Self-harm

Sex and Gender-based Analysis of this topic

Definition
Non-suicidal self-injury (NSSI) refers to bodily injury without the purpose of suicide, but results in some type of tissue damage [see also Suicide; 1]. Deliberate self-harm (DSH) is an umbrella term that includes all forms of self-inflicted injury regardless if it includes suicidal intent and/or tissue damage. According to the Canadian Institute for Health Information (CIHI), the primary mode of self-injury is poisoning (85%), followed by cutting/piercing (10%), and suffocation/strangulation (2%) [2]. Small scale studies continue to identify cutting, scratching, and burning as the most common forms of self-injury [3].

Approximately 140 women per 100,000 are hospitalized daily for self-injury [2]. Although hospitalization rates for self-injury have decreased over the last decade by approximately 15% [4], hospitalization rates only include those who are admitted to the hospital for their injuries. Emergency department data from the National Ambulatory Care Reporting System (NACRS) may provide more representative data on self-injury compared to hospitalization data [5]. It is estimated that the existing data on self-injury may be underestimated by approximately 60% as emergency data coded as “undetermined” may be NSSI or DSH. 
 
 
Sex Issues
The onset for self-injury among females is typically between the age of 14 and 24 years [3]. According to hospitalization data from 2009-2010, 58% of self-injury hospitalizations were for females [2]. Self-injury among women is more likely to result in inpatient hospitalizations and emergency department visits [2, 6]. Women are more likely to engage in self-injury, whereas men are more likely to complete suicide [7]. The rate of self-injury among those with mental illness comorbidities is common [2], however, some researchers have identified the importance of viewing self-injury as a coping response to certain social contexts rather than as symptom of any particular disorder [8]. 
 
 
Gender Issues
Emergency department visits for cutting/piercing or poisoning injury are more likely to be coded as self-injury in women compared to men of the same age group (under 65 years) [5]. Between the ages of 12 and 17 years, the number of self-injury cases among females was more than four times (1,536) the number of male cases (368). 
In addition to a history of mental health issues, self-injury may be the result of stressful life events, an environment characterized by abuse and/or loss, family or friends’ histories of suicides or self-harming, and/or difficulty with interpersonal relationships (e.g., social isolation) [9, 10]. A history of abuse or other invalidating experiences may result in low self-esteem and self-loathing for women, which have been identified as important factors leading to self-injury [3]. Reasons for engaging in self-injury among women include: regulation of affect (e.g., to reduce tension or relieve dysphoric feelings); self-punishment; interpersonal distress; sensation seeking; and anti-dissociation mechanisms [3]. As a result of feeling powerless, women may engage in self-injury to gain a sense of control. 
 
 
Diversity
Adolescence is a particularly sensitive period during which self-injury may begin due to societal pressures to fit in with peers and/or general difficulties with family, friends, or school [8, 11].  

Self-injury rates vary from province to province, with lower provincial rates among Prince Edward Island (55 per 100,000) and Ontario and Manitoba (58) compared to New Brunswick and Newfoundland and Labrador (81) [4]. Compared to the provinces, self-injury rates are substantially higher in the Yukon (192) and Nunavut (379). According to data from CIHI, individuals from less affluent neighbourhoods have twice the rates of self-injury compared to individuals from affluent neighbourhoods [2]. In more affluent neighbourhoods, parental criticism and youth alienation may be associated with self-injury behaviours [12].  

New forms of social media may provide a manner for women to communicate and compare their self-injury via blogs and videoblogs [13] which may glamorize self-injury behaviour(s). In one study, 15% of participants stated that their self-injury behaviour was motivated because of television and/or movies [3]. 
 
Equity
Self-inflicted physical pain may give women a sense of power in light of the powerlessness they feel in their lives. A history of sexual and/or physical abuse is common among women who engage in self-injury [14]. Engaging in self-injury may help women cope with the stress and emotional pain of past or present distressing and/or oppressive conditions in their lives [15]. Punitive methods and approaches to women who engage in self-injury may further exacerbate the women’s distress levels and lead to additional self-injury.

Neighbourhood income is an important factor in regards to self-injury. Women from low income neighbourhoods may exhibit high rates of self-injury due to additional stressors, such as violence and family poverty, which may also contribute to women’s overall feelings of powerlessness [2].
 
 
Critique
The NACRS, which tracks emergency department data and can provide useful information on self-injuries, has not been implemented across Canada [5]. Further, Canada does not have a national strategy to address self-injury [2]. Implementation of such a strategy and using the NACRS would help identify and track all self-injury behaviour(s) more concisely and help improve the existing research and subsequent prevention education on self-injury in Canada. In particular, additional education and awareness is needed for various health care professionals (e.g., family physicians) as women often seek out health services prior to presenting for acute medical care as a result of DSH [16].
 
 
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