Women in Cultural Transition: Suicidal Behavior in South African Indian Women Douglas R. Wassenaar, MA, Marchiene B. W. van der Veen, MSS, and Anthony L. Pillay, PhD Young South African Indian women are a population with relatively high rates of suicidal behavior. This article presents three illustrative case studies of nonfatal suicidal behavior by South African Indian women. The cases are discussed in relation to a review of epidemiological, historical, and sociocultural perspectives on South African Indian women. I t is argued that suicidal behaviors in this group can be understood in the context of sociocultural transition. Transitional tensions between traditional Indian culture and Westernization have an impact on traditional gendered power relations and generate conflicts that have intrapsychic and interpersonal consequences for women and for men. These in turn may have adverse effects on marital functioning, quality of life, and specific aspects of emotional functioning, which have been identified as precursors of suicidal behavior. The case studies are discussed with reference to gender narratives. Implications for prevention, intervention, and future research are discussed.
Suicidal behavior in South Africa is an emerging field of study, and reliable epidemiological and clinical data are relatively scarce. Decades of separatist apartheid legislation and the fragmentation of health and social services based on crude racial classifications have made the task of collating reliable mortality data difficult. A study by Flisher and Parry (1994), and further analysis of this and subsequent data by Wassenaar and Naidoo (1995)have begun to provide data that facilitates comparisons with international trends and also reveals trends within particular South African communities. This study will focus on the relationship between suicidal behavior and gender, and between gender, culture, and cultural transition. The need for a research focus on these issues is related to the differential rates of self-destructive behavior in specific gender and cultural groups described internationally (Brown, 1997; Ca-
netto & Lester, 1995b). The focus on young South African Indian women is driven by the relatively high incidence of suicidal behaviors in this group presenting at a general hospital staffed by the authors, over a number of years.
NONFATAL SUICIDAL BEHAVIOR Reliable epidemiological data on nonfatal suicidal behaviors are notoriously difficult to establish (Canetto, 1995). While there has been an increase in published research on aspects of nonfatal suicidal behavior in South Africa, most reports do not provide a coherent epidemiological picture. The gender ratio reported in most studies of nonfatal suicidal behavior show a female : male ratio of 2 : 1for suicidal behavior (Bosch, McGill, & Noor-Mahomed, 1995; Pillay, 1995; Wassenaar, 1987). A study of nonfatal suicidal behavior at
Douglas R. Wassenaar is Senior Lecturer in Clinical Psychology in the Department of Psychology, University of Natal, Pietermaritzbur , South Africa. Marchiene B. W. van der Veen i s Clinical Psychologist and Lecturer, Subdepartment of Medically Applied Psychology, University of Natal Medical School and Midlands Hospital. Anthony L. Pillay is Principal Clinical Psychologist and Senior Lecturer, Subde artment of Medically Applied Psychology, University of Natal Medical School and Midlands Hospital. Agdress corre spondence to D. R. Wassenaar, De artment of Ps chology, University of Natal, Private Bag XO1, Scottsville, Pietermaritzburg, 3209, S o u 8 Africa. E-maic
[email protected]. 82
Suicide and Life-Threatening Behavior, Vol. 28(1), Spring 1998 0 1998 The American Association of Suicidology
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an Indian’ high school (Pillay, 1995) revealed that 4% of the pupils were referred to the school counselor in a 1-year period as a result of suicidal behavior. Overdoses were the primary method used in 84% of these cases. A study by Flisher, Ziervogel, Chalton, Leger, and Robertson (1993) in the Cape yielded a rate of 7.890 amongst high school students, which approaches figures for the United States reported by Pfeffer (1989).A high rate of nonfatal suicidal behavior in Indian women in Britain was also reported by Rao (1994). SUICIDE MORTALITY As in most international studies, the male : female gender ratio for suicide mortality in the South African White population is approximately 4 : 1 (Wassenaar & Naidoo, 1995).With regard to South African Indians, however, the ratio is 3.5 : 1, which is consistent with the higher rates for Asian women reported by Canetto and Lester (1995b). The mean annual suicide rate for South African Indian women is 3.4 per 100,000 of population, which is lower than the rate for South African White women (5 per 100,000)(Wassenaar & Naidoo, 1995) or for females in the United States (4.5 per 100,000) (Clark & Fawcett, 1992; MQcicki, 1994). The rate for South African Indian women is higher than the rate for North American Black and Hispanic women, however (Canetto, 1992a; Clark & Fawcett, 1992). We chose to focus on the younger South African Indian female group, as this population is overrepresented at a general hospital served by the authors. In addition, it will be argued that young Indian women are more vulnerable to the stresses of cultural transition than the previously politically dominant White group, who nevertheless have suicide rates comparable to White women in the United States. Within the South African Indian female
‘During the apartheid era separate schools existed for designated racial groups.
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group, which is the focus of this article, the highest suicide mortality (11.4 per 100,000) is within the 15-24-year-old age group (Flisher & Parry, 1994). This rate contrasts markedly with rates of 0.5 per 100,000 or less as age increases to 50-60 years old in this population group (Flisher & Parry, 1994; Wassenaar & Naidoo, 1995). This peak rate in the 15-24 age grdup has also been found in Asian and South American populations (Canetto, 1994) and among Indian women in Great Britain (Rao, 1994). I t is argued that the combined, concurrent stressors of adolescence and sociocultural transition contribute to the peak of suicide mortality in this age group. There is also a difference in suicide method for the South African Indian female group. While White males and f e males used firearms as the primary suicide method, Indian females used hanging and poisoning as their main methods, while Indian males used hanging more than any other method. Since the peak suicide rate in Indian females is in the 1524 age group, one might speculate that this group does not have ready access to firearms compared with older age groups or other cultural groups (see Kushner, 1985, pp. 549-550). As Flisher and Parry (1994) point out, the relatively high suicide rate in the Indian female 15-24 age group warrants further research and intervention. INDIAN SOUTH AFRICANS South Africa is currently known as “The Rainbow Nation” because of its cultural diversity. There are avariety of races, and a greater variety of cultures within the race groups. While cultural diversity is seen as a national asset, the interaction of cultures results in the blurring of cultural norms and boundaries at individual, family, and cultural group levels. The longoverdue demise of statutory segregation (apartheid) has increased cross-cultural contact, especially in the desegregation of schools. However, families wishing to r e
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tain a core cultural identity in their children find themselves increasingly faced with children who aspire to lifestyles and goals associated with other cultural groups. Acculturation has been described by Berry (1987) as “a culture change that results from continuous first-hand contact between two distinct cultural groups” (p. 97). The change occurs at social (collective) and psychological (individual)levels, and change usually affects the previously nondominant group the most. Thus, the Indian community would be affected more in this process than the previously dominant white group. I t has been argued elsewhere (Pillay, 1989; Wood & Wassenaar, 1989) that families and individuals in cultural transition are particularly prone to stresses that may manifest as suicidal behavior. The destabilization of the disempowered position traditionally occupied by Indian women as well as the cultural sanctioning of suicidal behavior as “feminine” appear to increase conflict and vulnerability to suicidal behavior in Indian women. This is particularly evident in families that have preexisting interactional pathology (Pillay & Wassenaar, 1997a, 199713). The Indian community in South Africa comprises about 3% of the country’s population, with the remainder comprising 74% of Black African descent, 14% Whites, and 9% “Coloured (having mixed racial origins, as defined by outdated apartheid race classification). Indians were first landed in South Africa as indentured workers to sugar farmers in the Eastern seaboard region currently known as Kwa-Zulu Natal. This province has the largest proportion of South African Indians. The Indian community comprises roughly 2090 of Moslem faith, with the remainder being Hindu (70%) or Christian (10%)(Pillay, 1989). Traditionally, Indian families are patriarchal, and women occupy submissive positions and have domestic and familial responsibilities in extended family structures. Various historical forces, including the development of a capitalist economic system and increasing educational and
vocational opportunities for women, have challenged and undermined this traditional system, with many hybrid arrangements being developed to accommodate the simultaneous demands of traditional Indian culture and a Western Englishspeaking world. While some families appear to adapt to such coexisting pressures creatively, others appear to suffer chronic tension, poor communication, poor problem identification, role conflict, and low cohesion (Pillay & Wassenaar, 199713). Such families are statistically associated with suicidal behavior, particularly for women (Pillay & van der Veen, 1995). Exploration of the possible reasons for this statistical association is the subject of the present article. Similar gender-linked tensions are internationally associated with suicidal behavior (Sefa-Dedeh & Canetto, 1992),particularly in Asian countries and in countries where women have low social status (Brown, 1997; Canetto, 1997; Canetto & Lester, 1995a; Rao, 1994; Vijayakumar & Thilothammal, 1993).A study of the precipitants of suicidal behavior in South African Indian women found that 6690 were married and that 8890 of these cited marital conflict as a precipitant of the suicidal behavior. Furthermore, 51.5% of them had suffered violent abuse during these conflicts, in which substance abuse by the husband was a further factor in 49% of these cases (Pillay & van der Veen, 1995). Many of these women reported feeling helpless, powerless, and trapped by the patriarchal structure of the traditional one-income marriage. Although declining in frequency, arranged marriages still occur in some Indian families, and the autonomous choice of a partner based on romantic love is forbidden. However, exposure to Western media, feminism, and an emerging democratic culture is undermining these traditions. “Young women now view these old customs with distaste and are prepared to die rather than live with a partner who is forced upon them” (Vijayakumar & Thilothammal, 1993, p. 45). In addition, many younger Indian women are completing tertiary education and have changed their
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cultural values. However, this younger age group also has the highest suicide rate for young Indian women (Flisher & Parry, 1994; Wassenaar & Naidoo, 1995). The crosscurrents of English, postcolonial Western liberal education and the traditional, Asian patriarchal family structures appear to generate high levels of intrapsychic tension, interpersonal conflict, and hopelessness. In the course of modern education and socialization, young Indian women are exposed to a variety of Western norms, values and practices, including the emancipation of women from patriarchy and submission to male dominance. However, for those women raised in traditionally orthodox families, these influences are not easily assimilated into their personal and family lives due to the opposition and resistance of parental figures. These factors, combined with poor conflict resolution skills in particular families, lead to suicidal behavior in this particular cultural matrix (Pillay & Wassenaar, 1997a, 1997b; Wassenaar, 1987; Wood & Wassenaar, 1989). White, European-origin women are not as exposed to similar sociocultural stresses, therefore, the particular socio- and psychodynamics of their suicidal behavior should be subjected to a separate narrative analysis that takes their historically racially privileged but gender-inferior power position into account. The studies discussed earlier suggest that cultural transition and consequent interpersonal and intrapsychic conflict associated with the redefining of the lived meaning of gender (Kaufman, 1994) by these women must be seen as major stressors in suicidal behavior, particularly in relationships or families that have preexisting communicational and interactional problems. Substance abuse by the male partners must be seen in a similar context and as a further amplifier of conflict. Substance abuse and abusive behavior by male partners cause further severe emotional and economic stress in households (Pillay & van der Veen, 1995). Women in these situations, especially those with young children, often develop a sense of
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hopelessness about their future, with the result that suicidal behavior may be increasingly seen as an option that is culturally normative, particularly for women. It is a response that women “are permitted to make” (Cloward & Piven, 1979, p. 663).
GENDER AND SOCIAL CHANGE The perspective on gender adopted in this article regards gender as an active, lived process in which complex social and psychological forces actively reproduce social and cultural behaviors that are presumed to be natural and are attributed to biological sex (Canetto, 1997; Glenn, 1982; Tavris, 1991; Unger, 1997).The behaviors deemed gender-linked are active “micropolitical activities” that occur “as both an outcome of and a rationale for various social arrangements and as a means of legitimating one of the most fundamental divisions of society” (West & Zimmerman, 1987, p. 14). Gender is thus seen here as the product of social actions; “it is something that one does, and does recurrently, in interaction with others” (West & Zimmerman, 1987, p. 29). In this article sociocultural transition is seen as a force that is redefining the positions Indian women see themselves as legitimately aspiring to, and in this sense it represents a perturbation in the reproduction of gendered inequalities. This has led to increased conflict with males in particular, who, even though they may espouse liberated gender expectations, tend to be slower to change their lived behavior than their attitudes (Kaufman, 1994). There is amongst Indian women an increasing reluctance to reproduce traditional institutional arrangements based on sex difference (Vijayakumar & Thilothammal, 1993). Women are increasingly reluctant to “do” deference, while men are less reluctant to “do”dominance (West & Zimmerman, 1987). This sets up tensions, which in some cases are expressed in suicidal acts, as the following cases show. The cases were simply selected as typical examples that presented themselves
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at our clinic recently. All of the women were South African Indian females of at least third-generation immigrant families, of Hindu or Moslem religious faith, and educated in English as a primary language of instruction.
CASE 1: ALISHA Alisha, a 28-year-old single woman, was seen in the hospital after her third suicidal act. She had taken an overdose of antidepressants because she had felt “worthless’’ and her life had felt “empty” at the time. She had felt that “if this is all my life is going to be, then I’d be better off dead.” In the hospital she related that she was feeling “very confused but “glad that she was not dead, feeling that “suicide is not going to solve my problems; I have to deal with them.” She went on to explain that she was a “schizophrenic”but that she was on treatment (monthly depot of flupenthixol, 40 mg., and biperiden for sideeffects) and was “fine.”She appeared to be very aware and accepting of her “mental illness,” and described herself when “sick as someone who “hears voices” and starts to “think strange things like the television is giving me special messages.” Alisha was the second eldest of four children. All her siblings were married. She lived with her parents and her eldest brother and his wife in a small rural town. Her family owned a shop in the town and ran a small farm. According to her clinical notes, Alisha’s first suicidal act had been when she was psychotic at age 16 and the second was due to her engagement being broken off at age 20. I t was written that her family appeared very concerned at the time (second suicidal act) and were trying to sort out “the whole affair with the ex-fiancee’sfamily.” At that time a follow-up appointment was made but not kept. On exploration, Alisha admitted to often having thought of suicide a few months prior to her third suicidal act. She had been feeling miserable and frustrated. “I could do more with my bachelor of arts
degree” than “clean house and cook.” She had been feeling that her life “was going nowhere” and that it was “unproductive and empty,” leaving her feeling “worthless.’’She had discussed this with her general medical practitioner, who prescribed antipsychotic medication for her and advised her to see a clinical psychologist for psychotherapy. Alisha stated that she had wanted to receive psychotherapy but that her father had said that she needed a “letter from someone” referring her to a psychologist each time she requested to see one. She stated that she was dependent on her father for money and transport and thus was reliant on him to see a psychologist. She related further that she would “like to live in [the city] and have a flat of my own and have a job but my father will never allow me to. He’s scared I won’t be able to cope on my own and that I will become sick again.” This left her feeling “confused,“as she found staying at home and doing housework andlor helping in the family shop “empty” and “unfulfilling.” I t appeared that Alisha was powerless to resolve the conflict between meeting her own need to be productive and independent and her father’s need to keep her “safe” at home. During the session it became clear that Alisha did not want to die. She wanted to “face”her problems but did not know how to do so. She felt that she needed psychotherapy, and she was thus referred to a clinical psychologist in her area.
Comment In this case the patient’s submission to her father’s power is exacerbated by traditional power inequities and her previous diagnosis of schizophrenia. However, her mental status in the present context was without any evidence of schizophrenia, and her father’s overprotection did not appear to be justified by her mental status. Her gender and diagnosis, however, appear to provide her father with a rationale for negating her academic qualification
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taken the overdose in the hope that it would solve her problem. When asked if she felt it had, she said that it had not, as her parents were still against her seeing the boyfriend. She knew that her parents wanted to “protect” her from him, but felt that she “lovedhim” and that he would not leave her, as “he didn’t when he was threatened and hit” by her father 2 months prior to the suicidal act. She wanted to leave school to be with him and stated that “he really loves me and is going to get a divorce.” When concern was expressed about him being married and having a child, she responded by reiterating that she believed in him and trusted him. It appeared that she felt that her parents were wrong in not accepting him as her boyfriend and that she felt powerless to change their attitude. As the main area of conflict appeared to be between Chantel and her parents, a follow-up appointment was made to see the family in the hope of reaching some compromise and improving communication within the family. Chantel, her mother, and Chantel’s boyfriend Vijay arrived for the next appointment. Chantel’s mother said that her husband had refused to come as he felt that “there was nothing to discuss.” Her mother expressed her concerns about the relationship, saying that she was worried that Vijay was not going to get a divorce and “where would that leave Chantel, her future spoiled?” She was also worried that he had a child by his wife and therefore had a responsibility toward his wife. I t concerned her that if he could leave his CASE 2: CHANTEL wife then he could also abandon Chantel Chantel, a 16-year-oldgirl, was seen at the at some later stage. She was also anxious psychology clinic of a general hospital about Chantel’s schooling, as she would after having taken an overdose of her jeopardize her future if she did not at least mother’s blood pressure tablets and a bot- finish the 10th grade. She wanted a “bettle of analgesics. She had taken the over- ter future” for her daughter. Vijay apdose after her father had found out that peared to accept Chantel’s mother’s conshe was still seeing her boyfriend, who cerns and agreed with her suggestion to delay “courting” Chantel until his divorce was 22 years old and married. She presented as tearful and with mild was finalized. Chantel, however, appeared psychomotor retardation (possibly due to to idolize Vijay and would not accept that the overdose). She stated that she had any of her mother’s concerns could be real-
and for thwarting her wish to be selfsupporting in a neighboring city. His reluctance to support her request for psychotherapy suggests a degree of selfinterest in keeping her tied to the home and assisting him in the family business. This young woman is caught in a chasm between two cultures, and legitimate attempts to communicate her distress have been ignored. She is caught between two competing cultural definitions of her personal power and is unable to “marry” the two without dire consequences (family rejection). To submit and comply with the family expectations would leave her feeling stifled and stagnant developmentally. Her financial and emotional dependence on her family exacerbates her distress. The rural setting in which she lives heightens her isolation, and even her need for professional psychological help is denied by her father. The suicidal behavior can thus be understood as a desperate attempt to change her circumstances in a way that has a degree of cultural acceptability. This case reflects all the circumstances described by Canetto (1994) as risk factors for suicidal behavior: “socioeconomic disadvantage, unemployment, hostile relationships, and a history of suicidal behavior among family and friends” (p. 517). Her diagnosis of schizophrenia also requires systematic reevaluation; if confirmed, psychoeducational intervention with her father would appear to be indicated (Barrowclough & Tarrier, 1994).
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interpersonal status is extremely low (Brown, 1997; Canetto, 1997; Canetto & Lester, 1995b),although in some societies (e.g., the United States and Great Britain, where women’s social status is relatively high) affluent women have high suicide mortality. Low socioeconomic status cannot thus be seen as a sufficient predictor of women’s suicidal behavior in isolation from specific historical, traditional, and interpersonal forces. Bhanu’s intermittent attempts to assert herself within the hostile, domineering marital system may be remnants of previously functional coping strategies that were suppressed by her abusive husband, who exploited cultural patriarchy to perpetuate his dominating abuse. Her residual coping strategies were thus impotent in this violently dysfunctional marital system. Canetto (1992b)cites research suggesting that up to 25% of suicidal women are battered in this way. In addition, the traditional role of women in Indian culture appears to have contributed to her sense of powerlessness in the marriage. Furthermore, her husbands personality characteristics and substance abuse generated high levels of stress in the household, increasing the risk of suicidal behaviour in his wife (Canetto, 1992a; Pillay & Vawda, 1989). The suicidal act can be seen as a desperate but dysfunctional attempt to change her intolerable life situation; the language of suicidal behavior is, as Jack (1992) describes it, “a generally well understood signal” in this cultural groupm (p. 24).
DISCUSSION These three cases illustrate the intersection of traditionally sanctioned patriarchal domination and oppression of women, cultural transition, and interpersonal pathology commonly associated with suicidal behavior in this community. I t is important to note that each of the three women described in this article is burdened with economic hardship and low social status in addition to the sanctions
imposed on females. The labelslsocial constructions “mental patient,’’ “rebellious adolescent,” and “battered wife” are further crosses for these women to bear. It is argued that men in similar or equivalent situations would be unlikely to be cast in such passive roles. Rather, there is an expectation that a “mentally ill” male would be aggressive and domineering, a troubled adolescent boy would test the norms and morals of society, and a “henpecked husband would fight for his socially sanctioned authority over his wife and family and the exercise of his civil rights. Socialized powerlessness, economic disadvantage, and increasing exposure to a “Western” lifestyle perceived as more egalitarian and free contribute to “acculturative stress” (Hovey & King, 1994, p. 35) and to the cycle of self-injury. Similar patterns have been reported in Chinese American youth who were described as being in “culture conflict” (Blinn & Shiang, 1994, p. 58).The impact of race, class, and gender in these “minority” communities is described by Burck and Daniel (1995): “Experiences of selfhood are also affected profoundly by race, class, and culture. . . anyone defined by the dominant culture as ‘other’has faced similar contradictions of experiences to those we have described for women” (p. 39). Each of the women described in our cases identified her powerlessness as gender-linked (Jack, 1992). Their suicidal actions were a desperate attempt to take powerful action and to make an impact on their interpersonal context, ideally achieving egress from intolerable psychological pain (Shneidman, 1993). The suicidal behavior can be seen as occurring in a context of interpersonal, cultural, and gender transformational conflict “in which their ability to negotiate is progressively restricted until suicide becomes the only culturally sanctioned behavior possible” (Canetto, 1994, p. 521). Where the patient is an adolescent, as in Case 2, the role conflict is heightened by the usual role conflicts of adolescence, which adds to the risk of suicidal expression (McDowell & Stillion, 1991). Women’s oppression by traditional
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patriarchy and associated male superiority is illustrated in a further recent case where a young man’s mother became suicidal after he married and announced his plan to live apart from his mother. His mother’s suicidal act unsettled him and his wife. His resulting ambivalence about his decision to leave his mother led to his new wife engaging in suicidal behavior. Both of these women link their physical and emotional survival to their attachment to this young man, who is unable to reconcile these divided loyalties nor cope with the extreme traditional culturally sanctioned dependencies of these two women (see Canetto & Feldman, 1993). These specific culture and gender factors must be addressed in intervention (Canetto, 1994) and prevention (Wassenaar, Pillay, Burns, & Davies, 1993) beyond the more usual clinical issues associated with individual distress and suicidality. It is clear from these cases that treatment and prevention efforts need to address family and interpersonal communications with a sensitivity to the transitional nature of gender in this community and its slide into Westernization. Even “Western” gender values are associated with female suicidality (Canetto, 1997), demonstrating women’s discontent with their ‘traditional’ social condition (Kushner, 1985). Prevention thus needs to address social awareness at broad community and social levels: “An understanding of how gender is produced in social situations will afford clarification of the interactional scaffolding of social structure and the social control processes that sustain it” (West & Zimmerman, 1987, p. 34). Clinicians need to be aware of the complexities of these forces in order to provide appropriate and sensitive services in these contexts. Continuing professional education programs for clinicians working with such cross-cultural situations is essential in order to avoid culture collision in the therapeutic relationship. Gender issues must be more explicitly addressed in view of recent reviews highlighting the greater incidence of depression in women than in men (Culbertson, 1997) and the de-
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velopment of a critical gender-sensitive family therapy (Burck & Daniel, 1995). “Women may find themselves holding contradictory expectations: on the one hand, communities see them as providers of stability in these times of trauma and rapid change, on the other they frequently carry the potential and the push for change” (Burck & Daniel, 1995, p. 48). Men, too, must increasingly confront the paradoxes associated with the power and the pain of the dominant position (Kaufman, 1994). At the level of prevention, a multifaceted, culture-specific, pilot schoolbased intervention program appears to have had a positive effect in reducing adolescent suicidal behavior (Wassenaar et al., 1993). A t a treatment level, individual psychotherapy, counseling, and emancipatory family and marital therapy appear to be essential and effective (Burck& Daniel, 1995; Pillay & Wassenaar, 1995; Wassenaar, 1987). Future research requires a more explicit focus on gender in cultural transition, with an emphasis on subsequent intrapsychic, interpersonal, and social conflicts and their consequences for women and for men.
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