Addressing Suicide: National Strategy, Social Stigma & Gender Gap

A photo of Rue de Marseille in Tunis on January 21, 2022, by Ahmed Zarrouki.

Trigger Warning: This post discusses suicide. If you are in Tunisia and seeking resources or help on any of the issues discussed in this article, please scroll to the bottom of this page.*

In 1972, professor Sleim Ammar, a pioneer of Tunisian psychiatry, warned that suicide would be “a public health problem” in North Africa that would “threaten the health of its populations and the stability of its national health systems,” according to a summary of Ammar’s work. In recent years, there have been some efforts by governments and civic associations to build a more comprehensive approach to the issue, but it’s far from enough according to health volunteers and professionals Meshkal spoke with. At the same time, some indelicate media coverage of suicide incidents has contributed to copycat attempts while neglecting to explore key aspects, like the fact that a vast majority of suicides are men.

For a very brief period of time, a suicide made national headlines again on December 9, 2021, when 51-year-old Sami Essifi died after setting himself on fire at the Ennahda party’s headquarters in Tunis. Most reporting at the time focused on Essifi’s relationship with the Ennahdha party: his family and others claimed he was victim of the party with which he had once been aligned, while Ennahdha head Rached Ghannouchi said Essifi was “another martyr of the struggle to liberate Tunisia from injustice, dictatorship, corruption and marginalization, and another victim of poverty.” Yet reporting on the specifics of the case did not open the door to a broader exploration of the issue of suicide or mental health. Some coverage even failed to mention the word “suicide.”

According to some accounts, Sami Essifi was seeking help from Ennahdha in receiving financial assistance from the State, but his suicide may also be an indication that he was in need of medical assistance as well. For people suffering mental health issues in Tunisia, there are social and cultural norms that can prevent them from seeking help, particularly for men. This is in addition to the State’s inadequate provision of services and what some say is a lack of importance given to mental health and suicide prevention.

Men’s silent crisis

There were 372 cases of suicide in Tunisia in 2016 according to a national suicide report by the Ministry of Health. While suicide affects people of all ages, from children to the very old, the average age was 37.  

Around the world, suicide statistics indicate that men commit suicide three times more often than women. In Tunisia as well, as indicated in the official 2016 report, 70percent of those who committed suicide that year were men; that number was 72 percent in 2015.

A chart produced by Tunisia’s Ministry of Health in its 2016 National Suicide Statistics Report indicating the gender ratio among suicides in 2016.

A chart indicating the gender ratio among suicides in 2016 according to Tunisia’s 2016 National Suicide Statistics Report, Tunisian Ministry of Health

It’s not that women don’t attempt suicide; in fact, Professor Fatma Charfi, a child and adolescent psychiatrist at Mongi Slim hospital told Meshkal that suicidal women make more suicide attempts than men. But their attempts are often less violent, so result less often in death. They also “seek help more and express their discomfort more” than men, she said.

This gender difference is clear when looking at some of the data. Another 2016 report by the Health Ministry entitled “Tunisian Health Examination Survey” (THES) found that among people with depression, 38 percent of women reported taking treatment; for men, that number was just under 30 percent.  

In trying to understand some of the social factors behind suicide, including gender differences, Meshkal reached out to Meryem Sellami a social anthropologist who focuses on gender, social relationships to the body, identity construction and adolescent risk behaviors. According to her, the main reason for suicidal men being relatively less expressive about their health condition is the dominant patriarchal standards of society.

“Men are not educated to express their feelings” Sellami said. “They are ashamed of their own emotions; we don’t teach them about empathy. We encourage men’s aggressiveness instead of taming it.”

“Manliness is acquired and not some natural innate trait. We have to teach our boys that it’s okay to be vulnerable. Mothers must accept to value their [sons’] humanity more than their manliness. Social roles in our country must evolve everywhere. The education sector is archaic, but so is the media which overvalues ​​masculinity to the detriment of men” she added.

Suicide has many causes

Trying to explain how a person becomes suicidal is difficult as there are many factors at play. Up to ten percent of suicides don’t have any mental illnesses, according to Charfi. But the remaining 90 percent, as one might expect, do suffer from mental illnesses, with depression the leading illness among them followed by personality disorders and then substance addictions.

But for those who don’t suffer from mental illness, psychiatrists have also found a way to describe some of the social factors at play in suicide: what Charfi calls “adversity”.

“People who commit suicide—when compared with people who do not that live in the same environment with the same social conditions, same age and same sex—they found that people who commit suicide have a lot of adversity factors. They accumulate negative elements of life, whether it’s experiencing violence as a child, negative family environment, neglect, school failures, etc.…Suicidal acts occur in a moment of isolation. So, the populations most at risk are young, lonely and single men,” said Charfi, adding that being a single man is itself a major risk factor for suicide.

The underlying factors for suicide don’t always lead to suicide. According to Sellami, the same factors can also manifest as addictions, risky behavior, neglect of self-care, relationship issues, or personality disorders.

Stigmatization and false information

Leila Sarra Chaibi is a psychiatry resident at Razi hospital, Tunisia’s only public hospital dedicated to entirely to mental health. She’s also the founder of the Tunisian Association for the Promotion and Prevention of Mental Health Among Youth. Chaibi told Meshkal that she founded the association because she witnessed a lot of people around her that were suffering but did not know where to get support. She discovered that basic resources—even for medical professionals—were lacking, and she could not find who to contact to correct this deficiency. She gave the example of psychological first aid training, which teaches people what to say to a suicidal person or how to help a person having a panic attack.

At the height of the Covid-19 pandemic, Chaibi volunteered to answer phone calls at the psychological assistance unit that the Ministry of Health created to deal with the psychological fallout of the pandemic and lockdowns. That unit, consisting of 200 psychologists, psychiatrists and medical practitioner volunteers, took phone calls on a toll-free hotline. While manning the hotline, Chaibi had a call that stood out to her and prompted her to start an association.

The phone call was a 30-year-old woman who, after a long period of feeling bad mentally, finally consulted a psychiatrist who diagnosed her with severe depression and prescribed her a drug. But when she went to fill the prescription, a pharmacist advised her against taking it because of its potential side effects and addictive qualities.

“Of course we took care of her and sent her to another psychiatrist. But I kept asking myself, how did we get to that phone call? How did she get the courage to consult a psychiatrist and accept the fact that she’s mentally ill and then all of a sudden change her mind?” Chaibi said

Chaibi believes that the pharmacist’s unsolicited advice in that instance came from a lack of education and a broader social stigmatization of mental illness. For Chaibi, the woman who called her had overcome many hurdles to seek help—only to be stopped at the point of a medical professional who discouraged her from getting the treatment she needed. It was after that call that Chaibi decided to do something about changing things, including among health professionals who she said should know better.

“Even in psychiatry, there are certain psychiatrists that stigmatize their own patients. But [it’s true] in other specialties too where some doctors will refuse to operate or take a patient into the intensive care unit for fear of them not following their rehabilitation program or something,” she added.

For Chaibi, medical professionals need to do a better job putting their social judgments aside when treating patients.

“Just follow the science. If it says that someone who’s suffering from a certain illness can’t be treated, don’t do it. Otherwise, you have to treat them without stigmatizing them,” she said.

Stigmatization of mental patients has a long history in Tunisia with roots in the colonial system. A paper entitled “History of stigmatization of the mentally ill in Tunisia,” which appeared in the 2007/08 volume of the French clinical and professional journal “l’Information Psychiatrique,” found that after the birth of modern psychiatry under French colonialism at the turn of the 20th century, Tunisian mental patients suffered from racial segregation and discrimination. Dr. Salem Eschadely, the first Tunisian psychiatrist, suffered numerous professional abuses from his French colleagues and was suspended between 1939 and 1946 for his political activism in the Tunisian nationalist movement as well as his attempts to improve the conditions of Tunisian patients. He was then kicked out of the council of the Order of Physicians in 1950. According to the paper authors Cheour Mejda et al., Eschadely suffered professional attacks from his French counterparts because he opposed the racist and anti-scientific doctrines of Dr. Porot, head doctor of the “insane quarters” of the Charles Nicolle hospital, who attributed to “race” and “religion” the origin of psychoses in North Africa.

Associations Step In

The aim of Chaibi’s association, which she founded in February 2021, is to work on reducing the stigma around mental health, talking and sharing information around mental illness and educating people about drugs and their negative side effects.

An event about suicide held on the International Survivors of Suicide Loss Day, November 20, 2021, held at Gallerie DADA-19 in Tunis; Photo courtesy of the Association Tunisienne De La Promotion Et Prévention En Santé Mentale Chez Les Jeunes, originally published on their Facebook page.

She said she could not find any other civic association that focused on her specific concerns, motivating her to start her own operation which is now comprised of 25 members.

The first project that the association did was a video screening project called “Hedhy Hkeyti” [This is my story]. In it, they film mental illness sufferers speaking about their experiences.

“This helps others identify with them and feel like it could happen to anyone and understand and accept the fact that they’re sick and that they could get better by seeking treatment,” explained Chaibi.

Their second project, Zaama Tounsi Yaaref [Do You Reckon a Tunisian Knows]) is still in production. According to Chaibi, it’s aimed at fact-checking and correcting the misconceptions of everyday people after interviewing them on the street about mental illness. Chaibi’s association also plans to work on a project focused on young people, going to high schools and universities to discuss mental health. Already Chaibi and her colleagues went to a university to host a film screening followed by a live discussion about suicide that brought in an anthropologist and a psychiatrist.

But Chaibi realizes charities and civic groups can only do so much in the absence of broader public health policies from authorities targeting mental illness.

“There still a lot of work to do, but if there’s someone that will make a big impact in changing things, it’s the government. Everywhere in the world there is an [official] hotline for suicide prevention for example. But we still don’t have one here,” she noted. “The government doesn’t care; I’ve seen no initiatives or interest on the issue of mental health. I would personally rely more on civil society to do more change.”

Mental health is “not a priority” for government

Najla Arfa, the coordinator at the Tunisian Social Observatory at the Tunisian Forum for Economic and Social Rights (FTDES) told Meshkal that the last they heard from the government on the issues of suicide and mental health was in 2016 when they released the last national report on suicide.

“A complete revamp of the system is required, a complete governmental system. We have to change mentalities and reprioritize the citizen. There is no effective and efficient consideration of the matter, and even if they do organize some initiative there is no results in terms of concrete performance indicators” Arfa told Meshkal.

“They need to listen to the citizens’ needs and from there build your campaigns and strategies. We’re still living in a parochial system where they know better what’s best for us.” she added. “What does the state prioritize? Does it prioritize the members of parliament and their luxury service cars or our hospitals and our citizens’ mental health? We’re just asking for our basic constitutional rights. The State, by disregarding these issues, is inflicting an internationally recognized form of invisible violence.”

Professor Fatma Charfi, who is also the president of the technical committee for the fight against suicide at the Ministry of Health, says that there aren’t enough projects promoting mental health in Tunisia.

“We wrote a very nice strategy in 2013 called SNAPS (National Strategy for Promotion of Mental Health) and it was put in a drawer,” Professor Charfi told Meshkal.

The 58-page “SNAPS” report offers detailed guidelines for a comprehensive national strategy without including a projected budget.

Tackling mental health at the national level requires “a multi-sectoral strategy,” according to Charfi, including easily accessible data.

“It is a strategy which requires coordination between several sectors, serious budgeting and the establishment of a data system,” Charfi said.

I told Charfi that I struggled to find data while researching this article.

“You [Meshkal reporter] experienced yourself the lack of a database,” said Charfi. “I wanted to make a national registry on suicide. I made two reports in 2015 and 2016 and I stopped because we lack the resources. It took me three months to go around the ten forensic medicine services in the country. We don’t have long term governments, and if we want to execute a strategy of this magnitude, we’ll need five to ten years.”

Apart from building a data system, Charfi recommends that Tunisia work at three levels to mitigate suicide: universal prevention targeting everyone with some basic mental health promotion while strictly regulating access to toxic substances like rat poison and pesticides; more selective prevention strategies targeting at-risk groups; and finally, prevention at the micro-level, trying to detect suicidal people and support them and their social networks.

The latter, Charfi said, is something “we already did in partnership with the [Health Ministry’s] Directorate for Medicine in Schools and Universities, where we set up an intervention unit each time there is a student who commits suicide in a school, in order to detect the subjects at risk and accompany the students who were close the deceased child,” said Charfi.

Young Werther in Tunisia

Media can also play a key role in the prevention of suicide—or in making things worse. The Werther effect (or copycat effect) is a systematic increase in the suicide rate whenever there is widespread but insufficiently precautionary media coverage of a suicide. The effect takes its name from Goethe’s 1774 novel “The Sufferings of Young Werther.” The release of the book, which tells the suicide of its main character, was followed by a wave of suicides.

In Tunisia, a study published in 2016 by forensic pathologist Mehdi Ben Khelil and six other authors showed that “self-immolation frequency tripled during each of the five years after the 2011 Tunisian Revolution” and that “a copycat effect was presumably the trigger to the increase of self-immolation rate after the Revolution.”

While Mohamed Bouazizi’s self-immolation in December 2010 sparked mass uprisings, it was not the first or the last. His act had social and political aspects and effects that have been the subject of numerous studies by social scientists. Ben Khelil et al. point to such suicides “occurring in public places and in front of public administrations as well as suicides motivated by financial problems or conflicts with a state representative,” but in another paper, the same authors also blamed the media for spreading the trend noting “an imitation phenomenon triggered by the excessive media coverage of Bouazizi’s self-immolation.”

Aside from the socioeconomic and political meanings of such acts, Dr. Charfi also sees the media as often playing a problematic role.

“There have been many acts of suicide by imitation. In 2015 there was a wave of suicide in Kairouan because there was too much media coverage which was not in accordance with the World Health Organization recommendations on suicide,” Dr. Charfi told Meshkal. “We diagnosed the Werther effect, and we went to train journalists. I did several training seminars. They [journalists] are very well aware…they have changed a lot, they have learned how to talk about suicide, what are the things to say and not to say.”

In 2016, after a 15-year-old girl committed suicide in Mourouj, just south of the capital, many media outlets circulated the sensationalist news that the reason behind her suicide was her rumored association with a satanic sect. That information was later debunked by Ilhem Barboura, a representative of the Ministry of Education, and the girl’s father.

More recently, the national broadcast regulator HAICA (High Independent Authority for Audiovisual Communication) suspended the television program “Rendez-vous 9” for a week and fined the private TV station Attessia 10,000 dinars  for broadcasting “violent and shocking images” of Sami Essifi setting himself on fire in the Ennahda headquarters.

Breaking taboos

Meshkal surveyed several young Tunisians who said they had attempted suicide at least once in their lifetime and asked them a single question: “What could have been done by society/family/government/medical professionals to prevent them from attempting suicide?”

One common theme among those surveyed was that most of them felt like having a more supportive familial environment and more empathetic and compassionate societal norms towards mental illness (specifically depression), would have helped them.

“Being kind to people genuinely, just being kind and offering a safe, non-judgmental zone to speak up,” was one response.

Another respondent pointed to society’s “toxic productivity” demands as putting too much pressure on people. “I tell myself that if we had a psychologist in high school, it would have been better. I also experienced a lot of harassment in public transportation in particular. All that made me gradually lose my energy,” she told Meshkal.

Nevertheless, one of the respondents stated that according to him, nothing could have been done to stop him.

“I was diagnosed with depression and generalized anxiety disorder and early-stage psychosis. I had one of the best therapists in Tunis. My parents were super supportive and understanding. I had a lot of close friends that were helping me in every step of the journey. I did not have ‘major’ problems per se; but I don’t see something happening that could have prevented it all from happening. It’s a pathology that needs treatment, as simple as that. Although I was getting treatment, I was on antidepressants and strong anxiolytics [anti-anxiety medication], my psychiatrist said that it was a suicidal crisis, and it usually [lasts] 24 to 48 hours, and I needed to be under suicide watch for that duration.”

The fact that more than two dozen strangers were willing to speak to this Meshkal about such a traumatic and personal crisis as suicide after a social media call asking for testimonies may signal that some taboos around suicide and mental health are diminishing.

*If you are in Tunisia and seeking resources or help on any of the issues discussed in the article, these are some phone numbers of associations and public health resources that were suggested to us:

Association Tunisienne de la Promotion et Prévention en Santé Mentale: 23974466
Activistes Tunisiens pour la Santé Mentale: 71600339 – 98964719
Association Tunisienne pour la Promotion de la Santé Mentale: 73448885 – 98408349
Health & Psychology: 71809013
Razi Hospital: 70162200