical association of suicide with non-heteronormative sexualities is characterized by a research production that is mostly published in English and outside Latin American contexts (Pineda, 2013PINEDA, C. A. Etiología social del riesgo de suicidio en adolescentes y jóvenes lesbianas, gay y bisexuales: una revisión. Psicogente, Barranquilla, v. 16, n. 29, p. 218-234, 2013.; Teixeira-Filho; Rondini, 2012TEIXEIRA-FILHO, F. S.; RONDINI, C. A. Ideações e tentativas de suicídio em adolescentes com práticas sexuais hetero e homoeróticas. Saúde e Sociedade, São Paulo, v. 21, n. 3, p. 651-667, 2012.). As explained by Tomicic et al. (2016TOMICIC, A. et al. Suicidio en poblaciones lesbiana, gay, bisexual y trans: revisión sistemática de una década de investigación (2004-2014). Revista Médica de Chile, Santiago, v. 144, n. 6, p. 723-733, 2016.) in a systematic review of the issue, most of the studies are produced in Anglo-Saxon countries, evidencing situations typical of the geopolitics of knowledge. For this reason, an analysis of suicide from a gender perspective in Latin America is central. At this point, the ideological positions that increasingly influence the political arena and limit the research agendas associated with gender studies cannot be ignored. This would show how researchers find themselves under social relations and cultural meanings that affect them and may have an impact on their theoretical perspectives. In this case, a large number of situations of violence - including suicide - experienced by people with non-heteronormative sexualities are invisible.

In short, extratheoretical interests mark research on suicide in these groups. It means that, beyond the theoretical and methodological precautions proposed by researchers at the time of designing their research, are a series of implicit social and political phenomena that influence this kind of studies. For this reason, as previously expressed, it is important to propose a constant and rigorous analysis of the gender prejudices that exist in the research and the theories produced. Perhaps one way to achieve this objective is to think about of suicide from a critical gender approach.

Suicide in dispute? Possible contributions of gender studies to the study of suicide

Thinking about the contributions of gender studies to the interpretation of suicidal behavior allows considering some of the arguments previously proposed. Initially, it may be helpful to question the essentialist positions about suicidal behavior (Marsh, 2015MARSH, I. Critiquing contemporary suicidology. In: WHITE, J. (Ed.). Critical suicidology: transforming suicide research and prevention for 21st century. Vancouver: UBC Press, 2015. p. 15-30.). This means understanding the phenomenon from its contexts and not as an inherent expression of pathology, which favors the understanding of the local social, political and cultural aspects in which suicides occur. This position questions the models and interventions that tend to medicalize this behavior.

One of the fields that has been important in achieving a desensitizing understanding on suicidal behavior has been the critical suicidology movement and critical studies on suicide (White, 2015WHITE, J. Shaking up suicidology. Social Epistemology Review and Reply Collective, Victoria, v. 4, n. 6, p. 1-4, 2015.). From this perspective, it has been considered that the problem of suicide is inscribed in social and historical logics that are broad and that distance themselves from practices that interpret the phenomenon from a pathological point of view. For this reason, the notion of gender that is adopted by critical suicidology questions the biologicist readings of sex and recognizes the cultural meaning of sexuality that is inscribed in suicidal behavior (Jaworski, 2016JAWORSKI, K. The gender of suicide: knowledge production, theory and suicidology. New York: Routledge, 2016.).

Questioning the essentiality of suicide allows us to problematize some of the traditional variables used to approach the phenomenon, such as, for example, the notion of sex. Many studies on suicide - even those conducted by the States - are characterized by coding populations from a binary differentiation between male and female. This causes the issue of gender to be subsumed to a dichotomous sexual differentiation. For this reason, it is central to evaluate and conceptualize the notions of sex and gender in studies related to suicide in the general population, but without losing perspective of their intersectional character. This means not omitting the elements associated with class, race, and functional diversity that permeate sex and gender.

On the other hand, the interpretation of suicide from a gender perspective makes it necessary to consider approaches that do not pathologize non-heteronormative sexualities. For this reason, it is central that research approaches can question the theoretical frameworks that conceptualize these forms of sexuality from the spectrum of pathology. Although it is currently recognized in diagnostic manuals that sexual orientation or gender diversity cannot be classified as pathological, pathologization is persistent and is expressed in areas that go beyond diagnosis. The ways of pathologizing, as previously shown, are evidenced in the theoretical imaginary of the fields of knowledge in which gender diversity is associated with risk (De La Espriella, 2007DE LA ESPRIELLA, R. Homofobia y psiquiatría. Revista Colombiana de Psiquiatría, Bogotá, DC, v. 36, n. 4, p. 718-735, 2007.). Consequently, one of the starting points for thinking about the link between gender, sexuality and suicide is in distancing oneself from the theoretical habituation that interprets the experience of dying by one’s own hand as the effect of a failure in the life experience of a person and his or her sexuality.

However, possibly one of the central implications of thinking about suicide from gender studies lies in a politicization of mental health. This point implies assuming that health is part of a complex social network that goes beyond expert discourse and requires a constant critique of bureaucratized visions of health. For this reason, the place of gender studies would consist in producing and activating visions about death, gender and sexuality that dispute cultural meanings about the public. In the destabilization of interpretations that blur social and political situations about suicide, in order to offer intellectual tools that appeal to mental health interventions that go beyond economic calculation or market needs; evidencing that situations such as suicide are crossed by interpretation systems that reproduce forms of patriarchal domination.

Finally, one of the aspects that would be central is to recover the voices and knowledge of those who have gone through the experience of suicide, such as survivors, families and friends. One of the characteristics of gender studies in recent years has been to produce knowledge that is situated in and emerges from the experience of people, their sexuality and their corporeality. This allows to understand the value of situating gender practices in local spheres, preventing them from being erased by theoretical abstractions. Therefore, this perspective allows that death by one’s own hand should not be assumed as a calculable effect of sexual diversity and that, on the contrary, it should be understood that some ways of life are marked by death due to situations of vulnerability and precariousness. Situations that are usually dissolved among the abstract speeches of experts and by some complicit silences of society. Speeches and silences that have marked the existence of people like Sergio Urrego.

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