'Plue plun' male, 'kath klei' female: gender differences in suicidal behavior as expressed by young people in Cambodia.

Few studies from low- and middle-income countries use qualitative methodology to explore suicidal behavior among young people. In Cambodia, young people face the challenge of rapidly changing times and are vulnerable for suicidal behavior as revealed by research in transitional economies. This study seeks to gain a deeper understanding of the suicidal phenomena from a gender, psychosocial and cultural perspective. Six focus-group discussions were conducted among boys and girls, aged 15-19 years, in two secondary schools in a suburban area close to Phnom Penh, the capital city. The data was analyzed using thematic analysis approach. The participants highlighted the gender difference in suicidal behavior by describing the suicide-prone, acting-out male as 'plue plun', while suicide-prone females were described as caught in constricted, tunneled-thinking behavior, expressed as 'kath klei'. Parental attitude and family environment were also pointed out as the chief causes of discontent and there was a strong wish on the part of young people to find space for modern values within the traditional family. The young people's awareness of their challenges in everyday life suggests that school-based programs to prevent suicidal behavior ought to be gender-sensitive and peer-focused.

Background

Young people between 10 and 19 years are 20% of the global population, constituting the largest age group in the world, and about 85% of them live in low- and middle-income countries (Brown, Larson, & Saraswathi, 2002). Globalization, economic-restructuring and resulting socio-cultural transition in pre-industrialized countries have significant impacts on young people, leading to psycho-social stress, mental health problems and suicide (Bucholtz, 2002). The prevalence of suicide and psychosocial risk factors vary across countries and regions, which implies that socio-cultural factors play an important role in suicidal behavior (Colucci & Martin, 2007). Loneliness, rejection and marital conflict are associated with suicide in high-income countries, whereas intergenerational-conflict, love-failure and exam-failure are more common stressors in low- and middle-income countries (Vijayakumar, John, Pirkis, & Whiteford, 2005). In a study from India (Kar 2010), young people with suicidal ideation report childhood trauma and stressful life events more than adults. Patel, Flisher, Hetrick and McGorry (2007) underscore the relationship between poor mental health and other issues such as educational achievement, substance abuse, violence and suicide. There is a need to see beyond the ‘mental-health-frame’ and understand suicide among young people in the psycho-social and gender perspectives (Roen, Scourfield, & McDermott, 2008).

Studies across many countries report gender difference in suicidal behavior and its determinants, which need deeper understanding to prevent suicide among young people (Jegannathan & Kullgren, 2011; Kaess et al., 2011). The suicide rate among boys is higher than among girls in high-income countries: in North America five times higher among boys than girls (Anderson, 2002), with similar trends in Western Europe, Australia and New Zealand (World Health Organization, 2011). In low- and middle-income countries, gender difference in suicide among young people is less pronounced (Aaron et al., 2004; Philips, Li, & Zhang, 2002). In Cambodia, no reliable data are available on suicide rates. In a study on suicidal expressions among young people in Cambodia by Jegannathan and Kullgren (2011), boys reported suicidal plans more often (17.3%) than girls (5.6%), while girls reported more attempts (7.8%) than boys (0.6%). This is similar to findings from Nicaragua (Obando Medina, Jegannathan, Dahlblom, & Kullgren, 2012). A nationwide youth risk-behavior survey from Cambodia among young people in the age group of 11 to 18 years reported that 19% of them expressed suicidal thoughts and 14% made suicidal plans. Among the youth who had suicidal thoughts, 39.5% had attempted suicide one time and and 12.4% more than three times (Ministry of Education Youth and Sports Cambodia, 2004). In another survey among most at-risk young people in Cambodia in the age group of 10 to 14, 3.5% of the female and 15.2% of the male respondents reported using drugs (Ministry of Education Youth and Sports Cambodia, 2010). In the above study, 23% of the female and 41% of the male respondents reported being sexually active, which is of concern, as substance abuse and early sexual experiences are well known risk factors for suicidal behavior (Dubey et al., 2001).

Most of the studies in suicidology, particularly from low- and middle-income countries, are based on quantitative methods and there is a genuine need to use qualitative methods to deepen the understanding of what suicidal behavior means to young people in different cultural contexts (Hjelmeland & Knizek, 2010). It is important to engage young people to explore their world and to understand the factors leading to suicidal behavior in the context of peer, family, school and the rapidly changing society (Lanuza, 2000). Most of the qualitative studies about suicidal behavior among young people are from high-income countries, with few exceptions (Herrera, Dahlblom, Dahlgren, & Kullgren, 2006; Hjelmeland et al., 2008), and this study in Cambodia aims to narrow this gap.

The objectives of the study were to understand how young people in Cambodia perceive the challenges in their everyday lives, to explore their views related to suicide and to gain deeper understanding of the suicidal phenomena.

Methods

Research setting

Cambodia ranks as one of the poorest countries in the Asia-Pacific region. One-sixth of the land is covered by landmines, a legacy of war. This is a challenge where 80% of the 14.5 million are engaged in sustenance agriculture and 40% of the population lives under absolute poverty (< 1 US$ per day) (Dasgupta, Deichmann, Meisner, & Wheeler, 2005). There are 95 men for every hundred women and 42% of the population is under the age of 20 years. While 78% complete primary school, only 45% complete secondary-level education (Cambodia Population Census, 2008). The two government secondary schools from which we recruited the young people for this study are located at Takhmau, the headquarters of Kandal Province, 11km south of Phnom Penh, the capital of Cambodia. There are about 58,300 inhabitants in Takhmau, mainly farmers, though some of them work in the garment factories that have sprung-up in the recent past. There are two higher secondary schools, one primary school and a teacher training school in Takhmau.

Participants

For the focus-group discussions (FGDs), we recruited the participants by purposive sampling. Every alternate name was chosen from the attendance registers of class 10 and 11 in the two schools, asking the student whether she/he was willing to join the FGDs. If someone was not inclined to join, we called upon the next person in the register. Two students were absent and one declined to participate.

Six groups with eight students each – two mixed groups and two of either gender – were formed. We involved both mixed and gender-wise groups to get a gender-specific perspective, as well as points of views across the gender in an interactive context, as cultural-conditioning may restrict the participants, particularly young women, from expressing themselves freely in a mixed-group setting (De Jong & Van Ommeren, 2002). We limited the size of the group to eight to allow everyone's voice to be heard and to have optimal depth and range in the discussion (Dahlgren, Emmelin, & Winkvist, 2004).

Process

We explained the process of FGDs and the roles of the facilitator and the note taker to the participants. The facilitator, a native Khmer (Cambodian language) speaker, started the discussions with ‘warm-up questions’ and gradually moved from general (youth situation) to specific (suicide among young people) issues, using a topic-guide. It started with general questions such as ‘What is the situation of young people in Cambodia’ and ‘What do you think are the reasons for young people dying in Cambodia’, moving on to specific questions such as, ‘What do you know about young people in Cambodia committing/attempting suicide’ and ‘Can suicide be prevented and how?’ A quiet place within the school campus was selected to facilitate recording and the FGDs lasted 45 to 90 minutes. The note-taker, moderator and the researchers met after the FGDs to reflect about non-verbal communication, significant repetitions, overall ambience and experience of the participants (Mack, Woodsong, MacQueen, Guest, & Namey, 2005).

Data analysis

The recordings were transcribed by the note-taker and translated from Khmer to English. The transcripts were analysed using the six-phased-process described by Braun and Clarke (2006) and we used their 15-point checklist-criteria for thematic analysis to cross-check the steps of our analysis. ‘Open-Code’ software 3.4 was used for coding and analysis (ICT Services and System Development and Division of Epidemiology and Global Health, 2009). We noted the word-repetitions and key-indigenous terms such as ‘kath klei’ and ‘plue plun‘, ascertained the meanings by discussing with fellow team-members and using extensive memos (Buetow, 2010). Initially, the codes and sub-themes were identified inductively and tabulated along with the corresponding data-extract, including the line-number in the transcribed text for easy verification during the audit-trail. During the subsequent readings of the text, the themes and the sub-themes were modified when relevant.

Ethical considerations

We explained the purpose of the FGDs and issues of confidentiality to the participants and obtained permission to record the discussions. Further, to maintain the confidentiality, fictitious names are given when we refer to the discussants in this article. We gave the option to opt out at any time during the discussion. The contact details of counselors were given to the participants of the FGDs but there were no self-referrals. In accordance with Cambodian practices, the director of the referral hospital where the research team was working approved the study. Since participants were aged 15 years and above, informed consent was obtained from themselves and the head of the school gave permission to conduct the study. The parents were informed about the study by the school administration through the parent association. Ethical clearance was obtained from the regional research ethics committee of Umeå University, Sweden (Dnr: 07–046M).

Results

The participants felt comfortable meeting in their own setting during school hours and they actively engaged in the discussion. The following themes were identified: Suicide-vulnerable plue plun young men, kath klei suicidal young women, Negotiating for space with and in the family and Suicide prevention through schools.

Suicide-vulnerable ‘plue plun’ young men

The young people talked about materialistic, defiant and delinquent young men in contemporary Cambodia, as illustrated by responses from several participants in mixed and girls’ groups: ‘the young people want cell phone, like fun and extravagance, and skip school; they are overjoyed [plue plun], disobey their parents, go to night-clubs and use drugs with their friends’. Ratha, a boy from the mixed group, explained his understanding of plue plun and the gender difference in suicidal behavior as:

Excitement [plue plun'] refers to, going out with friends and abusing drugs … end up sad and commit suicide. Girls, in contrast, tend to commit suicide out of disappointment… by hanging themselves, taking massive dose of medicine following failed relationship.

Vannak, from one of the boys’ groups, attributed this to external influences:

I think that most Cambodian teenagers today are influenced by foreign culture … certain types of movies have violent scenes, young people mistake this as reality and imitate at the expense of their education and self-development.

Codes and subthemes are further shown in Table 1.

Table 1.

Codes and subthemes related to suicide-prone plue plun males.

Quotes from focus-group discussions	Code	Sub-themes	Theme
Young men are materialistic, want cell phones, motorbikes etc., don't think about the future, play truant	Materialistic young men Carefree young people	Over-indulgent
… demand money, lie to parents, miss classes, do what they want (plue plun), peer-based suicide-prevention program may help young people	Delinquent youth Positive-peer influence	Delinquent	Delinquent suicide-prone male
… take drugs, no critical thinking, decide too quickly (plue plun), commit suicide due to serious problems	Impulsive youth Self-destructive youth	Suicidal
… are over stimulated (plue plun), outside-influences like internet-pornography flow into our country, get involved in love-affairs	Other culture influenced Acting-out male	Plue plun
… drive fast… like gangsters, too drunk to control themselves, get in to fights, don't listen to parents	Aggressive, impulsive youth Rebellious youth	Aggressive	Acting out
… prefer modern lifestyle, steal money, and commit robbery, when love fails girl lose hope, boys die of excitement and girls of disapointment	Novelty-seeking youth ‘Boys die of excitement’	‘Boys die of excitement’

‘Kath klei’ suicidal young women

Many participants from both mixed as well as gender-specific groups said that ‘young women are at risk for suicide as they are prone to kath klei, a Khmer expression that is interpreted as ‘constricted, superficial, short-sighted or tunneled-thinking’. Srey, from a girls'-group said:… the term kath klei means “think superficially” … [and] refers to a situation when the young person will do anything… don't think about future … do what they think, even commit suicide’. Philikka, from the same group, reflected: ‘… this [kath klei] happens to young women more, as they are seen inferior in Cambodian society’. Thira, a boy from mixed group, said, ‘… girls are weaker in mind’ to which a girl from the same group responded, ‘that is why they could not accept when heart-broken, become short-sighted [kath klei] and end their lives’. Rose, from a girls’ group, complained: ‘the parents are forcing us to marry when we want to study’, while Piseth, from another girls’ group, pointed out the situation leading to suicide:

When a young women is raped or become pregnant before marriage, the neighbors look down upon her … as she is no longer a virgin … she will be thoughtless [kath klei], feel ashamed because in Cambodian society women need to take care of virginity and purity for her husband.

Kanya, a girl from the same group, followed:

… they think that she was not raped but consented [to sex]… do not see her as a victim and think low of women … while traditions do not bind men’. Socheatha, a girl from mixed group, said: ‘I think most girls are shortsighted [kath klei]… I will not think of suicide … will consider my family, studies and my future.

Codes and subthemes are further shown in Table 2.

Table 2.

Codes and subthemes related to kath klei suicidal females.

Quotes from focus-group discussions	Code	Sub-themes	Theme
Women are looked down upon in Cambodian society when they have male friends, have no freedom to choose career, are forced to marry by parents	Inferior women Voiceless at home	Voiceless
… cannot do anything they want, men go out, visit ‘karaoke’, go travelling, women do not have these rights	Denial of rights Bias against women	Tradition bound	Tradition bound, voiceless female
When parents do not give us freedom, do not respond to our requests… it is lack of thoughtfulness (kath klei) to kill oneself… rather than study hard to become good citizen	Controlling parents Suicide-leads to freedom from oppression	Gendered culture
Young women are short-sighted (kath klei), young men rarely commit suicide when they have done wrong, women upset… overdose or hang themselves	Short-sighted women Vulnerable women	Vulnerable female
Idea of killing self is not being thoughtful, women think superficially (kath klei) when committing suicide	Kath klei Suicide vulnerable women	Kath klei	Kath klei suicidal female
… are inferior, when problems occur, young women, unlike men, who find comfort in the bottle, will shed tears, broken-hearted	‘Men find solace in the bottle, women in tears’	‘Women die of disappointment

Negotiating for space with and in the family

The young people identified adverse family environment as a source of distress and cause for suicide. Peth, from a boys’ group, said: ‘most [young people] die of traffic-accident, as they drive fast… mainly due to lack of affection from parents – they [young people] run-away from home … to commit suicide’. Sokha, from a mixed group, was pleading: ‘Hmm! I could see that nowadays many men drink alcohol, have second-wives [mistresses], so their children feel helpless… consider suicide … we wish parents can show us the good way’ and Theun, from the same group, added: ‘…when father have second wife, young men get angry… they might kill their stepmother and themselves too’. Ratha, a boy from the mixed group, pointed out the authoritarian-communication as a major challenge:

When our parents say: ‘Are you older than me? Are you my father or I am your father’ … we get angry with them because individuals [young people] can express their ideas in a good way … but if parents make such statements, it hurts their children.

Vannak, from the boys’ group, hoped: ‘we wish our parents are better educated and understand us …’. Sita, from a girls’ group, said: ‘[young people] can make decision by themselves. We do not want parents to decide for us’. Sophana, from another girls’ group, emphasized negotiation, said: ‘But if we do not discuss with parents, we face difficulty … we need to talk together, get the advice as well as make them [parents] understand [us]’.

An overview of codes and subthemes are shown in Figure 1.

Figure 1.

Codes and sub-themes related to negotiating for space with and in the family.

Suicide prevention through schools

Rattanak, a young man from mixed group, felt lack of education is an impediment for suicide prevention: ‘… in rural area, they never go to school… sometimes their parents become angry… if they had been at school they will know about suicide [prevention], but they [parents] do not understand.’ While exploring the possibility of suicide prevention among young people, in response to the question whether suicide can be prevented, most of the FGD participants expressed the need for preventive services: ‘it will be useful to educate and train peer-group in schools and they can help each other’.

Discussion

The young people in our study highlighted the gender difference in suicidal behavior by using the expressions plue plun and kath klei (Table 1 and Table 2) to describe the suicide-vulnerable male and female, respectively (Figure 2).

Figure 2.

Gender differences in suicidal behavior as expressed by young people in Cambodia.

The plue plun male (Table 1 and Figure 2) was described as young person caught between bicultural identities, global and local (Arnett, 2002), and vulnerable to suicidal behavior in the background of substance abuse, conduct disorder and impulsive behavior, as confirmed by other studies (Goldston et al., 2009; Ilomäki, Räsänen, Viilo, Hakko, & The STUDY-70 Workgroup, 2007; McGirr et al., 2007). In particular, impulsivity has been suggested as a key-factor for suicidal behaviour among young people (Javdani, Sadeh, & Verona, 2011).

The phrase kath klei (Table 2) describes ‘constricted or tunneled-thinking’, one of the key constructs of Becks cognitive triad of depression (Abela & D'Alessandro, 2002), which makes individuals, particularly women, vulnerable for suicide (Evans et al., 2005). Our study-participants explained how young people with tendency for kath klei, whether female or male, are looked down upon in society (Table 2), though this applies mainly to girls who are traditionally considered inferior in Cambodia (Miles & Thomas 2007). The shame and the stigma attached to pregnancy before marriage (Hastings, Northman, & Tangney, 2002), and the associated risk of suicide due to unwanted pregnancies (Fisher et al., 2011), was the concern of the discussants in our study. The gendered culture and social norm of considering pregnancy out of wedlock as a catastrophe in the lives of young women may explain the high rate of suicide in countries recovering from conflict and civil strife (Bolz, 2002), such as Cambodia. Fullagar (2003) explains that ‘suicidal feelings are shaped through the gaze of the other (families and communities) among women whose lives are wasted in the process of coming to terms with the self, emotion and life’ (p. 298), which is similar to the suicidal pathway described by the participants in our study (Figure 2). The specific rules and the code of conduct for girls in Cambodia, called chbap srei, is distressing and the girls in our study found themselves caught between the traditional and modern values (Brickell, 2011) within the family system.

The discussants, both from the mixed and gender-specific groups, highlighted the parental attitude and family environment as one of the chief causes of youth discontent leading to suicidal behavior (Figure 1 and Figure 2), as revealed by other studies in Asia (Wai, Hong, & Heok, 1999; Xing et al., 2010). Our study participants explained the gulf between their aspirations and their parents’ expectations (Xiong & Detzner, 2005) that pitted them against their parents. This is most common in countries in transition from rural, hierarchical to industrialized, egalitarian societies, where the youth face intergenerational conflicts (Kim & Singh, 2004). Lowe (2003), in his study among Micronesian adolescents, reports family conflict to be the main cause of suicidal behavior among young people. The girls in our study complained that while they liked to pursue higher education, their parents wanted them to get married or take up the family business (Table 2), a situation very similar to that in rural West Bengal (Da Costa, 2008). Alcoholism, mental illness and domestic discord were cited by our study-participants as reasons for running away or committing suicide (Figure 1), which is akin to the situation of young people in other low- and middle-income countries (Herrera, Dahlblom, Dahlgren, & Kullgren, 2006; Khurana, Sharma, Jena, Saha, & Ingle, 2004). The young people in our study were keen to negotiate with their parents to have their say (Figure 1) and find space for modern values within the traditional family system (Thomson & Holland, 2002).

Both boys and girls in our study were concerned about the challenges and tensions they faced in the background of rapid development of information technology and market forces (Table 1), which is highlighted by Gale and Fahey (2005). ‘Known structures are coming apart and this evokes feelings of fear’ but also ‘spaces of opportunity will be opened’ as pointed out by Jain, Keupp, Höfer and Kraus (2002, p. 131), and this came across during the discussions. The young people in our study echoed the views of Miller, Eckert and Maza (2009) when they suggested peer-based suicide-prevention programs in schools.

Limitations

Interaction is a key feature in FGDs but participants may also be influenced by each other in a group discussion, which is an inherent limitation of the FGD as a method. As the study was done within the school campus, the students might have come out with ‘expected responses’ and female respondents could have ‘under-played’ in group discussions. The responses from students from semi-urban environments may not reveal the situation of the majority of young people in Cambodia, which is predominantly rural, but the young people in our study did touch upon rural-urban differences.

Conclusion

Young people in Cambodia are aware of the challenges they face today. Customized, gender-sensitive and peer-focused school-based programs may be an opportunity to prevent suicidal behavior among young people in Cambodia.