Bradley Secker/Demotix. All rights reserved.

Erbil, Iraq—More than 60 percent of 14-year-old Belen’s* body is burnt. The afternoon sun shone through a window to reveal a fragile girl lying motionless in her hospital bed at the burn unit at West Erbil Emergency Hospital in northern Iraq, her mother by her side. The unit was eerily quiet and cold, and modern like so many other buildings popping up in the region.

Belen lay still as Dr. Zawand Alrashaeed, the resident doctor who’d been assigned to show me around, pulled back her sheet to show the extent of her burns. Her body was thickly bandaged except for her face and parts of her legs. Her mother interrupted to pass around sweets—an unwavering gesture of Kurdish hospitality.

To help Belen heal, a skin graft would be made from healthy skin on her legs to replace the scared skin on her abdomen and neck, Dr. Alrashaeed explained. While Belen was stable—those with such serious burns carry a high chance of mortality—she still had a long way to go.

“I come from a poor family in a rural area,” Belen said. “I had a fight with my family.” She paused and began crying softly. Without going further, it was clear this was no accident.

“Sadly this was a case of attempted suicide,” Dr. Alrashaeed said as he turned to me and shook his head. “She didn’t have access to medication and drugs like you do in the west.” Had Belen had the chance, she would have attempted suicide with pills, he implied.

Belen, like most women in Iraq who set themselves on fire, had doused herself in kerosene from head to toe. And like Belen, most women who attempt this grisly form of suicide generally come from poorer rural areas.

Self-immolation as a dramatic form of protest is well documented across the Middle East, from Egypt to Morocco. The Arab spring was triggered in 2011 in Tunisia when Mohamed Bouazizi set himself on fire after claiming he was slapped by a policewoman. But since the fall of Saddam Hussein, it has become an alarmingly common trend in the Kurdish region of northern Iraq. But why?

While some doctors estimate self-immolation has claimed the lives of as many as 10,000 women since the region gained autonomy in 1991, reliable data is scarce. Some doctors I spoke to say there are incidents of self-immolation every day, others refute the claim and say media reports have inflated the issue.

According to the hospital’s most recent figures, there were 1,000 outpatients with burns covering less than 20 percent of their body in November alone. An additional 70 patients with severe burns were admitted and seven patients had burns to more than 80 percent of their body; only two survived.

Doctors here say that even at the best burn units in the world, there’s a high mortality rate for those with burns covering more than 75 per cent of the body. If a burn is severe, doctors want to immediately accelerate the healing process to reduce the risk of infection. Once the patient is stable, which usually takes a month or so and involves twice-daily dressings, she undergoes reconstruction. While a woman’s chance of survival is greater if she makes it to the hospital, there is still the risk she will die from kidney failure or infection.

Unlike Belen, however, most of the other women I spoke with at the burn unit in the heart of Iraqi Kurdistan’s capital, which housed about eight women, claimed their burns were accidents: a cooking accident or a problem with their heater.

One woman’s body and face was so badly burnt she was unrecognizable; another woman, 25 year-old Parishan, had burns over 57 percent of her body—a heater accident, she whispered.

There has been anecdotal evidence to suggest the incidence of self-immolation has been getting worse but it’s difficult to paint an accurate picture of the scope of the problem because of a lack of reliable figures.

While often the decision to self-immolate is made by a woman herself to escape a life of shame or misery, others are pressured by family members.

A major barrier preventing an understanding of the size and nature of the problem is that when women are hospitalised for burns, they almost always pretend it was an accident for fear of retaliation from the perpetrator, fear of further violence and/or fear of being homeless.

Many women don’t even make it to hospital—they die from their burns before they reach the emergency department—and it is difficult to tell from forensic evidence alone whether the person committed suicide at their own will, or was coerced or even murdered.

“We just don’t know the extent of the problem,” Dr. Lawand Meran, director of West Erbil Emergency Hospital, explained. “If a woman burns herself, when the police show up to investigate, she’s afraid and she denies she did it to herself. She says it was an accident.”

Dr. Meran and neurosurgeon Dr. Ali Muhaydeen said the Erbil governorate had seen an increase in the number of burns since 2010. The doctors attributed the increase to the influx of Syrian refugees in 2011 and the present day crisis: peshmerga wounded by improvised explosive devices (IEDs) laid by the Islamic State and the internal displacement of hundreds of thousands of people who use fire for heating and cooking. Accidents are common but so is pretending it was accident.

Doctors and NGO workers I spoke to about the issue provided a glimpse into a highly patriarchal society marred by honour killings and gender-based violence.

Dr. Ahmed Amin is the director of the Trauma Rehabilitation and Training Centre (TRTC), a small mental health clinic, which was founded in 2007 in Sulaymaniyah, a city in southern Kurdistan.

Dr. Amin painted a grim picture of Kurdish history as context to begin to understand the self-immolation phenomenon. The Iraqi Kurds not only suffered decades of trauma and torture under Saddam’s ruling but violence meted out by the Kurdish authorities, namely the Kurdistan Regional Government (KRG).

“Mental health hasn’t been taken seriously for years,” he said, adding he had no shortage of patients who’ve experienced beatings, rape, mock executions and emotional abuse. Often, Dr. Amin said, it’s common for those who’ve experienced torture to inflict it on others in other forms such as gender-based violence.

“Imagine what life she's living through so as to prefer death by burning,” he added.

Despite a law passed in 2008 criminalising honour killings as murder, they are still common in Kurdistan and enforcing the law remains a challenge.

Many women feel trapped in arranged marriages and with few other options turn to suicide to escape. Another form of abuse taking place across the region is coerced self-immolation. In essence, as one NGO worker explained to me, the woman is told by her husband or male relative “tomorrow you will not be here, make yourself disappear”. And she does just that.

Nearly all female suicides in Kurdistan happen in the home, where women have access to flammable liquids such as kerosene. “A woman can’t go outside without the permission of her brother, father or husband,” Dr. Meran pointed out.

For the women who do survive, seeking protection and help in both the legal and psychological sense is not only difficult but also highly stigmatised.

“If they burn themselves intentionally, it’s a social problem and we don’t interfere. To us, the cause is important but why is not so important,” Dr. Meran said. “Mental illness is like a prison sentence here.”

One organisation trying to change that mentality is the Heartland Alliance, which is piloting a new program in Sulaymaniyah, whereby a patient and her family work together with doctors, psychologists and nurses to make patient-centred care decisions. In a first, the organisation is also helping doctors to work together with lawyers.

“We’re trying to implement a new way of thinking,” Heidi Diedrich, Iraq coordinator of the Heartland Alliance, said. The NGO works with the burn unit in Sulaymaniyah and the Ministry of Health and for Diedrich, the ability to run such a program in Kurdistan is evidence enough the Kurds want to instigate change in the community.

Diedrich stressed that once a woman is released from hospital, the first three or four days are critical—it’s the time a woman is most likely to attempt suicide again.

“We need to educate those at risk. The youth hold the key on what needs to change,” she said.

But as Dr. Meran pointed out, for those women who make it back home, reintegration is tough. They have to not only cope with their physical changes that will stay with them for life but the realisation that they’re back in the same situation as before.

“It’s a very painful choice to make. Sometimes the woman survives and she’s a cripple. She’s worse off.”