I Would Rather Just Go Through With It Than Be Called A Wussy-an Exploration Of How A Group Of Young South African Men Think And Talk About Suicide.pdf

568183 research-article2015

JMHXXX10.1177/1557988314568183American Journal of Men’s HealthMeissner et al.

Article

I Would Rather Just Go Through With It Than Be Called a Wussy: An Exploration of How a Group of Young South African Men Think and Talk About Suicide

American Journal of Men’s Health 2016, Vol. 10(4) 338­–348 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1557988314568183 ajmh.sagepub.com

Birte Meissner, M.Sc1, Jason Bantjes, D Litt et Phil1, and Ashraf Kagee, PhD1

Abstract Worldwide suicide is a deeply gendered phenomenon. In South Africa, approximately 80% of suicide completers are male. This study aimed to investigate how a group of young South African men understand and think about suicidal behavior. In-depth semistructured interviews and thematic analysis using a grounded theory approach revealed that this group of young South African men had permissive attitudes to suicide and viewed suicide as a morally defensible alternative in specific situations. They spoke of suicide as a goal-directed behavior that provides a means of regaining control, asserting power, communicating, and rendering oneself visible. From this perspective, suicide was understood as a brave act requiring strength and determination. These data have congruence with the Theory of Gender and Health, which proposes that constructions of masculinity may be implicated in the attitudes and beliefs young men in South Africa hold toward suicide. Keywords attitudes, beliefs, suicide, men, masculinity, South Africa

Introduction In most countries, suicide is a deeply gendered phenomenon (World Health Organization, 2007). In South Africa, 80% of completed suicides are male but little is known about the reasons for this disproportionate gender distribution, or the extent to which attitudes and beliefs about suicide among men in the country are implicated in this pattern of behavior (Bantjes & Kagee, 2013). A large body of literature in health psychology has identified that the status of men’s health is influenced by gender norms and the attitudes, beliefs, and behaviors adopted by males (Courtenay, 2003; de Visser & Smith, 2006; de Visser, Smith, & McDonnell, 2009; Galdas, Cheater, & Marshall, 2005; Tyler & Williams, 2013). These findings support the assertion that among the reasons for the highly skewed gender distribution of suicides in South Africa are factors such as gender differences in attitudes toward suicide and dominant ideals about masculinity and manhood—what has come to be called hegemonic masculinity (Cleary, 2012; Connell, 2000; Connell & Messerschmidt, 2005). These findings also raise important questions about how suicide is socially constructed in South Africa and what attitudes and beliefs men hold about suicide. This article reports on an exploratory qualitative investigation into the ways in which a group of young men in South Africa

understand and make sense of male suicidal behavior. The findings, which are discussed within the framework of the theory of gender and health proposed by Courtenay (2000), have implications for future research which seeks to understand the sociocultural and cognitive factors that influence suicidal behavior among men.

Literature Review Theoretical support for the idea that cognitive processes play a role in the etiology of suicide can be found in the Integrative Motivational Volitional (IMV) model of suicide (O’Connor, 2011), which explicitly identifies attitudes and perceived social norms as mediators that account for the progression from defeat/humiliation to suicidal behavior. There is also empirical evidence that attitudes and beliefs are an important mediator of suicidal behavior. Gibb, Andover, and Beach (2006), for example, report that attitudes to suicide act as a moderating 1

Department of Psychology, Stellenbosch University, Stellenbosch, South Africa Corresponding Author: Jason Bantjes, Department of Psychology, Stellenbosch University, Private Bag X1, Matieland 7602, South Africa. Email: [email protected]

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Meissner et al. variable between suicidal ideation and symptoms of hopelessness and depression in men. Evidence suggests that individuals who complete suicide hold far more permissive attitudes toward suicidal behavior than individuals who do not (Arnautovska & Grad, 2010; Bayet, 1922; Jukkala & Mäkinen, 2011; Salander Renberg, Hjelmeland, & Koposov, 2008; Salander Renberg & Jacobsson, 2003; Zemaitiene & Zaborskis, 2005), suggesting that at an individual level there is a positive relationship between suicide and permissive attitudes toward suicide (Eskin, Voracek, Stieger, & Altinyazar, 2011; McAuliffe, Corcoran, Keely, & Perry, 2003). It has, however, been reported that aggregate rates of suicide within a country decline as general attitudes toward suicide become more tolerant (Salander Renberg & Jacobsson, 2003). This apparent contradiction is accounted for by the stigma hypothesis (Eskin, 1995), which asserts that suicidal individuals are less likely to seek help for fear of stigmatization in societies where there are widely held negative attitudes toward suicide. However, if attitudes toward suicide are generally permissive, then individuals are more inclined to engage in suicidal behavior (Eskin et al., 2011). Platt (1989) has also suggested that intolerant and hostile cultural attitudes toward suicide may prompt some individuals to engage in overt suicidal behavior as an act of defiance and as a means of prompting a strong reaction from others. Studies suggest that younger generations, unlike older generations, do not view suicide in moral or religious terms and instead frame suicide as an individual right (Curtis, 2010; Miller, Segal, & Coolidge, 2001), although there are exceptions that suggest that elderly individuals hold more permissive attitudes to suicide than the youth (Segal, Mincic, Coolidge, & O’Riley, 2004). Scholars postulate that more accepting attitudes toward suicide among young people have contributed to the dramatic increase in youth suicides over the past half century (Arnautovska & Grad, 2010; Bagley & Ramsay, 1989; Boldt, 1988). Evidence suggests gender differences in attitudes toward suicide, with women being less accepting of suicidal behavior than men and men being more inclined to view suicide as an individual right than women (Dahlen & Canetto, 2002; Mueller & Waas, 2002). Men also seem to express more empathetic attitudes and exhibit less judgment toward individuals who complete suicide regardless of the precipitating factors (Dahlen & Canetto, 2002). Research suggests that the gender of the person engaging in suicidal behavior influences how others appraise the act. Linehan (1973), for example, reported that men who attempted but did not complete suicide were more stigmatized than women who engaged in the same behavior, presumably because suicide is often judged to be a masculine act while attempted suicide is seen as feminine (Canetto, 1997; Lester, 1995).

Cross-cultural studies have reported the contextual nature of attitudes toward suicide and have demonstrated the influence of sociocultural norms and religious beliefs on how people understand suicide (Salander Renberg et al., 2008). For example, Hjelmeland et al. (2006) employed the Attitudes Towards Suicide Questionnaire to compare students from Norway and Uganda, with exploratory and confirmatory factor analysis revealing different factor structures between the two groups. Similarly, Lester and Akande (1998) reported that Nigerian students were more inclined than Zambian students to view suicide as a mental illness and a cry for help while Zambian students were more tolerant and accepting of suicide than Nigerian students. Eshun (2003) reported that Ghanaian students have significantly more negative attitudes toward suicide than American students. A number of other studies have used the Suicide Opinion Questionnaire to identify significant differences in attitudes toward suicide in different countries (Colucci & Martin, 2007a, 2007b; Domino & Groth, 1997; Lester & Akande, 1994; Lester & Icli, 1990). The majority of cross-cultural studies on attitudes toward suicide are quantitative (Colucci & Martin, 2007a, 2007b) and have simply described differences in attitudes without illuminating the underlying reasons for these differences. This paucity has prompted calls for qualitative work to explore the reasoning behind the attitudes so that they might be understood and contextualized (Eshun, 2003; Hjelmeland & Knizek, 2010). Much of the work on attitudes and beliefs toward suicide come from high-income countries, with comparatively fewer studies exploring how people living in developing countries think about suicide (Patel & Kleinman, 2003; Vijayakumar, Nagaraj, Pirkis, & Whiteford, 2005). The handful of studies conducted in sub-Saharan Africa suggest a predominantly negative attitude toward suicide (Adinkrah, 2012; Eshun, 2003; Lester & Akande, 1994; Osafo, Hjelmeland, Akotia, & Knizek, 2011b), with religious beliefs and communal morality reported to be the key determinants of attitudes toward suicide (Hjelmeland et al., 2008; Knizek, Kinyanda, Owens, & Hjelmeland, 2011; Osafo, Hjelmeland, Akotia, & Knizek, 2011a, 2011b; Peltzer, Cherian, & Cherian, 1998). Only two published studies report on attitudes to suicide in South Africa, both of which focus on high school students and describe the pattern of attitudes without exploring the underlying cognitive processes or cultural contexts that determine these attitudes. Mayekiso (1995) reported that while secondary school students in Umtata, South Africa, generally disapproved of suicide, more than a third of students indicated that suicide was acceptable under certain circumstances, such as parent death, divorce, and loss of contact with parents, chronic physical illness, unresolved problems, and love–relationship

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problems. A quantitative investigation of attitudes toward suicide among Black high school students (n = 100) in Umtata, South Africa, reported a strong negative attitude toward suicide with participants expressing a belief that concern about the impact of suicide on the family is a barrier to suicide (Mayekiso, 2010). The aim of the present study was to investigate how young South Africa men think about suicide and elucidate the beliefs and attitudes they hold toward suicidal behavior.

Method Purposeful sampling was used to recruit males between the ages of 18 and 25 years enrolled in the final year of their undergraduate degree at a university in the Western Cape, South Africa. Emails were sent to male students enrolled in third-year psychology and physiology courses (n = 241), inviting them to participate in an interview exploring attitudes and beliefs about suicidal behavior. The authors chose to recruit from these two classes because there are students from all faculties (including arts, social sciences, science, medicine, and commerce) enrolled for these subjects. A meal voucher of ZAR40 (the equivalent of approximately US$3.60) was offered as an incentive to take part in the study. A second wave of email invitations to participate in the study was sent out 1 week later. The intention was to repeat this process by emailing other groups of male students enrolled at the university and to recruit to saturation. Initially 15 students responded to the email (8 from the third-year psychology course and 7 from the third-year physiology course), yielding a 6.2% response rate. Subsequently two participants withdrew from the study citing a high academic workload as a reason. Interviews were conducted with the 13 participants, and following analysis of these interviews, the authors decided not to recruit further as no new themes were emerging. The participants were all between the ages of 20 and 25 years, with a mean age of 22 years. Four participants disclosed having attempted suicide once previously, five participants reported past episodes of suicidal ideation, and four participants reported no history of suicidal behavior. None of the participants expressed acute suicidal ideation or intention at the time of the interviews. The sample was ethnically diverse; seven participants were White, four participants were Colored, and two participants were Black. Six participants reported their home language to be English, four Afrikaans, one Xitsonga, one Sesotho, and one English/Afrikaans bilingual. Almost all participants were Christian, except one who reported being agnostic and two who reported being atheists. Three participants self-identified as gay. The interviews were semistructured and based on an interview schedule that was designed to elicit information

about previous experience of suicide, how participants make sense of and understand suicidal behavior among men, and attitudes toward suicide. Participants were also asked to share their opinions in response to four vignettes that described various situations in which males engaged in suicidal behavior (i.e., suicide in response to academic pressure, unemployment, relationship problems, and mental illness). Interviews lasted between 90 and 120 minutes. During the interviews, participants expressed a number of perceived group norms based on their understanding of young South African men and their perceptions of why men engage in suicidal behavior. The nine participants with a history of suicidal behavior spoke about their personal experience and shared insights into how they thought about and made sense of their own suicidality. The data are thus a mix of personally expressed attitudes and beliefs and perceptions of social norms for men in the country. Interviews, which were audio recorded and transcribed, were conducted by the first author (a White female postgraduate student in her mid-20s). Data were analyzed using thematic analysis, following the process of encoding data as outlined by Braun and Clarke (2006). The process was data-driven, and once themes emerged, the theoretical implications of the findings were considered. This grounded theory approach enabled us to identify congruence between the current findings and the theory of gender and health proposed by Courtenay (2000). Ethical and institutional permission to conduct this research was obtained. Participants signed an informed consent form and were given the option of withdrawing at any time. Data were kept confidential and the privacy of the participants was protected. It is a significant limitation of this study that participants were only recruited from two academic departments of the university. This article thus gives voice to a group of young men from a particular subsection of South African society, which cannot said to be representative of all young men in the country. Nonetheless the findings provide useful insights into how some young men in South Africa talk and think about suicide and could serve as a basis for future work of this kind focusing on other groups of men in the country.

Findings Most participants expressed a permissive attitude toward suicide and articulated a belief that suicide is a personal choice and individual right. They stated that individuals should be free to exercise choice over ending their lives without moral judgment or legal consequences. Implicitly, participants indicated that they valued individual freedom and autonomy.

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Meissner et al. I think you have a choice. . . . He (God) gave us one thing: Choice. The reason why we have right and wrong is choice. . . . And there is no one to blame but you, because you choose that (suicide). (Julien)

Participants expressed a perception that individuals have the power to choose not to kill themselves, implying that individuals (having personal power, agency and autonomy) are responsible for their own suicides. Yes, like many times I was in deep depression and I would be like in my room, my door closed and everything is dark, I would just sit there . . . then I would just think about everything and how I would die and could die and who will miss me and all of that. So I kinda had this self-pity and then I realized many times it’s just that single moment of choice. I just got to choose to open my window, put on the light, make up my bed and just play with my dogs for a couple of moments and then I feel better. (Nico)

Participants stated that they believed that men are justified in completing suicide when they are in severe physical pain or suffering from a severe physical illness. Gerhard, for example, asserted that “it is ok for people to be put out of misery if pain is the reason”; he then went on to say that suicide would be a justified response to severe physical illness. Participants also stated that suicide was justified when a person did not have a support system or lived in a situation where there was no one to mourn their death. It (deciding to kill myself) was a very easy choice to make in terms of no one is ’gonna miss me when I am gone. (Julien)

Although most participants affirmed the right of an individual to choose suicide, they acknowledged that people are relational beings who have a responsibility toward others. I do think that everyone has their own choice to take their life, but morally again it is not fair on the people that you leave behind, I think. You know, because you are basically stealing yourself or stealing from them as well, because there is some sort of connection or relation to you. So you are not a being unto yourself only, but you are a being of somebody else as well and you steal from them if you take your own life. (Gerhard)

All participants expressed a belief that suicide should and could often be prevented. Furthermore, they stated that men usually signaled their desire to die via a range of verbal and nonverbal cues (e.g., withdrawing and isolating themselves) and engaging in self-destructive behaviors (such as substance abuse and self-mutilation). Participants also expressed a belief that suicidal individuals sometimes concealed their desire to die and that suicide could be an

impulsive act. Implicit in this perception is the belief that not all suicides are preventable. These views appear to underline the young men’s conviction that individuals are responsible for their own lives and are responsible for seeking help and communicating distress. Many participants stated that it would be difficult for them to complete suicide and most said they would be too scared to enact a suicide plan. Their impression was that the will to live was strong and that considerable force, strength, and determination are required to end a life. In this context, participants articulated a belief that to complete suicide is an act of bravery, requiring courage, strength and resolution. Men, we can’t cry and we can’t talk about our feelings and sometimes they just feel like . . . we rather go through with it [suicide] . . . because we don’t wanna be labelled as a “wussy” (someone who is weak, vulnerable or frightened) . . . ja, rather just go through with it. (Sam)

Several participants expressed a perception that suicide is a goal-directed behavior carried out by men, who, as rational beings, make logical decisions about life and death. So it kind of gets into a pro’s and con’s factor thing, you know. So if I do live, and if I don’t. So you weigh these things and you are just actively seeking a reason. (Gerhard) I think (people complete suicide) mainly when the reason for not living outweighs the reason for living. (Henrich)

Framing suicide as a conscious choice and goaldirected behavior implies that individuals engage in suicidal behavior with specific motives and an implicit desire to achieve a particular outcome or wished-for-state. Participants articulated a number of motives which they perceived to underlie men’s suicidal behavior, including escape-orientated motives, existential motives, interpersonal/communication motives, and identity motives. Many participants shared a perception that suicidal behavior was motivated by a desire to escape an unbearable situation. Suicide was thus understood to be the result of escape-orientated motives within situations in which there is no other perceived way out. . . . that you think to yourself, “I can’t handle it. I just want it to go away.” I’ll do anything to let it go away. (Christo) . . . for them (suicidal individuals) the only way out is death, not be around to deal with it anymore. (Heinrich)

Other participants associated this desire to escape with the experience of being trapped, stuck, suffocated, and restricted. Allied to this, some participants echoed

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Baumeister’s (1990) idea that suicide was motivated by a desire to escape painful self-awareness and uncomfortable feelings.

seeing me as a person with feelings. Ja, that is why I stopped (trying to ill myself). I don’t have (suicidal) tendencies any longer.

I think it is more of the emotions, the pressure and the stress that you feel . . . that you think to yourself, I can’t handle it, I just want it to go away. (Michael)

Participants identified particular interpersonal motives for engaging in suicidal behavior. These included a desire to communicate distress to others, wishing to hurt others, seeking to control the behavior of others, and attempting to elicit sympathy. Participants said that suicide had a communicative function and that they engaged in suicidal behavior as an interpersonal strategy in extreme situations where other forms of communication are perceived to be inadequate or inappropriate.

Some participants expressed a perception that suicidal behavior is motivated by a desire to sleep and hence end awareness rather than a conscious wish to be dead. . . . to understand suicide I realised that it is not that one would pursue death, you don’t get to a point. No one pursues death. For some strange reason the will to live is greater than the will to die. And when you have those thoughts, the will to live is greater, it really is. . . . It’s not that I want to die, it’s just that you want to be able to just switch off and if you weren’t to wake up again it’s ok. (Richard)

Some participants stated that they believed that men engaged in suicidal behavior as a way of regaining control or asserting power. These can be understood as existential motives which direct a person toward suicidal behavior with the desire to feel strong and in control, particularly when one is feeling powerless, marginalized, or invisible. Michael, for example, described how his own suicidal behavior was motivated by a desire to assert control over his life in response to feeling disempowered by growing up in a home where his behavior was tightly regulated. Growing up in a house where rules are rules, you know there is no going back and forth, it’s just rules and being in the house felt like you are being suffocated, it felt like you are being watched . . . that is why I felt trapped. I couldn’t express myself.

Participants identified the experience of being marginalized and feeling invisible as an important cause of suicide. They stated that some individuals engaged in suicidal behavior paradoxically as a means of asserting their existence and rendering themselves visible. Themba, for example, attributed his own suicidal behavior to feeling insignificant because “nobody cares,” which led him to conclude, “It’s best if I just take my life.” He described how this feeling of being invisible was a result of his experience of emotional neglect as a child. He said attempting suicide was a means of compelling others to take note and “see” him. Similarly, Michael described how his own suicidal behavior was curtailed by his experience of not being seen and having his emotions witnessed: . . . like people started believing in me and actually seeing who I really am, not just the “emo” kid. . . . People start

I needed attention because nobody saw my pain, probably also because of my shame. I wanted somebody to see my pain. I don’t know who. I probably wanted everyone to see. (Nico)

Participants shared a perception that some young men engaged in suicidal behavior with the intention of affirming a particular identity or identifying with a subculture, as a way of affirming a rebellious or adventurous identity: Obviously teenagers are gonna talk about it, always pushing the boundaries, being a bit rebellious, you know. You see it as something that’s exciting, but something that definitely got a taboo to it. And anything that is generally a taboo, people are generally very interested by it. (Heinrich)

Similarly, Michael stated that as a teenager he was part of a group of friends who were curious about death. This peer group shared an explicit goal, that is, to find out what it means to die. Michael explained that the group culture precipitated acts of deliberate self-harm among all the group members, contributed to his own suicide attempt, and led to the completed suicide of his best friend. All participants expressed the view that young South African men were under pressure to conform to rigid, narrow, restrictive, and traditional gender norms. Their perception was that in order to achieve manhood, men were required to perform (achieve success), provide for and protect their families, demonstrate strength, retain control, conceal vulnerability, and affirm heterosexuality. The participants believe that failure to conform to these hegemonic ideals of masculinity is chief among the reasons why men in the country engaged in suicidal behavior. If you are 30 or 40, you have to have kids, you need to buy your wife a brand new house and you have all these expectations from society itself. . . . From 18 to let’s say 25 you are under so much pressure. You are starting your

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Meissner et al. tertiary education and you need to start looking at future plans. You have your girlfriend and you know that you need to now start finishing up and then you need to buy a home and you need to start fulfilling your roles now. So you are under a lot of pressure at that stage in terms of what you gonna do with your life, because you wanna start your life. That pressure could obviously lead to suicide if you can’t fulfil those things in due time. (Michael)

Many participants described their experience of feeling under pressure to perform and achieve success. They attributed suicidal behavior to the experience of failure. Jack, for example, described how his own attempted suicide was precipitated by poor academic performance. You suddenly just become a failure. . . . The one night after an exam, I went for a drive with my car. It was late at night and it was raining and all the rest . . . I’ve decided . . . what if no one ever had to know how big of a f-up I am . . . what if no one ever had to figure out, you know. I decided to try to roll my car, but it didn’t work. (Jack)

Participants’ subjective experience was that group norms in South Africa prescribe that men should restrict their displays of emotion, silence their fears, and hide their sadness. They noted that the requirement to suffer in silence was particularly marked in relation to expressing emotions in the company of other men. A lot of men will not want to go and express their emotions for fear of being stigmatized as homosexual. (James) I think men are more likely to commit suicide than women because there is also an attitude or a culture that I’ve experienced where men are not as expressive as woman . . . it’s considered demasculinating (sic) for a man to express insecurity, to express failure, to express fear. (Richard)

Participants stated that many young South African men were reluctant to access support because doing so amounted to admitting they had lost control and were unable to solve their problems on their own. They stated that accepting help was a threat to their independence and autonomy. Men always feel that they have to be strong and they have to sort of carry the weight and just shrug it off and keep going. (Heinrich)

Participants stated that it was difficult for others to detect when men were at risk of suicide because males were practiced at concealing their distress and vulnerability. Their perception was that the need to maintain the appearance of being in control and of coping prevented men from accessing help and hence placed them at risk of suicide.

Participants noted that instead of seeking help, men who were distressed withdrew and isolated themselves, ignored and denied their problems or engaged in other self-destructive behaviors, such as excessively using alcohol and drugs, engaging in risk-taking behavior, or behaving aggressively and violently. Their perception was that these self-destructive responses to psychological distress were socially sanctioned ways for men to discharge conflicted emotions. Many participants expressed a perception that masculinity was equated with heterosexuality and that gay young men in South Africa were stigmatized as feminine, which is to say that they are less than a man. Participants attributed suicidal behavior to this experience. For example, Jack, a gay participant, described his perception that many suicides are caused by the experience of gay men not feeling free to be authentic within a society that restricts the behavior of men. Similarly, Nico described his perception that suicides may be the result of gay young men in South Africa feeling disconnected and under pressure to conform to gender norms. Ok, I recently came out of the closet and I think that is the thing that you probably see in your research as well, especially gays is committing suicide a lot. . . . That is probably a reason why guys also commit suicide (because) they can’t be the man they want to be in terms of maybe wanting to be a bit softer, or maybe I want to be expressing myself more in this way or that way. (Jack) Another big example [for why men commit suicide] would be young White Afrikaans males who are homosexual, having nowhere to go and not being able to come out to their parents. They have nowhere else to go because of all the pressure put on them (to conform to masculine ideals). (Nico)

Discussion The young men who participated in this study expressed a permissive attitude to suicide and argued that it is a personal choice. Participants viewed suicide as a legitimate way for men to deal with conflicted feelings (such as shame, loss, or vulnerability), particularly when these feelings were elicited by the experience of not living up to societal expectations. Nonetheless, they also stated that suicide was not justified when one’s death would cause suffering to others. They affirmed autonomy and independence while simultaneously acknowledging the need to honor obligations to others. The group as a whole viewed suicide as a brave act requiring resolution and strength. They described suicide in nonpsychiatric terms, positioning men who die by suicide not as mentally ill victims but rather as rational and resolute beings who exercised agency by logically

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deciding to utilize suicide to achieve a particular goal. For them, suicide was a tool that could be employed to escape, assert power, regain control, affirm existence, express an identity, and communicate with others. The way they spoke about suicide reflected their belief that men are rational beings who can exercise agency, bravery, and strength by completing suicide. Most of the sample said that they did not believe they would be able to kill themselves because suicide is a difficult act to perform. On the one hand, the perception that it is difficult to complete suicide, and their assertion that they did not believe they had the courage to kill themselves, appeared to be protective factors. On the other hand, paradoxically, because it is framed as “difficult” and “challenging,” suicide may represent an effective way for these young men to re-empower themselves when feeling impotent or marginalized. Participants indicated that clear and rigid social norms dictated and regulated the behavior of young men in South Africa. This finding is consistent with a number of other studies that describe a hegemonic masculinity among young South African men characterized by ideals of autonomy, power, control, heterosexuality, and achievement (Hearn & Morrell, 2012; Ratele, 2001, 2006; Walker, 2006). The young men in this study showed an acute awareness of these perceived gender norms, which they experienced as societal expectations. Their perception was that failure to conform to these norms precipitated feelings of shame and guilt, social exclusion, impotence, and isolation. Within this context, suicide represented an apparent logical solution by providing a way to re-empower oneself and escape difficult feelings associated with being isolated or shunned by society. Such feelings could also make it easier to complete suicide, as feeling rejected by and disconnected from society would presumably discharge any sense of social obligation to stay alive. There appears to be a paradox in the way these men talk about masculinity. On the one hand, they asserted that conforming to hegemonic ideals of masculinity requires them to adopt behaviors that make it difficult to access support or express fear, pain, and vulnerability. In contrast, they said that not conforming to these perceived gender norms liberated them to express emotions and access support, yet such a stance positioned them on the outside, socially disconnected, and at risk of being stigmatized and shamed for not conforming to gender norms and perceived societal expectations. The participants expressed a range of beliefs and attitudes toward suicide that demonstrate that they viewed suicide as a behavior that could be employed in the service of denying weakness or vulnerability and asserting control, strength, and bravery. Suicide represented a way of being strong and robust while dismissing any need for

help, care, or support. It is as if, for these young men, suicide is a way of “doing gender”; a way to demonstrate hegemonic masculinity while compromising personal well-being. As Saltonstall (1993) has noted, gender is in part performed through the way one “does health” (p. 12). This finding is consistent with previous studies on gender and suicide conducted in developed western countries (Canetto, 1992, 1997; Canetto & Sakinofsky, 1998). The finding that this group of young South African men hold attitudes and beliefs that place them at risk of engaging in suicidal behavior is congruent with a large body of literature that reports that in developed countries men are more likely than women to adopt beliefs and behaviors that compromise their health, while simultaneously being less inclined than women to engage in behaviors that promote longevity and well-being (Brown & McCreedy, 1986; Brownhill et al., 2005; Canetto & Cleary, 2012; Cato & Canetto, 2003; Courtenay, 2003; Houle, Mishara, & Chagnon, 2008; Kandrack, Grant, & Segall, 1991; Lonnquist, Weiss, & Larsen, 1992; Mechanic & Cleary, 1980; Oliffe et al., 2012; Patrick, Covin, Fulop, Calfas, & Lovato, 1997; Payne et al., 2008; Ratner, Bottorff, Johnson, & Hayduk, 1994; Robertson, 2007 ; Rossi, 1992; Sayers, 2010 ; Walker, Volkan, Sechrist, & Pender, 1988 ). Likewise there is a growing body of literature from South Africa that identifies how constructions of masculinities compromise the health and well-being of men (Barker & Ricardo, 2005; Jewkes, Morrell, Sikweyiya, Dunkle, & Penn-Kekana, 2012a, 2012b). Courtenay (2000) has offered a theory of gender and health as a conceptual framework for understanding the relationship between constructions of masculinity and men’s health behaviors and beliefs. Crafted from a social constructionist and feminist perspective, the theory of gender and health proposes that men adopt a range of health-related beliefs and behaviors to perform masculinities. The health-related behaviors and beliefs regarded as masculine in any society are embedded in social interactions, cultural practices, rituals, social norms, and institutional structures (Courtenay, 2000). Performing these health-related behaviors and beliefs is a micropolitical act in the sense that these performances demarcate a boundary between “masculine” and “feminine,” help maintain a particular social order, and preserve men’s privileged position as the “stronger sex” (Courtenay, 2000). As with all behaviors associated with hegemonic masculinity, the health-related behaviors regarded as masculine within any social group are a function of factors such as ethnicity, economic status, educational level, sexual orientation, and context (Connell, 2000; Courtenay, 2000). Within the theory of gender and health, males, far from being passive victims of their biology or slaves to culturally prescribed roles,

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Meissner et al. are active participants who engage in a dialectical process of constructing and reconstructing dominant norms of masculinity (Courtenay, 1999). This dialectical process is played out in relation to other men, to women, and to institutional structures. such as the health care system (Courtenay, 2000). Within this theory, the beliefs and attitudes articulated by the young men in the current study must be understood to be a function of a broader social and political system. Such a view prompts important questions such as: What are the social and institutional structures which help sustain and reproduce the attitudes and beliefs about suicide expressed by these men? What are the dimensions of power and social inequality that provide the context for the beliefs and attitudes expressed? How do health care workers and institutional structures (such as the health care system) participate in the social systems which create these gendered health behaviors and beliefs? Thinking about and finding answers to these questions needs to be integral to research which seeks to curb suicide in South Africa. It is important to establish how widespread the attitudes and beliefs expressed by this group of young men are among other groups of men in South Africa, as these social cognitions may have important public health implications, particularly for how mental health professionals communicate with men about suicide and respond to men seeking help with suicidal ideation. For example, if the beliefs and attitudes expressed by this group of young South African men are widely held by other men in the country then it would suggest that public health messages that frame suicide only as a symptom of mental illness may not have resonance with men who perceive suicidal behavior as a form of assertive expression. Similarly, responding to suicidal men in any way that curbs their autonomy and independence or leaves them feeling disempowered may not be effective in preventing suicides. Stressing social obligations and reestablishing connections to friends and family would seem to be an important part of reducing the likelihood of men completing suicide, provided these are not perceived by young men as a curtailment of their independence. Similarly, providing opportunities for suicidal men to reconnect to their strength, agency, and rationality may reduce the risk of their completing suicide. Furthermore, if the attitudes and beliefs expressed by this group of young men are identified to be commonly held among other young South African men, then it would suggest that public health messages about suicide targeted at young men should be aligned with the hegemonic masculine ideals of strength, power, control, rationality, and responsibility to others. Of course, it is one thing to position help-seeking as a strong, empowering health behavior, but it is quite different for the health care system to reinforce hegemonic masculinity. As noted by de Visser and McDonnell (2012)

public health messages that are aligned with hegemonic masculinity run the risk of propping up gender inequality and may thus inadvertently reinforce the social system that contributes to the problem. There are already examples of suicide prevention programs in developed countries that take account of gender differences toward suicide and help-seeking (Robinson, Braybrook, & Robertson, 2014; Robinson & Robertson, 2010). One clear example of this is the “We’re in your corner” campaign instituted by The Samaritans in the United Kingdom (Pitman, Krysinska, Osborn, & King, 2012). Consideration needs to be given to how these gender-sensitive suicide prevention programs might be adapted for the South African context.

Conclusion This study suggests that some young men in South Africa may be at increased risk of suicide because of the attitudes they hold and their perceptions of the dominant constructions of masculinity in the country. The way these young men speak about male suicidal behavior is consistent with accounts of “a crisis in masculinity” and of “threatened masculinities” described by authors such as Morrell (2001, 2002) and Walker (2006). Research is required to determine how widespread these beliefs and attitudes toward suicide are and to determine how they may be shaped by society and institutional structures such as the health care system in South Africa. This article focuses attention on the need for more work to be done exploring how constructions of masculinity influence the well-being of men in South Africa and what interventions are needed to promote men’s health. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) disclosed receipt of the following financial support for the research and/or authorship of this article: This research was partly funded by a Thuthuka Grant (Reference: TTK13070620647) from the South African National Research Foundation (NRF).

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