Method used:

• We cannot, of course, have direct ex post access to the reasons that led a human being to commit suicide. Unfortunately, it is too late to have his testimony. “Psychological autopsies” which are by definition “a post‐mortem investigative procedure aimed at establishing and evaluating the risk factors for suicide present at the time of death, with the aim of determining with the highest degree of certainty the mechanism having leads to death” are still too rare to be used in a quantitative approach. On the other hand, we can know better, although still imperfectly, the reasons that led women to undergo ST, this is what we saw in the previous chapter. It is well known that the reasons for suicide are multifactorial, however, epidemiological studies
  learn that the strongest predictor of suicide is having ever had a ST. There is therefore a very powerful link between suicide and TS, the same causes producing the same effects in more extreme. This is how, for lack of another more scientifically assured method, we
  are led to formulate the hypothesis of the same distribution of the causes of TS in the causes of suicides.
• The testimonies collected in many cases of proven forced suicide, of which we have provided a few examples in the previous deliverable “Inventory of the concept of forced suicide in Europe”, confirm our assumptions that psychological violence within the couple can be the main cause of a passage to the act. The comorbidities generally associated with these acts (depression, anxiety disorders, etc.) can also be interpreted as consequences of this violence.
• This scientific “for lack of a better word”, combined with epidemiological studies on the causes of domestic violence and the findings of case observations conducted by experts in domestic violence, leads us to validate the hypothesis of a percentage of
  suicides attributable to violence within the couple at least around 11%. This figure is only valid for countries in the European and American regions (as defined by the WHO) because of the few studies on which it is based (United States, United Kingdom, France).

Estimated number of FS in Europe :

• We therefore start from an examination of the number of female suicides by age group for the EU27 MS provided by Eurostat for 2017, which is the most recent year with complete published mortality figures (Causes of death – deaths by country of residence and occurrence) for these
  countries. The raw data are as follows for female suicides:

Applying our 11% FS percentage uniformly to all female suicides in MS, we obtain the table below:

We therefore observe that:

• the number of forced suicides in France in 2017 is estimated at 209 ;
• the number of forced suicides in Belgium in 2017 is estimated at 52 ;
• the total number of forced suicides in the EU27 MS in 2017 is estimated at 1,136.

The impact on the number of feminicides in France in 2017:

• The figures produced each year since 2006 by the Delegation for Victims (DAV) of the General Directorates of the National Police and the National Gendarmerie on violent deaths within couples are essential in determining the number of victims. Thus, for 2017,
  we have the following figures for violent deaths:

Women victims within a couple (feminicides): 130
Male victims in a relationship: 21
Child victims: 25
Collateral victims: 12

• These data remain incomplete due to the fact that we lacked a figure for suicides of women whose main cause is the violence they suffer within the couple, the “forced suicides”, as the ultimate consequences of psychological, physical and/or sexual violence
  endured. Adding to this data our estimate of the number of FS for France in 2017, we obtain:

Women victims within a couple (feminicides): 130
Female victims of forced suicide: 209, for a total of 339 female SCV deaths for 2017.

We have deliberately excluded from this total the suicides of the perpetrators of the homicides so as not to group together the victims and the perpetrators of the crimes in the same total, nor the children and collateral victims in order to stick to the number of female victims only. However, it is true that we add together observed figures (those of the DAV) and estimated figures (those of forced suicides), but we are thus certainly closer to reality than with observed figures alone.

• It is thus nearly one woman victim per day that the violence within the couple in France in 2017 and not one every 3 days, as it is usually reported if one considers restrictively the only feminicides.

The impact on the number of feminicides in Belgium in 2017:

• In Belgium, there are on average about 40 feminicides per year, but there are still no official records from the public authorities. In Belgium, there are on average about 40 feminicides per year, but there are still no official records from the public authorities. This platform gathers organizations independent from governments and political parties that wish to reflect and act against violence against women in Belgium, through a feminist reading and approach. This blog lists the crimes, puts faces to the numbers and does so in order to put pressure on the authorities. Thus, for 2017, we have the following figures for violent deaths: Female victims within the couple (feminicides): 43; Child victims: 4.
• These data remain incomplete due to the fact that we lacked a figure for suicides of women whose main cause is the violence they suffer within the couple, the “forced suicides”, as the ultimate consequences of the psychological, physical and/or sexual violence
  suffered. Adding to these data our estimate of the number of FS for Belgium in 2017, we obtain: Female victims within a couple (feminicides): 43; Female victims of forced suicide: 52; for a total of 95 female SCV deaths for 2017.

We have deliberately excluded child victims from this total to keep the number of female victims alone. However, it is true that we add together observed figures (unofficial figures reported in the press by associations) and estimated figures (those of forced suicides), but we are thus certainly closer to reality than with observed figures alone.

• It is thus nearly one woman victim every 4 days that domestic violence in Belgium in 2017 and not one every 10 days, as it is usually reported if we consider restrictively only feminicides.
• In Europe (EU27), more than 1,000 women die by forced suicide, which must be added to the number of feminicide victims.
• We therefore call on the political authorities, the media and the associations to refer to this figure which is much higher, and unfortunately closer to reality, than the already unbearable figures usually quoted.

Limitations of estimation:

Following the steps in our reasoning to arrive at our estimate of the number of FS, we successively:

• synthesized the too few studies concerning the possible causes of suicide attempts in women;
• determined a percentage of TS attributable primarily to CHVs;
• hypothesized that this percentage of TS causes could be applied to the causes of completed suicides themselves;
• applied this same percentage to all MS in Europe EU27.
• We also applied a conservative rule by choosing the lower bound of the percentage of SC causes attributable to SCVs, being aware that the number of suicides recorded in official reporting mechanisms of causes of death is systematically underestimated, by clearly explaining our calculation procedure and its possible weaknesses.
• We are aware that this costing mechanism is not scientifically assured, but that it leads to a “reasoned order of magnitude”. It seems to us that we are closer to the truth about the magnitude of women’s deaths from SVC by including this figure than by excluding it!

Ways to improve it: There are several ways to improve the robustness of our methodology:

• Proposal 1: Carry out in-depth and specific studies in France and in other MS on the link between VSC on the one hand and suicide attempts on the other hand in order to better enlighten, understand, quantify and prevent forced suicides. This project is part of that.
• Proposal 2: Systematically record data on possible CSVs in post-suicide police or gendarmerie investigations, while of course “gendering” the data collected. This means systematizing psychological autopsy procedures to better investigate the causes of suicides.
• Proposal 3: Raise awareness and train front-line personnel (police, gendarmes, firefighters, emergency personnel) on the existence and detection of attempted suicides linked to domestic violence.

Studies on the link between domestic violence and suicide or ST:

It is essential to consider intimate partner violence as a public health issue. In fact, according to WHO figures, women who are victims of intimate partner violence lose one to four years of healthy life. In addition, this violence multiplies by
two the health care expenses for these women. It is also important to point out that the costs of domestic violence amount to an impressive 16 billion euros in Europe.

Several studies have aimed to analyze the consequences of intimate partner violence on women’s mental health, some of which have highlighted the correlations between such violence and suicide attempts by female victims. A presentation of these articles is given in the following lines.
Note: We logically assume that the figures given in the articles refer to the life up to then when no other duration is mentioned.

• Article n°1 : Morvant, C., Lebas, J., & Chauvin, P. (2002). The consequences of domestic violence on women’s health and their management in primary care medicine. Retrieved from https://www.researchgate.net/profile/PierreChauvin/publication/10900409_Consequence
  s_of_domestic_violence_on_women%27s_health_and_their_management_in_primary_health_care/links/5c8fc216299bf14e7e844d97/Consequences‐of‐domestic‐violence‐on‐womens‐health‐and‐their‐management‐in‐primary‐health‐care.pdf [France]

A 2002 study analyzing the consequences of domestic violence on women’s health reached some conclusions.
First of all, it is important to note that half of the women who are hospitalized in psychiatry suffer from violence at the hands of their partner. In addition, the risk of post-traumatic syndrome and of depression appears to be greater in the context of domestic violence than in the context of sexual violence suffered in childhood. The same applies to the use of psychotropic drugs, which is very high among these women victims. It is, in fact, 4 to 5 times higher compared to the general population.
Finally and most fundamentally, as a consequence of the previous elements, they would make 5 times more suicide attempts compared to the general population.

• Article n°2 : Cavanaugh, C. E., Messing, J. T., Del‐Colle, M., O’Sullivan, C., & Campbell, J.C. (2011). Prévalence et corrélats du comportement suicidaire chez les femmes adultes victimes de violence conjugale. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3152586/pdf/nihms282593.pdf [USA]

The purpose of this study was to highlight the prevalence and correlates of suicide threats and suicide attempts among 662 female victims of intimate partner violence. According to the National Institute of Health, women who experience intimate partner violence have
more likely to have suicidal thoughts and/or behavior. Indeed, a study reveals that female victims are7 times more likely to present suicidal thoughts compared to women who are not confronted with this type of violence. In addition, one in five victims
threatened or attempted suicide in their lifetime.
The article adopts an interesting intersectional perspective.

Thus, women suffering from a chronic or disabling illness were 2.4 times more likely to have threatened or attempted suicide than others. These data can be explained by the fact that these people may be more socially isolated and controlled by their spouse and may therefore see suicide as the only possible way out.
Younger women are significantly more affected.

Ethnicity is also an important variable since African American victims are 40% less likely to have threatened or attempted suicide than Latin Americans. In addition, certain circumstances may increase the risk that victims of violence threaten or attempt suicide.

For starters, victims at greater risk of experiencing life-threatening assaults from their intimate partners are significantly more likely to have threatened or attempted suicide.

In addition, serious abuseinflicted by the spouse as well as the dangerousness of the spouse also have an impact.

These findings can be explained by the fact that in the event of fear for their life, victims may consider suicide as the only means of exercising control over a situation that has become untenable. The considerable danger incurred in the context of a violent relationship impacts the mental health of women who are victims of it, who are more likely to suffer from post-traumatic stress disorder, anxiety and depression. These consequences attached to serious violence on the mental health of women aggravate, in turn, the likelihood that victims will have suicidal thoughts.

Finally, it appeared that female victims whose spouse had threatened or attempted suicide presented a higher risk of having themselves threatened or attempted suicide.

• Item 3: Devries, K.. M., Mak, J. Y., Bacchus, L. J., Child, J. C., Falder, G., Petzold, M., Astbury, J., & Watts, C. H. (2013). Intimate Partner Violence and Incident Depressive Symptoms and Suicide Attempts: A Systematic Review of Longitudinal Studies. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3646718/pdf/pmed.1001439.pdf [USA, Australia, India, Sweden, Nicaragua, South Africa].

This systematic review and meta‐analysis, including longitudinal studies published before February 2013, aims to investigate the links between intimate partner violence and depression and suicide attempts, and vice versa.

Some studies have, on the one hand, revealed that the contexts of conjugal violence were strongly and systematically associated with depressive disorders and suicides. A survey found that intimate partner violence doubled the risk of suffering from depressive symptoms.

On the other hand, there are associations in the opposite direction. An analysis showed that depressive symptoms doubled the risk of women being victims of domestic violence.

The present study confirms this bidirectional direction: women with depression are more likely to be in an abusive relationship, but being in an abusive relationship predicts a depressive disorder and thus increases the risk of a suicide attempt.

• Item 4:Feminist Citizen. (2019). Domestic violence: depression and suicidal desire. Retrieved from https://static.mediapart.fr/files/2019/10/02/enquete‐cf‐violences‐ conjugales‐et‐envie‐suicidaire.pdf [France].

The “Citizen Feminist” movement aimed, in the present investigation, to highlight the phenomenon of forced suicides. 584 victims responded to an online questionnaire.

It appears from his study that 76% of the victims declared having had suicidal thoughts, that 29% of them had attempted suicide and that 13% were hospitalized in psychiatry.

These figures can be explained by several reasons: the feeling that suicide is the only solution to end the pain felt; the will to find “peace”; the desire to resume controlthrough suicide; willingness to comply with expectations of the aggressor; the feeling of being unable to live without the perpetrator or the multiplication of constraints.

• Item 5 : Hirigoyen, M.‐F. (2009). De la peur à la soumission. Retrieved from https://www.cairn.info/revue‐empan‐2009‐1‐page‐24.htm [France]

This article aims to highlight the devastating effects of domestic violence on the health of women who experience it.

Violence between intimate partners can, first of all, cause psychological disorders such as anxiety, sleep disorders, difficulty concentrating, etc. These difficulties lead, for many of these women, to heavy consumption of alcohol, toxic or even psychotropic drugs.

A number of psychosomatic disorders may also present themselves. Some female victims may suffer from chronic pain, headaches, breathing difficulties, etc.

It is important to highlight that depression affects more than half of women victims of violence from their spouse. They would also make 5 to 8 times more suicide attempts compared to the general population.

• Item 6 : Chan, K. L., Straus, M. A., Brownridge, D. A., Tiwari, A., & Leung, W. C. (2008). Prevalence of dating partner violence and suicidal ideation among male and female university students worldwide. Retrieved from http://hub.hku.hk/bitstream/10722/60541/1/Content.pdf [21 pays]

This is a survey aimed at measuring the proportion, within a large sample of students, of people who have perpetrated physical and/or sexual violence against their intimate partner. It was also a question of making the link between domestic violence and
suicidal thoughts.

The study shows that there is a strong correlation between violence between intimate partners and suicidal ideation, both on the side of the perpetrators and that of the victims. It is depression that explains the relationship between dating violence and suicidal ideation.

The survey also highlighted the fact that women exposed to intimate partner violence are more likely than others to have attempted suicide. Rates of suicide attempts among female victims range from 20 to 26%.

• Item 7 : Chang, E. C., Yu, E. A., Kahle, E. R., Du, Y., Chang, O. D., Jilani, Z., Yu, T., & Hirsch, J. K. (2018). The Relationship Between Domestic Partner Violence and Suicidal Behaviors in an Adult Community Sample: Examining Hope Agency and Pathways as Protective Factors. Retrieved from
  https://www.researchgate.net/publication/320289498_The_Relationship_Between_Domestic_Partner_Violence_and_Suicidal_Behaviors_in_an_Adult_Community_Sample_Examining_Hope_Agency_and_Pathways_as_Protective_Factors/link/5c34bca8299bf12be3b798d3/download [USA]

98 people aged 18 to 64 took part in this study aimed at determining the links between hope, domestic violence and suicidal ideation.
Domestic violence has a heavy impact on the mental health of women who experience it. They are, in fact, more likely to suffer from, among other things, depression, anxiety, eating disorders and post-traumatic stress.
Studies have shown that 20% of female victims of intimate partner violence had threatened or attempted suicide in their lifetime. Although it is known that intimate partner violence can worsen suicidal behavior, few studies
were carried out to determine the potential protective factors that could reduce the risk that they adopt these said behaviors. This is why this article aims to determine to what extent hope could have an influence both on domestic violence and on the risk that it leads to suicidal behavior.
The results of the study that was conducted go in two opposite directions: hope can indeed attenuate the relationship between domestic violence and suicidal behavior but it can also exacerbate it. An explanation for understanding the second effect is as follows: the fact,
for a person, having a high level of hope can make them more vulnerable when faced with an accumulation of stressful life events, such as during experiences of domestic violence. However, further studies are needed to understand to what extent hope may be more or less beneficial for victims of intimate partner violence.

• Item 8 : Wolford‐Clevenger, C., & Smith, P. N. (2017). The Conditional Indirect Effects of Suicide Attempt History and Psychiatric Symptoms on the Association Between Intimate Partner Violence and Suicide Ideation. Retrieved from http://europepmc.org/backend/ptpmcrender.fcgi?accid=PMC5647881&blobtype=pdf [USA]

The purpose of this survey was to deepen the understanding of the link between violence between intimate partners and suicidal behavior, more specifically in the situation of women seeking shelter with ad hoc professionals. The study aimed to interrogate the impact of coercive control on suicidal thoughts. 134 women participated in this cross-sectional study. The survey highlights the fact that the victims seeking shelter have an increased risk of having had suicidal thoughts and attempted suicide (34%) compared to both other victims who do not seek such help (6.6%) and women in the general population (4.2%). These results may, among other things, be justified by the fact that these women are subject to coercive control by their spouses.

The concept ofcoercive control refers to: “repetitive strategies, some violent and some not, whose cumulative effects must be analyzed in their broader context of domination”.

It unfolds throughtwo mechanisms.

On the one hand, the perpetrator may resort to coercion. The latter refers to any strategy adopted by the perpetrator of the violence in order to get what he wants in the immediate future. The use of force or the threat to use it are methods that can be used in this regard.

On the other hand, the aggressor can use the control strategy. Control takes the form of a series of strategies that can take place at different times during the relationship. They can materialize through the deprivation of rights and resources and the imposition of micro-regulations. These refer to rules dictated by the executioner which can take multiple forms and which aim to maintain the control and domination of the perpetrator over his victim.

Thus, unlike violence between intimate partners, which is manifested by acts that take place according to a certain gradation and in an episodical manner, the notion of coercive control refers to the cumulative and invisible strategies that the spouse puts in place, some of which can be seen as less serious.

Numerous studies have, in fact, highlighted that coercive control was strongly associated with suicidal ideation and behavior.

It is the theory of fluid vulnerability that would make it possible to understand the links between coercive control, psychiatric symptoms and suicidal behavior. According to this theory, “stressors activate acute vulnerability to suicide through a
suicidal”, which involves distinct responses, favoring the risk of suicide, on the part of the cognitive, affective, physiological and behavioural/motivational systems”.
“Specifically, cognitive responses involve one or more negative core beliefs, such as worthlessness and hopelessness. The affective system is characterized by dysphoria, involving various negative mood states such as sadness, anger, and anxiety. The physiological components of this mode involve heightened arousal. The behavioral and motivational aspects of the suicidal mode involve a clear desire for death or the intention to end one’s life.
It is important to note that previous suicide attempts will create a lasting vulnerability, thus predisposing women victims to the activation of the suicidal mode. The latter will thus be activated more often by victims who have made several suicide attempts than by those who have made only one or have not made one due to the existence of this vulnerability to the suicidal mode.
Women in controlling relationships may be vulnerable to negative self-directed thoughts. It thus appears that victims who seek help suffer from depressive symptoms, post-traumatic stress disorder, despair, etc.
According to the theory of fluid vulnerability, these disorders increase the risk of adopting suicidal behaviors.

• Item 9 : Coker, A. L., Smith, P. H., Thompson, M. P., McKeown, R. E., & Bethea, L. (2004). Social Support Protects against the Negative Effects of Partner Violence on Mental Health. Retrieved from https://uknowledge.uky.edu/cgi/viewcontent.cgi?referer=&httpsredir=1&article=1114&co
  ntext=crvaw_facpub [USA]

The present survey was conducted among 1152 women victims of intimate partner violence, ranging in age from 18 to 65 years old in family medicine clinics between 1997 and 1999. The objective pursued was to determine what was the impact of violence on health
mental health of victims and to what extent social support could reduce this impact.

Violence between intimate partners has consequences on the mental and physical health of the victims. The latter are, in fact, more likely to suffer from drug dependence, symptoms of post-traumatic stress, depression, anxiety and behaviors
suicidal.

It appears, following this survey, that, among women who testified to the violence suffered from other people, those who received support from these people presented a reduced risk of having thoughts or adopt suicidal gestures. These victims were
less likely to have poor mental or physical health.

• Article n°10: Pico-Alfonso, MA, Garcia-Linares, MI, Celda-Navarro, N., Blasco-Ros, C., Echeburua, E., & Martinez, M. (2006). The Impact of Physical, Psychological, and Sexual Intimate Male Partner Violence on Women’s Mental Health: Depressive Symptoms, Posttraumatic Stress Disorder, State Anxiety, and Suicide. Retrieved from https://www.liebertpub.com/doi/pdf/10.1089/jwh.2006.15.599 [Espagne]

This study aimed to establish the impact of violence between intimate partners (physical, psychological and sexual) on the mental health of victims. To do this, a comparison between 75 physically and psychologically abused women; 55 women psychologically
abused; and 52 non-abused women; was conducted.

It appears that women victims of violence (whether physical and psychological or only psychological) have a higher risk of presenting depressive and anxious symptoms, post-traumatic stress and suicidal thoughts.

It should be noted that, according to this study, there is no difference in terms of impact on the health of victims between those exposed to physical and psychological violence and those exposed only to psychological violence . These results seem important in the
insofar as moral violence is still strongly considered to be violence of lesser gravity within the collective unconscious.

• Article n°11: Mason, R., & O’Rinn, SE (2014). Co‐occurring intimate partner violence, mental health, and substance use problems: a scoping review. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4240863/pdf/GHA‐7‐24815.pdf [Canada]

This literature review identified 35 articles examining the link between intimate partner violence and mental health, published between 2004 and 2014. The purpose of this work was to teach front-line mental health professionals what they needed to know to provide
appropriate care for women victims of intimate partner violence.

Declared an epidemic in 2002 by the WHO69, violence between partners, which mainly affects women, also takes on different forms and has more severe consequences for women.

These consequences include an increased risk of developing a mental health disorder, including, for example, addiction70, depression, dysthymia, suicidality , phobia, generalized anxiety disorder or post-traumatic stress disorder.

In particular, emotional or psychological abuse has been associated with low self-esteem, depression and post-traumatic stress disorder.

The risk of femicide has been associated with the presence of both depression and post-traumatic stress disorder. Alcohol use by the victim, on the other hand, was not associated with lethal risk. Indeed, in another study, victims who suffered the most severe forms of violence
were more likely to have comorbidities.

One possible explanation for the links between childhood and adult abuse and substance use is that childhood abuse can lead to low self-esteem, depression, anxiety, guilt and other issues. psychological, which in turn
result in vulnerability to adult victimization and self-medication via the products.