Worldwide, nonfatal deliberate self-harm is common among young people. However, when studying this phenomenon, methodological issues arise. Differences between genders have been found in presenting to the hospital following self-harm and in motive for engaging in this troubling behavior.
In this article, we highlight some of the methodological issues that arise when conducting research into the prevalence of deliberate self-harm. We provide an overview of the literature, focusing on gender differences among adolescents who engage in deliberate self-harm, and we summarize the findings relating to gender from our school-based survey of over 6,000 adolescents from England aged 15 and 16 (Hawton et al., 2002; Rodham et al., 2004). Finally, we highlight the implications of these findings for clinicians and health professionals.
Prevalence of Adolescent Deliberate Self-Harm
In the United Kingdom, adolescents are involved in more hospital presentations to general hospitals for deliberate self-harm than any other age group, with females in the 15- to 19-year age group being particularly vulnerable (Hawton et al., 2003, 1997). Worldwide, nonfatal deliberate self-harm is common in young people, especially young females (Schmidtke et al., 1996). (Many acts of deliberate self-poisoning or self-injury involve nonsuicidal intentions, especially in adolescents [Hawton et al., 1982]. As a result, the term deliberate self-harm is increasingly used in Europe to denote any nonfatal acts of self-harm, irrespective of the intention.)
Paradoxically, although suicidal ideation and attempts are more common among females (Garrison et al., 1993; Gould et al., 1998; Grunbaum et al., 2002), suicide is more common among males. This is true for North America, Western Europe, Australia and New Zealand (Gould et al., 2003). This finding is supported by our in-depth review of the international literature focusing on the prevalence of suicidal phenomena in adolescents in the general population (Evans et al., in press). For example, the rates of suicidal thoughts and behaviors in females were at least 1.25 times higher than those in males, and for suicide attempts in the previous year, the rate in females was more than twice that in males.
Evidence regarding the prevalence of deliberate self-harm in adolescents usually comes from three main sources: 1) historical information from psychiatric samples; 2) hospital admissions; and 3) general population or epidemiological surveys. While all three sources provide valuable evidence on the problem of suicidal behavior in adolescents, the prevalence of suicidal phenomena will be underestimated and a distorted picture of the population provided if the reliance on prevalence is placed just on hospital admissions or psychiatric samples. For example, many adolescents who present to general hospitals with deliberate self-harm report previous episodes for which they did not receive medical attention (Hawton et al., 2002; 1996). Furthermore, hospital-based studies are likely to only include individuals who are situated toward the extreme end of the continuum of suicidal behavior (i.e., those involved in acts with more serious physical consequences). Studies of psychiatric samples are likely to be even more biased.
Nevertheless, hospital-based studies have shown that deliberate self-harm is common among adolescents, with an estimated 25,000 presentations to general hospitals annually in England and Wales alone (Hawton et al., 2000). We also know from community-based studies that many adolescents who engage in deliberate self-harm do not present to hospitals (Choquet and Ledoux, 1994) and that those who do so, often report previous episodes without hospital presentation (Hawton et al., 2002, 1996). The underestimation of overall prevalence of deliberate self-harm in hospital-based studies may be greater for females than males because males select more dangerous methods for self-harm and are consequently more likely to receive medical attention (Canetto, 1997; Cantor, 2000; Choquet and Ledoux, 1994; Kann et al., 2000; Pearce and Martin, 1993). Community-based population studies are, therefore, considered to be the method likely to provide the most accurate information on the prevalence of suicidal phenomena.
Until recently, no sizeable community studies of deliberate self-harm in adolescents in the United Kingdom had been carried out. With the exception of Meltzer and colleagues (2001), who conducted an interview-based study of over 4,000 adolescents and their parents, studies that have been conducted in this field have been small. In a study in London of 529 females aged 15 to 20 years who were screened for evidence of depression, Monck and colleagues (1994) found that nearly 13% had suicidal ideas in the month beforehand. In a student sample in Birmingham, England, 63% of females and 45% of males reported having had suicidal ideas, with actual acts of deliberate self-harm in 4% and 1.5% respectively (Salmons and Harrington, 1984). In a more recent survey of Oxford University students, 35% of the females and 31% of the males reported thoughts of suicide (Sell and Robson, 1998). Self-harm by cutting or other means was reported by 10% of females and 5% of males. Thus, although community studies have been conducted in the United Kingdom, many have relied on data collected from either small or convenience samples, and, therefore, the extent to which these studies include representative samples of adolescents is uncertain (de Wilde, 2000; Yuen et al., 1996).
Factors Associated With Deliberate Self-Harm
In our large-scale, school-based study (Hawton et al., 2002), we found that deliberate self-harm within the previous year was far more common in females than in males (11.2% versus 3.2%, respectively). Interestingly, although there was such a large difference between the percentages of males and females who reported engaging in deliberate self-harm, the proportions of each who actually presented to the hospital were remarkably similar, with only slightly more males (14.7%) than females (12.3%) reporting that they had been to the hospital as a result of deliberate self-harm in the previous year. As mentioned earlier, this may be reflective of the fact that males tend to select more dangerous methods for self-harm and are, therefore, more likely to receive medical attention (Canetto, 1997; Cantor, 2000).
For both genders in our study, there was an incremental increase in deliberate self-harm associated with an increase in consumption of cigarettes, drugs and alcohol (Hawton et al., 2002). Furthermore, multivariate analysis showed that factors significantly associated with deliberate self-harm in the past year in both females and males were having friends who had recently self-harmed, family members who self-harm, drug use and low self-esteem. In addition to these factors, depression, anxiety and impulsivity were independently associated with deliberate self-harm among females, but not males. For both males and females, having an awareness of peers who had engaged in deliberate self-harm was significantly associated with the likelihood of the adolescents having engaged in deliberate self-harm themselves.
Gender Differences in Motivation
An important aspect of understanding the factors that lead to deliberate self-harm is an examination of the motives (or intentions) behind the act. A number of studies have focused on this issue (e.g., Bancroft et al., 1979, 1976; Hjelmeland et al., 2002; Williams, 1986). These studies have, however, all been confined to patients admitted to the hospital as a result of self-poisoning. There are two limitations to this approach. First, those who engage in deliberate self-harm but who do not go to the hospital as a result are not included. Such a strategy omits this potentially large group of individuals who self-harm but do not receive medical attention. Second, since the focus of these studies has been solely on individuals who take overdoses, our current understanding of the motives involved in deliberate self-harm can only be applied to those who take overdoses and receive medical treatment rather than to the general population of adolescents who self-harm.
We examined the gender differences in motives of adolescents who self-harm who took part in our school-based study and compared those who engaged in self-poisoning with those who chose self-cutting (Rodham et al., 2004). We found that only 6.31% of those who engaged in self-cutting compared to 22.9% of those who engaged in self-poisoning reported that they had gone to the hospital as a result of their deliberate self-harm episode (thereby reinforcing the importance of widening the scope of the research in order to focus on a more comprehensive sample than simply one of patients admitted to hospital).
There were no gender differences within the group of participants who engaged in self-poisoning. However, females who self-cut compared to males who self-cut were far more likely to explain their self-harm episode by saying that they had wanted to punish themselves. They were also more likely to say that they were trying to get relief from "a terrible state of mind."
Implications for Professionals
Although in cross-sectional research (such as our school-based study [Hawton et al., 2002]) it is not possible to determine a causal relationship between the factors investigated and the incidence of deliberate self-harm, it is possible to demonstrate whether or not an association exists between them. The multivariate analysis we conducted indicated that specific factors were independently associated with deliberate self-harm among our adolescent sample. For example, for both genders, simply being aware of peers who had engaged in deliberate self-harm was a factor that was strongly associated with their own likelihood of engaging in deliberate self-harm. This association suggests a possible modeling effect, which is in accordance with other evidence on contagion of suicidal behavior in adolescents (Gould et al., 1989) and clearly has implications for how schools can help to manage suicidal behavior, as well as the involvement of clinicians and health care professionals in the design and evaluation of school-based prevention initiatives. At the very minimum, we suggest that it is of paramount importance to educate young people about alternative approaches to solving problems, as well as teaching them how to recognize their problems and contact different sources of help.
Finally, we have shown that when males and females are compared, different factors are associated with deliberate self-harm. For example, depression and anxiety were much more noticeably associated with deliberate self-harm in females. Furthermore, we found significant gender differences in terms of the motives that were offered by adolescents who self-cut to explain their self-harm episode (Rodham et al., 2004). Males who self-harm have typically received far less attention than females, yet recent work has indicated that just as many males as females who self-cut are seen in accident and emergency departments (Hawton et al., 2004). Thus, for the clinician assessing adolescents who self-harm, the findings of our study highlight the need to include an exploration of the motives for engaging in self-harm and a recognition that there may be significant gender differences in the reasons offered. Furthermore, the health care professional engaged in designing a program for the promotion of mental health should contemplate addressing the following issues: self-esteem, depression, anxiety and impulsivity while considering that a different emphasis of each issue may be required in order to address the differences we have identified between the two genders.
Dr. Rodham is a chartered health psychologist and lecturer at the University of Bath, England.
Dr. Hawton is director of the Centre for Suicide Research at the University of Oxford, England.
Ms. Evans is a trainee clinical psychologist at the University of Oxford, England.
Bancroft J, Hawton K, Simkin S et al. (1979), The reasons people give for taking overdoses: a further enquiry. Br J Med Psychol 52(4):353-365.
Bancroft JH, Skrimshire AM, Simkin S (1976), The reasons people give for taking overdoses. Br J Psychiatry 128:538-548.
Canetto SS (1997), Meanings of gender and suicidal behavior during adolescence. Suicide Life Threat Behav 27(4):339-351.
Cantor CH (2000), Suicide in the western world. In: The International Handbook of Suicide and Attempted Suicide, Hawton KE, Van Heeringen K, eds. New York: Wiley & Sons, pp9-28.
Choquet M, Ledoux S (1994), Adolescents: Enquete Nationale. Paris: INSERM.
de Wilde EJ (2000), Adolescent suicidal behaviour: a general population perspective, In: The International Handbook of Suicide and Attempted Suicide, Hawton KE, Van Heeringen K, eds. New York: Wiley & Sons.
Evans E, Hawton K, Rodham K (in press), Factors associated with suicidal phenomena in adolescents: a systematic review of population-based studies. Clin Psychol Rev.
Garrison CZ, McKeown RE, Valois RF, Vincent ML (1993), Aggression, substance use, and suicidal behaviors in high school students. Am J Public Health 83(2):179-184 [see comment].
Gould MS, Greenberg T, Velting DM, Shaffer D (2003), Youth suicide risk and preventive interventions: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry 42(4):386-405 [see comment].
Gould MS, King R, Greenwald S et al. (1998), Psychopathology associated with suicidal ideation and attempts among children and adolescents. J Am Acad Child Adolesc Psychiatry 37(9):915-922.
Gould MS, Wallenstein S, Davidson L (1989), Suicide clusters: a critical review. Suicide Life Threat Behav 19(1):17-29.
Grunbaum JA, Kann L, Kinchen SA et al. (2002), Youth risk behaviour surveillance-United States, 2001. J Sch Health 72(8):313-328.
Hawton K, Fagg J, Simkin S (1996), Deliberate self-poisoning and self-injury in children and adolescents under 16 years of age in Oxford, 1976-1993. Br J Psychiatry 69(2):202-208.
Hawton K, Fagg J, Simkin S et al. (1997), Trends in deliberate self-harm in adolescents in Oxford, 1985-1995. Implications for clinical services and the prevention of suicide. Br J Psychiatry 171:556-560 [see comment].
Hawton K, Fagg J, Simkin S et al. (2000), Deliberate self-harm in adolescents in Oxford, 1985-1995. J Adolesc 23(1):47-55.
Hawton K, Hall S, Simkin S et al. (2003), Deliberate self-harm in adolescents: a study of characteristics and trends in Oxford, 1990-2000. J Child Psychol Psychiatry 44(8):1191-1198.
Hawton K, Harriss L, Simkin S et al. (2004), Self-cutting: patient characteristics compared with self-poisoners. Suicide Life Threat Behav 34(3):199-208.
Hawton K, O'Grady J, Osborn M, Cole D (1982), Adolescents who take overdoses: their characteristics, problems and contacts with helping agencies. Br J Psychiatry 140:118-123.
Hawton K, Rodham K, Evans E, Weatherall R (2002), Deliberate self harm in adolescents: self report survey in schools in England BMJ 325(7374):1207-1211.
Hjelmeland H, Hawton K, Nordvik H et al. (2002), Why people engage in parasuicide: a cross-cultural study of intentions. Suicide Life Threat Behav 32(4):380-393.
Kann L, Kinchen SA, Williams BI et al. (2000), Youth risk behavior surveillance-United States, 1999. MMWR CDC Surveill Summ 49(5):1-32.
Meltzer H, Harrington R, Goodman R, Jenkins R (2001), Children and adolescents who try to harm, hurt or kill themselves. London: Office for National Statistics. Available online at: www.statistics.gov.uk/ downloads/theme_health/Childselfabuse_v1.pdf. Accessed Dec. 2, 2004.
Monck E, Graham P, Richman N, Dobbs R (1994), Adolescent girls I. Self-reported mood disturbance in a community population. Br J Psychiatry 165(6):760-769.
Pearce CM, Martin G (1993), Locus of control as an indicator of risk for suicidal behaviour among adolescents. Acta Psychiatr Scand 88(6):409-414.
Rodham K, Hawton K, Evans E (2004), Reasons for deliberate self-harm: comparison of self-poisoners and self-cutters in a community sample of adolescents. J Am Acad Child Adolesc Psychiatry 43(1):80-87.
Salmons PH, Harrington R (1984), Suicidal ideation in university students and other groups. Int J Soc Psychiatry 30(3):201-205.
Schmidtke A, Bille-Brahe U, DeLeo D et al. (1996), Attempted suicide in Europe: rates, trends and sociodemographic characteristics of suicide attempters during the period 1989-1992.
Results of the WHO/EURO Multicentre Study on Parasuicide. Acta Psychiatr Scand 93(5):327-338.
Sell L, Robson P (1998), Perceptions of college life, emotional well-being and patterns of drug and alcohol use among Oxford undergraduates. Oxford Review of Education 24(2):235-244.
Williams JM (1986), Differences in reasons for taking overdoses in high and low hopelessness groups. Br J Med Psychol 59(pt 3):269-277.
Yuen N, Andrade N, Nahulu L (1996), The rate and characteristics of suicide attempters in the native Hawaiian adolescent population. Suicide Life Threat Behav 26(1):27-36.