Murray, C.D., MacDonald, S. and Fox, J. (2008) Body satisfaction, eating disorders and suicide ideation
in an internet sample of self-harmers reporting and not reporting childhood sexual abuse. Psychology,
Health and Medicine, 13(1), 29-42.
Body Satisfaction, Eating Disorders and Suicide Ideation in an Internet
Sample of Self-harmers Reporting and Not Reporting Childhood Sexual Abuse
RUNNING HEAD: Self-harm and Childhood Sexual Abuse
Sophie MacDonald, Craig D. Murray1 and Jezz Fox
School of Psychological Sciences
University of Manchester
Word Count: 5592
1
Contact: Dr. Craig D. Murray, School of Psychological Sciences, University of
Manchester, Oxford Road, Manchester, M13 9PL, UNITED KINGDOM, TEL: +44
(0)161 275 2556, Email: Craig.murray-2@manchester.ac.uk
1
Body Satisfaction, Eating Disorders and Suicide Ideation in an Internet
Sample of Self-harmers Reporting and Not Reporting Childhood Sexual Abuse
Abstract
Background: This study examined differences between self-harmers who had and who
had not been sexually abused in childhood with regards to other risk factors and
associated behaviours commonly identified in the research literature as being related to
self-harm.
Methods: Participants (N=113, Mean age=19.92 years) were recruited via self-harm
internet discussion groups and message boards, and completed a web questionnaire
assessing measures of body satisfaction, eating disorders, childhood trauma, and suicide
ideation.
Results: Self-harmers who reported a history of childhood sexual abuse scored higher on
measures of body dissatisfaction, eating disorders, suicide ideation, physical abuse,
physical neglect, emotional abuse and emotional neglect.
Conclusions: These findings implicate sexual abuse as a powerful traumatic event that
can have severe repercussions on an individual, not only in terms of self-harming
behaviour but also in terms of developing a wide range of maladaptive behaviours in
conjunction with self-harm.
2
Introduction
Self-harm has been gaining ever more attention from researchers in recent times
as a response to an increasing awareness of the widespread nature of the problem
(Favazza, 1998; Pembroke, 1994). The term subsumes an extensive range of behaviours
(Putnam and Stein, 1985). For example, self-mutilation (Brodsky, Cloitre and Dulit,
1995; Favazza, 1998; Favazza and Rosenthal, 1993), self-injurious behaviour (Herpetz,
1995; Shearer, 1994; Solomon and Farrand, 1996), deliberate self-harm (Pattison and
Kahan, 1983; Patton, Harris, Carlin, Hibbert, Coffey, Schwartz, and Bowes, 1997;
Taiminen, Kallio-Soukainen, Nokso-Koivisto, Kaljonen and Helenius, 1998) and selfwounding (Brooksbank, 1985; Tantum and Whittaker, 1992) have all been utilized in the
description of ‘a form of actively managed self-destructive behaviour that is not intended
to be lethal’ (Warm, Murray and Fox, 2003, p72).
Attempts at measuring the extent of self-harming behaviour draw on admissions
to Accident and Emergency departments (Hawton, Kingsbury, Steinhardt, James and
Fagg, 1999; Hawton, Fagg and Simkin, 1996). However, the majority of self-harming
individuals are likely to remain hidden within society, conducting their self-harm in
secret (Conterio and Lader, 1998), as their self-harm often does not require medical
treatment (Choquet and Menke, 1989; Hawton, Rodham, Evans and Weatherall, 2002).
Briere and Gil (1998) found that 4% of a general population sample, and 21% of a
clinical sample reported self-harming behaviour, while prevalence rates of 12% (Favazza,
DeRosear and Conterio, 1989) and 14% (Ross and Heath, 2002) in college and high
school samples respectively have been reported.
3
Much of the available research studying risk factors for self-harm have examined
the relationship between childhood trauma and self-harm behaviour, concluding that
early trauma is a critical factor in the development of self-harm (Van der Kolk, Perry and
Herman, 1991; Briere and Gil, 1998; Favazza, 1999). Abuse and neglect in childhood
have been found to be related to self-harm behaviour in later life (Green, 1978; Lowe,
Jones, MacLeod, Power and Duggan, 2000; Schaffer, Carroll and Abramowitz, 1982;
Wiederman, Sansone and Sansone, 1999), with between 62 and 79 percent of selfharmers reporting a history of childhood trauma (Favazza and Conterio, 1989; Van der
Kolk et al, 1991; Yaryura-Tobias, Neziroglu and Kaplan, 1995).
A body of research has focused on childhood sexual abuse as a strong risk factor
for self-harm behaviour (Crowe and Bunclarke, 2000; Lipschitz, Winegar, Nicolaou,
Hartnik, Wolfson and Sowthwick, 1999; Baral, Kora, Yuksel, and Sezgin, 1998;
Boudewyn and Liem, 1995; Shapiro, 1987; Zlotnick, Shea, Pearlstein, Simpson, Costello
and Begin, 1996). Indeed it has been shown that sexual abuse has the strongest
association with self-harming behaviour of all forms of abuse (Van der Kolk et al, 1991;
Yates and Carlson, 2003). This association may result in part from the feelings of selfblame that sexual abuse often invokes (Shapiro, 1987). Moreover, those who have
experienced sexual abuse do often perceive it as a major influence on their decision to
self-harm (Warm et al., 2003).
In contrast to the above, some studies have reported no evidence of a relationship
between childhood sexual abuse and self-harm behaviour (Brodsky, Cloitre and Dulit,
1995; Zweig-Frank, Paris and Guzder, 1994a; 1994b). However, these studies have been
subject to methodological limitations in terms of the use of inappropriate statistics and
4
weak power, suggesting that the absence of findings showing a relationship between selfharm and sexual abuse may not correspond to an actual absence of such a relationship
(Gratz, Conrad and Roemer, 2002).
Despite markedly less attention (Gratz, Conrad and Roemer, 2002), other forms of
abuse have also been implicated in the development of self-harm behaviour. For instance,
Green (1978) found that physically abused children engaged in significantly more selfdestructive behaviour (including deliberate self-harm) than physically neglected children
or a control group with no history of physical abuse. Similarly, physical neglect (Baral et
al, 1998; Van der Kolk et al, 1991), and emotional abuse (Dubo, Zanarini, Lewis and
Williams, 1997; Martin and Waite, 1994; Van der Kolk, 1996; Linehan, 1993) have also
been linked with the development of self-harm behaviour. Significant correlations have
been found between childhood neglect and various forms of self-destructive behaviour,
including self-cutting and suicide attempts (Van der Kolk et al, 1991). In addition,
research by Martin and Waite (1994) has implicated both paternal and maternal
emotional neglect, in terms of a lack of parental care and protection, in the development
of self-harm.
While a significant portion of self-harmers experience sexual abuse (Yeo and
Yeo, 1993), many do not (Brodsky, Cloitre and Dulit, 1995; Zweig-Frank, Paris and
Guzder, 1994a; 1994b). Sexual abuse in itself does not necessarily transfer into self-harm
behaviour but may do so. This seems to be more likely in the absence of effective forms
of emotional support (Linehan, 1993). A sense of powerlessness and incapacity to
understand and manage painful feelings may then be dealt with via self-harm (Yates,
2004).
5
While sexual abuse appears to be an important risk factor for the development of
self-harm, it is not the only risk factor and can often be absent from self-harm etiology. In
addition, it could be an important influence while related and associated with a number of
other potential risk factors. Indeed it has been shown that self-harming behaviour is also
frequently associated with eating disorders (Favazza, DeRosear and Conterio,
1989Garfinkel, Moldofsky and Garner, 1980), substance dependence (Favazza and
Conterio, 1989; Schwartz, Cohen, Hoffman and Meeks, 1989), body satisfaction and selfesteem problems (Finkelhor, 1988; Low et al, 2000), suicide ideation (Low et al, 2000;
Walsh and Rosen, 1988), and the aforementioned physical abuse and physical and
emotional neglect (Van der Kolk, 1996).
Perhaps the most obvious place to start when looking at the various relationships
which may exist between sexual abuse and other factors within self-harming samples is
with an examination of the associations between childhood sexual abuse and other forms
of abuse. Although sexual abuse has been shown to be the greatest predictor of self-harm
over and above other forms of childhood trauma (Van der Kolk et al, 1991; Yates and
Carlson, 2003), physical and emotional abuse and neglect have nonetheless proved to be
strong risk factors for self-harm (Van der Kolk, 1996). Indeed, correlations between all
forms of abuse have been noted, and it has been documented that multiple forms of
maltreatment often co-occur (Briere and Runtz, 1988; Rosenberg, 1987). Therefore, it is
hypothesised here that those self-harming individuals who have a history of sexual abuse
will also have been subject to many other forms of maltreatment simultaneously,
meaning that they will show higher levels of childhood trauma than individuals who did
not experience sexual abuse.
6
The extent to which eating disorders may be associated with sexual abuse has
been assessed by a number of studies, with reviews of the findings (Pope and Hudson,
1992; Connors and Morse, 1993) indicating that results are conflicting. Schaff and
McCane (1994) demonstrated a weak association between sexual abuse and eating
disorders in college students, while Hastings and Kern (1994), using a similar sample,
found the association to be extremely clear. Despite some contradictory data from general
population samples, clinical data has provided some strong evidence for the relevance of
sexual abuse to the development of eating disorders (Gleaves and Eberenz, 1994; Waller,
1992).
One possible mediating factor between unwanted sexual experience and eating
disorders is dissatisfaction with the body or body image. Andrews (1992) found that
shame over physical appearance was a mediating factor between abuse and bulimia. In
addition, sexual abuse could lead to dissatisfaction with the body or the attachment of the
traumatic experience to a specific part of the body, leading to subsequent attempts to alter
the body (Calam and Slade, 1994), via an eating disorder to control weight for instance,
or via self-harm in order to cope with the trauma. Body dissatisfaction is also a feature of
eating disorders (Garfinkel, Goldbloom, Davis, Olmstead, Garner and Halmi, 1992), with
evidence to suggest an association between sexual abuse and body perception in anorexic
and bulimic women (Oppenheimer, Howells, Palmer and Challoner, 1985; Waller, Everill
and Calam, 1994). However, Calam, Griffiths and Slade (1997) report findings that make
it difficult to conclude that there is a strong association between sexual abuse and body
dissatisfaction, suggesting that whatever the mediating variables between sexual abuse
and eating disorders, it is unlikely that body dissatisfaction will exert a strong influence.
7
The present study will aims to provide evidence in order to aid clarification of
whether there are associations between sexual abuse, eating disorders and body
dissatisfaction by people reporting self-harm behaviour. It is hypothesised that a
relationship between childhood sexual abuse and eating disorders will be apparent as the
majority of evidence from previous studies (Hastings and Kern, 1994; Gleaves and
Eberenz, 1994; Waller, 1992) suggests such a correlation. However, evidence for an
association between sexual abuse and body dissatisfaction, even as a mediating factor, is
weak (Calam, Griffiths and Slade, 1997). In contrast, lower self-esteem as the result of
body dissatisfaction can act as a pathway between childhood sexual abuse and later selfharm (Low et al, 2000; Finkelhor, 1988), suggesting a relationship between sexual abuse
and body dissatisfaction by people reporting self-harm. Therefore it is hypothesised that
self-harming individuals with have a history of childhood sexual abuse will be report
higher levels of body dissatisfaction than those self-harming individuals who do not have
such a history.
While some research has argued that self-harm is distinct from attempted suicide,
suicidal ideation has been found in 28-41% of self-harm cases (Gardner and Cowry,
1985; Jones, Congin, Stevenson, Straus and Frei, 1979; Pattison and Kahan, 1983). In
addition, a history of sexual abuse acts as a strong risk factor for suicide ideation and
actual suicide attempts (Boudewyn and Liem, 1995; Yeo and Yeo, 1993; Deykin, Alpert,
and McNamara, 1988; Beautrais, 2000; Paolucci, Genuis and Violato, 2001; Bergen,
Martin, Richardson, Allison and Roeger, 2003; Vajda and Steinbeck, 2000; Zlotnick,
Mattia and Zimmerman, 2001).
However, methodological flaws in the available research on this issue means that
8
the relationship between sexual abuse and suicide ideation is still uncertain (Rogers,
2003). One key concern has been the use of samples which are unrepresentative of the
general population. For instance, previous studies using participants recruited during
hospital attendance (Hawton, Fagg and Simkin, 1996) have been subject to such bias, as a
substantial body of evidence has indicated that the majority of suicide attempts and
incidences of deliberate self-harm do not receive medical attention (Choquet and Menke,
1989; Hawton et al, 2002), and that those who do receive medical attention differ in
demographic and psychosocial characteristics from those that do not (Kann, Kinchen,
Williams, Ross, Lowry, Grunbaum and Kolbe, 2000). In addition, previous studies have
often been self-selecting which may have resulted in samples biased towards individuals
who have been negatively affected by their experiences (Rogers, 2003).
In order to go some way in remedying this situation, the present study makes use
of a novel sampling technique, namely the use of the Internet to obtain participants from
self-harm discussion groups. Previous studies using this method have found a significant
proportion of participants have not previously come in to contact with health
professionals regarding their self-harming behaviour (Warm, Murray and Fox, 2002).
Therefore, while this approach is potentially not without its own problems, it does enable
the inclusion of participants who have not necessarily come into contact with
professional treatment, and who engage in a variety of self-harm behaviours. Here it is
expected that those self-harming individuals who have been subject to childhood sexual
abuse will exhibit a higher rate of suicide ideation than those who have not experienced
sexual abuse.
9
Method
Participants
A total of 113 participants took part in the study, with a mean age of 19.92 years
(SD=5.29; Range=14-41). Of these, 104 participants were female (Mean age=19.78;
SD=5.22; Range=14-41) and 9 were male (Mean age=21.56; SD=6.09; Range=16-33).
Participants were contacted via self-harm internet discussion groups and message boards
which were located by means of a web based search of Yahoo groups and internet
message boards using the terms ‘self-harm’ and ‘self-injury’. Groups were chosen on the
basis of an adequate member base (i.e. more than 60) and message boards were chosen
according to the number of individuals’ posting to the site on a daily basis (i.e. more than
20).
Materials
Respondents completed an online web questionnaire comprising an item assessing
general demographic information and information pertaining to the onset, frequency and
methods of self-harm, followed by six validated scales assessing other related behaviours.
Each of the questionnaire components will now be detailed in the order they were
presented.
Measures
Items assessing demographic and self-harm information: Respondents were asked
to provide information on their age and sex, as well as information regarding the onset of
10
self harm, the frequency and duration of self-harm, and the methods of self-harm utilized.
The SCOFF Questionnaire: The SCOFF questionnaire was developed by Morgan,
Reid and Lacey (1999) in order to provide a new simple screening tool for eating
disorders. They developed five questions addressing core features of anorexia nervosa
and bulimia nervosa (e.g. Do you worry you have lost control over how much you eat?).
Respondents are asked to answer ‘yes’ or ‘no’ to the five questions. An answer of ‘yes’
scores one point whilst an answer of ‘no’ scores no points. A score of two or more
indicates a likely case of anorexia nervosa or bulimia (possible range of scores = 0-5).
The Body Satisfaction Scale (BSS): The BSS was developed by Slade, Dewey,
Newton, Brodie and Kiemle (1990) to measure satisfaction or dissatisfaction with body
parts. The scale consists of 16 named body parts (e.g. head, tummy, legs) to which the
respondent is asked to indicate on a 7-point Likert-type scale their degree of satisfaction
with each. Responses range from ‘very satisfied’ (1) to ‘very unsatisfied’ (7), leading to a
possible score range of 16-112.
The Childhood Trauma Questionnaire: Short form (CTQ-SF): The CTQ-SF was
developed and validated by Bernstein, Stein, Newcomb, Walker, Pogge, Ahluvalia,
Stokes, Handelsman, Medrano, Desmond and Zule (2003) as a screening measure for
maltreatment histories in both clinical and nonreferred groups. The CTQ-SF was derived
from the original CTQ which is a 70-item self-administered inventory assessing
childhood abuse and neglect (Bernstein, Fink, Handelsman, Foote, Lovejoy, Wenzel,
Sapareto and Ruggiero, 1994). Items on the CTQ ask about experiences in childhood and
adolescence and are rated on a 5-point Likert-type scale with response options ranging
from ‘Never true’ (1) to ‘Very often true’ (5). The CTQ has five clinical scales: Physical
11
abuse (bodily assaults on a child by an adult or older person that posed a risk of or
resulted in injury); Sexual abuse (sexual contact or conduct between a child younger than
18 years of age and an adult or older person); Emotional abuse (verbal assaults on a
child’s sense of worth or well-being or any humiliating of demeaning behaviour directed
towards the child be an adult or older person); Physical neglect (the failure of caretakers
to provide for a child’s basic physical needs, including food, shelter, clothing, safety and
health care); and Emotional neglect (the failure of caretakers to provide for a child’s basic
emotional and psychological needs, including love, belonging, nurturance and support).
In the CTQ-SF, each type of maltreatment is represented by five items to provide
adequate reliability and content coverage whilst substantially reducing the overall number
of items in the scale. Sample CTQ-SF items all begin with ‘When I was growing up…’
and include: ‘I was called names by my family’ (emotional abuse); ‘I was hit hard
enough to leave bruises’ (physical abuse); ‘I was touched sexually’ (sexual abuse); ‘I felt
loved’ (emotional neglect); and ‘I didn’t have enough to eat’ (physical neglect). Scoring
the CTQ-SF is accomplished by summing item raw scores on each respective factor. The
resulting sub-scale scores can be considered an index of trauma severity and each has a
possible range of 5-25.
The Positive and Negative Suicide Ideation Inventory (PANSII): The PANSII was
developed and validated by Kopper, Barrios and Chiros (1998) as a brief measure for
assessing the frequency of positive and negative thoughts related to suicidal behaviour.
This self-report measure of suicide ideation contains 14 items, 8 pertaining to negative
suicide ideation (e.g. Felt hopeless about the future and you wondered if you should kill
yourself?), and 6 pertaining to positive suicide ideation (e.g. Felt confident about your
12
plans for the future?). Participants were asked to respond to each item using the sentence
beginning ‘During the past two weeks, how often have you…’ on a 5-point Likert-type
scale. Responses ranged from ‘None of the time’ (1) to ‘Most of the time’ (5). In order to
compile the final measure, responses for the positive suicide ideation items were reverse
scored and summed, and then added to the summed scores of the negative suicide
ideation items. A higher score therefore indicates more negative suicide ideation. The
possible range of scores is 14-70.
Sexual abuse measure
The measure of sexual abuse in the present study is obtained by summing
participants’ total scores on five questions of the Childhood Trauma Questionnaire: Short
form (Bernstein, Stein, Newcomb, Walker, Pogge, Ahluvalia, Stokes, Handelsman,
Medrano, Desmond and Zule, 2003). A score of 20-25 is used to signify sexual abuse,
and a score of 5-10 is used to signify no sexual abuse.
Procedure
Permission to conduct the study was first obtained from the Ethics Committee of
the researchers’ host institution. The questionnaire containing each of the seven measures
detailed above was compiled as a web-based questionnaire and was set-up on the internet
with its own web-address. Self-harm internet groups and discussion boards which had
been previously chosen were contacted either directly or via a moderator, dependent upon
the procedures in place for each individual site. The information they received contained
a brief outline of the study along with the web-address the questionnaire was situated at,
13
with the request that they participate in the study. Upon visiting the web-site as
advertised in the initial contact messages, participants were once again provided with a
brief outline of the study along with the contact details of the researchers if any additional
information was required. In addition a consent form was provided so the respondent
could continue to participate in the study. Participants were reminded that all responses
would be confidential and that they were free to withdraw from the study at any point.
After completing the consent form, participants were asked to click the ‘next’
button at the bottom of the screen and were taken to the first page asking for the personal
information of sex, age and country of residence, frequency of self-harm, age of onset,
and so on. By again clicking the ‘next’ button participants were taken to the first of the
seven scales. After each scale had been completed, continuation to the next stage was
accomplished by clicking the ‘next’ button. Before proceeding to the next stage
participants’ submission was validated to ensure responses to all items on the scale. If the
validation failed they were presented with a message stating there were errors in their
submission, with the items requiring attention being highlighted. Upon completion of the
seven scales, participants were taken to a final page indicating that all of the information
required had been gathered and were now ready for submission. In order to submit the
information so that it was recorded the participant was asked to click the ‘submit’ button
at the bottom of the page. Following submission respondents were thanked for their
participation.
Results
14
Table 1 summarises respondents’ demographic information, including age and
sex, and information pertaining to their self-harming behaviour, including onset age,
frequency and methods of self-harm.
[INSERT TABLE 1 ABOUT HERE]
The sample was predominantly female (92%), with a mean age of 19.92 years.
The mean onset age for self-harm was 14.2 years, with the majority of respondents
engaging in self-harm on a weekly basis (46.9%). In addition, it was found that although
cutting was the predominant method of self-harm utilized (100%), a variety of other
methods are used, with the majority of respondents having used between two and six
methods of self-harm (82.3%).
Mean scores for the experimental measures used in the study are shown in table 2.
Respondents mean scores indicate that those participants indicating a history of sexual
abuse (n=22) scored higher than those who did not (n=72) on measures of body
dissatisfaction (M=79.64, compared to 67.40), eating disorders (M=2.95, compared to
2.01), emotional neglect (M=16.55, compared to 14.25), emotional abuse (M=19.00,
compared to 13.08), physical neglect (M= 12.59, compared to 9.03), physical abuse
(M=13.14, compared to 7.57) and suicide ideation (M=55.14, compared to 46.49).
The results of the ANOVA significance test are shown in table 2. Those with a
history of sexual abuse scored significantly higher than those without a history of sexual
abuse on measures of body dissatisfaction [F(2, 110) = 3.975, p = .022]; eating disorders
[F(2, 110) = 4.214, p = .017]; emotional neglect [F(2, 110) = 3.953, p = .022]; emotional
abuse [F(2, 110) = 12.050, p = <.001]; physical neglect [F(2, 110) = 10.293, p = <.001];
15
physical abuse [F(2, 110) = 12.087, p = <.001]; and suicide ideation [F(2, 110) = 3.863, p
= .024].
Discussion
The results of this study provide broad support for the hypotheses outlined earlier,
namely that self-harmers who have been sexually abused in childhood are more likely to
report a variety of other maladaptive experiences and behaviours than self-harmers who
have not. Overall, this study has stressed the importance of childhood sexual abuse not
only as a risk factor for self harm itself, but also as a factor which raises the susceptibility
of self-harming individuals to other potential risk factors and associated behaviours,
which have also been shown to severely influence self-harming behaviour.
Specifically, one of the most significant findings in this study pertains to the
relationship between childhood sexual abuse and other forms of abuse, namely emotional
abuse, emotional neglect, physical abuse and physical neglect. The results indicate that
each type of these forms of abuse is significantly associated with sexual abuse, with those
self-harming individuals with a history of childhood sexual abuse being more likely to
report a prior history of each type of abuse. Such findings support the hypotheses of the
study and suggest that although sexual abuse is perhaps most strongly associated with
self-harming behaviour (Van der Kolk et al, 1991; Yates and Carlson, 2003), many forms
of abuse co-occur. This is consistent with previous research stating that multiple forms of
maltreatment often occur simultaneously (Briere and Runtz, 1988; Rosenberg, 1987) and
highlights the importance of all forms of abuse in self-harm etiology (Van der Kolk,
1996; Low et al, 2000).
16
Of all the forms of abuse, emotional neglect showed the smallest significant
difference between groups. This could be seen as a result of the previously observed fact
that although an association between emotional neglect and self-harm does exist, the
strongest associations are between various forms of abuse, as opposed to forms of neglect
(Dubo et al, 1997; Lipschitz et al, 1999), as abusive incidents, particularly those of a
sexual nature, involve more scapegoating and targeting, whereas neglect is often
uniformly distributed across the family (Green, 1978). Therefore, the presence of sexual
abuse will provide the strongest risk for later self-harming behaviour, and when added
with further forms of abuse, an individual may experience a heightened sense of being a
target, resulting in an increased amount of trauma and a greater likelihood of selfharming. While emotional neglect can also prove traumatic, it may not act as a pathway
to self-harm in the same manner, as the feeling of being victimized is not as strong.
The significant difference found on a measure of disturbed eating in the present
study between self-harmers who had, and who had not, been sexually abused as children
suggested a strong relationship between sexual abuse and eating disorders, supporting the
results of Hastings and Kern (1994), Gleaves and Eberenz (1994) and Waller (1992),
whilst adding further contradictory evidence to the claim that there is a non-existent
association between eating disorders and sexual abuse (Schaff and McCane, 1994).
Specifically, the results of this study indicate that, as hypothesised, self-harming
individuals who have been sexually abuse as children are significantly more likely to
report behaviours indicative of an eating disorder than those not exposed to such abuse.
One argument is that sexual abuse may lead the individual to become dissatisfied with the
body, through the attachment of the traumatic experience to the whole, or various parts of
17
the body (Calam and Slade, 1994). This traumatic association with the body may lead to
attempts to alter the body via the development of an eating disorder, and via self-harm in
order to somehow displace or reduce the trauma.
In conjunction with this finding, this study has corroborated previous evidence on
the relationship between body satisfaction and sexual abuse in self-harm samples. Past
research has suggested a mediating role of body dissatisfaction, between the variables of
sexual abuse and the development of an eating disorder (Calam and Slade, 1994;
Oppenheimer et al, 1985; Waller et al, 1994), as well as between sexual abuse and selfharm itself (Low et al, 2000; Finkelhor, 1988). The findings of the present study add
further support to such research, suggesting that self-harming individuals who have been
subject to childhood sexual abuse are more likely to suffer body satisfaction problems.
Here, the previous trauma of a sexual abuse incident may be manifested in how the
individual perceives themselves, consequently suffering body dissatisfaction and turning
to self-harm as a way to provide a sense of relief from this previous trauma (Van der
Kolk et al, 1991; Connors, 1996). These results therefore provide further counter
evidence to the claims of Calam, Griffiths and Slade (1997) that any relationship between
body satisfaction and sexual abuse is weak.
Moreover, the findings of the present study have indicated a significant
relationship between suicide ideation and childhood sexual abuse as reported by selfharmers, consistent with previous research which suggests that sexual abuse is a predictor
of suicidal ideation, suicide attempts and acts of self-harm (Zlotnick et al, 2001; Vajda
and Steinbeck, 2000; Low et al, 2000). As predicted, the present study found that those
self-harming individuals who had been subject to childhood sexual abuse reported higher
18
levels of suicide ideation than those who had not, supporting the previous research
findings of Evans, Hawton and Rodham (2005).
From the above findings it can be argued that although distinct in their nature
(Soloman and Farrand, 1996; Winchel and Stanley, 1991), there appears to be an
association between self-harm and suicide ideation (Low et al, 2000). It is suggested that
the trauma of previous childhood sexual abuse leads to a significant amount of distress
for the individual to deal with which they find difficult, resulting in a number of suicide
related thoughts as well as self-harming behaviour. Self-harm can be seen as a way of
dealing with such traumatic and distressing experiences in a manner alternative to
suicide; despite experiencing high levels of suicide ideation, self-harm may act as a
method which avoids following through on such thoughts whilst relieving the tension
caused by the reminiscence of the traumatic experience (Soloman and Farrand, 1996).
To summarise, the results of this study provide a number of significant findings
on the role of sexual abuse as a precursor for other risk factors and associated behaviours
of self-harm. Such findings implicate sexual abuse as an extremely powerful traumatic
event that can have severe repercussions on an individual, not only in terms of selfharming behaviour but also in terms of developing a number of maladaptive behaviours
in conjunction with self-harm.
Comparable to the limitations of studies on the relationship between suicide
ideation and sexual abuse described by Rogers (2003), this study is also subject to
potential methodological problems such as a research sample which may not be
representative of the self-harming population. However, this is a pervasive problem in
self-harm research. Previous studies have often been biased through the use of
19
participants recruited during hospital attendance (Hawton, Fagg and Simkin, 1996), as
there has been a substantial body of evidence indicating that both suicide attempts and
incidences of deliberate self-harm often do not receive medical attention (Choquet and
Menke, 1989; Hawton et al, 2002), with those that do differing in demographic and
psychosocial characteristics from those that do not (Kann et al, 2000).
Similarly, the present study recruited participants through the use of self-harm
internet groups and message boards, which may have resulted in a biased sample. For
instance, those individuals who may use or post to message boards may characteristically
differ from self-harming individuals in the general population. For instance, people who
visit self-harm internet sites may be more likely to have injured themselves, or thought of
injuring themselves in the recent past, which could have an influence upon the results,
particularly with regards to the frequency of respondents’ self-harm (Murray, Warm and
Fox, 2005). In addition, participation was completely self-selecting meaning the sample
consisted of only those participants who decided to visit and complete the web based
questionnaire, as opposed to all members of the self-harm internet groups and message
boards. Such sampling methods may have resulted in samples biased towards individuals
who have been more negatively affected by their experiences than individuals in the
general population (Rogers, 2003) and also lead to a reliance upon respondents’
subjective evaluations of their experiences which cannot be independently verified
(Murray, Warm and Fox, 2005). Consequently, there is a need to be cautious when
making claims about self-harming populations which may differ considerably from that
employed in the present study.
Despite such possible methodological problems in terms of biased sampling, the
20
present research does have some advantages in that it is not limited to those self-harming
individuals that have been admitted to Accident and Emergency departments or who have
been referred to psychiatric services. Past research into self-harm has often recruited
samples in this way (Hawton, Kingsbury, Steinhardt, James and Fagg, 1999; Hawton,
Fagg and Simkin, 1996) and as such has excluded the majority of self-harmers who are
known not to require medical treatment (Choquet and Menke, 1989; Hawton, Rodham,
Evans and Weatherall, 2002) and therefore remain hidden within society (Conterio and
Lader, 1998). The present study has the benefit of reaching such hidden populations
(Warm, Murray and Fox, 2003), thereby gaining results from individuals who may not
have ordinarily been able to contribute to research on self-harm.
Another possible weakness in the study’s methodology was the measure of sexual
abuse used. Rather than using a measure which required the participants to state whether
they had, or had not, been sexually abused as children, the measure used in this study was
compiled of the total score of participants on a five question five-point Likert-type scale.
Therefore, by using a score of 20-25 out of 25 to signify sexual abuse, and a score of 5-10
out of 25 to signify no sexual abuse, a dichotomous (yes/no) indication of childhood
sexual abuse was not used, and a number of participants (15%, n=17) who scored in the
mid-range were not included in the analysis. It is possible that while the measure used
classified respondents with a low score as not having experienced sexual abuse, these
individuals along with those individuals not included may indeed believe that they were
sexually abused. However, the sexual abuse measure utilized in the present study does
have its advantages. Firstly, the compilation of the sexual abuse measure was based on
the fact that it has been questioned whether classifying sexual abuse as a dichotomous
21
event (one that did or did not happen) is necessarily correct, with the suggestion that it is
better understood as an experience that varies along continuous dimensions such as
frequency, severity and duration (Lipschitz, Bernstein, Winegar and Southwick, 1999).
By assessing sexual abuse along such dimensions and by using the resulting scores to
define the presence or absence of sexual abuse the present study has avoided
interpretational problems of what sexual abuse constitutes, which other methods
requiring simply a ‘yes’ or ‘no’ answer may be subject to, as each individual may have a
different understanding as to what the term sexual abuse relates to.
In response to the possible limitations of the present study, a number of further
study areas have been highlighted. Firstly, in addressing the problem of biased sampling
the study could be repeated with a variety of participants. As is commonly known, selfharm has prevalence rates of between 12% and 14% in high school and college students
and is widely found in the general population (Favazza, DeRosear and Conterio, 1989;
Ross and Heath, 2002). The utilization of such participants in the general public, in
colleges and schools as well as those individuals utilizing self-harm internet groups and
message boards, would provide a solid basis for being able to generalise the results of the
study to the wider self-harming population. In addition, sex could be investigated if a
larger sample of male self-harmers was employed, in order to discover whether the
reported associations of sexual abuse and other risk factors in the sphere of self-harm are
comparable in males and females.
In conclusion, in line with much previous research this study has suggested that
childhood sexual abuse is an extremely important factor in self-harm etiology as it not
only acts as a prime risk factor itself, but acts as a pathway to increase the susceptibility
22
of self-harming individuals to a number of other risk factors and associated behaviours.
Specifically it has highlighted the important relationships that exist between sexual abuse,
eating disorders, body satisfaction problems, suicide ideation, physical and emotional
abuse, and neglect. The study has produced some important indications in self-harm
etiology, and has provided a basis for much further research.
23
References
Andrews, B. (1992). Shame as a mediating factor between early abuse and
psychiatric disorder. Paper presented to the British Psychological Society Conference,
London.
Baral, I., Kora, K., Yuksel, S. and Sezgin, U. (1998). Self-mutilating behaviour of
sexually abused females in Turkey. Journal of Interpersonal Violence, 13 (4): 427-437.
Beautrais, A. L. (2000). Risk factors for suicide and attempted suicide among
young people. Australian and New Zealand Journal of Psychiatry, 34: 420-436.
Bensley, L. S., Van Eenwyk, J., Speiker, S. J. and Schoder, J. (1999). Selfreported abuse history and adolescent problem behaviours. 1. Antisocial and suicidal
behaviours. Journal of Adolescent Health, 24: 163-172.
Bergen, H. A., Martin, G., Richardson, A. S., Allison, S. and Roeger, L. (2003).
Sexual abuse and suicidal behaviour: A model constructed from a large community
sample of adolescents. Journal of the American Academy of Child and Adolescent
Psychiatry, 42 (11): 1301-1309.
Bernstein, D. P., Fink, L., Handelsman, L., Foote, J., Lovejoy, M., Wenzel, K.,
Sapareto, E. and Ruggiero, J. (1994). Initial reliability and validity of a new retrospective
measure of child abuse and neglect. American Journal of Psychiatry, 151: 1132-1136.
Bernstein, D. P., Stein, J. A., Newcomb, M. D., Walker, E., Pogge, D., Ahluvalia,
T., Stokes, J., Handelsman, L., Medrano, M., Desmond, D. and Zule, W. (2003).
Development and validation of a brief screening version of the Childhood Trauma
Questionnaire. Child Abuse and Neglect, 27: 169-190.
24
Boudewyn, A. C. and Liem, J. H. (1995). Childhood sexual abuse as a precursor
to depression and self-destructive behaviour in adulthood. Journal of Traumatic Stress, 8:
445-459.
Briere, J. and Gil, E. (1998). Self-mutilation in clinical and general population
samples: Prevalence correlates and functions. American Journal of Orthopsychiatry, 68
(4): 609-620.
Briere, J. and Runtz, M. (1988). Multivariate correlates of childhood
psychological and physical maltreatment among university women. Child Abuse and
Neglect, 12: 331-341.
Brodsky, B. S., Cloitre, M. and Dulit, R. A. (1995). Relationship of dissociation
to self-mutilation and childhood abuse in borderline personality disorder. American
Journal of Psychiatry, 152: 1788-1792.
Brown, M. Z., Comtois, K. A. and Linehan, M. M. (2002). Reasons for suicide
attempts and non-suicidal self-injury in women with borderline personality disorder.
Journal of abnormal psychology, 111 (1): 198-202.
Brooksbank, D. J. (1985). Suicide and parasuicide in childhood and early
adolescence. British Journal of Psychiatry, 146: 459-463.
Buddeberg, C., Buddeberg, F. B., Gnam, G., Schmid, J. and Christen, S. (1996).
Suicidal behaviours in Swiss students: An 18-month follow up survey. Crisis, 17: 78-86.
Calam, R. M., Griffiths, R. and Slade, P. D. (1997). Eating disorders, body
satisfaction and unwanted sexual experience: U. K., Australian and U. S. data. European
Eating Disorders Review, 5 (3): 158-170.
25
Calam, R. M. and Slade, P. D. (1994).Eating patterns and unwanted sexual
experiences. In: B. Dolan and I. Gitzinger (Eds.). Why women?: Gender issues and eating
disorders. London: Athlone Press.
Carroll, J., Schaffer, C., Spensley, J. and Abramowitz, S. I. (1980). Family
experiences of self-mutilating patients. American Journal of Psychiatry, 137: 852-853.
Choquet, M. and Menke, H. (1989). Suicidal thoughts during early adolescence:
Prevalence, associated troubles and help-seeking behaviour. Acta Psychiatrica
Scandinivica, 81: 170-177.
Connors, M. E. and Morse, W. (1993). Sexual abuse and eating disorders.
International Journal of Eating Disorders, 13: 1-11.
Conterio, K. and Lader, W. (1998). Bodily Harm. Hyperion: New York.
Crowe, M. and Bunclarke, J. (2000). Repeated self-injury and its management.
International Review of Psychiatry, 12: 48-53.
Deiter, P. J. and Pearlman, L. A. (1998). Responding to self-injurious behaviour.
In: P. M. Kleespies (Ed.). Emergencies in Mental Health Practice: Evaluation and
Management (pp. 235-257). New York: Guilford Press.
Deykin, E. Y., Alpert, J. J. and McNamara, J. J. (1988). A pilot study of the effect
of exposure to child abuse or neglect on adolescent suicidal behaviour. American Journal
of Psychiatry, 149: 1299-1330.
Dohm, F. A., Striegel-Moore, R. H., Wilfley, D. E., Pike, K. M., Hook, J. and
Fairburn, C. G. (2002). Self-harm and substance use in a community sample of black and
white women with binge eating disorder or bulimia nervosa. International Journal of
Eating Disorders, 32: 389-400.
26
Dubo, E. D., Zanarini, M. C., Lewis, R. E. and Williams, A. A. (1997). Childhood
antecedents of self-destructiveness in borderline personality disorder. Canadian Journal
of Psychiatry, 42: 63-69.
Evans, E., Hawton, K. and Rodham, K. (2005). Suicidal phenomena and abuse in
adolescents: A review of epidemiological studies. Child Abuse and Neglect, 29: 45-58.
Favazza, A. R. (1989). Why patients mutilate themselves. Hospital and
Community Psychiatry, 40 (2): 113-127.
Favazza, A. R. (1998). The coming of age of self-mutilation. Journal of Mental
and Nervous Disease, 186: 259-268.
Favazza, A. R. (1999). Self-mutilation. In: D. G. Jacobs (Ed.). The Harvard
Medical School Guide to Suicide Assessment and Intervention (pp. 125-145). San
Francisco: Jossey-Bass.
Favazza, A. R. and Conterio, K. (1988). The plight of chronic self-mutilators.
Community and Mental Health Journal, 24 (1): 22-30.
Favazza, A. R. and Conterio, K. (1989). Female habitual self-mutilators. Acta
Pschiatrica Scandinavia, 79: 283-289.
Favazza, A. R., DeRosear, L. and Conterio, K. (1989). Self-mutilation and eating
disorders. Suicide and Life-threatening Behaviours, 19 (4): 352-362.
Favazza, A. R. and Rosenthal, R. (1993). Diagnostic issues in self-mutilation.
Hospital and Community Psychiatry, 44: 134-140.
Fergusson, D. M., Horwood, L. J. and Lynskey, M. T. (1996). Childhood sexual
abuse and psychiatric disorder in young adulthood: 2. Psychiatric outcomes of childhood
27
sexual abuse. Journal of the American Academy of Child and Adolescent Psychiatry, 3
(10): 1365-1374.
Finkelhor, D. (1988). The trauma of child sexual abuse: Two models. In: G. E.
Wyatt and C. J. Powell (Eds.). Lasting Effects of Child Sexual Abuse (pp. 61-82). Beverly
Hills, CA: Sage.
Gardner, D. L. and Cowry, R. W. (1985). Suicidal and parasuicidal behaviour in
borderline personality disorder. Psychiatric Clinics of North America, 8 (2): 389-403.
Garfinkel, P. E., Goldbloom, D., Davis, R., Olmstead, M. P., Garner, D. M. and
Halmi, K. A. (1992).Body dissatisfaction in bulimia nervosa: Relationship to weight and
shape concerns and psychological functioning. International Journal of Eating
Disorders, 11 (2): 151-161.
Gleaves, D. H. and Eberenz, K. P. (1994). Sexual abuse histories among treatment
resistant bulimia nervosa patients. International Journal of Eating Disorders, 15: 227231.
Gratz, K. L. (2003). Risk factors and functions of deliberate self-harm: An
empirical and conceptual review. Clinical Psychology Science and Practice, 10: 192-205.
Gratz, K. L., Conrad, S. D. and Roemer, L. (2002). Risk factors for deliberate
self-harm in college students. American Journal of Orthopsychiatry, 72 (1): 128-140.
Green, A. H. (1978). Self-destructive behaviour in battered children. American
Journal of Psychiatry, 135: 579-582.
Gross, J. J. and Munoz, R. F. (1995). Emotion regulation and mental health.
Clinical Psychology: Science and Practice, 2: 151-164.
28
Grossman, D. C., Milligan, B. C. and Deyo, R. A. (1991). Risk factors for suicide
attempts among Navajo adolescents. American Journal of Public Health, 81: 870-874.
Hastings, T. and Kern, J. M. (1994). Relationships between bulimia, childhood
sexual abuse and family environment. International Journal of Eating Disorders, 15:
103-111.
Hawton, K. (1986). Suicide and Attempted Suicide among Children and
Adolescents. Beverly Hills: Sage.
Hawton, K., Fagg, J. and Simkin, S. (1996). Deliberate self-poisoning and selfinjury in children and adolescents under 16 years of age in Oxford, 1976-1993. British
Journal of Psychiatry, 169: 202-208.
Hawton, K., Kingsbury, S., Steinhardt, K., James, A. and Fagg, J. (1999).
Repetition of deliberate self-harm by adolescents: The role of psychological factors.
Journal of Adolescence, 22: 369-378.
Hawton, K., Rodham, K., Evans, E. and Weatherall, R. (2002). Deliberate selfharm in adolescents: A self-report study in schools in England. British Medical Journal,
325: 1207-1211.
Herpetz, S. (1995). Self-injurious behaviour: Psychopathological and nosological
characteristics in sub-types of self-injurers. Acta Psychiatrica Scandinivica, 91: 57-68.
Herpetz, S., Sass, H. and Favazza, A. R. (1997). Impulsivity in self-mutilative
behaviour: Psychometric and biological findings. Journal of Psychiatric Research, 31:
451-465.
29
Jones, I. H., Congin, L., Stevenson, J., Straus, N. and Frei, D. Z. (1979). A
biological approach to two forms of human self-injury. Journal of Nervous and Mental
Disease, 167: 74-78.
Kann, L., Kinchen, S. A., Williams, B. I., Ross, J. G., Lowry, R., Grunbaum, J. A.
and Kolbe, L. J. (2000). Youth risk behaviour surveillance-United States. Morbidity and
Mortality Weekly Report, 49: 1-96.
Kerfoot, M. (1980). The family context of adolescent suicidal behaviour. Journal
of Adolescence, 3: 335-346.
Kopper, B. A., Barrios, F. X. and Chiros, C. E. (1998). The positive and negative
suicide ideation inventory: Development and validation. Psychological Reports, 82: 783793.
Lena, S. M. and Bijoor, S. (1990). Wrist cutting: A dare game among adolescents.
Canadian Medical Association Journal, 142 (2): 131-132.
Linehan, M. M. (1993). Cognitive-behavioural treatment of borderline
personality disorder. New York: Guilford Press.
Lipschitz, D. S., Bernstein, D. P., Winegar, R. K. and Southwick, S. M. (1999).
Hospitalized adolescents’ reports of sexual and physical abuse: A comparison of two selfreport measures. Journal of Traumatic Stress. 12: 510-537.
Lipschitz, D. S., Winegar, R. K., Nicolaou, A. L., Hartnik, E., Wolfson, M. and
Sowthwick, S. M. (1999). Perceived abuse and neglect as risk factors for suicidal
behaviour in adolescent inpatients. Journal of Nervous and Mental Disease, 187 (1): 3239.
30
Lowe, G., Jones, D., MacLeod, A., Power, M. and Duggan, C. (2000). Childhood
trauma, dissociation and self-harming behaviour: A pilot study. British Journal of
Medical Psychology, 73: 269-278.
Martin, G. and Waite, S. (1994). Parental bonding and vulnerability to adolescent
suicide. Acta Psychiatrica Scandinavia, 89: 246-254.
McLane, J. (1996). The voice on the skin: Self-mutilation and Merleau-Ponty’s
theory of language. Hypatia, 11: 107-121.
Mehrabian, A. (1994). Manual for the alcohol and drug use scales. (Available
from Albert Mehrabian, 1130 Alta Mesa Road, Monterey, CA 93940).
Mehrabian, A. (1997). Manual for the Child Trait Arousability (Converse of the
Stimulus Screening) Scale. (Available from Albert Mehrabian, 1130 Alta Mesa Road,
Monterey, CA 93940).
Morgan, J. F., Reid, F. and Lacey, J. H. (1999). The SCOFF questionnaire:
Assessment of a new screening tool for eating disorders. British Medical Journal, 319:
1467-1468.
Motz, A. (2001). The Psychology of Female Violence: Crimes against the Body.
Philadelphia: Taylor & Francis.
Murray, C. D., Warm, A. and Fox, J. (2005). An internet survey of adolescent
self-injurers. Australian e-Journal for the Advancement of Mental Health, 4 (1), 2005.
Oppenheimer, R., Howells, K., Palmer, R. L. and Challoner, D. (1985). Adverse
sexual experience in childhood and clinical eating disorders: A preliminary description.
Journal of Psychiatric Research, 19: 357-361.
31
Osuch, E. A., Noll, J. G. and Putnam, F. W. (1999). The motivations for selfinjury in psychiatric inpatients. Psychiatry, 62: 334-346.
Pao, P. (1969). The syndrome of delicate self-cutting. British Journal of Medical
Psychology, 42: 195-206.
Paolucci, E. O., Genuis, M. L. and Violato, C. (2001). A meta-analysis of the
published research on the effects of child sexual abuse. Journal of Psychology, 135: 1736.
Pattison, M. E. and Kahan, J. (1983).The deliberate self-harm syndrome.
American Journal of Psychiatry, 140: 867-872.
Patton, G. C., Harris, R., Carlin, J. B., Hibbert, M., Coffey, C., Schwartz, M. and
Bowes, G. (1997). Adolescent suicidal behaviours: A population based study of risk.
Psychological Medicine, 27: 715-724.
Pembroke, L. (1994). Self-harm: Perspectives from Personal Experiences.
London: Survivors Speak Out.
Pope, H. G. and Hudson, J. I. (1992). Is childhood sexual abuse a risk factor for
bulimia nervosa? American Journal of Psychiatry, 149: 455-463.
Putnam, N. and Stein, M. (1985). Self-inflicted injuries in childhood: A review
and diagnostic approach. Clinical Paediatrics, 24: 514-518.
Reder, P., Lucey, C. and Fredman, G. (1991). The challenge of deliberate selfharm by young adolescents. Journal of Adolescents, 14: 135-148.
Rey Gex, C., Narring, F., Ferron, C. and Michaud, P. A. (1998). Suicide attempts
among adolescents in Switzerland: Prevalence, associated factors and comorbidity. Acta
Psychiatrica Scandinavia, 98: 28-33.
32
Rogers, J. R. (2003). Sexual abuse and suicide: Why we may not know what we
think we know. Archives of Suicide Research, 7: 83-91.
Rosenberg, M. S. (1987). New directions for research on the psychological
maltreatment of children. American Psychologist, 42: 166-171.
Ross, S. and Heath, N. (2002). A study of the frequency of self-mutilation in a
community sample of adolescents. Journal of Youth and Adolescence, 31 (1): 67-77.
Sabo, A. N., Gunderson, J. G., Najavits, L. M., Chauncey, D. and Kisiel, C.
(1995). Changes in self-destructiveness of borderline patients in psychotherapy: A
prospective follow-up. Journal of nervous and mental disease, 183 (6): 370-376.
Safer, D. J. (1997). Self-reported suicide attempts by adolescents. Annals of
Clinical Psychiatry, 9 (4): 263-269.
Santa Mina, E. E. and Gallop, R. M. (1998). Childhood sexual and physical abuse
and adult self-harm and suicidal behaviour: A literature review. Canadian Journal of
Psychiatry, 43: 793-800.
Schaff, K. K. and McCane, T. R. (1994) Childhood abuse, body image
disturbance and eating disorders. Child Abuse and Neglect, 18: 607-615.
Schaffer, C. B., Carroll, J. and Abramowitz, S. I. (1982). Self-mutilation and the
borderline personality. Journal of Nervous and Mental Disease, 170: 468-473.
Schwartz, R., Cohen, P., Hoffman, N. G. and Meeks, J. E. (1989). Self-harm
behaviours (carving) in female adolescent drug abusers. Clinical Paediatrics, 28: 340346.
Shapiro, S. (1987). Self-mutilation and self-blame in incest victims. American
Journal of Psychotherapy, 41: 46-54.
33
Shearer, S. L. (1994). Phenomenology of self-injury among inpatient women with
borderline personality disorder. Journal of Mental and Nervous Disease, 182: 524-526.
Simeon, D. and Favazza, A. R. (2001). Self-injurious behaviour: Phenomenology
and Assessment. In: D. Simeon and D. Hollander (Eds.). Self-injurious Behaviours:
Assessment and Treatment (pp. 1-28). Washington, D. C.: American Psychiatric
Publishing.
Simpson, M. A. (1975). The phenomenology of self-mutilation in a general
hospital setting. Canadian Psychiatric Association Journal, 20 (6): 429-433.
Slade, P. D., Dewey, M. E., Newton, T., Brodie, D. and Kiemle, G. (1990).
Development of the body satisfaction scale (BSS). Psychology and Health, 4: 213-226.
Solomon, Y. and Farrand, J. (1996). ‘‘Why don’t you do it properly?’’ Young
women who self-injure. Journal of Adolescence, 19 (2): 111-119.
Sonneborn, C. K. and Vanstraelen, P. M. (1992). A retrospective study of selfinflicted burns. General Hospital Psychiatry, 14 (6): 404-407.
Spandler, H. (1996). Who’s hurting who? Young people, self-harm and suicide.
Manchester: 42nd Street.
Suyemoto, K. L. (1998). The functions of self-mutilation. Clinical Psychology
Review, 18: 531-554.
Taiminen, T. K., Kallio-Soukainen, K., Nokso-Koivisto, H., Kaljonen, A. and
Helenius, H. (1998). Contagion of deliberate self-harm among adolescent inpatients.
Journal of the American Academy of Child and Adolescent Psychiatry, 37: 211-217.
Tantum, D. and Whittaker, J. (1992). Personality disorder and self-wounding.
British Journal of Psychiatry, 161: 451-464.
34
Vajda, J. and Steinbeck, K. (2000). Factors associated with repeat suicide
attempts among adolescents. Australian and New Zealand Journal of Psychiatry, 34:
437-445.
Van der Kolk, B. A. (1996). The complexity of adaptation to trauma: Selfregulation, stimulus discrimination and characterological development. In: B. A. Van der
Kolk, A. C. McFarlane and L. Weisaeth (Eds.). Traumatic Stress: The effects of
overwhelming experience on mind body and society (pp. 182-213). New York: Guilford
Press.
Van der Kolk, B. A., Perry, J. C. and Herman, J. L. (1991). Childhood origins of
self-destructive behaviour. American Journal of Psychiatry, 148: 1665-1676.
Virkkunen, M. (1976). Self-mutilation in antisocial personality (disorder). Acta
Psychiatrica Scandinavia, 54: 347-352.
Wagman Borowsky, I., Resnick, M. D., Ireland, M. and Blum, R. W. (1999).
Suicide attempts among American Indian and Alaska native youth. Archives of
Paediatric and Adolescent Medicine, 153: 573-580.
Waller, G. (1992). Sexual abuse and the severity of bulimic symptoms. British
Journal of Psychiatry, 161: 90-93.
Waller, G., Everill, J. and Calam, R. (1994). Sexual abuse and the eating
disorders. In: L. A. Alexander Mott and D. B. Lumsden (Eds.). Understanding Eating
Disorders. Washington, DC: Taylor and Francis.
Walsh, B. W. and Rosen, P. M. (1988). Self-mutilation: Theory, Research and
Treatment. New York: Guilford Press.
35
Warm, A., Murray, C. and Fox, J. (2003). Why do people self-harm? Psychology,
Health and Medicine, 8 (1): 71-79.
Wiederman, M, W., Sansone, R. A. and Sansone, L. A. (1999). Bodily self-harm
and its relationship to childhood abuse among women in a primary care setting. Violence
Against Women, 5 (2): 155-163.
Wiessman, M. M. (1975). Wrist cutting: Relationship between clinical
observations and epidemiological findings. Archives of General Psychiatry, 32: 11661171.
Williams, J. M. G. (2001). Suicide and Attempted Suicide: Understanding the Cry
of Pain. London: Penguin.
Winchel, R. M. and Stanley, M. (1991). Self-injurious behaviour: A review of the
behaviour and biology of self-mutilation. American Journal of Psychiatry, 148 (3): 306315.
Wonderlich, S. A., Crosby, R. D., Mitchell, J. E., Thompson, K. M., Redlin, J.,
Demuth, G., Smyth, J. and Haseltine, B. (2001). Eating disturbance and sexual trauma in
adulthood and childhood. International Journal of Eating Disorders, 30: 401-412.
Yaryura-Tobias, J., Neziroglu, F. and Kaplan, S. (1995). Self-mutilation,
anorexia, and dysmenorrea in obsessive compulsive disorder. International Journal of
Eating Disorders, 17 (1): 33-38.
Yates, T. M. (2004). The developmental psychopathology of self-injurious
behaviour: Compensatory regulation in post traumatic adaptation. Clinical Psychology
Review, 24: 35-74.
36
Yates, T. M. and Carlson, E. A. (2003). Fragile Foundations: The Developmental
Antecedents of Self-injurious Behaviour. Paper presented at the Society for Research in
Child Development. Tampa, FL.
Yeo, H. M. and Yeo, W. W. (1993).Repeat deliberate self-harm: A link with
childhood sexual abuse? Archives of Emergency Medicine, 10: 161-166.
Zlotnick, C., Mattia, J. and Zimmerman, M. (2001). Clinical features of survivors
of sexual abuse with major depression. Child Abuse and Neglect, 25 (3): 357-367.
Zlotnick, C., Shea, M. T., Pearlstein, T., Simpson, E., Costello, E. and Begin, A.
(1996). The relationship between dissociative symptoms, alexithymia, impulsivity, sexual
abuse and self-mutilation. Comprehensive Psychiatry, 37: 12-16.
Zweig-Frank, H., Paris, J. and Guzder, J. (1994a). Psychological risk factors and
self-mutilation in male patients with BPD. Canadian Journal of Psychiatry, 39: 266-268.
Zweig-Frank, H., Paris, J. and Guzder, J. (1994b). Psychological risk factors for
dissociation and self-mutilation in female patients with borderline personality disorder.
Canadian Journal of Psychiatry, 39: 259-264.
37
Table 1: Demographic and self-harm information of participants.
Sex:
Male
Female
Age:
Range
Mean
Median
Mode
Self-harm onset Age:
Range
Mean
Median
Mode
Frequency of self-harm: Daily
Weekly
Monthly
Less than monthly
Types of self-harm:
Cutting
Burning
Hitting
Scratching
Scalding
Other
Total types utilized:
One
Two
Three
Four
Five
Six
8% (n=9)
92% (n=104)
14-41
19.92 (SD=5.29)
19.00
17.00
4-31
14.20 (SD=3.47)
14.00
13.00
22.1% (n=25)
46.9% (n=53)
16.8% (n=19)
14.4% (n=16)
100% (n=113)
50.4% (n=57)
64.6% (n=73)
77% (n=87)
13.3% (n=15)
36.3% (n=41)
17.7% (n=20)
19.5% (n=22)
24.8% (n=28)
12.4% (n=14)
19.5 (n=22)
6.2% (n=7)
38
Table 2: Mean scores (with standard deviations) and results of ANOVA significance
tests on experimental measures.
Measures
Body
Dissatisfaction
Eating Disorder
Emotional
Neglect
Emotional
Abuse
Physical neglect
Physical Abuse
Suicide Ideation
Self-Harmers Who Had
Been Sexually Abused
(N=22)
79.64 (20.87)
Self-Harmers Who Had Not
Been Sexually Abused
(N=72)
67.40 (16.18)
Sig
2.95 (1.73)
16.55 (4.43)
2.01 (1.48)
14.25 (4.49)
.017
.022
19.00 (4.26)
13.08 (5.29)
<.001
12.59 (3.55)
13.14 (6.78)
55.14
9.03 (3.31)
7.57 (4.01)
46.49
<.001
<.001
.024
.022
39