A Cry for Help and Protest: Self-Immolation in Young Kurdish Iraqi Women -A Qualitative Study.

BACKGROUND: Suicide is a major psychiatric emergency that has always been a topic of great interest to researchers. Self-immolation is a heinous suicide method that is common in Eastern societies. The present study was conducted to explore probable issues which might lead to self-immolation in young Kurdish Iraqi women.
METHODS: The present qualitative study was conducted in Soran, Erbil Governorate in Iraq, and the surrounding villages of Soran District (March 2015 to May 2016). Using purposive sampling, we conducted 24 in-depth interviews with women who had done self-immolation. The obtained data were analyzed using conventional content analysis.
RESULTS: The analysis of the data obtained from the interviews led to the extraction of five categories which seems to be related to self-immolation attempts, including not having control over personal life, marital conflicts, seeking attention, instilling guilt in the family members, and resentment towards male dominant community.
CONCLUSION: Self-immolation is a multidimensional phenomenon that has not come to exist overnight and is rooted in various factors that join to encourage self-immolation attempts by women in critical situations. Comprehensive preventive strategies, such as cultural changes, along with education are required to help lower the rate of self-immolation.

INTRODUCTION

Suicide is a major psychiatric emergency that has always been a topic of great interest to researchers. Different suicidal attempt methods are used in different countries based on their dominant culture, religion, symbols and emulations.1 Suicide is currently the fourth leading cause of death in people aged 15 to 44 and the sixth leading cause of disability worldwide.[1-3]

Self-immolation is a heinous suicide method that is common in Eastern societies compared to the West.[1,3,4] Self-immolation is extremely painful for both the victim, who may remain alert until death, and for the witnesses.[1,4] For whatever reasons it takes place, self-immolation leads to irreparable personal and social damage for the individual, community and family and has always been of interest to researchers in different fields as a symptom of social pathology.[1,5]

Every day, burn hospitals in Kurdistan witness female victims of self-immolation who have found no other solution to their life problems than to destroy themselves in the most horrendous ways.[5] Dramatic social changes, economic problems and population growth have made the society extremely vulnerable.[6] According to statistics, Middle Eastern and East Asian countries have a high rate of self-immolation.[7]

Self-immolation has been reported as the preferred method of suicide in 27% of the cases in developing countries such as Iran, India and Sri Lanka.[8] The annual prevalence of self-immolation has been reported to be 2.9 to 21 per 100,000 people in the Eastern Mediterranean region, depending on the climate and socioeconomic and cultural conditions.[2]

The tendency toward self-immolation has increased in recent years among the young population, especially young women.[9] According to the statistics provided by the Director of the Violence against Women Watchdog (the Ministry of Interior, Kurdistan, Iraq), 73% of the women attempting self-immolation are 14-30 years old, suggesting a social predicament faced by young Kurdish Iraqi women.[10]

A study conducted in Sulaymaniyah province in Iraqi Kurdistan showed that, of the 197 cases of self-immolation, 6% were man and 94% were women, with an annual prevalence of 8.4 per 100,000 and a 13 to 1 female to male risk ratio; these risk factors are related significantly to other factors such as female gender, adolescence (age 11 to 18), poor education, spring season and small families.[9] In another study conducted in Sulaymaniyah, of the total number of 760 cases admitted to burns wards over a five-year period, (519 female and 241 male) 386 patients (50.7%) had attempted self-immolation; of these, 345 (46.6%) were females and 41 (4.1%) were males. Suicidal attempts have mostly been reported in married and poorly-educated women. Having an arrogant spouse and a forced marriage were the most common reasons for self-immolation.[11]

In a research conducted in Mosul over a one-year period from 2011 to 2012, of the 459 burn cases admitted, 103 (22.44%) were cases of self-immolation, with a 61% degree of burn, which is significantly higher than burns the caused by hot water (20%) and flames (56.5%). The rate of mortality was 80.6% in the self-immolation cases and 14.9% in the accidental burns. The mean age of the victims was 24.3 in the self-immolation cases and 15.6 years in the accidental burns.[8]

The results of another study showed that 57% of the women who had attempted suicide were city dwellers, the majority of them were illiterate, and financial difficulties comprised their biggest problem. Female victims were exposed to extreme domestic violence and most (89%) were 15-30 years old; however, the percentage of self-immolation attempts appears to have reduced with age in this study.[12]

A review of literature showed that the majority of studies conducted on burns and self-immolation have used quantitative method. In Kurdistan-Iraq no qualitative study has been done on self-immolation among women. Considering that cultural issues, ethnicity and underlying conditions can be involved in the incidence of such phenomenon, conducting a qualitative study by which first-hand and in-depth data could be obtained from the participants seemed necessary.

A complete knowledge of the victims’ personal motives is essential for beginning an effective medical intervention.[13] Besides, the experience of one incident in one culture may be vastly different from the same experience in another culture and the underlying causes of the incident will therefore differ.[13] The findings of this research can thus help us make more effective decisions and consider programs for assisting these individuals. Moreover, it can be useful for preventing similar events in future. Through qualitative studies, researchers can be the voice of victims to families and authorities.[2] Therefore, the researchers conducted this study to understand the experience of these women and tried to explore the problems which might have led them to self-immolation attempt.

MATERIALS AND METHODS

The present research is a qualitative conventional content analysis. In such studies, the categories extracted are coded directly from the text of the data and the researcher immerses in the data to reach a new insight and inductively construct the categories.[14]

This study was approved by the Ethics Committee of Tehran University of Medical Sciences, International Campus (No. 130.1118, date 10.08.2014). In this study, the researchers were interested in finding the probable facilitators of self-emmolation among Kurdish women in Iraq, the subject that was not searched qualitatively in the previous researches, and there was not enough first-hand information in this regard.

The study population consisted of women living in urban and rural areas of Soran District in Erbil Governorate in Kurdistan, Iraq from March 2015 to May 2016. The participants had survived from self-immolation attempts in recent years. The inclusion criteria consisted of age over 18, no history of psychological disorders, psychotropic medication use, drug and alcohol abuse and deliberate self-immolation attempt. The participants with burns on their face or over their bodies, and with more than six months since their self-immolation attempt were interviewed. The percentage of burn in women who participated in our study was more than 25%. Participants whose family did not agree with the interview were excluded from the study.

The first two questions from the participants were: “Let’s talk about the moment that you decided to burn yourself” and “Please tell me about yourself and the condition in which you did it”.

To comply with ethical principles, interviews were conducted with those participants whose family agreed with the interview. First the researcher conducted a brief meeting with their families/spouses and gave them some information about the aims of the study, confidentiality of information and anonymity.

Before the study, informed written consents were obtained from all the participants. Participation in the study was completely voluntary and they were informed of their right to withdraw from the study at any stage and were also ensured of the confidentiality of their data. The participants were selected through purposive sampling. The details of some of the participants were obtained by visiting the medical records of hospitals with burns departments, reviewing the records of discharged patients in burns hospitals. After examining the patients’ details, the ones who met the criteria were contacted and appointments were made for their participation in the study. The study sample size was determined with the saturation of the data. The interviews continued until no further new data, codes or categories emerged. Following the necessary arrangements, data were collected at their home or another place of their choice using semi-structured in-depth interviews.

A total of 24 interviews were performed. All interviews were recorded with the informants’ permission except for three, for which only notes were taken. Each interview was transcribed verbatim immediately. A deeper understanding of the concept was obtained following several times of careful reading of the transcripts and the key concepts were identified. Categorization was performed based on the relevance to the context, observed reactions, and outcome. In this research, conventional content analysis has been used; it is generally used to shed light on less studied phenomena that lack a theoretical framework.[14] Considering data saturation, interviews were continued until no new code or category emerged.[15] For code extraction, two researchers independently analyzed the interviews and it increased the validity of the extracted codes.[16] The initial codes were merged based on their similarities and differences. Thereafter, larger categories were formed at each stage until the final categories were obtained.[17] Prolonged engagement with the data led to frequent review of the transcripts and immersion in the data, along with peer debriefing with 3 women who had the same experience and helped the researcher to get the trustworthiness. Moreover, all three members of the research team followed up the process of coding and reached a consensus about the final codes and categories. The codes and categories were also distributed among ten participants to ensure their agreement about the extracted categories and to see whether they were able to find characteristics of their own lives in the categories. Credibility was boosted through member checking, validation of emerging themes in upcoming participant interviews, and debriefing with expert supervisors. Prolonged engagement with participants and maximum variation of sampling were used for validation and credibility of data. Verifiability or objectivity is obtained once other researchers can clearly follow the path of research and measures are taken by the researcher. Transferability in this study indicates that the findings resulting from the data can be transferred to other groups with similar terms and conditions. Conformability, which refers to the extent to which the findings of a study are shaped by the respondents and not researcher bias, motivation, or interest, was achieved by audit trails strategy. Moreover, dependability was achieved by using external edit. It shows that the findings are stable and consistent over the times and the results could be repeated when the same data collection method has been used.[15-17]

RESULTS

A total of 24 women were interviewed (Table 1). According to the results of the analysis, five categories emerged which seems to be related to the self-immolation in the women participating in this study: Not having control over personal life, marital conflicts, seeking attention, instilling guilt in the family members, and resentment towards male dominant community (Table 2).

Table 1

The Participants’ Demographics Characteristics

Demographic Variables	No. of Participants
Age
21-25	12
26- 30	4
31-35	2
36- 40	4
41- 45	2
Marital Status
Married	14
Single	10
Education Level
Illiterate	14
Primary School	7
High School	3
Employment Status
Employed	10
Unemployed	14
Place of Living
Urban	9
Rural	15
Duration After burn (Year)
0-3	7
4-6	8
7-10	9
Duration of Interview (Minuets)
<40	1
40-50	9
>50	14
Total	24

Table 2

Categories and Subcategories of Self-Immolation in Young Kurdish Iraqi Women

Categories	Subcategories
1) Not having control over personal life	A: Undue strictness of their parents and family
	B: Looking for independency
2) Marital conflicts	A: Socio-economic problems
	B: Forced/ arranged marriage
3) Seeking attention	A: Feeling lonely in various stages of their life
	B: Painful experiences in childhood
4) Instilling guilt in the family members	A: Anger towards one self, God and others
	B: Sense of inadequacy
5) Resentment towards male dominant community	A: Sense of hatred towards life
	B: Disappointment versus revenge

1. Not having control over personal life has been mentioned by many of the participants.

1. A: According to interviews, undue strictness of their parents and family was one of the main problems they faced in their lives and believed that it was related to their willingness for self-immolation attempt.

“Despite being 26, my family still impose strict rules on me, especially my brother and father take care of my personal plans. I can’t go anywhere alone and must always have someone to go with me”(P 6).

A number of the participating women noted their parents’ disagreement with their pursuit of university education and even rejection of their suitors and their determination to make decisions about their daughter’s marriage.

“My family was against me pursuing my education. They rejected my suitor and made me do the house work. I’d sometimes thought to myself, how do I put an end to it all?” (P 9).

1. B: Looking for independence was among other issues addressed by our participants. They did not have the right to decide for themselves in their daily problems and like everything else in their life, men preserved this right for themselves. Their mind was constantly preoccupied with thoughts like ‘Will they stop me and my decision from going through?’ The participants merely wanted to have the right to choose for themselves and to have control over their own life, and by their attempt at self-immolation, they merely wanted others to understand that they were tired of not having control over their own life.

“Unlike my brother, I don’t have the right to be friends with just anyone I like and see them whenever I want to, because our family traditions do not allow this; I am afraid I might shame them”(P 18 ).

2. Marital conflicts

2. A: Traditional and forced marriages, infertility and remarriage of the spouse or polygamy.

2. B: Socio-economic problems were addressed by participants in their interviews. They wanted to escape from forced marriage, maltreatments by the husband and his family and the husband’s threat of remarrying due to infertility.

“I have been tortured by my husband’s interfering family for not being able to bear a child; they encouraged my husband to re-marry, so that they could have a grandchild”(P 13).

3. Seeking attention was one of the main findings in their interviews. Feeling that they were not valued by their family and that no one had any time for them or cared about their existence, they were left with no choice other than attempting self-immolation.

3. A and B: Feeling lonely in various stages of their life and painful experiences during childhood have been noted by many participants.

“I was not important to anyone. I had no one to confide in. My father was there, but he never felt my presence because of my stepmother. I was always alone. I can’t remember much else, until one day, I decided to do this” (P 11).

4. Instilling guilt in the family members was another important category in this research.

4. A and B: Anger towards oneself, God and others and a sense of inadequacy was expressed by many participants. They explained that, through their self-immolation attempt, they perhaps wanted to make others feel guilty, especially the controlling members of their family or society. They felt that they had to prove it to the family and community that they were not happy with being controlled by others.

“I was quarreling with God, so I did this to send a message from myself and others like me, and to make my family feel guilty”(P18).

5. Resentment towards male dominant community was the last category in this study.

5. A and B: Feelings like sense of hatred toward life and disappointment versus revenge emerged from the data analysis. Their self-immolation was in fact a cry for help. Most of the participants said angrily that men in their family believed that women had to obey with no protest.

“Although I always stayed at home and helped my mother with the house chores, I was faced with my brother’s great disagreement and meddling when I asked for a cell phone and we had a great fight”(P5).

DISCUSSION

Based on the analysis in this study, lack of control over personal life, marital conflicts, seeking attention, instilling guilt in the family members and resentment towards male dominant community have been considered as the main categories.

According to the results, most of the participants who attempted self-immolation were married, which is consistent with the results obtained by some other studies.[11,18,19]

Differences in interests, violence and the undue strictness of the husband and family were some of the main complains of the participants for their self-immolation attempts that pertained to the two first categories of the research which were not having control over personal life and marital conflicts. They expressed their disappointment and anger about always being ordered around by their husbands and family and having to comply without saying a word and not being respected by their husbands and family for their opinions. These women did not know what strategy to adopt to remove these problems. No single factor is sufficient to explain why a person died by suicide, however, the inability to realize one’s dreams, such as dreams of continuing school and pursuing university education and the effects of adverse childhood factors tend to be interrelated and correlated, and act cumulatively to increase risks of suicide and put these women under much pressure so that they may prefer to die with an anxious heart.[5,20]

Some participants revealed that they chose to do self-immolation to get rid of marital conflicts. Issues like traditional and forced marriage, infertility, the husband’s remarrying (polygamy) and the large age gap between the couple, especially in rural and nomadic areas, have been noted by many women. Infertility and encouragement of the husband by his family to remarry in order to have a child appear to have caused the inability of these women to solve their problems. Studies conducted in India also report marital conflicts as a facilitator of self-immolation.[21]

They referred to their experience about physical and emotional abuse. Domestic violence is considered a personal problem in many third-world countries where men own their women. Such behaviors are not considered a crime in these societies and the law does not protect women against them. The psychological and physical pressure of raising several children with a husband who has several wives are probably the main causes of violence. Studies conducted by World Health Organization show similar results.[22]

Previous studies have reported economic problems as a sub-category of marital conflicts that comprise the main reason for self-immolation in many less-developed countries.[23,24] As to seeking attention, self-immolation appears to be a way of venting out anger and showing protest in this group. Based on the interviews, they tried to seek others’ attention and send them a persuasive message. By using the bravado of fire, they want to voice their complaints, so that those who have shut their eyes and ears and ignored them for so many years can hear what they have to say; these women may intend to affect a greater change in their surroundings and their own life may seem rather insignificant in the face of this great purpose.[25,26]

Another emerged was creating a sense of guilt in the family members for category subjecting women to inequalities and endless control. Sex discrimination and inequalities were evident in the words of these women. In their view, society imposes unbearable limitations on women, while it leaves men free to achieve their goals and meet their needs.[25] Ignoring the personal and social rights of women in some societies, especially in rural ones, due to their dominant culture, is likely to lead to such consequences as mental problems and depression, thus forcing women toward self-immolation as the only way out of these problems.[1]

Based on the interviews, they wanted to open the eyes of those who have denied them of their rights and want to make them understand their demands. In seeking the right to control their own life, these women are forced to attempt self-immolation due to their inability to solve their problems and their little power and poor reactions.[25,27]

The fifth category emerged in this study was resentment towards male dominant community. Most Kurdish women’s rights activists believe that, in these regions, self-immolation and suicide are a kind of protest against the male-dominated society and the discriminations and limitations imposed by the father, brothers, and the husband’s family. Women enjoy far less freedom of choice and action than men. It seems that recent social developments and changes have increased the women’s expectations and in turn made men more defensive, as they wish to preserve their traditional male-dominated society.[25]

Going to the hard-to-rich rural areas was one of the strengths of this study. In fact, the culture in rural areas is still the dominant culture in Kurdistan, and the most self-immolation cases occur in these rural areas. The study achieved to bring the voice of these suffering women to the attention of decision-makers. It seems that increasing awareness among different sectors of society is one of the most important plans for officials. The findings of this study may cause incentive towards adopting methods to prevent reoccurrence of such events. The education of men about women’s equal rights from childhood can be an appropriate and effective way. On the other hand, empowering women to learn about appropriate problem-solving techniques increases their self-esteem, develops their sense of independence, and can have a good protective effect on these women.

One of the limitations of this study was the participants’ fear of their husbands; in order to overcome this problem, the researcher had a secluded meeting with the husbands and important family members before conducting the interviews.

CONCLUSION

The present study demonstrated that self-immolation is a major psychiatric health issue in Iraqi Kurdistan. The findings of this study revealed that the culture of the Kurdish society is male-dominated in which spouses, fathers and brothers have the primary responsibility for making decisions for women. It appeared that men’s control over women and limitations imposed by them have angered the women and perhaps might have acted like a spark for them to have inappropriate reactions such as self-immolation.

It is suggested that in future quantitative interventional studies should be conducted based on the results of the present study, aiming at preventing suicidal attempts among vulnerable women.