2011 2nd International Conference on Behavioral, Cognitive and Psychological Sciences
IPCSIT vol.23 (2011) © (2011) IACSIT Press, Singapore
Gender Differences in Non-Suicidal Self-Injury: Are They on the
Verge of Leveling Off?
Ingrid Van Camp1+, Mattias Desmet1 and Paul Verhaeghe1
1
Department of Psychoanalysis and Clinical Consulting, Ghent University, Belgium
Abstract. Aims: Traditionally, non-suicidal self-injury (NSSI) is considered to be a mainly feminine
phenomenon. The last decade, however, empirical reports of the gender ratio seem to vary extensively. In this
study prevalence, gender ratio and methods of non-suicidal self-injury are assessed, and compared to the
findings of contemporary literature.
Methods: Prevalence and gender ratio were assessed by means of a self-report questionnaire during a mass
screening of Belgian first-year psychology students. This screening was cross validated by means of the SelfInjurious Thoughts and Behaviors Interview, for participants who engaged in NSSI more than once lifetime
rate. This interview also assesses the age of onset of NSSI and the self-harming methods that were used.
Results: No difference in prevalence or age of onset between genders was found. Differences in methods of
NSSI were observed, but were smaller than expected. Possible explanations for the apparent disappearance of
gender differences are discussed.
Keywords: adolescents, deliberate self-harm, gender differences, non-suicidal self-injury.
1. Introduction
Non-suicidal self-injury (NSSI) is defined as the intentional direct injury of the own bodily tissue
without conscious suicidal intent [1-2]. In the United States it is also known as deliberate self-harm (DSH)
[3-5]. It is distinguished from suicide attempts and ritually or culturally sanctioned body modification (e.g.
piercings) [2]. While some older studies refer to this behavior as self-mutilation, most authors [6] now
reserve this term for the more severe mutilating forms that are associated with psychosis. NSSI is a rapidly
increasing phenomenon in today’s society, in high-income industrialized countries as well as for example
among street children in developing countries [7]. In general it is assumed that about 4% of the general adult
population in Western countries suffer from a NSSI problem. In studies of psychiatric patients this
percentage varies between 4.3% and 77% [8-9]. In several empirical studies in the United States the NSSI
percentages varied between 14% and 21% for high-school students and between 14% and 35% for university
psychology students [4].
These percentages are very divergent. Also as concerns the gender ratio, there is little consensus.
Roughly there are two tendencies. One of the most consistent findings in the research literature until the end
of the 20th century was that NSSI occurred 1.5 to 3 times more in females as compared to males [10]. On the
other hand, many recent studies failed to establish a difference in gender ratio [11-16]. This is nonetheless
not a consistent finding, since some studies still obtain gender differences [17-19]. Also many clinical
practitioners still see NSSI as a mainly feminine problem. This raises the important question whether NSSI
in males has been underestimated both in the past as in current clinical practise, or whether a leveling off of
the differences between males and females is occurring.
We believe that both answers are partly true and that NSSI in males has been underestimated in the past
because of differences in the self-harm methods that were used, and because of a focus on mainly feminine
+
Corresponding author Tel.: + 32/9/264.63.54; fax: +32/9/264.64.88
E-mail address: Ingrid.vancamp@UGent.be
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samples. On the other hand, we also believe that because of a change in male role patterns a leveling off
might be occurring. In order to illustrate this hypothesis we give an outline of our research in first-year
psychology students. Literature shows that there not only seems to be a general increase in the prevalence of
NSSI [10, 20-21], but that this phenomenon also occurs more and more in out-patient treatment [22], as well
as in individuals who seek no treatment at all [23]. Therefore we chose to conduct our study in a community
sample as opposed to a clinical sample. We expected to find no difference in gender for the prevalence of
NSSI. For the methods of NSSI that were used, we expected that punching into doors or walls, and burning
would be masculine forms of NSSI [24], and that scraping and cutting would be feminine forms [17].
Hawton and Harriss [25] link gender differences in the onset of NSSI to the earlier onset of female puberty,
with the accompanying elevated vulnerability for affective disorders. Therefore we also expected an earlier
onset of NSSI in females because of a different pace of development for both genders in early adolescence.
2. Study 1: Screening for a History of NSSI.
2.1. Participants
Questionnaire packets were distributed to 471 first-year psychology students at the beginning of a class
session of a regular course at a large Belgian university. Students were informed that the testing process was
voluntary and that they had the option of discontinuing participation at any time. All participants signed
informed consent forms, after which they were given ample time to fill in the packet before the actual lecture
started. Participants were not compensated. Four hundred and fifty-nine of the test packets were completed,
resulting in a response rate of 97.45%. Twelve students chose not to participate. Since the aim of this
screening was to study NSSI in young adults, four participants over the age of 30 were excluded from the
analysis. The mean age of the remaining participants was 18.69 years (s: 1.169, n = 455), ranging from 17
years to 27 years.
2.2. Measures and Procedure
The mass testing was introduced as a study concerning the relationship between emotions and certain
types of riskful behavior. The test packets consisted of four questionnaires. Questionnaires 1, 2 and 4 were
part of another study. Questionnaire 3 was our screening questionnaire. This procedure was chosen to
conceal the actual purpose of the screening. The study was approved by the universities Ethics Committee.
Riskful behavior questionnaire (RFB): This questionnaire was developed specifically for this screening. It
consists of 12 items that assess the amount of different kinds of riskful behavior that the participant engages
in. Items include outwardly directed aggression, verbal aggression, engagement in dangerous sports,
vandalism, excessive drinking, drug abuse, smoking, gambling, shop lifting, lying, suicide attempts and
NSSI. Test item 9, which screened for NSSI, was phrased: “Have you ever intentionally hurt or injured
yourself without the intent to die?”. The same procedure of using a single screening item was followed by
Briere and Gil [11] and in the Self-Harm Behavior Questionnaire [8, 26]. The 12 test items (RFBa) were
answered on a five-point Likert scale, ranging from 1 (‘never’) to 5 (‘regularly’). For each item participants
were also asked to indicate how riskful they actually considered the behavior to be (RFBb). Here also they
were instructed to answer on a five-point Likert scale ranging form 1 (‘not at all riskful’) to 5 (‘indeed very
riskful’). In order to look for differences between self-harmers and non-self-harmers the total for RFBa was
calculated without item 9 (pertaining to NSSI). This total is presented as RFBa(-9). For RFBb the total for all
12 items was calculated.
3. Study 2: Individual Interviews.
3.1. Participants
Participants who indicated during the mass screening that they had engaged in NSSI more than once
lifetime rate, were thereafter invited by email to voluntarily take part in an individual interview. Of the 95
invited participants, 46 took part in the interview. One female participant opted out during the interview.
Participants received a book purchase voucher of 10 euro to thank them for their participation. The 49
students that chose not to participate in the interview were subsequently contacted by email with the question
whether they would be willing to complete a written internet questionnaire. This questionnaire consisted of
29
the same questions as were asked during the individual interview. Another eight students completed the
internet questionnaire. This resulted in a total response rate of 60% for this part of the study.
The data of three participants were not included in the analysis because of indications of a history of
psychosis. Among these were two female respondents who participated in the individual interview, and one
anonymous respondent that completed the internet questionnaire.
3.2. Measures and Procedures
All individual interviews were administered by the first author, and consisted of the Self-Injurious
Thoughts and Behaviors Interview (SITBI) [27]. The SITBI is a structured interview consisting of six
modules. For the purpose of the current study, only module f (non-suicidal self-injurious behavior) of the
SITBI(short) was administered, after it was translated to Dutch using a front and back translation procedure
following the guidelines by Hambleton and Patsula [29]. Model f inquires about the age of onset and
frequency of NSSI, and offers an extensive list of methods of NSSI that are being read out loud to the
participants who have to indicate for each method whether or not they have engaged in it. The SITBI proved
to have a strong interrater reliability (average κ = .99, r = 1.0) and test-retest reliability (average κ = .70,
intraclass correlation coefficient = .44) over a 6-month period. Concurrent validity was demonstrated via
strong correspondence between the SITBI and other measures of NSSI (average κ = .87) [28]. After
administering the SITBI (short), module f, two questions were asked about a previous history of delusions or
hallucinations. Participants that answered positively on one of the screening questions were excluded from
the analysis, following the procedure applied in similar research [16, 30].
4. Results
Prevalence and Gender Ratio of NSSI: In the current study the prevalence of NSSI in Belgian first-year
psychology students was 35.51% (34.51% after excluding participants with indications of a history of
psychosis). Table 1 shows the self-reported frequency of NSSI for the total sample without participants over
the age of 30 years (n= 4), and without participants with indications of a history of psychosis (n = 3). The
total population consisted of 92 males and 360 females. Twenty six males indicated that they had at least
once engaged in NSSI, as compared to 133 females. A chi-square test with Yates’ continuity correction for
2x2 tables revealed no significant difference for gender x NSSI (χ² = 2.057; p: .151). Of the participants that
engaged in NSSI more than once lifetime rate, 14 were male and 85 were female. Those were the
participants that were invited to participate in the individual interview.
Age of Onset of the first NSSI episode: The mean age of the first NSSI episode for respondents who
engaged in NSSI more than once, had a range of minimum 10 years and maximum 17 years. The mean age
for females only was 13.93 years (s = 1.94; n = 40); for males only it was 14.00 years (s = 2.00; n = 5). A
two-tailed t-test revealed no significant gender difference for the age of onset of NSSI (p = .936).
Other riskful behaviors:Table II shows that both female and male self-harmers engaged significantly
more in other riskful behaviors than non-self-harming subjects. Non-self-harming females assessed the
riskfulness of the presented behaviors to be significantly higher than their self-harming counterparts. The
same trend existed among males, but to a lesser and non-significant extent.
Methods of NSSI: The data for NSSI methods were gathered from both the individual interviews and the
internet questionnaires. This sample included 45 females and 7 males (ratio 6.4 : 1). Most participants used
multiple methods of NSSI. Because of the small number of male participants and the relatively large number
of NSSI methods that were used, the gender differences are presented as ratios. Punching into walls and
doors occurred in both genders (4 females, 3 males; ratio 1.33 : 1). It is more prevalent in males, but it is not
an exclusively masculine method. Contrary to our expectations, we found burning as a method used by
females (3 females, 1 male), as was self-battery (11 females, 2 males; ratio 5.5 : 1). Biting, which was
expected to be a feminine method of NSSI, was also used by men (10 females, 2 males). Cutting and
scraping mostly occurred together as methods. Therefore they were included into one group. Almost twice as
many females used this method in comparison to males (37 females, 3 males; ratio: 12.3 : 1). Inserting
objects under the skin or the nails occurred in both genders (4 females, 1 male).The SITBI(short), module f
30
[23] also assesses methods of compulsive self-harm [27]. This is the case with items 69(3) pulling ones hair
out, 69(5) picking at a wound, and 69(9) picking at the skin.
Engaged in
NSSI
males
females
never
once
A few
times
66
227
12
54
10
58
occas
ionall
y
2
16
regularl
y
2
5
Total
92
360
Table I. Gender ratio of NSSI
Female
RFB
a(9)
RFB
b
nNSSI
Female
NSSI
21.42
24.71
42.81
40.06
t
5.697*
*
2.811*
*
Male
nNSSI
Male
NSSI
t
26.15
31.00
3.237*
*
38.63
37.54
.515
**: t-value is significant at a 0.01 level (t-tailed)
Table II. Other riskful behaviors
We noticed from the individual interviews that these methods of compulsive self-harm follow a
completely different course than the methods of episodic self-harm. Compulsive self-harm tends to start at an
earlier age, and usually persists after the other self-harm methods are abandoned. The participants also
considered compulsive self-harm as related but different from NSSI. Therefore we disregarded all data
pertaining to these three items.
5. Discussion
Gender ratio. In this study, in a community sample of young adults, we found no gender differences in
the life time rate of NSSI. This stands in contrast to the notable gender differences that were found in the past.
This can be explained in two ways. On the one hand the observed differences from the past might be caused
by research biases. In the past, data were primarily collected in psychiatric populations, where female
patients tend to form a majority. Studies also focused almost exclusively on cutting as a method of NSSI.
Since this method was used more often by women [17, 22], this explains why NSSI was assumed to be a
feminine phenomenon. On the other hand, we do believe that NSSI is indeed occurring more frequently in
men because of an evolution from a traditional masculine role pattern to more equality between the sexes.
With the changes in Western society in which men lose their position of authority, there has already been a
dramatic increase in the number of men that suffer from eating disorders. With this social change the
percentage of men that engage in NSSI can also be expected to increase [32]. This point of view is supported
by the observation that NSSI occurs frequently in prison populations [33], where men can be seen as
occupying an inferior position.
These changes also seem to be reflected in the smaller than expected differences in the methods of NSSI
that were used. Earlier studies have shown that girls tend to internalize, while boys tend to externalize [34],
which is believed to be the consequence of gender-bound socialization experiences [10]. Applied to NSSI
this would lead girls to harm themselves, while boys will be expected to exhibit more riskful behavior as a
form of self-harm [17]. Farber [7], for example, attributed NSSI to women, because of the observation that
men used other means of expressing their aggression, like becoming frequently involved in bar fights. Also
Bolognini and associates [33] assumed that men would rather express their aggression outwardly by injuring
others. Within this line of reasoning we expected that hitting a wall, door or metal pole with the fist would be
masculine forms of NSSI, because this behavior actually constitutes a transition between aggression against
the outside world and aggression against the self. This method proved actually to be applied by both genders.
This is one of the aspects that point in the direction that the gender differences in NSSI might be on the verge
of leveling off.
31
The results of our study also stand in contrast to contemporary studies that did find significant gender
differences. This can be explained by looking at the sample in which the study was conducted. In a Belgian
psychiatric sample Claes et al. [19] obtained a higher prevalence of NSSI in women as compared to men.
This can be explained by the observation that female self-harmers are more readily hospitalised because of
their NSSI per se, whereas men are more likely to be hospitalised because of other psychopathological
symptoms, while their small injuries often are considered part of daily life accidents [15].
Other studies, like the one by Hawton and Harriss [25], use a sample of individuals that present
themselves with self-inflicted injuries at an Accident and Emergency Department. In these cases, the higher
prevalence of NSSI in females can be explained by the observation that women seek out medical care more
easily [35]. This strategy for choosing a sample also leaves a majority of self-harmers undetected. In our own
research, less than 4% of the interviewees indicated that they ever sought medical care for their self-inflicted
injuries. A second remark concerning the Hawton and Harriss’ study, and others as well (e.g. ‘The Child &
Adolescent Self-Harm in Europe’ study [36-37]), is that their definition of deliberate self-harm includes all
purposefully inflicted injuries without ascribing intent. This means that, besides NSSI, also genuine suicide
attempts are included, which elevates prevalence numbers and confounds gender differences. Suicide
attempts follow a notably distinctive course from NSSI. The main differences are that suicide attempts
usually occur at a later age [20] and are more prevalent in men [25, 38]. This inability to agree on
terminology seriously complicates research on NSSI [35].
Limitations of this study. A limitation of the current study is the relatively low representation of male
participants in the sample of first year psychology students. Therefore it is advisable to replicate this study in
a sample that includes more male participants. A second limitation is the screening of self-harmers by means
of a single item. However, the same procedure of using a single screening item is followed by Briere and Gil
[11] and in the Self-Harm Behavior Questionnaire [8, 26]. The accuracy of this screening was also crossvalidated by way of the individual interviews and internet questionnaires. The most important limitation is
that our sample of first-year psychology students is not representative for the total population of young adults,
so that caution is needed in generalizing these results on gender differences. We nonetheless had multiple
reasons for choosing this sample. In order to conduct a sufficient amount of individual interviews, we wanted
to screen a sample with an expected high prevalence of NSSI. Previous research in the United States had
shown that NSSI percentages were very high among psychology students [4]. Although prevalence numbers
can also expected to be large in psychiatric samples, we preferred a community sample to avoid confounding
factors attributed to the clinical setting, as we discussed above. Since NSSI usually starts in early
adolescence, the choice of a young adult sample made it possible to obtain accurate data for the age of onset,
while in a younger sample we could not have identified self-harmers with a later age of onset.
Suggestions for further research. It would be of interest to replicate the individual interviews of this
study with larger groups of self-harmers. In order to obtain these larger groups, it will be necessary to screen
a much larger sample, preferably one that includes more male participants. We are planning our future
research to provide us with these data.
6. Conclusion
Evidence from clinical literature and empirical research suggests that there used to be a gender difference
in the prevalence of NSSI. This difference might have been real or it might be attributed to a focus of
research on mainly feminine samples and a gender difference in the methods of NSSI that are used. The
current study shows that scraping and cutting are used more by females, while males tend to resort to more
externalized methods of expressing anger (e.g. punching into walls). However, males are also starting to use
what were considered feminine methods of NSSI, while females are starting to also externalize anger. These
findings, together with the absence of a difference in prevalence and of the expected difference in the age of
onset, give rise to the question whether gender differences for NSSI are beginning to level off due to a
leveling of gender roles. As for the age of onset, it would be of interest to study whether this has a biological
basis. An indication for this could be found if the age of onset of puberty is also leveling for both genders
7. Acknowledgment
32
I. Van Camp thanks the students that participated in the mass testing and in the individual interviews.
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