Abstract
Introduction
In Canada, men account for four of every five deaths by suicide (Statistics Canada, 2012), and suicide is the second leading cause of death for men aged 15–24 years. Rates of suicide among young Canadian men are even more pronounced in rural areas—wherein, as community size decreases, male suicide rates increase (Hirsch, 2006). In her research into the health of young Australians, Quine et al. (2003) similarly found that rural males contrasted urban males in harboring greater concerns about depression and suicide. Rural male youth have also linked mental health concerns with geographic isolation, a lack of recreational opportunities, and reduced access to confidential health care resources (Graham et al., 2006; Hirsch, 2006; Patterson and Pegg, 1999). In addition, the depression and suicide literature reveals consistently higher rates of drug and alcohol use among young rural men and greater engagement in risk taking activities when intoxicated (Groft et al., 2005; Rhew et al., 2011). In terms of help-seeking, Quine et al. (2003) reported that rural male youth were more strongly aligned to the ethos of the “self-reliant male” in explaining their collective reticence to seek help for mental health concerns compared to their urban counterparts.
The aforementioned findings reflect the findings of wider research which advances the idea that the influence of socially constructed masculine ideals can alternatively hinder or support men’s health (Oliffe and Phillips, 2008; Sloan et al., 2010). Contrasted within this literature have been men’s experiences of depression and suicidality wherein some men self-harm (i.e. self-medicating with alcohol and other drugs), while others are able to garner the support of family and friends and catalyze better self-care practices (Oliffe et al., 2012). When considering the influence of place on men’s health, Little (2002, 2006), Little and Panelli (2003), and others (Alston, 2012; Ní Laoire, 2001) argue that rural men, especially those employed in resource extraction and farming industries, have stronger commitments to the masculine ideals of strength, invulnerability, and fearlessness. Factors including isolation, lack of access to confidential mental health services, job instability, and the economic uncertainty characterize many rural industries and can render rural men susceptible to mental illness (Alston, 2012; Hirsch, 2006; Judd et al., 2006). Complicating the heighten risk of mental illness is rural men’s concealment of depressive symptoms and/or suicidal thoughts and resistance to help seeking—strategies driven by the need to avoid being seen as “weak of mind” and lacking the resilience to fulfill breadwinner and family protector and provider roles (Alston, 2012; Coen et al., 2013; Parr et al., 2004; Philo et al., 2003).
Regardless of place, research on men’s health over the life course points toward the salience of age when considering men’s willingness or ability to release or relax one’s purchase on idealized masculinities. Robertson (2007) and Lohan (2007) highlighted how life course events, including fatherhood, serious illness, and/or growing old, can cause men to reconsider public performances of invulnerability and stoicism that can also be deeply destructive to men’s private lives. Alternately, Kimmel (2008), Pascoe (2011), and Hearn (1992) have found that younger men, particularly those in high school, have less success negotiating the public versus private bifurcation in masculine performativities and thus do not adopt a plurality of masculinities, some of which may protect health. Especially within their peer groups, young men respond to pressures to prove themselves by taking risks, exhibiting bravado, and embodying hyper-heterosexuality (Kimmel, 2008).
With reference to place and social space, Creighton and Oliffe (2010) drew on the gendered communities of practice model (Paechter, 2003) to describe how young men can sustain dominant masculine practices or reconfigure masculine norms. For some men, reconfiguring masculine norms toward more proactively advancing their health was reliant on removing themselves from particular groups and practices (Creighton and Oliffe, 2010). However, unlike young urban-based men who can access and inhabit an array of communities of practice, young men in rural contexts are often restricted and may end up engaging in public performances that are at odds with their internal values and experiences. With persistently high male suicide rates in rural Canada, there is a need for greater understandings of the locale specific factors and gender dynamics that can lead young rural men toward self-harm and suicide. This article responds to the need for in-depth reflection on rural male suicide by sharing survivor retrospectives about the suicide of a young rural-based Canadian man.
Methods
This article employed an instrumental case study approach to explore the experiences of family and friends who lost a 17-year-old boy—Thomas—to suicide. By providing an analysis of a single case, contextual insights to a particular phenomenon—suicide—were inductively derived (Stake, 1995) drawing on constructivist traditions that acknowledge and welcome multiple “truths” in chronicling participants stories and privileging what they believed to be important in the context of Thomas’ death (Yin, 2003). Employed also were photovoice methods in which participants took and talked to their photographs in sharing their retrospectives about Thomas (Oliffe and Bottorff, 2007; Oliffe et al., 2008).
Recruitment
Following university ethics approval, we invited men and women who had lost a male to suicide to take photographs to illustrate their experiences with a view to thoughtfully considering the needs of survivors and the design of targeted male suicide prevention programs. Postcards and posters detailing the study and inviting potential participants to contact the project manager by e-mail or telephone were posted at a variety of locations including bus stops and community centers and shared electronically through social media platforms (i.e. Facebook and Twitter) and on list serves. Eligible participants who agreed took part in the study during 2014. Participants received a CAN$200 honorarium to acknowledge their time and contribution to the study.
In the early stages of data collection, we interviewed a woman—Amelia—whose younger brother Thomas had died by suicide the previous year. Having grown up in the small town in which her brother died, Amelia felt strongly about raising awareness about rural men’s suicide. With the assistance of the project manager, the participant organized a visit to her home town, providing information to family and friends who might be interested in participating in the study. Among those who agreed to participate in the study, seven had known and were willing to talk about Thomas. Initial contact by the project manager with the seven participants was made by e-mail to arrange a telephone meeting to explain the study and the written consent form (sent via e-mail ahead of the telephone meeting). The participants were invited to take a series of photographs to tell their story, taking up to 2 weeks to complete the photovoice assignment. Subsequently, individual interviews were conducted wherein participants were invited to talk about their photographs as a means to discussing in detail their experiences and perspectives surrounding Thomas’ suicide.
Data collection
Participants were provided a written list of resources for support services they could contact if they experienced distress during or after their participation in the study. They were advised that the interview would be ceased if the interviewer observed participant distress and given assurances that they could withdraw from the study at any time without consequence. Following signed written consent and the opportunity to ask questions about the study, participants completed a demographic form. The interviews focused on the participant produced photographs whereby participants were invited to tell their stories through the images they had submitted. A range of open-ended questions were also used to encourage elaboration on specific content including: What was your relationship with the deceased like leading up to the suicide? What are your reflections about the causes or triggers of the suicide? What small town factors might heighten the risk of suicide for young men? What factors might be protective against male suicide? The interviews were conducted in a quiet space in a local church building, and on average, they took approximately 75 minutes. The interviews were digitally recorded, transcribed verbatim, and checked for accuracy. The participants’ photographs were inserted to the corresponding narratives in the transcribed interviews, and the interviews were anonymized by removing potentially identifying information. The participant interview transcripts were allocated a numerical code (i.e. P1 through P7), and a pseudonym was used to link specific illustrative photographs and narratives in the study findings.
While the circumstances around Thomas’ death are unique, to some extent, they also reflect the epidemiology of suicide among rural-based Canadian men where males under the age of 20 years have the highest rate of suicide (Canadian Institute for Health Information, 2006). By way of context, Thomas did not have a formal diagnosis or history of mental illness, and for those who knew him, Thomas’ suicide was completely unexpected. However, Thomas’ suicide note revealed significant pain associated with mental illness leading up to his death. Participants comprised six women and one man with various relationships to Thomas including, father, mother, sisters, aunt, and friends. Participants ranged in age from 22 to 57 years (mean = 41.1), and most (n = 6) currently lived and worked in the town where Thomas had died. The number of photographs taken by each participant ranged from 4 to 11 (mean = 8).
Data analysis
The analyses and key learnings from a single case can be used to develop theory around a topic (Hancock and Algozzine, 2006; Yin, 2003). Through seeking out multiple, potentially diverse, and/or discordant perspectives on a single case, we built a nuanced understanding of Thomas’ life and death, iteratively creating an account through continually revising interpretations to reveal patterns and divergent meanings (Yin, 2003). In terms of analytic approaches, we employed a constant comparative analysis whereby each of the transcripts and corresponding photographs were reviewed and subsequently compared. Within this process, written summaries were made to distil the predominant experiences and viewpoints of each participant, and by comparison, patterns were inductively derived to develop the case study of Thomas. We purposefully broke with traditions round coding data segments, instead reviewing and analyzing the data from each participant as a whole to retain the integrity and cohesiveness of their respective narratives and photographs. For the purpose of this analysis, photographs were not analyzed separately as data, but used as a way to augment, illustrate, and enrich the textual interview data. Photographs were also used by participants to provide visual metaphors and/or as a way of expressing material or symbolic descriptions of their rural community.
The findings are presented in three inductively derived themes, descriptively labeled, (1)
Findings
Contextualizing Thomas’ suicide
Thomas grew up in the small town in Canada with mixed agricultural/oil and gas industrial drivers and a population of 2500 people. His father Kevin had grown up in this small town with his large extended family. His mother Olivia grew up in a nearby city and moved to the small town when she married Kevin. Olivia described the adjustment moving to the small town: People who grow up here feel such an allegiance to the place. When I first moved here people would cast their arms about and say, “this is God’s country” and I would be like, “okay, if you say so,” but it kind of grows on you.
Olivia and Kevin built a farm about a 10-minute drive from town. Olivia worked as a schoolteacher and Kevin was a carpenter before changing careers to manage a business in the large city, 1.5 hours commute by car. Olivia and Kevin raised three children: two girls—Amelia and Lauren—followed by a son, Thomas. In the midst of the socially conservative environment of the small town, Olivia and Kevin made an effort to broaden the horizons of their children. Surrounded by friends involved in the arts and social justice efforts, the family frequently traveled outside the province and Canada to gain new experiences. Amelia remembered hearing, as she grew up, people commenting on their unique family orientation—both strongly engaged with and committed to the local small town community with an outward, progressive focus that connected them to the world outside where they lived.
Both Amelia and Lauren described their childhood as idyllic. The children grew up close to their nuclear and extended family and had fond memories of spending time with cousins, aunts, uncles, and grandparents who lived close by. Relatively wealthy by local standards, they never wanted for anything. As much they enjoyed being young in the small town, both girls knew from an early age that they were not expected to stay. As Amelia said, “it was never a question that we would leave this town as soon as humanly possible. We love our family but there—to be blunt—was nothing here for us.” When she was 16 years old, Amelia moved to the city and enrolled in an arts-based high school. As soon as she graduated, Lauren followed suit and enrolled in an engineering program at a university in the same city. To outsiders, it looked as though Thomas would similarly find his way to the city. Still at home, however, he seemed established in and connected to his small town community. By all accounts, Thomas was a popular, good-looking high school student who was exceptionally accomplished at sports and captained both the soccer and basketball teams. With the exception of mathematics, Thomas did well in school and achieved high marks. He was considered a leader not only because he was a gifted athlete but also because of his kindness to others and willingness to include diverse people in his circle of friends. According to friends and family, there was little indication that Thomas was unhappy living in his small town. That said, Amelia explained that at one point, Thomas had asked whether he might leave home and go, as his sisters had, to live in the city:
He asked my parents if he could do his final year of high school in [large city an hour outside of his home community] as I had. He wanted to get his own apartment. My parents told him no.
Why do you think he was not allowed to after you had been given permission?
I think they saw him as being too young. When I was that age I could keep a house. I don’t think they saw him as able to manage those skills. He seemed okay with that at the time, but who knows?
Thomas died on 26 June, the last day of grade 11. That afternoon, sitting at the kitchen table with his mom before soccer practice, Thomas got a phone call from the school principal. Olivia remembers Thomas getting up and taking the phone into another room. When he came back, Thomas told Olivia that because he and some other boys were texting during a final examination, they had been reported for cheating. Olivia was upset with him. A teacher herself, she was angry that he had made such a poor decision and let him know by asserting, “We did not raise you that way.” She told him that he should not go to soccer practice; he agreed, and Olivia returned to work.
By the time Olivia got to back to work at the school, she was feeling badly for their argument and texted Thomas to make sure that he was okay. After a little while, she had not heard back from him and texted again, suggesting, “It was then that I knew something had gone wrong. He always texted back.” Olivia called Thomas’ dad, who was working in the city to see whether he had heard from him. When Kevin said that he had not, Olivia got in her car to drive home, her anxiety mounting. She ran into the house calling his name: “The house was so quiet, eerily so.” Going from room to room, she paused at the bathroom worried at what she might find, but Thomas was not there. Coming back downstairs, she noticed a note on the kitchen table. She scanned to the end, reading Thomas’ final words: “I am going to hang myself in the shop.” Screaming, she sprinted only to find her son, gray and cold, hanging from the rafters of the outbuilding that he had helped build with his father the previous summer.
Kevin and Amelia rushed home from the city. As police officers came and went, followed by the coroner, Thomas’ parents and sister read his suicide note: Mom, I am so, so, so sorry for this. Please don’t blame yourself for this but I have decided to take my own life. This has nothing to do with anyone. It is completely my choice. I have had no joy in life for some time now and I feel terrible for being a disappointment to you and dad. I don’t like who I am.
Thomas went on to write how deeply he loved his parents, how grateful he was for the life that they had given him, and how much he respected them both. He wrote also of his depression and concerns that it would never go away, conceding that he couldn’t go on. He asked them to try to think about his suicide as ending his pain amid acknowledging, “No parent should have to experience their own child’s death, especially when you guys have given me such an amazing life.”
Missing the signs
One of the most predominant themes in the interviews was the self-interrogation engaged by Thomas’ family and friends. Thomas’ letter confirmed that he had been experiencing depression for some time, and yet none of the participants were able to report that they noticed any depressive symptoms or signs of trouble prior to the suicide. Kevin reflected on how much planning must have been involved for Thomas to ensure the rope had the length and strength appropriate to his height and weight, and that the knot would fasten. These details convinced Kevin that Thomas’ suicide was not spur of the moment, but rather calculated and meticulously planned: Thomas was 6’2” and that’s just an eight foot ceiling, rafter eight feet off the ground, so he didn’t have room to try, you know, the rope couldn’t stretch. His toes would have been just off the ground almost. I just imagine that it wasn’t impulsive that, uh, “I’m feeling like this right now,” and then it’s over. He decided and then he wrote us a letter and then he had to carry things out; he had to go get a piece of rope and he had to get a ladder to get where he was going.
Thomas’ family agonized over his death. What signs had they missed? What were the signs of this terrible pain that he must have been experiencing to take his young life? Why had he not felt like he could have said anything about what he was feeling? Olivia reflected, It was a shock to everybody, nobody, not his teachers, his principal … everybody said it was one of those cases that, you know, nobody believed. The person you least would’ve expected. Everybody wanted to be Thomas that was his age. He was looked up to, he was a leader, he made everybody laugh. He was kind.
Lauren submitted Photograph 1, which she saw as a metaphor for the shock of her brother’s passing: This September was so beautiful and warm and you could look out and see the garden full of life and all sorts of bounty waiting to happen and then, overnight the frost just came and we woke up to this. All that potential just gone and dead.
“An overnight frost.”
Maryanne, a close friend of the family, echoed the shock and confusion that many in the community articulated following Thomas’ suicide:
I think it was tough because there wasn’t, you couldn’t predict it. There was no timeline to it. There was like nothing that you could say, like if I see these signs in somebody else and I’ll know that they’re suicidal because there just didn’t seem to be any.
Maryanne, in a similar vein to the other participants, expressed how the unexpected nature of Thomas’ suicide shook her understandings and faith in rationality and ways of knowing people in the world. If a boy, who seemed to embody such health, life, and potential, could hide his internal misery and pain to the extent that the remedy was suicide, then anyone could be at risk. Moreover, preventing suicide became ever uncertain in the absence of telltale signs or tangible clues, and in this regard, Thomas might be understood as also
Living up to his public image
Another key theme emerged from the consensus among participants that Thomas was a “golden boy,” along with some concessions that such a strong public image may have exerted a degree of pressure on Thomas. While the reluctance to “speak ill of the dead” and the desire to preserve a grace-filled memory of the deceased can be common among suicide survivors, many participant stories were focused on Thomas’ qualities including his good nature, compassion, attractiveness, intelligence, and leadership. Qualities publicly revered and applauded but at odds with Thomas’ view of himself as joyless and ashamed.
Thomas’ family members wondered if his powerful public image imbued with strength and confidence may have been his undoing because some of the more common symptoms of depression were at odds with the face he showed to the world. Amelia spoke to Photograph 2 which illustrated Thomas’ public accomplishments—his sports awards and various trophies: I took this photo because, visually, I love the way that it is curated but it also reflects all that Thomas achieved over the course of his life. He was such a golden boy. You look at this stuff and you think that everything is going right for this kid.
The golden boy.
Implicit in Amelia’s narrative was that the outward artifacts, signifying Thomas’ successful negotiation of what was valued for young men in their small town, did not translate to an internal happiness and satisfaction. The pressures to consistently publicly perform at this level might have weighed heavily on Thomas.
Danielle, a family friend who was also a health care provider, had watched Thomas grow up. She had similar words about the way that Thomas might have felt challenged to admit to depression. With two young adult sons of her own, she reflected on how challenging it would be for children from “successful small town families” to admit, let alone exhibit any depressive symptoms: So, I look at Thomas and I look at his family and I look at the group of people that he was involved with and I think, I bet that sometimes that was overwhelming and easy to get lost and hard when you have been a reasonably successful person you’ve done well at things, you’ve been good at stuff, if you fail at anything, sometimes you don’t know what to do—you don’t know how to deal with that, you know? And if you do crappy on a test or you don’t get accepted for something, you’re not quite sure what to do with it, it can become an insurmountable obstacle and not know how to get around that, and you know, if you’re struggling with—you know, feelings of depression or feelings of not having a lot of self-worth, those things just become insurmountable.
Returning to the notion that they were deeply implicated in his suicide, Thomas’ parents individually reflected that, in their efforts to bring up happy, healthy, and confident kids, they may have failed to underscore that perfection and perpetual happiness were not realistic life goals. The image that they themselves had projected to their children was not punctuated by stories of the times when they had experienced feelings of unhappiness and/or inadequacy. Olivia remembered going through a really difficult time when she was Thomas’ age: I wrote poetry and I went to that dark place a few times and never would’ve been as deep as to follow through with any of that, and my mom told me that she went through a really hard time at uh that age too. None of us ever talked to Thomas or the girls about that and I, I think partly you don’t want to because you think if they’re doing ok you don’t want to make them feel like they have to go through something like that.
In the same vein, one of Amelia’s most powerful memories was of her father’s regret. She described him sitting in the living room with men, who were also farmers, shaking and crying wondering if they had failed their sons in very profound ways: I know in the immediate aftermath and for months after, he kept having the same conversation over and over again which was, “I wish that I had shown him how to be vulnerable,” or, “It’s okay to be vulnerable,” That being a man isn’t about, being strong and unaffected.
Kevin also told this story and elaborated on his reflection about what he wished he had done differently: I liked that I could operate in both worlds, right; that I could work in an office. I could build something and I thought that those skills that I had, physical skills, and knowledge were worthwhile passing on, and that was a big thing to me to teach Thomas stuff. And I’ve just thought since, I didn’t think about all the stuff that I could have taught- what you would handle differently, would be about vulnerability for myself. I think you tell all your kids the good stuff, the great, then that’s what they see; they see the good things. They see you as an adult when, you know, you’ve kind of got your stuff together. Or I think Thomas would, I mean he would see us somewhat struggle, but you don’t tell them, maybe you don’t remember what it felt like when you were 15 … I think he had a perception that perhaps I didn’t have these feelings and vulnerabilities and I wasn’t scared of things, and I didn’t hurt. And because he did that he didn’t measure up, and quite the opposite was probably true.
Evident in the narratives from Amelia and Kevin were revelations that inadvertently transmitting masculine ideals round self-reliance and strength may have isolated Thomas, invoking a reticence to reach out for assistance or self-disclose about insecurities and/or vulnerabilities. Remarkably, major depression was known to their family. Amelia’s depression had been a topic of conversation in the family for years before Thomas’ death. She described conveying her feelings to her parents as an unrelenting uphill battle, saying that they were unable to understand the darkness, pessimism, and hopelessness that she sometimes lived with. She remembered one notable argument that ended with her mother imploring her to be “more positive” and to “look on the bright side.” Exasperated, she went into her brother’s room and threw herself on his bed saying, “Mom just doesn’t get it.”
Amelia reflected, with some frustration, that Thomas had had opportunities to disclose his experiences of depression to her and perhaps waylay some of her own challenges round what she was feeling, questioning: “Why didn’t he take this opportunity to talk about his own depression.” While frustrated and mystified as to why Thomas did not speak up, Amelia and her parents attributed his silence to a desire to spare the family, as Olivia suggested, I think he just didn’t want us to go through what he thought we were going through to get him the help that he needed or get it sorted out and I think deep down he thought there really was no hope obviously. I think he just thought that there was nothing that he could do and it would be forever to see somebody and be on some meds and those wouldn’t work.
Living up to his public image likely brought significant pressures to Thomas according to most participants. A victim of his external markers of success to some extent, the emergence of depressive symptoms was internalized, and much of Thomas’ effort went toward concealing what he “really” felt. Kevin’s assertion that Thomas may have benefited from explicit permission to disclose his weaknesses and seek assistance also highlighted the distinction and discord between public and private performances of masculinity.
Down in rural Canada
The theme I still feel like [the small town] is a pretty like red neck [Canadian province] place … [The small town] is not a very welcoming place to wear skinny jeans to school or really for much diversity. Like it’s the kind of place where the others kind of like have one or two views of success and popularity and I think it’s really hard if you are different than that.
Danielle agreed with Lauren and Allison, suggesting that rural-based parents, even of very young children, encouraged normative, gendered behaviors with boys and girls. Danielle further explained that young men were “schooled” by the rural community into a very narrow version of masculinity and rewarded for conforming and punished when they deviated from idealized manly performances. She observed that young men who did not fit a specific small town image either adapted or left. This unwillingness to contest such masculine ideals often times served to reproduce and reify a homogeneous masculinity in the small town.
Danielle spoke to Photograph 3, illustrating her perception of the town where, “if you didn’t wear a baseball cap and own a half ton truck, there might be no place for you”: When I think about young people, that’s the thing that I see the most, you know? Is that it?—If you’re just a little bit outside the box, by god, there’s no place for you … I mean, if you don’t play hockey, god forbid you figure skate because that’s the end of the world there, go to (a neighboring city) and play in a band, do some kind of musical instrument—again, you’re just ostracized, right?
Half ton truck.
Maryanne, a teacher, also reflected on the cultural norms of the small town that might encumber and dissuade reaching out for help: The year before Thomas killed himself, there was in the curriculum they read a lot about the holocaust and really, really negative things and not novels and stuff that people need to know about, yes, but it was like we’re a bunch of really upset kids without the context that those survivors had hope and there are some good messages out there. And I think we get so bogged down with negative, negative, like I know for me global warming is one of my biggest anxieties. I’m stressed about it. Then I watch big companies and I’m like “what’s the point?” Like if I’m doing everything I can and they’re doing nothing, what am I supposed to do and so, but I think you need to have hope and find those pockets of people that are doing stuff and so that’s what. Like it wouldn’t make me kill myself, but it would make me think “what’s the point?” and I think lots of it comes, lots of suicide comes from “what’s the point?”
Evident here are assertions about the school’s responsibility to bolster not only hope but also a sense of civic interconnectedness. It was irresponsible, in Maryanne’s mind, for schools to turn loose students into the world without supporting their dreams and sense of optimism.
Drowning in rural masculinity emerged as a key consideration wherein the restrictive nature how young rural men should perform could be stress provoking. The need to align to damaging masculine ideals and the potential to buy into all that was wrong with the world amid prospects of never leaving this small town could serve to strip the hope from rural-based young men. In this regard, Thomas’ “
Discussion
In this article, to achieve the objective of gaining a deeper understanding of male suicide through examining a single case study, a combination of two innovative methods were used: an instrumental case study approach (Stake, 1995; Yin, 2003) and photovoice (Oliffe et al., 2008). The instrumental case study approach, applied here to the suicide of Thomas, is built upon the principles of traditional ethnography in that it situates a case within a community and seeks the perspectives of a number of significant others to gain a complex multi-authored understanding. Photovoice, we found, can anchor and advance this objective. By asking members of the community to add pictures, it provided a sensitive, participant led segue into their retrospectives on the deceased and the circumstances leading to his suicide. The result of this approach affords new and nuanced insights to rural men’s suicide which in turn may help to develop preventative actions in relation to male suicide and more broadly for men’s health promotion.
Thomas’ case study also clearly illustrates the need for an expanded definition of what depression might feel like for young men. A central tension in the stories of Thomas were the diverse hypotheses about why he did not name his own experience as depression. Is it possible that he saw his struggle as something else entirely? While no one can know the nature of Thomas’ interior experience, the reports from those close to him suggest he may have been hiding his depression, but it could also point to Thomas’ lack of mental health literacy and insight to the nature of his illness and potential for remedy. Some experts suggest, for example, that the lower reported rates of men’s depression may be due to the widespread use of generic diagnostic criteria that are not sensitive to depression in men (Cochran and Rabinowitz, 2003; Kilmartin, 2005). Depression in young women, as Amelia described, may be experienced as sadness, tearfulness, and a lack of energy (internalizing behavior), whereas in men, it may show itself as anger or irritability or as it seemed in Thomas’ case, as introversion and silence. So, while it is possible that Thomas consciously concealed his depression in order to preserve his public image and/or not be a burden on his family, it is also possible that he didn’t identify his experience as the same depression experienced by his sister.
This also points to the complexity of suicidal behaviors and actions toward suicide prevention. What Thomas’ case offers is the idea because of the reluctance young men can have to disclose feelings of sadness and vulnerability that all young men are at risk for suicide. Suicide risk is not limited to those who are exhibiting the most commonly cited risk factors (e.g. being bullied, socially isolated, diagnosed depression), instead “risk” can also exist for young men who appear happy, well-adjusted, and seem to fit in. Thomas’ case study reinforces the need for universal targeting of promoting and protecting the mental health and positive well-being of young men in rural areas by addressing deficits in the physical and social infrastructures. As noted in section “Introduction,” documented in the literature is the need to promote mental health in rural areas by addressing geographic isolation and lack of youth-centered transport options, the lack of recreational opportunities for young people, and the relative deficit of access to confidential health care resources, including sexual health services when compared with urban areas (Graham et al., 2006; Hirsch, 2006; Patterson and Pegg, 1999). In addition, the depression and suicide literature reveals consistently higher rates of drug and alcohol use among young rural men and greater engagement in risk taking activities when intoxicated which is acknowledged as an additional problem as well as by-product of the lack of alternative possibilities for socializing (Groft et al., 2005; Rhew et al., 2011).
Offered also by this study findings is insight to the undermining nature of institutional gender norms in schools that can restrict the avenues for young rural men developing self-efficacy and resilience. Retrospective perspectives on Thomas’ story highlighted, in particular, issues such as the uncertainty young rural men may feel in making transitions toward independent living in urban areas and the struggle for financial independence amid significant threats to one’s moral reputation, such as the accusation that Thomas had cheated on his examination. Thomas’ story ultimately also extends debates about how to universally target the physical deficits of rural areas for young men in terms of health service provision to muster community-level dialog around the impact of cultural norms, especially in relation to ideals of rural masculinities.
Young men can occupy contradictory social positions. Visible and revered from the burgeoning white, educated middle class are heroes who star as elite athletes and/or entrepreneurial innovators, fearless, and seemingly immortal forces of nature. However, young men also feature as the troubled and troublesome “guys” lagging behind the life-course milestones of their forefathers devoid of long-term relationships, career prospects, independent living arrangements, or mature ideas about sex and sexuality (Frosh et al., 2002; Kimmel, 2008; Nobis and Sanden, 2008). This binary is home to powerful masculine tropes imbued with gender regimes and hierarchies which influence young rural men’s expectations and actions. Of course, there is a continuum between these extremes but key and central is the public pursuit of masculine norms and ideals. In turn, the lack of space in rural milieus can be especially harsh in policing deviations from those traditional pursuits of masculine capital. As the friends and family of Thomas noted, there was little space and time for him to express himself beyond the identities that he had been modeled and took on.
In terms of study limitations, this case study was explicitly focused on gender in highlighting the complex mix of social factors in Thomas’ suicide. In relying on this frame and the reports of Thomas’ loved ones, we are, of course, limited in what we are able to say about other issues that may have been salient including biomedical diagnoses. While those close to Thomas may have suspected that he suffered from depression, we do not have sufficient evidence to conclusively assert the presence of a depression or specific traits linked to suicide such as narcissistic personality. In addition, our findings are limited in what they can reasonably say about specific subgroups including indigenous young men. However, these limitations can guide future research to further describe and ideally address the interconnections between masculinities and suicide within specific communities of practice as a means to developing men and place specific mental health services and suicide prevention programs.
In conclusion, the findings from this case study can be used to bolster promising ways forward to suicide prevention in rural communities. Highlighted is the need for community-based, universalized approaches that challenge rigid, gendered norms under which young men labor. Education and engagement of entire rural communities will likely aid identification and prevention of individual young men who may be silently struggling with depression and suicidal behaviors.