The role of gendered norms in driving suicidal behaviour in Vietnam: why are girls more vulnerable?

Drawing on primary qualitative data collection in 2017 and a review of secondary sources, For further details of the full study see www.odi.org/projects/2852-mental- health-study-children-and-young-people-vietnam. this article explores patterns of suicide among children and adolescents in Vietnam, with a particular focus on the role of gendered norms in driving suicidal behaviour. Vietnam’s reported suicide rate was 7.3 per 100,000 people in 2016, up from 6.7 in 2000. This data is, however, unreliable, and real rates could be higher. See WHO, Global Health Estimates 2016: Deaths by Cause, Age, Sex, by Country and by Region, 2000–2016 (Geneva: World Health Organization, 2016 (www.who.int/healthinfo/global_burden_disease/estimates/en/index1.html);  R. Blum et al., ‘Youth at Risk: Suicidal Thoughts and Attempts in Vietnam, China, and Taiwan’, Journal of Adolescent Health 50(3), 2012 Several factors intertwine to make some people more vulnerable than others, ranging from individual histories of psychopathology and cultural and social background to crisis-related factors, including the type and magnitude of the event, the threat to life and the extent of losses. In post- disaster contexts people may face insecurities and uncertainties arising from, for instance, unemployment and limited support structures. C. A. Alfonso ‘PTSD and Suicide After Natural Disasters’, Psychiatric Times, April 2018 (www.psychiatrictimes.com/ptsd/ptsd-and-suicide-after- natural-disasters). In countries undergoing large-scale economic change such as Vietnam, pressure is increasing on individuals and families as norms and expectations change, giving rise to mental and psychosocial distress. A. Gabriele, ‘Social Services Policies in a Developing Market Economy Oriented Towards Socialism: The Case of Health System Reforms in Viet Nam’, Review of International Political Economy, 13, 2006; A. Hansen, ‘The Best of Both Worlds? The Power and Pitfalls of Vietnam’s Development Model’, in Emerging Economies and Challenges to Sustainability (Abingdon: Routledge, 2014). Vietnam’s conflict history is still present in the minds of many of its people, and the country is highly exposed to natural hazards such as droughts, earthquakes, floods, forest fires, landslides, sea water intrusion, typhoons and volcanic eruptions. Global Facility for Disaster Reduction and Recovery, ‘Vietnam’ (www.gfdrr.org/en/Vietnam). Against this background, and in light of evidence that suicide rates among children and young people in Vietnam may be rising, Ministry of Health, Survey Assessment of Vietnamese Youth Round 2, 2010. it is crucial to understand how the current context places children and adolescents at risk.

Individual risk factors

In our sample, females were perceived as being at higher risk of suicide. Reasons put forward largely by boys for why girls are more likely to attempt or commit suicide include their greater susceptibility to emotions and living in remote areas, isolated from support structures: ‘There are more girls among those who commit suicide and do harm to their bodies like chopping their hands or confining themselves, as girls are more sensitive to their emotional issues. Their hearts are easy to be hurt, meanwhile boys are more steadfast and calmer when encountering a problem’. Gendered norms were mentioned as a strong driver for suicide, particularly for people in rural areas. Girls in one focus group discussion in Dien Bien Phu felt that norms around son preference in rural areas may put girls at higher risk of suicide: ‘In the commune, girls face more difficulties, because in ethnic [minority] groups, people often value men over women … some parents are not knowledgeable, so they often prefer having sons. They may treat daughters a bit differently’. Similarly, interviews with females found that, in rural areas in particular, norms persisted around what a girl ‘should’ do. One girl was told that she was better suited to be a flight attendant rather than a police officer like she wanted because she had a ‘beautiful body’. Attitudes such as these all contribute to creating contexts where girls may feel isolated and unheard, and consequently experience emotional difficulties that are potential risk factors for suicide.

Gendered norms were also found to be a risk factor for suicide among boys and men who felt unable to live up to expected masculine attributes and behaviours, including an inability to maintain the household, leading to negative emotions and sometimes suicide attempts; one 17-year-old male said that ‘Most men are under pressure from the responsibility to feed their wives and children, while in fact some are incapable of doing that’.

Household and relational factors

Relational factors influencing suicide ideation and attempted suicide among the study respondents included problems at home (being scolded by parents, lack of communication with parents, parents not having enough time to talk to their children, parents disagreeing with the choice of marriage partner, conflict between parents, a violent father, financial pressure and parental addiction); problems at school, including bullying, teasing, getting low marks and self-isolation; and failure in romantic relationships, such as being abandoned/discarded, usually by a boyfriend. All of these factors were said to lead to young people feeling sad, upset and frustrated, which in turn led them to attempt suicide and sometimes even succeed in taking their own lives.

Gendered norms related to early and forced marriage of girls, which are closely related to pressure to drop out of school, were frequently cited as a reason behind suicide attempts by young women. One respondent noted that there is fear of ‘being kidnapped’ into marriage in their area, and recounted how a 16-year-old girl who had been kidnapped had committed suicide because she was so unhappy in her new marital home. Instances of bullying and teasing in school were also linked with suicide ideation, particularly for boys; one explained that ‘Back then, I was often made fun of by a classmate. I’m very sensitive, so being made fun of by other people affects my feelings the most … they all liked to bully me and so I had suicidal thoughts’.

Access to the internet can be both a suicide risk and a protec- tive factor. Study respondents spoke about the internet as addictive, leading to anti-social behaviour such as stealing and affecting mental health and psychosocial wellbeing, particularly for boys. Limited leisure opportunities for children and young people often led them to spend a lot of time on the internet, which was also seen as being dangerous and a risk factor for suicide, particularly by girls. Many children mention- ed romantic relationships as being risk factors for suicide: ‘Many cases of suicide are due to emotional issues from intimate relationships’. Suicide triggers could include unrequited love, parents discovering, disapproving of or forbidding the relationship and, for girls in particular, feelings of jealousy.

Community factors

Study respondents suggested that socio-economic difficulties could be related to suicide. One adolescent male in An Giang stated: ‘The majority of those who commit suicide and use substances are from poor families’. Living in rural areas also emerged as a risk factor. Entrenched and discriminatory gendered norms frequently associated with ethnic minority status were most often cited as the reason why living in rural areas may be a risk factor. Indeed, key informant perceptions indicate a belief that Hmong people are more prone to suicide than other ethnic groups, further fuelling negative stereotyping and marginalisation. Hmong are the majority ethnic group in Dien Bien rural areas. Hmong people account for less than 10% of Vietnam’s population, and like other ethnic minorities in Vietnam (e.g. Tay, the Thai, the Khmer), are poorer, less likely to be employed, have poorer-quality education and are more likely to be married early than other ethnic minority groups (e.g. Kinh). Our findings indicated that not only are Hmong people perceived as being ‘haughty and proud’, but their limited awareness was considered a driver of suicide.

Not all the ethnic minority groups are the same. It occurs only with the Hmong people … Hmong people have a bad custom of eating la ngon to kill themselves … The reason relates to the superiority complex of Hmong people. When a child has an urgent matter with classmates or disagrees with their parents, he or she is easy to commit suicide.

Institutional factors

Services for mental and psychosocial health, including suicide prevention and treatment, are limited in Vietnam. What services do exist focus largely on severe mental health problems, but given that suicide results from factors which are often not related to severe mental health problems such services are largely inadequate. Even where services exist, people may be reluctant to access them for a range of reasons, including stigma, lack of awareness and lack of affordability. Even if they do access them, service quality is extremely variable and may not be age- and gender-sensitive, all of which can result in limited uptake. M. Do et al., ‘Perceptions of Mental Illness and Related Stigma Among Vietnamese Populations: Findings from a Mixed Method Study’, Journal of Immigrant and Minority Health 16(6), 2014.

Conclusions

At the individual level, the findings of this research show that young people, particularly girls, are more likely to face mental health and psychosocial difficulties. Hence, understanding the particularities of this population group as well as their needs and priorities in relation to suicide ideation and attempts is important to effectively direct resources towards those most in need, and to ensure, not only that services are gender-sensitive, but also that they address the specific needs of children and young people.

Both the family/household and the school setting either create an enabling/protective environment for suicide ideation and attempts, or can potentially be a risk factor for, or fuel, suicide ideation and attempts. Supportive family members, especially parents, can protect children facing stress and pressure, and can also be important carers for other household members facing psychosocial distress. Interventions at family level could include parenting and communication skills, and learning to recognise triggers and symptoms of mental distress.

At community level, the challenges of poverty and rural life are often compounded by gendered norms around early marriage, accepted masculine behaviours and stereotypes around ethnic identities, all of which can fuel suicide ideation and attempts. Greater awareness is needed of the links between discriminatory gendered norms – child marriage pressures, expectations around appropriate masculine behaviours – and the mental ill- health and social isolation that many girls and boys often feel in such situations. This awareness-raising could be done at various levels, starting at the commune level by providing communities with more information about symptoms, manifestations and available services.

At the institutional level, Vietnam has some experience of using a community mental health model, which appears to have been relatively successful. It would be useful to revisit and potentially expand this model, including providing mental health literacy training and programming to community health workers, for instance in counselling and referrals and in the identification and prevention of potential suicide cases. Improved coordination between child protection workers, medical workers, school staff and women’s and youth unions at commune level would be vital for this to be effective.

Given that schools are an existing platform to work with children and adolescents, it is critical to promote the role of the Ministry of Education as a champion for supporting child and adolescent mental health and psychosocial wellbeing. This could be done through teaching children skills to deal with emotional and psychological difficulties and relieving study pressure, often a cause of mental health distress, by evaluating the volume of knowledge children are expected to learn.

While the internet can be a driver of psychosocial distress, it can also be protective: school children engaged with it to learn, to help them deal with feelings of sadness or anger, to watch videos and to connect with friends. Facebook was frequently mentioned – possibly more by girls among the study respondents – as a vehicle through which to express feelings. Exploring and harnessing the potentially protective role of new technologies could be an important step in addressing issues around suicide ideation and attempts, alongside other strategies focusing on improving the broader mental health and psychosocial wellbeing of children and adolescents in Vietnam.

Fiona Samuels is a Senior Research Fellow at ODI. Taveeshi Gupta is an independent researcher.