|Year : 2014 | Volume
| Issue : 2 | Page : 109-110
Suicide in men is systematically underreported in Afghanistan
Janeris Loredo, Partam Manalai
Department of Psychiatry and Behavioral Sciences, Howard University, School of Medicine, NW, Washington, DC 20060, USA
|Date of Web Publication||18-Aug-2014|
Dr. Partam Manalai
Howard University, School of Medicine, 2041 Georgia Avenue, NW, Washington, DC 20060
Source of Support: None, Conflict of Interest: None
Suicide is a major public health concern in Afghanistan. However, in spite of substantial anecdotal reports of suicide incidences in the country, suicidal behavior (ideation, attempts, and completed suicide) has not been studied systematically in Afghanistan. Most of the data come from media reports. Such reports are inherently biased; most recent reports indicate that overwhelming majority of completed suicide are females (95%). Such observations are in stark contrast with what is seen globally and what was reported in 1960s in Afghanistan. We present a case of an Afghan man surviving a suicide attempt to highlight the underreporting of suicide and suicidal behavior in Afghanistan. We conclude that the Afghan people need international support to develop research strategies and devise suicide prevention methods to address the problem of suicide in Afghanistan.
Keywords: Afghan, Afghanistan, suicide, suicidality
|How to cite this article:|
Loredo J, Manalai P. Suicide in men is systematically underreported in Afghanistan. J Med Trop 2014;16:109-10
| Introduction|| |
Suicide is a major public health concern with almost a million people annually losing their lives to suicide globally.  About 170,000 people lose their live to suicide in India alone.  While females tend to show higher rates of nonfatal suicidal behavior, males have a much higher rate of completed suicide.  Recently, some unofficial statistics were released by the Ministry of Public Health of Afghanistan, suggesting that over 95% of completed suicide are females.  If taken at face value, these statistics would be surprisingly different than what is seen in the rest of the world. The most logical reason for the discrepancy is underreporting of male suicidal behavior in the country. Here, we present a case of Afghan man surviving a suicide attempt after a forced arranged marriage, followed by a discussion of challenges in ascertaining accurate statistics on suicidality and opportunities to study and prevent suicidal behaviors in Afghanistan.
| Case Report|| |
Mr. H, was a 21-year-old Afghan man, who up until a few months prior to the suicidal attempt, did not report any significant psychological stresses. His childhood was uneventful, personally and family psychiatric histories were unremarkable. He was a fit athlete with an interest in martial arts. He had good relationships with his peers. The patient had been involved in a number of romantic relationships with females (not uncommon but out of a norm for the culture). Mr. H was both admired and understandably coveted by his peers for this.
Mr. H's parents wanted him to marry a girl who was a relative of theirs. The parents' choice would be considered unattractive. Having had many experiences with "much prettier women," the patient could not tolerate the arranged marriage. Besides objecting to her physical attributes, Mr. H was against this arranged marriage due to a fear that his unattractive wife would end up as "a servant in the service of his parents."
Following an argument with his parents, Mr. H ingested a large amount of pesticide Malathion (O, O-dimethyl dithiophosphate of diethyl mercaptosuccinate). "Disappointed in his son's disgraceful act," his father refused to seek medical care and prevented the rest of the family from seeking help for him either. Neighbors transferred Mr. H to a local hospital by which time he had developed classical organophosphate poisoning. Fortunately, with appropriate treatment, his symptoms stabilized and he survived. He was discharged after only 2 days in inpatient setting. The patient's father refused to see the patient in the hospital. His suicide attempt was overlooked and his family eventually forced the arranged marriage. He was never referred to a psychiatrist and never followed-up and the event was never reported.
| Discussion|| |
Afghanistan is among the many countries where statistics of suicidal behaviors are not collected. Recently, more attention has been given to the plight of suicide in Afghans. However, because of socioeconomic reasons and somewhat exclusive international interests, most research is focused on women.  This restricted attention gives the false impression that suicidal behavior is less prevalent in Afghan men. As highlighted in our case report, suicidal behavior is not uncommon in Afghan men. The only study that systematically researched suicide in Afghanistan was published in 1970.  Gobar, in his study reported that the rate of suicide in Afghan men was equal to that in Norwegian men,  suicides in Afghan men outnumbering suicide in Afghan women by a ratio of 7:1.
Duplicating Gobar's study would be close to impossible in Afghanistan currently for a multitude of reasons. Since Afghanistan shares cultural and religious traditions with countries such as Iran, Turkey, India, and particularly Pakistan, one could extrapolate the suicide rates in Afghan men from available data these countries. World Health Organization multisite intervention studies on suicidal behaviors (SUPRE-MISS) studies suggest higher rate of suicide in Iranian men.  Similar trends are seen in Turkey  and India. , The North Western Frontier Province (NWFP) of Pakistan has identical demographics to Eastern part of Afghanistan; suicide statistics have much more generalizability to at least eastern parts of Afghanistan. In NWFP, men account for 74% of completed suicides.  Thus, the data from the region suggest that suicide in Afghan men is not lower than in women as reported by media.
Reasons for attempted and completed suicides vary from region to region. , Suicide data from above countries indicate domestic issues, and marital problems are common underlying factors resulting in suicidal behaviors. ,, In our case report, it is evident that Mr. H's suicide attempt was in response to being forced into an arranged marriage. In Gobar's study,  while relational problems accounted for most suicides in women, in men perceived shame, which was a major factor. Method of suicide also varies from region to region  with poisoning (especially pesticides and toxic gas), hanging, drowning, and firearms being most common in Asia.  Self-poisoning, as reported in our case report, is among the most common methods in Asian countries. ,
The reasons for underreporting suicides in Afghanistan are numerous; however, the main reason is social stigma. Suicide is a sin in Islam and a shameful event for the suicide-attempt survivors and their family members.  In cases of completed suicide, the family members may disguise suicide as an accident. Moreover, some of the suicide deaths may remain unaccounted since methods of suicide are dynamic and change overtime. For example, in Hong Kong, the first suicide by carbon monoxide inhalation of charcoal burning was reported in 1998 but by 2003, it was the second leading method of suicide in Hong Kong.  Beside cover-up, one possible reason lower suicide rate in Afghan men might be the availability of self-sacrifice for religious and patriotic reasons. By volunteering in armed conflicts, men can achieve their suicidal intent while avoiding social stigma associated with their suicide. Such observations need to be supported and validated with evidence. The recent reports clearly underrepresent male suicidality in Afghanistan.
| References|| |
|1.||WHO. Multisite intervention study on suicidal behaviours (supre-miss). Vol. 2014; 2014. |
|2.||Patel V, Ramasundarahettige C, Vijayakumar L, Thakur JS, Gajalakshmi V, Gururaj G, et al. Suicide mortality in India: A nationally representative survey. Lancet 2012;379:2343-51. |
|3.||Nock MK, Borges G, Bromet EJ, Cha CB, Kessler RC, Lee S. Suicide and suicidal behavior. Epidemiol Rev 2008;30:133-54. |
|4.||Majidy T. Women comprise 95 percent of suicides in Afghanistan: Officials. Tolo News Vol. 2013, Kabul, 2013. |
|5.||Gobar AH. Suicide in Afghanistan. Br J Psychiatry 1970;116:493-6. |
|6.||Bertolote JM, Fleischmann A, De Leo D, Bolhari J, Botega N, De Silva D, et al. Suicide attempts, plans, and ideation in culturally diverse sites: The WHO SUPRE-MISS community survey. Psychol Med 2005;35:1457-65. |
|7.||Suicide statistics, 2012. , 2013. Available from: http://www.turkstat.gov. [Last accessed on 2014 Jun 20]. |
|8.||Trivedi JK, Srivastava RK, Tandon R. Suicide: An Indian perspective. J Indian Med Assoc 2005;103:78-80, 82, 84. |
|9.||Khan MM, Naqvi H, Thaver D, Prince M. Epidemiology of suicide in Pakistan: Determining rates in six cities. Arch Suicide Res 2008;12:155-60. |
|10.||Wu KC, Chen YY, Yip PS. Suicide methods in Asia: Implications in suicide prevention. Int J Environ Res Public Health 2012;9:1135-58. |