The Imposition of a Coerced Autonomy: Suicidal “Bad Girls,” Human Service Professionals,and Gender Bias

Abstract

Through a thematic analysis of four cases of suicide by young women identified from the National Coronial Information System, I apply a gendered lens to understanding the ways in which human service professionals’ expectations of feminine behavior, led them to view these young women as “bad girls” and imposed a disempowering “coerced autonomy” framework onto them. In this framework, the girls were held responsible for factors that caused their distress but were denied self-determination in their diagnosis and/or treatment. I aim to broaden our understanding of how gendered expectations can have fatal consequences.

Keywords

mental health qualitative sexual abuse,social work/social welfare history and philosophy,research categories suicide suicidal femininities

Globally, women are more suicidal than men yet men die by suicide at a greater rate than women (Paul, 2021; WHO, 2023), a phenomenon known as the “gender paradox of suicide” (Canetto & Sakinofsky, 1998). Despite a high representation of suicidality among women, as well as trans and nonbinary people (Bretherton et al., 2021; Hill et al., 2022), research into the gendered nature of suicide has primarily focused on men and masculinity (Jaworski, 2003, 2010; Mallon et al., 2016). The 2018 “MeToo” campaign, in which millions of people, particularly women, around the world came forward and shared stories of sexual assault, prompted a call for fairer representation of women in suicide studies and discontinuation of the “othering” of women in suicide research (Mallon, 2018). Furthermore, the quantitative nature of suicide research and policy has thus far provided a minimal understanding of suicidality outside of cis-gender males (Bretherton et al., 2021; Fullagar & O’Brien, 2015; Hill et al., 2022; Jaworski, 2010). For example, quantitative studies demonstrate that women who died by suicide had high levels of posttraumatic stress disorder (PTSD), yet provide little insight into factors that caused the trauma (Canetto, 1994; Mallon et al., 2016; Pemberton & Loeb, 2020).

While quantitative approaches provide little insight into why women in particular suicide, popular cultural discourses about women's suicide tend to focus on the tragedy of what I refer to as “bullied angels,” a hegemonic trope of suicidal femininity that maintains the hierarchy within femininities. Angels are after all “pure,” white, and virginal, untainted by sexuality and sexual desires (yet assumed to be heterosexual). Hegemonic femininity posits an “ideal” type of femininity, for example, white, thin, middle-class, and young virginal cis-gender women, and that these types are more deserving of social rewards such as access to services, employment opportunities, and less need for surveillance and control (Budgeon, 2014). The way such idealized perceptions of femininity intersect with suicidal young women is evident in recent media coverage of the suicide of 14-year-old Dolly Everett, a story that captured international headlines. Dolly was the child face of Australian hat brand Akubra. The campaign image pictured blond and smiling Dolly, wearing an oversized Akubra hat in rural Australia. After her death, this image became prominent, as Kennedy & Coulter argued, because her young, white, blossoming beauty was seen as a “symbol of [white Australian] nationhood” (Kennedy & Coulter, 2018, p. 1). Dolly's suicide was the catalyst for “Dolly's Law” which provides victims of online harassment to seek apprehended violence orders in NSW (NSW Government, 2018) and the creation of Dolly's Dream—a charity which aims to end bullying (Dolly's Dream, 2022). Similarly, the story of Megan Meier, a young, white, American girl, who was catfished and bullied by friends and neighbors, and died by suicide at the age of 13, gained international and online interest (Collins, 2008). Her family also created a foundation in her memory to combat bullying, cyberbullying, and suicide (Megan Meier Foundation, 2022).

While these deaths strike a chord in public consciousness and the individual situations are tragedies, when the media representations of these cases are analyzed from a gendered angle, we can see the expectations and ideals of gender embedded in them and the way that hierarchies of femininity are reproduced and maintained. Further, the “bullied angel” trope of female suicide overlooks the complex realities of young women who die by suicide, for example, the overrepresentation of Aboriginal and Torres Strait Islanders among those who suicide (AIHW, 2023) and the role of socioeconomic risk factors in increasing risk of suicide among First Nations (and all) women (AIHW, 2022a). This oversight is replicated in current quantitative research, where a reliance on large-scale quantitative data gives the impression of unbiased categories of patient symptoms and social issues to explain why people suicide, for example as the result of depression or relationship issues (Fullagar & O’Brien, 2015; Hjelmland, 2015). Yet, the data itself relies upon the collections from and reporting of friends, family, and professionals who were in contact with the person who died and thus inherently relies upon reporter interpretation and memory (Tait et al., 2015). These variables are therefore not outside the realm of cultural constructions: they have been shown to vary over time, space, and politics—as well as patient-to-patient and practitioner-to-practitioner (Appignanesi, 2008).

The purpose of this article is to provide visibility to the experiences of a group of young Australian women who died by suicide that are hidden in quantitative studies of suicide and overlooked in media representations of female suicidality. This group of women, some of whom were marginalized because of Indigeneity or ethnicity, experienced multiple adversities in their childhoods. They were frequently physically and sexually abused, engaged in drug and alcohol abuse, and had frequent contact with police and child welfare services. From a service perspective, these young women were “at-risk,” and in previous eras would have been described as “delinquent” (Carrington & Pereira, 2009; Fattore & Mason, 2020). They form part of the group of women whom Brown (2011) and Schippers (2007) describe with empathy as “bad girls.” These women, in terms of public perception, are a threat to and the polar opposite of the tragic “bullied angel”; they are objects of public derision and fear rather than sympathy (Fattore & Mason, 2020).

This article draws on feminist theoretical framings to analyze gender and draws upon concepts of “bad girl” and “pariah” femininities developed respectively by Brown (2011); and Schippers (2007). The article explores the distinction between the concept of hegemonic (or idealized) femininity and one of its counterparts, “bad girl” femininity, and how labeling a young woman as a “bad girl” characterized her experiences of structural marginalization as a mental health problem and so individualized and pathologized her struggles. This article applies this gendered analysis to the experiences of four young Australian women characterized as “bad girls” using coronial inquiries into their deaths by suicide. It identifies how the service system is supposed to assist these young women pathologized and thus failed to recognize and support their needs. The article presents two major findings. First, the young women's life circumstances were framed by human service professionals as “poor decisions” made by the women. Second, the young women were blamed for having been sexually assaulted. I illustrate the ways that expectations of femininity can influence mental health diagnoses and the treatment of “bad girls” by organizations of care and argue that mechanisms of framing and blaming form part of a broader occurrence of what I describe as “coerced autonomy,” a manipulation by human service professionals of the young women's options after they seek help. I argue that the awareness of the role of gendered expectations in service providers’ interactions with young women seeking help could affect treatment relationships and possibly treatment outcomes, as well as provide some understanding of the experiences of young suicidal women who are not “bullied angels.”

Theoretical Understandings of “Bad Girl” Femininity

The concept of “bad girl” femininity was developed by Brown (2011) and Schippers (2007) to identify and explain established hierarchies of femininities. “Bad girls” are at the bottom of a hierarchy that favors white, thin, middle-class cis-gender women, characterized as “can-do girls” who have “the world at their feet” (Brown, 2011; Budgeon, 2014; Harris, 2003). “Can do” girls represent a type of hegemonic femininity—an idealized femininity that has high social value over other types of femininity and that also reinforces masculine power. This hierarchy of femininities is significant in understanding why certain discourses of female suicide capture the public imagination. Women who embody “can do” femininity are described as able to reap the rewards of feminist achievements which include unwavering resilience and drive towards success, notions of individuality, self-invention, and a self-belief that they “can do anything” (Harris, 2003). The counterpart to this perceived self-determination is that responsibility for any deviation from the trajectory of success is placed on the girl herself (Harris, 2003), compliance with the ideal is essential to “can do” femininity. Vulnerable women, whether nonwhite, trans, queer, poor, or some combination of these, may have precarious housing, schooling, and communities, and are frequently unable to achieve this “can do” femininity. Instead, they are pathologized and deemed in need of surveillance and control (Francombe-Webb & Silk, 2016). In the worst cases, these women are considered “bad girls” (Brown, 2011).

“Bad girls” are the counterpart of “can do” girls. Their anger may manifest in aggression and violence, qualities that are perceived to demonstrate a lack of resilience and the self-control required for self-determination. Anger performed by “bad girls” also undermines the patriarchal systems in which they operate, whereas “can do” girls are seen to be self-determining and compliant within existing systems of power. In her review of critical girlhood studies, Brown (2011, p. 113) posited that “the bad girl commits violence, ranging on a continuum from indirect and verbal aggression to direct and physical expressions. She is nasty and she is rough.” Brown adds that “particular scorn is reserved” for violent “bad girls” (Brown, 2011, p. 114). Though “can do” girls may express anger, they can express it in ways that maintain their “niceness” and “goodness” (Reay, 2001) such as through petitions and seeking police aid, and, for “bullied angels” who die by suicide, through foundations and awareness campaigns. What the hegemony of “can do” girl femininity highlights is that female anger is often only recognized as legitimate when it is performed in ways that are controlled, that recognize and cater to or support existing authority, and that fit into expectations of female service. Further, these particular expressions of anger tend to be reserved for privileged cis-gender women (and their families)—typically white and middle-class—who have the language and resources to be able to speak to and within incredibly complex systems of power and, perhaps most importantly, be heard within them (Cooper, 2018; Phipps, 2021).¹

By contrast, the way “bad girls” express anger is associated with the kind of danger and violence typically associated with and reserved for masculinity. Schippers (2007) uses the concept of “pariah femininities” to describe women who perform traditionally masculine practices such as anger, violence, and substance use, and who become socially stigmatized as the result. In a hierarchy of femininities, where “can do” girls can be left to their self-sufficiency, the “bad girls” or “pariahs” who transgress expectations of femininity are perceived to need surveillance and control—not just to manage the threat they pose to themselves but the threat they pose to systems of power including a patriarchal gender order in which, in health settings, women's lives are mediated and controlled by medicalized “expert” views of their thoughts and behaviors both during life and posthumously.

Understanding and awareness of hierarchies of femininities, the ways they are constructed, and expectations of hegemonic femininity within them, help to identify how women who do not conform to hegemonic ideals, including women who are violent, may be viewed by human service professionals as noncompliant, mentally unwell, and in need of surveillance and control. Women who refuse to comply with the help they are offered and who do not submit to treatment are constructed as “bad girl” pariahs. These “bad girls” are treated as noncompliant even as they are expected to be compliant. Expectations of autonomy are used against these young women by the human service professionals they turned to for help. In their engagement with the service system, the young women in this study were constructed by human service professionals as responsible for their own situations, yet powerless because of their “illnesses” which affected the assistance offered by narrowing help to pathologized and paternalistic options. I describe this situation as coerced autonomy and explore it in the next section.

Methods

Suicide research is predominantly quantitative and positivist in nature (Atkinson, 1978; Douglas, 1967; Hjelmland & Knizek, 2016; Shiner et al., 2009). Over a decade ago, Hjelmland and Knizek (2010) examined the field of suicidology and discovered a bias towards quantitative methodologies with similar scopes creating repetitious research. They argued to instead shift the focus of suicide research from “explanations,” such as cause and effect, to “understanding,” for example, how a suicidal person interprets their own behaviors. These sentiments reflect a significant and necessary shift towards the use of qualitative research methods in suicidology (Hjelmland & Knizek, 2010). Doing so allows us to understand those outside the “highest risk” for suicide (highest risk, for example, being men, farmers, and veterans), and as the media may have us believe, bullied teenage girls. Instead, we can broaden understanding of suicidality to a variety of experiences and reflect upon how some human service professionals managed some human service professionals manages some women before their suicide. In this article, “human service professionals” refers to health professionals, such as general practitioners (GPs), psychologists, psychiatrists, and hospital staff; police; and case workers and other professionals from community welfare organizations such as social workers and child welfare workers.

The article is based on a qualitative analysis of Australian coronial data. Four cases of suicide were selected from the Australian National Coronial Information System (NCIS) between the years 2014 and 2017. These were the most recent fully completed years at the time of application to access the NCIS (applied for in 2019 for access in 2020). The NCIS is a database of all coronial cases in Australia dating back to 2000 except for Queensland which began in 2001 and all cases in New Zealand from 2007 (NCIS, 2018). The NCIS provides quantitative variables for each case such as sex, age, Indigenous status, employment status, marriage, status, etc. and is maintained and accessed by the Victorian Department of Justice and Community Safety.

The prevalence of people who identified as Aboriginal and/or Torres Strait Islander is likely underrepresented within the NCIS because identifying as Aboriginal and or Torres Strait Islander is complex. Since colonization began, many Aboriginal and/or Torres Strait Islander people have been and continue to be stolen from their families due to large-scale government policy. Many may not identify as or know that they could be Aboriginal and/or Torres Strait Islander or do not wish to be identified in administrative datasets due to stigmatization and racism from (white) officials (Grieve Williams, 2014; Tait et al., 2018).

Ethics was sought and approved by Macquarie University's Human Research Ethics Committee (HREC) Humanities and Social Sciences (HASS), reference number 5201834315018; The Justice Human Research Ethics Committee (JHREC), reference number CF/18/30054; and the National Coronial Information System (NCIS), reference number M0425.

Each case contains up to four relevant case reports by those who investigated the death. One report is by police who investigate the death and recent life of the person who died, one is an autopsy report, one is a toxicology report, the fourth is a finding written by the coroner about whether the death was deemed a suicide and, in many jurisdictions, why that decision was made. Some cases contain none or all four of these reports.

Reports on the NCIS can provide a rich archive for qualitative analysis. The data often provides an account of a person's death and their life. Reports can vary in detail, from one sentence to hundreds of pages of evidence and summaries. Many reports included opinions and reviews from specialists, such as case reviews by impartial psychiatrists and psychologists at the request of the coroner. The evidence provided to the coroner includes notes taken while the person was alive, for example case notes from psychologists or GPs. There is also some variation in detail regarding Indigeneity. It is not always clear whether a person described in the cases was Indigenous, with the Indigenous origin field needing to be requested during the application process to the NCIS. However, in some cases Indigeneity or ethnicity is mentioned either by the coroner, the police, or the pathologist.

The first step in the analytical process was to review a pool of 172 cases of women who died by intentional self-harm (suicide) aged 15 to 19 because this is the highest age group for hospitalizations for self-harm (AIHW, 2022b). Each case was noted for use of hospital services before their deaths, which narrowed the cases further (n = 41). From there, indicators of “marginalization” such as sexual and/or physical assault (n = 33), drug use (n = 32), and/or violence perpetration (n = 7) were noted for further analysis.

From that pool of cases, the second step was to review the cases again and make a brief note of what happened and what broad themes could be identified. Due to the large variation in the detail and quantity of the data provided in each case, only cases with sufficient data to undertake a robust qualitative analysis were included, for example, the included cases had long, detailed histories, rather than a summary of the events leading up to death; multiple accounts and inputs from various sources, rather than just one or two people who found the body; and included coronial inquests or investigations. The young women identified had complex lives and needs and were frequently in contact with many types of care services such as police, child welfare officers, and health professionals. Pertinent information from the cases were copied from the NCIS and pasted into a password-protected Microsoft Word document for each case with all identifying information removed. From here they were reviewed again and coded for common themes regarding the girls’ use of human services which also included notes and memos within the document which spoke to the other cases and eventually hegemonic femininity and coercive autonomy. These documents were the foundations for the results section. Excerpts from the de-identified coronial cases which were copied into that file are reproduced in the “Results” section of this article. Two aspects of the cases were identified from the second step: that there were tensions between human service professionals and the young women's narratives and there was a commonality of victim blaming throughout the coronial process.

Having identified these initial findings, the third step was to return to academic literature to make sense of the themes identified. Concepts of “bad girl” and “pariah” and “hegemonic femininity” helped to provide the framework for further analysis. Application of these theories to the cases helped me to develop the concept of a coerced autonomy—that the girls’ treatment options were narrowed or retracted due to the human service providers’ perception of the young women as “bad girls.” This was achieved through a returning back and forth between the cases, the themes, the literature, and testing the burgeoning concept of a coerced autonomy. Based on this iterative process of analysis, the themes discussed in the next section were identified and used to organize the findings.

A final sample of four young women was chosen to allow for an in-depth qualitative analysis, with the aim to emphasize their individuality and personhood through the use of coronial cases (Fincham et al., 2011). The four cases also allowed for a degree of representation of similar experiences shared by young women whose cases were not included because they had less data or fewer indicators of “badness,” but who nevertheless may have encountered similar experiences with human service professionals due to being framed as “bad girl” or being blamed for their abuse throughout the coronial process. The aim of the sample was not to explain suicide generally, but to provide enough data to compare, contrast, and find similarities among young women who asked for help yet still died by suicide.

Qualitative analysis of coronial cases, though not representative of suicides generally, provides important insights into the social context of suicide (Scourfield et al., 2012). Though it may be argued that the sample was small, or the sampling created a confirmation bias, using small cases, as few as one, to identify systematic issues is one of the reasons coroners conduct inquests. Further, it is through this in-depth study that we can identify and attempt to change social and systematic problems and make recommendations for policy changes that are in the public interest. This qualitative approach allows for the analysis of social structures, such as gender hierarchies, while also maintaining the “fuzzy, messy reality” of coronial cases (Fincham et al., 2011, p. 44).

The cases of “Annabelle,” “Danielle,” “Alice,” and “Kelly” were analyzed (all identifying information has been changed or omitted). Each case was initially re-read through and coded for particular experiences and descriptions. To create and write the themes, there was constant back and forth between the codes, write-up, and data (Braun & Clarke, 2006). The themes were identified through an inductive analysis of the interactions between each young women and human service professionals and how these were portrayed within the context of the coronial inquiries (Braun & Clarke, 2006).

Results

Two findings demonstrate how human service professionals imposed coerced autonomy upon the young women by framing them as “bad girls.” First, the young women were described as powerful enough to have created their life circumstances through a series of “poor decisions” yet were diagnosed with a psychiatric model used to explain these poor decisions as manifestations of their mental illnesses. By framing them as “bad girls” human service providers held the young women responsible for any negative behaviors while denying them positive forms of power. Although human service professionals maintained the young women created their circumstances, they denied the young women any expression of their agency by punishing them for those circumstances. The second finding is that when the young women were sexually assaulted, they were overtly blamed or dismissed by those they turned to for help because they were intoxicated at the time of the assault.

The experiences of Danielle, Alice, Annabelle, and Kelly (aged between 15 and 19 years) are used to demonstrate coerced autonomy. Their cases are summarized below. The purpose of these vignettes is two-fold. One is to provide a sense of how their lives were constructed in the coronial cases, and what few details were provided regarding their individuality. Where such comments were given, they are noted as well as indicators of their “badness.” The second purpose is to give a sense, albeit briefly, of the adversity these young women experienced in their lives, to center their experience, and to restore their personhood which was undermined and erased by the imposed focus on their “badness.” Each provides a brief overview of their circumstances, including their interactions with human services.

Danielle

Danielle started to show symptoms of anxiety and depression since primary school. Her grades started dropping, and she had frequent contact with a range of human service professionals. She told her school counselor that she was feeling suicidal and then spent years in and out of hospital for her mental health. She had been residing in an assisted living hospital for teenagers for some years before the center closed. She had moved to an adult ward, where she died by suicide. She was described by the clinical director of a health facility she lived in as having an “emotionally unstable personality disorder,” and by a psychiatrist and acting clinical director of the same facility as having “a history of abuse and trauma including extra-familial sexual abuse and intra-familial physical abuse,” and engaging in alcohol and substance abuse. She was often in conflict with friends and family members. The clinical director described “many instances of self-harm and threats of suicide” which sometimes needed “on occasion three nurses at arms-length to ensure her safety from herself.” Danielle was sexually assaulted twice in the weeks before her death. Her case notes recorded the breadth of her contact with human services: “She had leisure and recreation therapy, interventions from social work, occupational therapy, dietetics, pharmacy, speech pathology, and psychology. She attended dialectical behavior groups and was supported to attend a church youth group.”

Alice

Alice was described by the director of the secure care center she had spent time in as a “bright, intelligent, outspoken and witty young woman who had a caring nature.” Alice was dedicated to her family including her mother and younger siblings. Alice was Aboriginal² and was in and out of foster placements. She was described in a report by child protective services as getting into “violent clashes” with women and girls, did not attend school, and had disengaged with services. Alice had health issues from childhood, including sexually transmitted diseases as a result of many sexual assaults. She was under the care of the State after being removed from her parents’ care along with her brothers and sisters. Not long before her suicide, Alice had been released from a “secure care center.” The center was described by its director as a trauma-informed “last resort” for children, who are involuntarily placed for therapy. The coroner noted the facility was “essentially a prison” and “would not be appropriate […] to attempt to provide therapeutic services to traumatized children over an extended period.” Alice had involuntarily stayed at the center multiple times. Alice was in contact with case workers, psychologists, social workers, hospital staff, and police before her suicide. Her behaviors by various care providers were described as “challenging” and “increasingly difficult,” and she was noted to frequently abscond from care.

Annabelle

Annabelle had an extensive history with an array of human service professionals. At one point Annabelle disputed her diagnoses. Annabelle was transitioning into living independently from a long-term mental health ward. She had a strained relationship with her mother with whom she was living during the transition. She was afraid of her brother, who had physically assaulted her in the past, but who had recently started living with the two women not long before her suicide. Annabelle had broken up with her boyfriend of some years, a man who had been convicted of various crimes after he had physically and sexually assaulted her. She had a long history of suicidality, self-harm, drug use, and complex mental health issues. Her case manager noted “when [Annabelle] was in elevated moods she displayed irritability, agitation, aggression, destruction to property and homicidal thoughts.”

Kelly

After her death, police described Kelly as homeless and known to exchange sex for drugs. She stopped attending school a year or so before she died. Her mother, Justine, tried to get help for them both after Kelly started becoming suicidal years before her death. She was known to self-harm and had tried suicide before. Kelly was raped by a man she trusted in the months before her suicide. There was very little description of Kelly in her coronial report beyond her social and mental health issues, but she appeared to like horse riding and had a loving relationship with her grandmother. Kelly had frequent contact with a GP, emergency hospital staff, police, and a psychologist. Though she frequently reached out to services for help eventually she became “difficult to assist,” as described by a doctor in her local emergency department and stopped engaging with services.

Coerced Autonomy: The Repositioning of Social Problems as Individual Responsibility and the Subsequent Narrowing of Options for Treatment and Care

This article's first finding is that coerced autonomy was imposed in the context of the individualization and pathologization of social problems, particularly sexual trauma and abuse, and how social problems were described as “poor decisions.” Sexual assault increases the risk for suicidal thoughts and acts (Dworkin et al., 2022) and problematic substance use (Ullman, 2016) which also increases the risk of suicidality (Poorolajal et al., 2016). This section explores the way these young women reacted to and coped with their social circumstances, such as through substance use and aggression, was reframed by human service professionals as symptoms of mental illness which repositioned the reasons for the behaviors from social to individual (Appignanesi, 2008; Brown, 2011) and both inside and outside the young woman's control.

Because the young women's social problems were repositioned in the manner outlined above, the coerced autonomy imposed on them did not so much involve them being forced to do something because of their perceived “badness,” but rather denied or limited the options provided to them by those with the power to offer help. This coerced autonomy is a product and reflection of gendered notions of femininity and mental illness as well as dichotomies of compliance and noncompliance, good and bad, and submission and autonomy, evident in the interactions between young women and those in positions of power in the service professions.

The young women were expected to be “can do” girls: to know how and when to ask for help when they needed it and to accept the help they were offered—to be compliant. Yet, when the young women acted autonomously, for example when they questioned their diagnoses, treatments, and/or their circumstances, they were labelled by human service professionals as noncompliant and troublesome highlighting a need for a trauma-informed care to be embedded in all care settings to avoid a traumatization of victims (Huo et al., 2023). Their perceived noncompliance was used as a basis for further diagnoses which further characterized their behaviors negatively and subsequently influenced the services made available to them. Specifically, diagnoses of personality “disorders” or “vulnerabilities” by health providers were often used to undermine the young women's autonomy and channel them into more restricted “client pathways” (Pollack, 2010).

A section of Danielle's report described her diagnosis of “severe” borderline personality disorder (BPD), and included a vague mention by a visiting psychiatrist that “her condition was characterized by […] a general impairment of her judgment.” However, the only specific “impaired judgment” referred to was her “episodic substance misuse.” Further, another psychiatrist mentioned “she exposed herself to risky unwanted sexual activity” while using alcohol. Danielle, Kelly, and Annabelle were all mentioned to have BPD, a condition which was regarded, at least in Danielle's case, as incurable. A psychiatrist, and the acting director of the health facility Danielle lived in, noted at inquest that she “did not think [Danielle] was going to be cured or be in remission from her personality and this was an enduring issue for her, which would require ongoing management.” In this context, we can see quite a distinct line being drawn by those in charge of her care from Danielle's occasional substance use and experiences of violence to characterize her circumstances as “judgments” she made and pathologize her problems as issues with her personality.

Other coronial reports were more direct in casting the young women's circumstances as their decisions. For example, the “much older adult males” who sexually assaulted and abused Alice when she was an underage child were described by the coroner as “men she chose as intimate partners.” Further, Alice was characterized by the coroner to have “continually placed herself at high risk including […] sexually transmitted diseases, […] poor physical health, being hit by a car when intoxicated […]” indicating some assumed level of control by Alice over the repercussions of her experiences of childhood trauma, social issues, or accidents. These depictions and treatment of the young women as poor decision-makers by human service professionals place the onus of responsibility for their circumstances on the young women themselves. In Alice's case, the responses of coroners and health professionals to her Aboriginality reproduce the neo-colonial understanding of Black women's bodies as exploitable for sex and “for the taking” (Behrendt, 2000; Conor, 2015).

Underpinning the presumed failure of the young women to make the “right” choices are deeply ingrained notions of hegemonic femininity which include whiteness, as well as tensions between autonomy and powerlessness in depictions of “symptoms” of their illnesses. On one of her many foster-care placements, Alice accused her foster parents of abuse. Alice, a young Indigenous woman, and her siblings were taken from her parents due to allegations of child abuse committed by her biological parents. The allegations against her parents were not corroborated by the children, however, when it came to the children's claims against their foster parents, the coroner noted:

Although a claim by [Alice] and her siblings that the caregivers were yelling at them, calling them names, and hitting them was not substantiated, the placement broke down. This was said to be due to [Alice]'s increasingly difficult behaviors and the caregivers’ limited capacity to manage these behaviors.

Alice, who was approximately 10 years old when she made the accusations against her foster parents, was held responsible for her poor behaviors and the breakdown of the foster placement while also not being a reliable source to substantiate allegations of abuse because of these behaviors.

Further, a coerced autonomy imposed upon the young women by the human service professionals following attempts at self-advocacy was highlighted by Annabelle's attempts to take control of her mental health. Annabelle, like many of the young women, was described as oftentimes “noncompliant” with her treatments as she questioned the validity of her diagnoses and subsequent treatments. Her compliance to medications was also framed as a barometer for her “insights” into her illness.³ Annabelle was principally diagnosed with Bipolar Affective Disorder⁴ but disputed this diagnosis and instead believed that she had complex-PTSD. Despite Annabelle seemingly never disputing that she had a mental illness, Annabelle often did not comply with her medication regime. During the inquest into her suicide, this noncompliance was used to indicate that Annabelle did not have insight into her bipolar diagnosis or mental health. Approximately a month after a culmination of events in which Annabelle was sexually assaulted, an incident of domestic violence in which she was the victim, and the subsequent breakup with her boyfriend, Annabelle had an appointment with her psychiatrist. During this appointment, Annabelle reported she had stopped taking her medications a month before. At the appointment her psychiatrist noted that:

She was goal orientated and identified her main goals were getting her pension and […] to live independently […] and appeared keen to continue follow up [… He] thought [Annabelle's] insight was present but limited, indicated by the fact that she had stopped taking her medications.

Here we see the “bad girl” framing and imposition of coerced autonomy: Annabelle's apparent good control over herself and her future was undermined by what the psychiatrist determined was her limited insight into her illness indicated only by her not taking medication she did not believe was appropriate for her. Her psychiatrist noted at inquest that she had come back a month and a half later asking for medications:

Against a background of previously ceasing medications against advice and being encouraged to recommence them, this was considered by [the psychiatrist] to be a positive sign because it showed [Annabelle] had insight into the fact her condition required treatment and because it showed a willingness to seek help.

Despite Annabelle's “willingness to seek help,” her psychiatrist failed to mention that Annabelle was not only regularly seeing him, but regularly seeing a private psychologist, a case manager, and an occupational therapist, an arrangement she had complied with for many years before her suicide. She was very active in her treatments and therefore willing to seek help. The psychiatrist's reduction of Annabelle's willingness to seek help (and her desire to take control of her issues and her illness) down to compliance with her medications diminished her self-advocacy regarding her diagnoses and treatments up to that point, a common issue in psychiatric settings (Shafer et al., 2016). She was expected to only take control of herself within the parameters of her treatment schedule, which she disagreed with in the first place. At the session mentioned, Annabelle wanted to restart her antidepressants, not her schedule of antipsychotics, which were prescribed for her bipolar diagnosis. She died a few months after this appointment with a mix of antipsychotics, anxiolytics, and antidepressants in her blood which indicated that she had recommenced her bipolar medications as per her psychiatrist's advice not long before her suicide.

Similarly, Kelly's case showed many instances of coerced autonomy through her interactions with help providers, including police and hospital staff. The following two excerpts are over a 3-day period less than a month after Kelly had been raped while she was under the influence of methamphetamines. During this 3-day period, Kelly accessed several services, including going to her GP and then to hospital. By the time she went to the GP, she had told police, her psychologist, and her mother about the rape.⁵ The GP visit, however, is pertinent to illustrating coerced autonomy because this was the last time Kelly voluntarily sought help from health services before she died some months later.

On [date] [Kelly] went to see [her GP] to obtain a pregnancy test. She disclosed suicidal thoughts, specifically of hanging herself. She acknowledged she had been using ice but stated this was not over the last three or four weeks. She also stated she had been drugged and forced to have sex and that was why she was concerned about possible pregnancy. The test was performed and was negative.

Here we see that Kelly attended her GP to ask for a pregnancy test. She reported she had been off methamphetamines for some weeks, possibly because she was worried she was pregnant. There was no mention of her GP offering anything to her beyond the pregnancy test, despite her indicating she was suicidal with a method in mind (increasing her risk of suicide), reporting a rape, and reporting being currently clean from drugs. Here we see a level of compliance from Kelly, she has sought help from an appropriate source and she has been forthcoming about why she was there. This can be interpreted as Kelly self-advocating and actively help-seeking. She received a negative pregnancy test and according to what was reported at her inquest that was the extent of her GP's response.

When analyzing this episode through the lens of “bad girl” femininity and coerced autonomy, we can see the absence of care provision from the GP. Further, the fact that Kelly's suicidality intensified after the GP visit should not be discounted as a coincidence. She went to the emergency department the evening of her GP visit and was admitted to the hospital for 2 days. The hospital file notes that summarized her discharge arrangements said:

On [date 2 days later] [Kelly] was discharged […] on the agreement that [Kelly] would re-engage with the long-term treating psychologist. Unfortunately [Kelly’s psychologist] was unable to contact [Kelly the next day]. [Kelly’s psychologist] had no means of engaging with [Kelly]unless [Kelly]wished to do so. Her mother confirmed that unfortunately [Kelly]had been refusing to engage with any services. It remained open for [Kelly] to contact the service, but she did not do so.

Kelly was released on the proviso that she would see her psychologist, which she did not do. However, when taken into context, it is clear that Kelly had been engaging with services: she had been to her GP where she disclosed her issues, and then was voluntarily admitted to the hospital for suicidality for some days. Up until that point she had been forthcoming about being raped, her drug use, and her suicidality with health providers and police. It seems this was Kelly's final attempt at help-seeking. We can see from her GP's lack of response to her needs that she turned instead to emergency services, during which time she appeared to lose trust in human service professionals.

After her visit to the GP and the emergency department above, it appeared that Kelly acquiesced to her role as a “bad girl” until her suicide. Her final visit to hospital includes a doctor noting she was “swearing at staff […] angry and dismissive […] not co-operative.” Her final hospital discharge notes included a list of treatments and options provided to Kelly during her stay. Midway, the notes said, “crisis numbers given.” Yet, the last note said that she “may not contact services due to no phone.” Kelly was not provided a phone.

Kelly's situation, as well as Danielle's, Alice's, and Annabelle's, crystalizes how a coerced autonomy was imposed upon the young women by human service professionals. The young women attempted to self-advocate and sought help for their circumstances: Alice for accusing her foster parents of abuse, Annabelle for questioning her diagnoses, and Kelly for seeking help for suicidality and potential consequences of being raped. Each young woman's attempts to get help were similarly undermined by human service professionals who cast the young women as “bad girls.” In the process, these professionals missed the opportunity to offer support to a trauma victim and in doing so contributed to their retraumatization. Further, human service professionals at inquest overlooked their acts of help-seeking and advocacy and instead framed the young women's noncompliance, sexual histories (both wanted and unwanted) and substance use as evidence that they were responsible for their negative circumstances. There was an expectation that the young women would seek help and comply without question, and those who questioned the help received or did not comply completely were blamed by human service professionals for their adverse life circumstances. In Danielle, Annabelle, and Kelly's cases, they were labeled with a personality disorder. We now turn to a particular example of coerced autonomy following disclosure of sexual assault.

The Coerced Autonomy Following a Disclosure of Sexual Assault

Each young woman experienced sexual assault proximate to their suicide. Each provided details to care organizations about their assault and each one was subsequently blamed for the assault, or the seriousness of the assault dismissed because she was intoxicated at the time of the assault. As shown in the previous section, Kelly's disclosure to her GP regarding her rape and subsequent need for a pregnancy test was largely ignored with no care provided beyond the pregnancy test requested. Other young women were provided a little more attention.

Danielle was sexually assaulted twice in the weeks before her suicide. She told staff in the assisted living hospital where she resided that both assaults happened while she was taking drugs with friends. The first occurred in her room in the mental health ward. Nursing staff mentioned giving her “support” (not elaborated upon) and offering for her to make a statement to police, which she declined because she said she did not say “no” to the perpetrator. There was no indication that nursing staff tried to support Danielle or provide information about what qualified as assault, for example, not saying no does not mean it was not rape. Two weeks after the first assault, the only follow-up was that she “had attended the [recommended] drug and alcohol group on [date] where [Danielle] was able to identify the risk associated with cannabis use.” Though it does not specifically say so, in this context the “risks associated with cannabis use” likely included the perceived heightened risk of sexual victimhood, as this was the only mention of counseling provided following the assault.

Similarly, Annabelle told her case manager that she had been sexually assaulted, the coroner reported her case manager told the inquest during her appointment:

[Case Manager] assessed [Annabelle's] vulnerability risk as moderate to high based on the fact she was reporting placing herself in risky situations with others and through engaging in substance abuse, which impaired her ability to make good decisions [… and] her risk-taking behavior […] may reflect personality vulnerabilities […]. [Case Manager] noted [to Annabelle] that this would need ongoing therapy rather than these “crisis” presentations.

Annabelle's sexual assault was minimized to a “risky situation” while she was using drugs with her boyfriend (who was alluded to as “with others” in that section of the report). Notably, all four young women took drugs with, and were subsequently assaulted by, people they knew well and trusted: boyfriends and friends, the types of relationships most commonly involved when people take drugs with others (AIHW, 2020) and not commonly associated with the “risk” suggested by Annabelle's case manager. Again, Annabelle's decision-making was questioned because she used drugs and then experienced sexual assault. Further, the case manager suggested Annabelle's “impaired” decision making was due to her “personality vulnerabilities.” Annabelle was informed her issues needed long-term therapeutic solutions outside of “crisis presentations,” undermining Annabelle's judgment regarding when to seek help and for what reasons.

Drug use, sexual assault and their link to coerced autonomy was most evident in Kelly's case. A couple of days after Kelly was sexually assaulted there were references to her mentioning it to police and hospital staff in notes regarding an attendance to the emergency department:

She informed the Emergency Department Registrar that she had been using cannabis, MOMA and amphetamines. It was after she had taken a large amount of drugs that she experienced a “freak out” and went to the police station in [town]. She wanted to report that something had happened to her while she was living with a 42-year-old drug dealer. However, she was unable to provide a statement at the time because she was affected by drugs. […] she was considered to be difficult to assist […] She punched the wall in the ward and fractured her finger. [Three days later it was noted] She gradually stabilized […] she had “emerging cluster B personality traits, borderline type.” This was complicated by her substance abuse. She was affected by methamphetamine intoxication at the time of her admission.

At inquest, Kelly's psychologist noted she had been updated by Kelly's mother about a week later that the police were still “following up [Kelly]’s complaint of being sexually abused […] whilst she was under the influence of ice.” Yet, there was no mention of any complaints made by Kelly in the police report provided to the coroner following her suicide some months later. The only allusion to her sexual assault was that “[Kelly] is known to associate with drug users in the [local] area[s].” The constant reminders that Kelly was a drug user in these extracts regarding her sexual assault depicted Kelly as someone beyond help.

The perception that Kelly was beyond help was echoed by the executive director of the hospital Kelly sought help from on her final visit before her suicide. The executive director noted, “[h]er long-standing difficulties and chronic risks associated with multiple health-risk behaviors were unlikely to benefit from acute inpatient mental health treatment.” Despite Kelly asking for help from the right places including the police and the emergency department, she was too “affected by drugs” to provide a statement to police or receive treatment. Instead, she was tentatively diagnosed with a personality disorder after she acted violently in hospital following a sexual assault. There was no mention of the use of a rape kit or any further investigation into her allegations. Only a note on her final admission to the hospital mentioned that Kelly was “At risk of being abused by others (sexually and violently) due to substance use.” This note reiterated that it was Kelly's choices, including her drug use, which had, and may continue to, get her sexually assaulted.

The young women's experiences indicate the complex state of coerced autonomy and the gendered expectations the young women constructed as “bad girls” faced when seeking help. Human service professionals justified imposing coerced autonomy on the young women by blaming them for their circumstances, including sexual assaults, based on their pathological and/or inherent badness, particularly in the context of substance use. Experimentation with substances is associated with hegemonic masculinity and this association functions to police gender behavior (Dempster, 2010). Young women who experiment with or use substances and/or alcohol are depicted as “unfeminine” and immoral, “slutty” and “in danger” of exploitation by men (Day et al., 2004; Hutton et al., 2016). Maintaining a level of decorum and moderation, particularly in regard to substance use and sexuality, is associated with “respectable” femininity (Hutton et al., 2016). This evidences a tension between expectations of class and femininity, in which young women who use drugs and alcohol and who are also “at risk” become highly immoral subjects in need of surveillance and management (Cossens & Jackson, 2020; Harris, 2003). Good girls do not get intoxicated and, therefore, are not sexually assaulted. For the young women who died, their intoxication was depicted as symptomatic of their “bad” personalities by health professionals they turned to for help.

Discussion and Conclusion

Through applying Brown's (2011) “bad girl” and Schippers’ (2007) “pariah” femininities to coronial cases, we can see a common story in which young women who were angry, violent, and/or drug users who asked for help appeared to be provided enough autonomy to be blamed for their adverse circumstances yet were denied autonomy in their treatments and care. This “coerced autonomy” was identified in a variety of situations between the young women and the people they turned to for help. In many instances before the girls’ deaths, service providers blamed the young women for their adverse life situations by reframing their circumstances as resulting from their “poor decisions.” In particular, the young women were pathologized both when they had been sexually assaulted while intoxicated and when they did not respond to these assaults with a performance of “can do” femininity. Human service providers granted the young women enough autonomy to hold them responsible for their assaults because they had chosen to be intoxicated yet allowed them no responsibility or agency in contributing to their own diagnosis or treatment. This coercive autonomy reinforces young women's dependence on human service professionals for help while simultaneously undermining their abilities to use the help they were (or were not) provided.

Each young woman asked for help on numerous occasions. It is at this intersection—between being “good” and asking for help yet being labeled “bad” because of the pathologization of what they seek help for—that we begin to see how the young women's autonomy became coerced by human service professionals. The young women were acknowledged to have enough power to be able to make their “poor decisions.” However, because their resulting behaviors were constructed as “symptoms” of a mental illness, the young women were re-cast as powerless in their attempts to seek help from those in a position to provide it. They were able to “decide” to be noncompliant but the noncompliance was also understood to be a symptom of their illnesses/badness, so when they questioned the help provided to them, these discussions were framed as illustrative of their inherent “bad” or “disordered” personalities, rather than attempts to self-advocate and gain power back over their bodies, their lives, illnesses, and treatments.

The term “personality disorders” was described by Appignanesi as “a diagnostic dump bin” (2008, p. 444), used as a means of labeling extremely difficult-to-treat “deviant” behaviors such as anger, resentment, and impulsiveness, particularly among women. These behaviors were used as evidence to negatively characterize the young women as “bad girls,” particularly following their sexual assaults while intoxicated. The characterization could then be used as a means of excluding them from treatment (Bergmans et al., 2015). Further, Chesler (1989) argued that these same behaviors—anger, resentment, and impulsiveness—can instead be understood as attempts to overcome female powerlessness, which in turn become pathologized and highlight a tension between compliance and noncompliance. The gendered tensions between powerlessness and attempts to overcome it are evident in the diagnostic criteria of BPD.

A BPD diagnosis could be interpreted as the diagnostic equivalent of being a “bad girl,” as BPD is one of the most stigmatized disorders a person can receive (Kulkarni, 2017). People with BPD are characterized as showing symptoms of “frequently express[ing] inappropriate, intense anger or have difficulty controlling their anger (Criterion 8). They may display extreme sarcasm, enduring bitterness, or verbal outbursts” (APA, 2013). The use of the word “inappropriate” to describe a behavioral symptom should not be overlooked and feeds into complex notions of expectations of femininity which implies a judgment on how one ought to respond to adverse situations. Furthermore, Kulkarni argues that the symptoms of BPD are common to individuals experiencing complex trauma and the diagnosis ought to reflect this external trigger of the behaviors, rather than a diagnosis that positions the behaviors as part of the sufferers’ personality (Kulkarni, 2017). All the young women, except for Alice, were either tentatively (emerging cluster B personality traits, borderline type) or definitively diagnosed (specific diagnosis was…) with BPD and each experienced multiple forms of violence and, more specifically, sexual assault.

Through the in-depth, qualitative analysis of only young women who died by suicide, this article has broadened our understanding of suicide by increasing the visibility of suicidal women who do not fit into the existing “high risk” profile, and by moving away from large-scale quantitative explaining of suicide which often included the “othering” of women. Though none of the four women in this article were identified as LGBTQ+ or other forms of marginalized identities, such as culturally and linguistically diverse (CALD), or experiencing disability, this does not mean that such people do not experience a coerced autonomy. Other people, such as those who are LGBTQ+, disabled, and/or CALD are also penalized in hierarchies of femininities and likely also experience a coerced autonomy in health care settings. This is an important avenue for future research.

Nonetheless, this article has highlighted the role of sexual assaults in the trajectories of suicidality among young women. Further, this article has expanded upon the trope of the young suicidal girl which emphasizes the idea that young women who die by suicide are bullied, white, angels. Similar to the way in which Scourfield et al. (2012) illustrated the role of gendered expectations in their qualitative study of masculinities among men who died by suicide, this article has shown how gendered expectations of femininity can profoundly impact interactions between young women seeking help and those who provide it. Through this approach, we have seen how gendered norms are (re)constructed among narratives of suicide.

The article demonstrated how the young women attempted to break out of the mold of “bad girl” by seeking appropriate care but were failed by the service system because of how they were perceived and lack of trauma informed care. Posthumously, we can see that the perception of the young women as “bad” continued in the evidence provided by human service professionals at inquest and further in the way this evidence was reported by the coroners in their findings. The reproduction and reinforcement of the “badness” of the young women via the coronial investigations into their deaths served to construct the young women's deaths as inevitable rather than avoidable. The privileging of the opinions of the professionals who constructed the young women as “bad” in the first place undermined the women's efforts whilst they were alive to seek help and break out of the “bad girl” pariah mold which continued after they died.

One of the main implications for social work and human service practice from the findings is the importance of holistic preventative approaches to human services and social work practice, especially approaches informed by anti-oppressive, anti-racist, and feminist underpinnings and that are trauma-informed (Dominelli & Campling, 2002; Fook, 2012; Levenson, 2017; Matteson, 2013). These approaches emphasize the need to understand an individual's place within wider social structures and frameworks, such as gender, race, disability, and class. Such approaches aim to challenge how systems, bureaucracies, organizations, and policies intersect with communities and individuals based on these social structures with varying degrees of efficacy in order to provide equal guidance to people in need of human services (Burke & Harrison, 2002). In the case of the young women, use of these approaches would have meant they were taken seriously when they voiced concerns about their situations and importantly, were not blamed for their sexual assaults but rather, empathized with and empowered to make choices they felt were right for them through discussion and empathy. Though we will never know if sufficient supports had been in place that the young women may not have died by suicide, we can postulate that if anti-oppressive, anti-sexist and anti-racist support was there for young women following their assaults which focused upon empowerment (Dietz, 2000), the young women may have at least been spared frictions with the human service professionals they turned to for help.

It is notable that these approaches to social work practice share some similarities with common suicide prevention models outlined in the suicide literature such as using gendered understandings of suicidal behaviors to support young people before crises get to the point of suicidal events (Canetto, 2021). However, suicide prevention models, such as the National Suicide Prevention Strategy 2020–2023 developed by the Australian Commonwealth could also be usefully informed by radical social work principles such as anti-oppressive, anti-racist, and feminist grounded and trauma-informed approaches to prevention (Dominelli & Campling, 2002; Fook, 2012; Matteson, 2013), by more fully acknowledging the role of power and forms of inequality in suicide.

A further implication for social work and all human services practice is the need for approaches similar to novel suicide prevention initiatives, such as those outlined in the National Suicide Prevention Strategy 2020–2023 (NSPPRG, 2020), rather than a focus on individual crisis intervention. These are “upstream” or preventative human service interventions which are centered upon “at risk” communities, such as Aboriginal and Torres Strait Islander communities that empower those community members to have control over interventions, treatments, and planning (Sjoblom et al., 2022). This moves away from neo-liberal understandings of “individual” issues and allows for intersectional understandings of people's experiences within larger structural policy, governance, and frameworks (Fook, 2012).

Despite the portrayal of the coronial process as “neutral,” we can see how power plays through the use of assumed “bureaucratic objectivity” in coronial cases (Fincham et al., 2011, p. 68). Similarly, Fincham et al. (2011) found that human service professionals who provided evidence at inquest asserted that appropriate care was provided and therefore, failure was the responsibility of the patient. Within the coronial reports analyzed here, the young women's attempts to seek help were frequently downplayed in the reporting of them. Alice, Danielle, Kelly and Annabelle were described in the coronial findings as unwilling to seek help despite having been in frequent contact with care services. The role of the coroner is often described as someone who will discover what happened before and after a death (Coroners Court NSW, 2020) and as they are “fact finders” in search of the “truth” (Victorian Government Solicitor's Office, 2022) these quite disparate interpretations of situations, such as how active the young women were in their treatment, become portrayed and detailed by those who are alive to tell their version of the story.

Though the role of the coroner is not to lay blame or find guilt, there is still a chance a person could be referred to their respective workplace's governing body or police for reprimand. So, it is no surprise that there may be some level of self-protection occurring among professionals called upon to provide evidence at inquest. These efforts to characterize the young women as bad girls are made simpler by the assumption that happy, stable young women tend not to suicide. Painting the picture of an unstable, angry, violent girl whose suicide seemed inevitable due to her own inability to look after herself is a more palatable story as to what happened than the alternative: young women who experienced trauma and who did not behave in “acceptable” feminine ways while seeking help were undermined and dismissed and ultimately found their autonomy through suicide.

Footnotes

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Harriet Townsend

Notes

Author Biography

Harriet Townsend is a scholar in the Discipline of Sociology, School of Social Sciences, Macquarie University, Sydney. Her work looks at normative expectations of gender and their role in understanding deaths by suicide among women. She uses a feminist informed sociological autopsy approach.

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